Provider and user perspectives on antenatal care delivery in KwaZulu-Natal and Limpopo, South Africa

Background: South Africa adopted evidence-based antenatal care (ANC) frameworks to improve maternal health outcomes. However, the maternal mortality ratio remains above Sustainable Development Goal target 3.1 and routine data indicate declining ANC first-visit coverage. Aim: This study sought to explore implementation gaps, barriers and facilitators in the delivery and uptake of ANC. Setting: Ugu and uMzinyathi districts in KwaZulu-Natal, and Capricorn and Waterberg districts in Limpopo, South Africa. Methods: A qualitative descriptive design was utilised. Semi-structured interviews were conducted with 70 purposively sampled participants, comprising 30 health system providers and 40 service users. Data were analysed thematically using NVivo. Results: Health system providers attributed declining ANC coverage to fertility decline rather than reduced access alone. Providers identified mentorship, community outreach and enhanced screening as key strengths. Implementation was constrained by staffing and equipment shortages. While service users recognised the benefits of ANC, they reported that long waiting times, negative provider attitudes and limited privacy during consultations undermined the quality of service delivery. Providers and service users linked delayed ANC initiation to financial constraints, stigma and pregnancy concealment. Conclusion: Improving early ANC initiation requires an approach that addresses health system, socioeconomic and cultural barriers. Concerns about declining fertility as a driver of declining coverage warrant further investigation into coverage calculation methodologies. Contribution: The study provides insights into the interconnected factors influencing ANC delivery and uptake in primary healthcare settings. It further highlights the need to consider changing fertility patterns when interpreting ANC coverage. The findings can inform targeted interventions and strengthen maternal health planning, monitoring, and service delivery.