Effective coverage for reproductive, maternal, neonatal and newborn health: an analysis of geographical and socioeconomic inequalities in 39 low- and middle-income countries

BACKGROUND

Inadequate access to quality maternal and child health services leads to poor health outcomes for millions of women, particularly in low- and middle-income countries (LMICs). This study aims to explore the effective coverage of reproductive, maternal, neonatal and newborn health (RMNCH) services and examines socioeconomic and rural and urban disparities in 39 LMICs.

METHODS

Using Demographic and Health Surveys (DHS) data, the research assesses RMNCH service quality by applying an effective coverage framework, which measures service contact, crude coverage, quality-adjusted coverage and user adherence-adjusted coverage. We applied weighted analyses to investigate the rural-urban differences in service coverage based on countries' Human Development Index (HDI) levels as well as crude coverage and socioeconomic levels.

FINDINGS

Urban areas generally exhibit better effective coverage across all RMNCH services compared with rural areas, with significant disparities in antenatal, childbirth and postnatal care. For instance, 85% (95% CI=85-86%) of urban women received skilled birth attendance compared with 64% (95% CI=64-65%) in rural areas. High-HDI countries show smaller rural-urban gaps in service coverage than low-HDI countries. Socioeconomic inequalities are more pronounced in rural areas, particularly in services that require higher quality and adherence to standards. Socioeconomic disparities are significant in LMICs with lower HDI and are more evident in harder-to-achieve quality indicators, such as user adherence to recommended practices or treatment. For example, in medium-HDI countries, the relative inequality index (RII) for antenatal care user adherence coverage is 3.6 (95% CI=3.4-3.8) in rural areas compared with 1.9 (95% CI=1.8-2.1) in urban areas.

INTERPRETATION

The research underscores the need for targeted interventions and policies to address these disparities. The evidence supports the need for a shift from focusing solely on access to care to improve the quality of care to address rural-urban and socioeconomic inequalities in RMNCH outcomes.

Evaluation of focused antenatal care services quality at University of Gondar Comprehensive Specialized Hospital, Central Gondar zone, Northwest Ethiopia

BACKGROUND

Antenatal care is the care that women receive during their pregnancy to ensure the health of the mother and her baby. The provision of information on birth preparedness in Ethiopia is still low, which implies identification of pre-existing health conditions that may affect the outcome of pregnancies was not provided. Even if the Focused Antenatal Care service was provided in our setup, maternal death was still high. In addition, as far as our search, the quality of antenatal care service in this facility has not yet been evaluated. As a result, the purpose of this study was to assess the quality of focused antenatal care services at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia.

METHODS

A mixed method case study evaluation design was employed at the University of Gondar Comprehensive Specialized Hospital from February 29 to March 29, 2020. Quantitative data was collected through exit interviews of 411 mothers who attended antenatal care follow-up and review of 422 clients' cards 2 months prior to the study period. Similarly, 35 items of resources inventory, 10 direct observations, and 12 key informant interviews were conducted. The data were entered into Epi-Data version 4.6 and exported to SPSS version 25 and it was analysed with the Evaluation judgment matrix analysis method. Qualitative data were transcribed, translated and analysed by using thematic analysis. The evaluation focused on availability, compliance, and satisfaction dimensions with 25 indicators to judge the quality of antenatal care services.

RESULTS

The overall quality of focused antenatal care services was judged as good, based on pre-set judgment criteria (76.7%), to which availability of resources, healthcare provider's compliance with the national guideline, and maternal satisfaction contributed, 73.3, 77.75, and 78.8%, respectively. Auditory and visual privacy were practiced which enhances patient confidentiality and personal dignity. The waiting area was perceived to be satisfactory by the majority (89%) of ANC clients, but there is no separate waiting area for ANC clients. Ten (10) client/provider interactions were observed, demonstrating that all clients were counseled about pregnancy danger signs.

CONCLUSION AND RECOMMENDATION

The overall focused antenatal care services quality was relatively good, although the availability of resources was fair. Some essential drugs and medical equipment were out of stock. Therefore, the hospital had better fulfill crucial medicines and equipment for better service quality.

An assessment of adequate quality antenatal care and its determinants in India

BACKGROUND

Antenatal care (ANC) is an important component in the continuum of care. Providing adequate quality ANC is necessary to prevent maternal and newborn mortality. The coverage of ANC has increased significantly in the last decade in India, but a mere increase in coverage is insufficient if the issue of quality is not simultaneously addressed. This study examines the change in each component of quality ANC between 2015-16 and 2019-21, highlights the factors associated with adequate quality ANC, and observes the state- and district-level distribution of adequate quality ANC during 2019-21.

METHODS

This study is based on data from the two most recent rounds of the National Family Health Survey (NFHS), the Indian equivalent of the Demographic and Health Surveys (DHS). These rounds were conducted in 2015-16 and 2019-21 in selected households of India with a total of 190,797 and 176,843 sampled births, respectively. The dependent variable was quality antenatal care, a composite variable consisting of skilled healthcare providers, timeliness, sufficiency, and appropriateness of content. The independent variables were mother's age, education, wealth quintile, birth order, mass media exposure, health insurance coverage, relationship with the head of household, facility exposure, intended pregnancy, history of adverse pregnancy outcomes, and other socio-demographic variables. Change in each component and dimension of quality antenatal care was assessed using data from both rounds of the survey. A multivariate multinomial logistic regression analysis was employed to identify the determinants of adequate quality ANC using the NFHS-5 data.

RESULTS

The findings revealed that 32 per cent of mothers received adequate quality antenatal care in 2019-2021, an increase of only 9% points compared to the 2015-16 period. Two significant barriers to achieving adequate quality antenatal care, in terms of appropriateness of content, were the provision of Iron and Folic Acid (IFA) tablets and counselling. The highest utilisation of adequate quality antenatal care was observed in the southern states. The utilisation of quality ANC increased with an increase in women's education and wealth status; and was more prevalent among those with health insurance coverage and exposure to mass media.

CONCLUSION

Despite some improvements in the coverage of antenatal care, the quality of antenatal care continues to be very low and needs urgent attention. Achieving quality antenatal care in both content and experience requires addressing service gaps and developing better measures to capture and improve women's care experiences.

Prevalence and determinants of readiness of health facilities for quality antenatal care services in Bangladesh

This study investigates the prevalence and determinants of readiness for quality antenatal care (ANC) services in Bangladesh using data from the 2017 Bangladesh Health Facility Survey (BHFS). We assessed the association between selected factors and the readiness index using multinomial logistic regression. We identified a significant gap in the availability and quality of ANC services, only 4.26% of health facilities provide quality ANC services, with rural facilities showing lower readiness compared to urban facilities (RRR:0.13; 95% CI: 0.06-0.31; p < 0.001). Community clinics and private hospitals have a lower likelihood of medium or high readiness compared to public hospitals or clinics. Health facilities with specialized care are more likely to demonstrate readiness for quality ANC services. Policy recommendations include increased healthcare funding, implementation of ANC guidelines, strengthened monitoring and evaluation of health facilities, and heightened community awareness. These measures should improve ANC, overall health outcomes, and public health policies.

Socioeconomic and geographic inequalities in antenatal and postnatal care components in India, 2016-2021

Despite the well-known importance of high-quality care before and after delivery, not every mother and newborn in India receive appropriate antenatal and postnatal care (ANC/PNC). Using India's National Family Health Surveys (2015-2016 and 2019-2021), we quantified the socioeconomic and geographic inequalities in the utilization of ANC/PNC among women aged 15-49 years and their newborns (N = 161,225 in 2016; N = 150,611 in 2021). For each of the eighteen ANC/PNC components, we assessed absolute and relative inequalities by household wealth (poorest vs. richest), maternal education (no education vs. higher than secondary), and type of place of residence (rural vs. urban) and evaluated state-level heterogeneity. In 2021, the national prevalence of ANC/PNC components ranged from 19.8% for 8 + ANC visits to 91.6% for maternal weight measurement. Absolute inequalities were greatest for ultrasound test (33.3%-points by wealth, 30.3%-points by education) and 8 + ANC visits (13.2%-points by residence). Relative inequalities were greatest for 8 + ANC visits (1.8 ~ 4.4 times). All inequalities declined over time. State-specific estimates were overall consistent with national results. Socioeconomic and geographic inequalities in ANC/PNC varied significantly across components and by states. To optimize maternal and newborn health in India, future interventions should aim to achieve universal coverage of all ANC/PNC components.

A cluster randomized controlled trial of an electronic decision-support system to enhance antenatal care services in pregnancy at primary healthcare level in Telangana, India: trial protocol

BACKGROUND

India contributes 15% of the total global maternal mortality burden. An increasing proportion of these deaths are due to Pregnancy Induced Hypertension (PIH), Gestational Diabetes Mellitus (GDM), and anaemia. This study aims to evaluate the effectiveness of a tablet-based electronic decision-support system (EDSS) to enhance routine antenatal care (ANC) and improve the screening and management of PIH, GDM, and anaemia in pregnancy in primary healthcare facilities of Telangana, India. The EDSS will work at two levels of primary health facilities and is customized for three cadres of healthcare providers - Auxiliary Nurse Midwifes (ANMs), staff nurses, and physicians (Medical Officers).

METHODS

This will be a cluster randomized controlled trial involving 66 clusters with a total of 1320 women in both the intervention and control arms. Each cluster will include three health facilities-one Primary Health Centre (PHC) and two linked sub-centers (SC). In the facilities under the intervention arm, ANMs, staff nurses, and Medical Officers will use the EDSS while providing ANC for all pregnant women. Facilities in the control arm will continue to provide ANC services using the existing standard of care in Telangana. The primary outcome is ANC quality, measured as provision of a composite of four selected ANC components (measurement of blood pressure, blood glucose, hemoglobin levels, and conducting a urinary dipstick test) by the healthcare providers per visit, observed over two visits. Trained field research staff will collect outcome data via an observation checklist.

DISCUSSION

To our knowledge, this is the first trial in India to evaluate an EDSS, targeted to enhance the quality of ANC and improve the screening and management of PIH, GDM, and anaemia, for multiple levels of health facilities and several cadres of healthcare providers. If effective, insights from the trial on the feasibility and cost of implementing the EDSS can inform potential national scale-up. Lessons learned from this trial will also inform recommendations for designing and upscaling similar mHealth interventions in other low and middle-income countries.

TRIAL REGISTRATION

CLINICALTRIALS

gov, NCT03700034, registered 9 Oct 2018, https://www.

CLINICALTRIALS

gov/ct2/show/NCT03700034 CTRI, CTRI/2019/01/016857, registered on 3 Mar 2019, http://www.ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=28627&EncHid=&modid=&compid=%27,%2728627det%27.

Factors associated with inadequate receipt of components and non-use of antenatal care services in India: a regional analysis

BACKGROUND

Failure to use antenatal care (ANC) and inadequate receipt of components of ANC pose a significant risk for the pregnant woman and the baby. This study aimed to examine a regional analysis of factors associated with receiving no ANC and inadequate receipt of components of ANC services among Indian women.

METHOD

Information from 173,970 women of reproductive age 15-49 years from the 2019-21 India National Family Health Survey (NFSH-5) was analysed. Logistic regression analyses that adjusted for cluster and survey weights were conducted to assess the socio-demographic and other factors associated with receiving non-use of ANC and inadequate receipt of components of ANC, respectively, in the six regions and 28 states, and 8 union territories in India.

RESULTS

Across regions in India, 7% of women reported no ANC, and the prevalence of inadequate and adequate receipt of components of ANC in all six regions ranged from 67 to 89% and 8% to 24%, respectively. Of all the 36 federated entities, the prevalence of inadequate receipt of ANC components was less than two-thirds in Tamil Nadu, Puducherry, Andaman and the Nicobar Islands, Odisha, and Gujarat. Our analyses revealed that associated factors vary by region, state, and union territories. Women from poor households reported increased odds of receiving no ANC in North, East and North-eastern regions. Women who reported no schooling in South, East and Central regions were associated with increased odds of receiving no ANC. Women from poor households in Himachal Pradesh, Bihar, Uttar Pradesh, Nagaland, Manipur, Uttar Pradesh, and Madhya Pradesh states reported significantly higher odds of inadequate components ANC than women from rich households. The receipt of inadequate components of ANC was significantly higher among women who never read magazines in Delhi, Ladakh, Karnataka, Telangana, Jharkhand, Maharashtra, Uttar Pradesh, Chhattisgarh, Arunachal Pradesh, Manipur, and Mizoram states in India.

CONCLUSION

A better understanding of the factors associated with and incorporating them into the short- and long-term intervention strategies, including free financial support from the Indian government to encourage pregnant women from lower socioeconomic groups to use health services across all regions, states and union territories.

A Review of the National Family Health Survey Data in Addressing India’s Maternal Health Situation

Objective: This study aims to understand the trend of research conducted on issues of maternal health in India considering data provided in five rounds of National Family Health Survey (NFHS).

Methods: Systematic review of literature has been conducted using multi-stage search and review process adapted from Page et al.’s (2021) PRISMA. Initially 14,570 studies were identified and only 134 articles meeting selection criterion were considered in this study.

Results: Approximately 32% studies have focused on regional and state variation of maternal health status; while 27% dealt with utilization of maternal healthcare services; and 19% the socio-economic determinants of maternal health. While few studies have discussed the place of delivery, antenatal care and post-natal care visits, only five studies focus on issues related to women’s autonomy, including their health-seeking behaviour, knowledge, attitude and practices related to maternal health.

Conclusion: Non-communicable diseases and its role in maternal health still remains an unexplored domain of research on maternal health in India. Moreover, there exists geographical skewness in the number of studies conducted, focusing especially on few provinces while none on few others.

Evaluations of effective coverage of maternal and child health services: A systematic review

Conventionally used coverage measures do not reflect the quality of care. Effective coverage (EC) assesses the extent to which health care services deliver potential health gains to the population by integrating concepts of utilization, need and quality. We aimed to conduct a systematic review of studies evaluating EC of maternal and child health services, quality measurement strategies and disparities across wealth quantiles. A systematic search was performed in six electronic databases [MEDLINE, EMBASE, Cumulative Index of Nursing and Allied Health (CINAHL), Scopus, Web of Science and Maternity and Infant Care] and grey literature. We also undertook a hand search of references. We developed search terms having no restrictions based on publication period, country or language. We included studies which reported EC estimates based on the World Health Organization framework of measuring EC. Twenty-seven studies, all from low- and middle-income settings (49 countries), met the criteria and were included in the narrative synthesis of the results. Maternal and child health intervention(s) and programme(s) were assessed either at an individual level or as an aggregated measure of health system performance or both. The EC ranged from 0% for post-partum care to 95% for breastfeeding. When crude coverage measures were adjusted to account for the quality of care, the EC values turned lower. The gap between crude coverage and EC was as high as 86%, and it signified a low quality of care. The assessment of the quality of care addressed structural, process and outcome domains individually or combined. The wealthiest 20% had higher EC of services than the poorest 20%, an inequitable distribution of coverage. More efforts are needed to improve the quality of maternal and child health services and to eliminate the disparities. Moreover, considering multiple dimensions of quality and the use of standard measurements are recommended to monitor coverage effectively.

Are Bangladeshi healthcare facilities prepared to provide antenatal care services? Evidence from two nationally representative surveys

Identifying high-risk pregnancies through antenatal care (ANC) is considered the cornerstone to eliminating child deaths and improving maternal health globally. Understanding the factors that influence a healthcare facility's (HCF) preparedness to provide ANC service is essential for assisting maternal and newborn health system progress. We aimed to evaluate the preparedness of HCFs to offer ANC services among childbearing women in Bangladesh and investigate the facility characteristics linked to the preparedness. The data for this study came from two waves of the Bangladesh Health Facilities Survey (BHFS), conducted in 2014 and 2017 using a stratified random sample of facilities. The study samples were 1,508 and 1,506 HCFs from the 2014 and 2017 BHFS, respectively. The outcome variable "ANC services preparedness" was calculated as an index score using a group of tracer indicators. Multinomial logistic regression models were used to identify the significant correlates of ANC service preparedness. We found that private hospitals had a lower chance of having high preparedness than district and upazila public facilities in 2014 (RRR = 0.04, 95% CI: 0.01-0.22, p-value = <0.001) and 2017 (RRR = 0.23, 95% CI: 0.07-0.74, p-value = 0.01), respectively. HCFs from the Khulna division had a 2.84 (RRR = 2.84, CI: 1.25-6.43, p-value = 0.01) and 3.51 (RRR = 3.51, CI: 1.49-8.27, p-value = <0.001) higher likelihood of having medium and high preparedness, respectively, for ANC service compared to the facilities in the Dhaka division in 2017. The facilities that had a medium infection prevention score were 3.10 times (RRR = 3.10, 95% CI: 1.65-5.82; p-value = <0.001) and 1.89 times (RRR = 1.89, 95% CI: 1.09-3.26, p-value = 0.02) more likely to have high preparedness compared to those facilities that had a low infection prevention score in 2014 and 2017 respectively. Facilities without visual aids for client education on pregnancy and ANC were less likely to have high (RRR = 0.29, 95% CI: 0.16-0.53, p-value = <0.001) and (RRR = 0.55, 95% CI: 0.30-0.99, p-value = 0.04) preparedness, respectively, than those with visual aids for client education on pregnancy and ANC in both the surveys. At all two survey time points, facilities that did not maintain individual client cards or records for ANC clients were less likely to have high (RRR = 0.53, 95% CI: 0.31-.92, p-value = 0.02) and (RRR = 0.41, 95% CI: 0.25-0.66, p-value = <0.001) preparedness, respectively, compared to their counterparts. We conclude that most facilities lack adequate indicators for ANC service preparedness. To improve the readiness of ANC services, government authorities could focus on union-level facilities, community clinics, private facilities, and administrative divisions. They could also make sure that infection control items are available, maintain individual client cards or records for ANC clients, and also ensure ANC clients have access to visual aids.

The association between institutional delivery and neonatal mortality based on the quality of maternal and newborn health system in India

Over 600,000 newborns in India died in their first month of life in 2017 despite large increases in access to maternal health services. We assess whether maternal and newborn health system quality in India is adequate for institutional delivery to reduce neonatal mortality. We identified recent births from the cross-sectional 2015–2016 National Family Health Survey and used reported content of antenatal care and immediate postpartum care averaged at the district level to characterize health system quality for maternity and newborn services. We used random effect logistic models to assess the relationship between institutional delivery and neonatal (death within the first 28 days of life) and early neonatal (death within 7 days of live births) mortality by quintile of district maternal and newborn health system quality. Three quarters of 191,963 births were in health facilities; 2% of newborns died within 28 days. District-level quality scores ranged from 40 to 90% of expected interventions. Institutional delivery was not protective against newborn mortality in the districts with poorest health system quality, but was associated with decreased mortality in districts with higher quality. Predicted neonatal mortality in the highest quintile of quality would be 0.018 (95% CI 0.010, 0.026) for home delivery and 0.010 (0.007, 0.013) for institutional delivery. Measurement of quality is limited by lack of data on quality of acute and referral care. Institutional delivery is associated with meaningful survival gains where quality of maternity services is higher. Addressing health system quality is an essential element of achieving the promise of increased access to maternal health services.

Non-utilization of public healthcare facilities during sickness: a national study in India

Aims

Healthcare utilization is a major challenge for low- and middle-income countries, especially for the publicly funded facilities. The study has tried to explore the women’s opinion behind the non-utilization of public healthcare facilities in India.

Subjects and methods

This was a cross-sectional study using nationally representative samples of 351,625 women of reproductive age (15–49 years) from the 29 States and seven Union Territories. Indian National Family Health Surveys NFHS-4 (2015–2016) was the data source. The respondents were asked why the members of their households do not utilize public healthcare facilities when members of their households are sick. They have options to respond either ‘yes’ or ‘no’. Five reasons for non-utilization of public healthcare were asked: (i) ‘there is no nearby facility’; (ii) ‘facility timing is not convenient’; (iii) ‘health personnel are often absent’; (iv) ‘waiting time is too long’; and (v) ‘poor quality of care’.

Results

The majority of the women in India (88%) said that their family members did not use public healthcare facilities. The reasons behind this were 'no nearby facilities' (42.4%), 'inconvenient facility timing' (29.6%), 'poor quality of care' (52.3%), 'health personnel often absent' (16.8%) and 'long waiting time' (39.9%).

Conclusions

importantly, during the last 10 years, the utilization of public health care facilities has dropped significantly, which should be taken seriously as the Indian Parliament has been placing emphasis on equity.

Are the Poor Catching Up with the Rich in Utilising Reproductive, Maternal, New Born and Child Health Services: An Application of Delivery Channels Framework in Indian Context

The article is aimed to assess trends in wealth-related inequalities in coverage of reproductive, maternal, neonatal and child health (RMNCH) interventions using delivery channels framework in Indian context, at national level as well as at state level—Tamil Nadu (TN) and Chhattisgarh (CG)—a better off and poorer state, respectively. We used National Family Health Survey—3rd (2005–2006) and 4th (2015–2016) to study the trends and differentials of inequalities in the RMNCH coverage. We have used two summary indices—absolute inequalities using the slope index of inequality (SII) and relative inequalities using the concentration index (CIX). Culturally driven interventions had pro-poor inequalities in TN, CG and in India, but the coverage has improved significantly for the women from wealthier households recently. Environmental interventions were highly inequal in distribution, particularly for the ‘use of clean fuels’. Inequalities in the coverage of health facilities-based interventions has reduced in TN, CG and overall India, but more so in TN. The inequalities in coverage of community-based interventions have reduced over the period of ten years in TN, CG as well as at national level. Adopting RMNCH delivery channel framework could be useful for assessing and monitoring the progress of public health programmes. Policy makers can gain insights from the success of coverage of various interventions and determine specific implementation strategies to reduce inequalities in the coverage and its effectiveness.

Social and Regional Disparities in Utilization of Maternal and Child Healthcare Services in India: A Study of the Post-National Health Mission Period

BACKGROUND

India has enjoyed enhanced economic growth, but has fared poorly in human development indicators and health outcomes, over the last two decades. Significant health inequities and access to healthcare continue to exist and have widened within communities across states. This study examine the changes and disparities in maternal and child healthcare (MCH) among disadvantaged and advanced social groups in three states of India.

DATA AND METHODS

Four rounds of National Family Health Survey data were used to measure infant mortality rate (IMR) and under-five mortality rate (U5MR) according to the social groups for the selected states. This study investigates the socio-economic inequities manifested into caste and class differentials and inequities in availability, utilization, and affordability of maternal and healthcare services. Descriptive statistics and the logistic regression model were used. Individual- and household-level covariates were employed to understand the differentials in healthcare utilization.

RESULTS

The probability of not receiving full antenatal care (ANC) or full immunization for the children was highest among the Scheduled Caste/Scheduled Tribe (SC/ST) families, followed by economic class, mother's education and residence. Tamil Nadu showed the highest utilization of public health facilities, while Bihar was the poorest in terms of health outcomes and utilization of MCH care services even after the pre-National Health Mission (NHM) period. Bihar and West Bengal also showed private healthcare dependence.

CONCLUSION

This study detected the presence of significant caste/tribe differentials in the utilization of MCH care services in the selected states of India. Limited accessibility and unavailability of complete healthcare were the foremost reasons for the under-utilization of these services, especially for people from disadvantaged social groups. The result also suggested that it is perilous to confirm "Health for All" immediately. It will be the efficiency with which India addresses inequities in providing healthcare services and guarantees quality care of health services.

Quality of antenatal care and its sociodemographic determinants: results of the 2015 Pelotas birth cohort, Brazil

Background

Inadequate antenatal care (ANC) has been associated with adverse pregnancy outcomes. ANC quality is considered a key component of the right to health and a route to equity and dignity for women and their children. Although ANC coverage is relatively high in Brazil, there are revealed some health disparities when coverage is examined by socio-demographic determinants. In this study we evaluated ANC quality and its socio-demographic determinants using data from the 2015 Pelotas birth cohort, Rio Grande do Sul, Brazil.

Methods

This study is part of the 2015 Pelotas population-based birth cohort (n = 3923 pregnant women) conducted in southern Brazil. ANC quality was assessed through 19 content and service utilization indicators recommended by the Brazilian Ministry of Health. Descriptive analyses and associations of each of the ANC indicators and independent variables were performed using the chi-square and linear trend test. ANC indicators were analyzed individually and aggregated as a score. Associations between ANC score quality and socio-demographic variables were assessed with ordinal regressions. Mediation analysis with G-computation was performed to estimate direct and indirect effect of mother’s level of education on ANC quality mediated by the number of consultations and timing of ANC initiation. Base and post confounders were included.

Results

The results showed that except for breast examination, height measurement, tetanus toxoid vaccination and ANC starting at the first trimester, all ANC indicators showed more than 80% coverage during ANC visits.

In the adjusted analysis, inadequate quality ANC was associated with lower maternal education level, not having a partner, being multiparous, being attended by a private provider and by the same professional in all consultations. In the mediation analyses, 6.8% of the association between ANC quality and mother’s education was mediated by the trimester in which ANC started, while 12.8% was mediated by the number of ANC visits.

Conclusions

ANC quality is associated with pregnant women’s socio-demographic characteristics. Significant efforts are needed to improve the quality of facility-based maternity care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07053-4.

Utilization of antenatal care services in a remote, tribal and hilly district of Himachal Pradesh: Challenges to access

BACKGROUND

A traditional African phrase, 'A pregnant woman has one foot in the grave' expresses the immense health risks associated with pregnancy and childbirth. Antenatal care (ANC) is considered an important determinant to alleviate mortalities and morbidities associated with maternal health.

OBJECTIVES

The study aimed to identify the utilization pattern of ANC services by pregnant women in a remote, tribal, and hilly district of Himachal Pradesh and to understand their healthcare needs during antenatal period.

METHODS

A community based descriptive, cross-sectional study was carried out in 41 far-flung villages of Lahaul and Spiti district in Himachal Pradesh, India, using a mixed-method approach of data collection. Purposive sampling was done to select 103 females who had experienced delivery in the past 2 years and were residents of Lahaul for minimum of 3 years. The participants were interviewed using a semi-structured questionnaire and the data were analysed by SPSS-20.

RESULTS

The study revealed high utilization of ANC services by indigenous women, but it was accompanied by physical, psychological, and financial hardships. The triple challenge of inadequacy of quality antenatal services, transport facilities, and unfavourable weather conditions compelled women to leave their communities in Lahaul and relocate to adjoining districts during the maternity period.

CONCLUSION

Pregnancy is still a stressful event that disrupts the link between families and communities in such underserved areas. The study recommends the establishment of programs that promote availability of quality ANC services within the rural and remote communities.

'I was scared I will end up in another abortion': a mixed-methods study assessing the impact of COVID-19 pandemic and lockdown on the antenatal care of pregnant women in Puducherry, South India

BACKGROUND

As a mitigation measure for COVID-19 pandemic, lockdown was implemented in India for a period of 2 months (24 March-31 May 2020). Disruption in antenatal care (ANC) provisions during lockdown is expected due to diversion of public health facilities on pandemic.

OBJECTIVE

To assess the proportion of pregnant women who had not completed the ideal number of antenatal visits, availability of iron-folic acid (IFA) supplements and challenges in availing health services during the period of lockdown.

METHODS

A concurrent mixed-methods study was conducted among pregnant women in Puducherry, India. Information on obstetric characteristics and details regarding antenatal visits were collected through telephonic interviews. In-depth interviews were conducted to understand the perceived challenges in availing health services during the lockdown period.

RESULTS

Out of 150 pregnant women, 62 [41.3%; 95% confidence interval (CI) 33.6-49.3] did not complete the ideal number of visits and 61 (40.7%, 95% CI 32.7-49.0) developed health problems. Out of 44 women who received medical care for health problems, 11 (25%) used teleconsultation. Of all the women, 13 (8.7%, 95% CI 4.9-14.0) had not taken the IFA supplements as prescribed by the health provider. Economic hardship, restricted mobility, lack of information about the health system changes and psychological stress due to the fear of COVID were the challenges in accessing care.

CONCLUSIONS

Two out of five pregnant women did not complete the ideal number of visits and developed health problems during the lockdown period.

Facilities are substantially more influential than care providers in the quality of delivery care received: a variance decomposition and clustering analysis in Kenya, Malawi and India

Introduction

Improving the quality of care during childbirth is essential for reducing neonatal and maternal mortality. One barrier to improving quality of care is understanding the appropriate level to target interventions. We examine quality of care data during labour and delivery from multiple countries to assess whether quality varies primarily from nurse to nurse within the same facility, or primarily between facilities.

Methods

To assess the relative contributions of nurses and facilities to variance in quality of care, we performed a variance decomposition analysis using a linear mixed effect model on two data sources: (1) the number of vital signs assessed for women in labour from a study of nurse practices in Uttar Pradesh, India; 2) broad-scale indices of respectful and competent care generated from Service Provision Assessments in Kenya and Malawi. We used unsupervised clustering, a data mining technique that groups objects together based on similar characteristics, to identify groups of facilities that displayed distinct patterns of vital signs assessment behaviour.

Results

We found 3–10 times more variance in quality of care was explained by the facility where a patient received care than by the nurse who provided it. The unsupervised clustering analysis revealed groups of facilities with highly distinct patterns of vital signs assessment, even when overall rates of vital signs assessments were similar (eg, some facilities consistently test fetal heart rate, but not other vitals, others only blood pressure).

Conclusion

Facilities within a region can vary substantially in the quality of care they provide to women in labour, but within a facility, nurses tend to provide similar care. This holds true both for care that can be influenced by equipment availability and technical training (eg, vital signs assessment), as well as cultural aspects (eg, respectful care).

Do women's empowerment and socioeconomic status predict the adequacy of antenatal care? A cross-sectional study in five South Asian countries

OBJECTIVES

Relative to the attention given to improving the measurement of adequacy of antenatal care (ANC) in South Asian (SA) region, the influence of women's empowerment and socioeconomic status (WESES) on adequate ANC services has hardly received any attention. This study aimed to investigate the present scenario of adequacy of ANC in SA and how its adequacy was associated with WESES.

SETTING AND PARTICIPANTS

Using the Demographic and Health Survey data set of five SA countries, that is, Afghanistan, Bangladesh, India, Nepal and Pakistan, 48 107 women were selected in this study who received at least one ANC component and had at least one live birth in the 3 or 5 years preceding the survey.

ANALYSIS

Multilevel logistic regression models were used to investigate the relationship between adequacy of ANC and WESES.

RESULTS

Only 30% women received adequate ANC in SA, ranging from 8.4% (95% CI 7.1% to 9.9%) in Afghanistan to 39.8% (95% CI 37.4% to 42.2%) in Nepal. The poor utilisation of adequate ANC services was most prevalent among the women residing in rural areas and that of poor families as well as low empowerment status in SA countries. Different levels of WESES, that is, highly empowered but poor (adjusted OR (AOR): 1.33; 95% CI 1.18 to 1.49), lowly empowered but rich (AOR: 2.07; 95% CI 1.84 to 2.32) and highly empowered and rich women (AOR: 3.07; 95% CI 2.75 to 3.43), showed significant positive association with adequate ANC services than the poor and low empowered women, after adjusting the potential covariates.

CONCLUSION

As unsatisfactory level of adequate ANC services has been observed in SA region, this study suggests a nationwide comprehensive improvement of women's empowerment status as well as establishment of necessary healthcare centres in remote areas is essential to ensure long-term and sustainable adequacy of ANC services.

Correction to: Inequalities in the utilisation of maternal health Care in Rural India: Evidences from National Family Health Survey III & IV

An amendment to this paper has been published and can be accessed via the original article.

Antenatal care service satisfaction and its associated factors among pregnant women in public health centres in Hawassa city, Southern Ethiopia

Background:

Self-reported client satisfaction is vital in order to address service provider and facility-based factors that can be upgraded to maximise antenatal care (ANC) satisfaction and utilisation in service-providing institutions.

Objective:

This study aimed to assess ANC service satisfaction and associated factors among pregnant women attending Hawassa city public health centres (HC), Sidama regional state, Southern Ethiopia.

Methods:

This health facility–based cross-sectional study was conducted on 422 pregnant women from 14 March to 13 April 2017. Exit interview data were collected from pregnant women attending care service at five randomly selected public HC.

Results:

Overall, 79.2% were satisfied with the ANC service. As per specific components, 74.2% of respondents were satisfied with the information provided, and 74.2% were satisfied with the institution’s health care. Respondents who had received iron tablets were 3.2 times more likely to be satisfied than their counterparts (adjusted odds ratio (AOR)=3.2, 95% confidence interval (CI) 1.7–5.9). Pregnant women who were counselled on human immunodeficiency virus infection and its testing were 4.3 times more likely to be satisfied than those who had not received such counselling (AOR=4.3, 95% CI 2.2–8.4). Also, those women who waited ⩽30 minutes (AOR=2.6, 95% CI 1.2–5.5) and who received information on foetal movement (AOR=3.5, 95% CI 1.8–6.5) were significantly associated with ANC service satisfaction.

Conclusion:

More than 20% of pregnant women were not satisfied with ANC services. This reflects a need for attention in each aspect of health-care service provision in order to assure client satisfaction.

Maternal health care service utilization among young married women in India, 1992-2016: trends and determinants

BACKGROUND

Maternal deaths among young women (15-24 years) shares 38% of total maternal mortality in India. Utilizing maternal health care services can reduce a substantial proportion of maternal mortality. However, there is a paucity of studies focusing on young women in this context. This paper, therefore, aimed to examine the trends and determinants of full antenatal care (ANC) and skilled birth attendance (SBA) utilization among young married women in India.

METHODS

The study analysed data from the four rounds of National Family Health Surveys conducted in India during the years 1992-93, 1998-99, 2005-06 and 2015-16. Young married women aged 15-24 years with at least one live birth in the 3 years preceding the survey were considered for analysis in each survey round. We used descriptive statistics to assess the prevalence and trends in full ANC and SBA use. Pooled multivariate logistic regression was conducted to identify the demographic and socioeconomic determinants of the selected maternity care services. The significance level for all analyses was set at p ≤ 0.05.

RESULTS

The use of full ANC among young mothers increased from 27 to 46% in India, and from 9 to 28% in EAG (Empowered Action Group) states during 1992-2016. SBA utilization was 88 and 83% during 2015-16 by showing an increment of 20 and 50% since 1992 in India and EAG states, respectively. Findings from multivariate analysis revealed a significant difference in the use of selected maternal health care services by maternal age, residence, education, birth order and wealth quintile. Additionally, Muslim women, women belonging to scheduled caste (SC)/ scheduled tribe (ST) social group, and women unexposed to mass media were less likely to utilize both the maternal health care services. Concerning the time effect, the odds of the utilization of full ANC and SBA among young women was found to increase over time.

CONCLUSIONS

In India coverage of full ANC among young mothers remained unacceptably low, with a wide and persistent gap in utilization between EAG and non-EAG states since 1992. Targeted health policies should be designed to address low coverage of ANC and SBA among underprivileged young mothers and increased efforts should be made to ensure effective implementation of ongoing programs, especially in EAG states.

Socioeconomic Determinants of Maternal HealthCare Utilisation in Zambia: 1997-2014

This study aims at exploring the trends and socioeconomic inequalities in the use of maternal healthcare utilization between 1997 and 2014. Data were analyzed using descriptive and multivariate regression methods. Women in the higher wealth quintiles (Q4 and Q5) generally had higher prevalence of using health facility delivery and postnatal care services compared with those in the lower wealth quintiles (Q1 and Q2), whereas the prevalence of timely and adequate antenatal care visit was comparatively higher among those in the lower wealth quintiles. Findings indicated important sociodemographic inequalities in using maternal healthcare services, addressing which may help promote the utilization of these services.

Factors associated with non-utilization of postnatal care among newborns in the first 2 days after birth in Pakistan: a nationwide cross-sectional study

Background

Recent data indicated that approximately four in every ten newborns in Pakistan do not receive postnatal care (PNC) services in the first 48 hours after delivery.

Objectives

This study aimed to identify factors associated with the non-utilization of PNC for newborns in Pakistan using the 2017–18 Pakistan Demographic and Health Survey (PDHS).

Methods

This was a cross-sectional analytical study utilizing data from 3887 live-born newborns recorded in the 2017–18 PDHS. Non-utilization of PNC was assessed against a set of independent factors using multilevel logistic regression analysis, and the population attributable risk estimates of factors associated with non-utilization of PNC were also calculated.

Results

There were 1443 newborns (37%) in Pakistan whose mothers did not utilize PNC check-ups in the first 2 days after delivery. The non-utilization of PNC was largely attributable to newborns delivered at non-health facilities 53% (47% to 59%) and those born to uneducated women 27% (13% to 38%). Adjusted analyses indicated that newborns with higher birth order and with a birth interval of more than 2 years, women who perceived their baby to be small at birth, women with no formal education and those living in regional areas of Khyber Pakhtunkhwa and Federally Administered Tribal Areas were significantly associated with non-utilization of PNC services.

Conclusions

Tailored health messages by community health workers, including door-to-door visits on utilizing health facilities through pregnancy to the postnatal periods, are needed and should target places of low socioeconomic status, including educationally disadvantaged women from regional areas of Pakistan.

Women's Empowerment as a Mitigating Factor for Improved Antenatal Care Quality despite Impact of 2014 Ebola Outbreak in Guinea

Improving maternal outcomes and reducing pregnancy morbidity and mortality are critical public health goals. The provision of quality antenatal care (ANC) is one method of doing so. Increasing women’s empowerment is associated with positive women’s health outcomes, including the adequate timing and amount of ANC use. However, little is known about the relationship between women’s empowerment and quality ANC care. Despite a history of political instability, low women’s equality and poor maternal health, the Republic of Guinea has committed to improving the status of women and access to health. However, the 2014 Ebola outbreak may have had a negative impact on achieving these goals. This study sought to examine factors in the relationship between women’s empowerment and the receipt of quality ANC (indicated by the number of health components) within the context of the Ebola outbreak. This study conducted multiple logistic regressions examining associations between covariates and the number of ANC components received using data from the 2012 and 2018 Guinea Demographic Health Surveys. Several aspects of women’s empowerment (healthcare decision-making, literacy/access to magazines, monogamous relationship status, contraceptive use, socio-economic status/employment) were significantly linked with the receipt of a greater number of ANC components, highlighting the importance of women’s empowerment in accessing quality maternity care.

Women's satisfaction with the quality of antenatal care services rendered at public health facilities in Northwest Ethiopia: the application of partial proportional odds model

OBJECTIVES

The study was aimed: (1) to describe the quality of antenatal care (ANC) at public health facilities in Northwest Ethiopia, including dimensions of the structure, process and outcome; and (2) to assess the relationship between ANC satisfaction and structure and process dimension of ANC quality.

DESIGN

Cross sectional.

SETTING

Healthcare facilities providing ANC services in Northwest Ethiopia.

PARTICIPANTS

795 pregnant women attending the antenatal clinics at 15 public health facilities and 41 health workers working for the surveyed facilities.

OUTCOME MEASURES

The outcome variable, women's satisfaction with ANC, was constructed from multiple satisfaction items using principal component analysis on an ordered, categorical and three-point Likert scale. The key hypothesised factors considered were structural and process aspects of care. Data were analysed using the partial proportional odds model with 95% CI.

RESULTS

The result revealed that only 30.3% of the pregnant women were highly satisfied, whereas 31.7% had a lower satisfaction level. The findings showed that process quality indicators better predicted client satisfaction. In relation to this, better scores in history taking (aOR₁=aOR₂; 1.81 (95% CI 1.25 to 2.60)), counselling (aOR₁ = aOR₂; 1.89 (95% CI 1.33 to 2.69)) and screening (aOR₁= aOR₂; 18.10 (95% CI 11.52 to 28.39)) were associated with achieving higher satisfaction. We also observed a significant but lower satisfaction among women in the late trimester of pregnancy (aOR₁ = aOR₂; 0.87 (95% CI 0.78 to 0.97)). However, we did not see any significant relationship between structural variables and client satisfaction.

CONCLUSIONS

The study demonstrated that women's satisfaction with ANC was low. The contents of ANC services covered during client-provider interaction were the main factors affecting client satisfaction. This suggests that efforts are required to improve the competencies of health professionals to make them more effective while dealing with clients.

Stunting among Preschool Children in India: Temporal Analysis of Age-Specific Wealth Inequalities

Adequate nutritional intake for mothers during pregnancy and for children in the first two years of life is known to be crucial for a child's lifelong physical and neurodevelopment. In this regard, the global nutrition community has focused on strategies for improving nutritional intake during the first 1,000 day period. This is largely justified by the observed steep decline in children's height-for-age z scores from birth to 23 months and presumed growth faltering at later ages as a reflection of earlier deprivation that is accumulated and irreversible. Empirical evidence on the age-stratified burden of child undernutrition is needed to re-evaluate the appropriate age for nutrition interventions to target among children. Using data from two successive rounds of National Family Health Surveys conducted in 2006 and 2016, the objective of this paper was to analyze intertemporal changes in the age-stratified burden of child stunting across socioeconomic groups in India. We found that child stunting in India was significantly concentrated among children entering preschool age (24 or above months). Further, the temporal reduction in stunting was relatively higher among children aged 36-47 months compared to younger groups (below 12 and 12-23 months). Greater socioeconomic inequalities persisted in stunting among children from 24 months or above age-groups, and these inequalities have increased over time. Children of preschool age (24 or above months) from economically vulnerable households experienced larger reductions in the prevalence of stunting between 2006 and 2016, suggesting that policy research and strategies beyond the first 1000 days could be critical for accelerating the pace of improvement of child nutrition in India.

Is Distribution a Problem in Iron-Folic Acid Consumption in India? An Exploration of District Level Household Survey

Aims:

Anemia accounts for 40% of maternal deaths in India. In order to address this problem, the Government of India implemented the largest programme with the greatest potential to reduce maternal mortality by free distribution of Iron-Folic Acid (IFA) supplementations especially during Antenatal Care (ANC) visits. But the major concern among the policymakers and researchers has been poor adherence to the supplement among pregnant women. However, we tend to think that given the severity of the problem, there is no investigation on the adherence issue. Hence, the aim of the paper is to understand whether IFA consumption by pregnant women in India is largely a distribution problem of IFA supplements through ANC.

Background:

The distribution of Iron-Folic Acid (IFA) supplementation is not working especially through Antenatal Care (ANC) attendance. The program implementers believe that it is because of lack of adherence to IFA supplements by pregnant women. It is important to investigate the problem before any policy changes are made without proper evidence.

Objectives:

The purpose of this study is to examine whether the problem of IFA consumption by pregnant women is due to the problem of public distribution of IFA supplements through ANC attendance.

Methods:

This study had used the fourth round of District Level Household Survey data, which collects information on IFA supplements, their distribution and consumption. Bivariate and tri-variate analyses were used to understand the relationship between IFA distribution to pregnant women and their consumption patterns in 19 Indian states and two Union Territories (UTs) of pregnant women (88,487) and between the age of 15-49 years.

Results:

In almost all the states except Chhattisgarh, more than 75% of the pregnant women consumed 100 or more IFA supplements when they received 100 or more IFA supplements from providers. Similar is the case even among those women who received 100 or more IFA supplements through 1 or 2 ANC attendance except Arunachal Pradesh (60%), Meghalaya (67%), Pondicherry (57%) and Andaman and Nicobar (0%). The consumption of IFA supplements among pregnant women gets better than 75% if they receive 100 or more supplements only after attending three or more ANCs.

Conclusion:

It seems that distribution is a problem in the consumption of IFA supplements by pregnant women in India. Full antenatal attendance by the women could be part of the problem but not supplying at least 100 IFA supplementations to even those who attend ANC due to stock-outs and ineffective management is a serious concern. Hence, Governments should distribute at least the recommended 100 IFA supplements to the women in their 1st ANC attendance to address anaemia.

Quality antenatal care services delivery at health facilities of Ethiopia, assessment of the structure/input of care setting

BACKGROUND

According to the Donabedian model, the assessment for the quality of care includes three dimensions. These are structure, process, and outcome. Therefore, the present study aimed at assessing the structural quality of Antenatal care (ANC) service provision in Ethiopian health facilities.

METHODS

Data were obtained from the 2018 Ethiopian Service Availability and Readiness Assessment (SARA) survey. The SARA was a cross-sectional facility-based assessment conducted to capture health facility service availability and readiness in Ethiopia. A total of 764 health facilities were sampled in the 9 regions and 2 city administrations of the country. The availability of equipment, supplies, medicine, health worker's training and availability of guidelines were assessed. Data were collected from October-December 2017. We run a multiple linear regression model to identify predictors of health facility readiness for Antenatal care service. The level of significance was determined at a p-value < 0.05.

RESULT

Among the selected health facilities, 80.5% of them offered Antenatal care service. However, the availability of specific services was very low. The availability of tetanus toxoid vaccination, folic acid, iron supplementation, and monitoring of hypertension disorder was, 67.7, 65.6, 68.6, and 75.1%, respectively. The overall mean availability among the ten tracer items that are necessary to provide quality Antenatal care services was 50%. In the multiple linear regression model, health centers, health posts and clinics scored lower Antenatal care service readiness compared to hospitals. The overall readiness index score was lower for private health facilities (β = - 0.047, 95% CI: (- 0.1, - 0.004). The readiness score had no association with the facility settings (Urban/Rural) (p-value > 0.05). Facilities in six regions except Dire Dawa had (β = 0.067, 95% CI: (0.004, 0.129) lower readiness score than facilities in Tigray region (p-value < 0.015).

CONCLUSION

This analysis provides evidence of the gaps in structural readiness of health facilities to provide quality Antenatal care services. Key and essential supplies for quality Antenatal care service provision were missed in many of the health facilities. Guaranteeing properly equipped and staffed facilities shall be a target to improve the quality of Antenatal care services provision.

Inequalities in the utilisation of maternal health Care in Rural India: Evidences from National Family Health Survey III & IV

BACKGROUND

Since the implementation of National Rural Health Mission (NRHM) in 2005, Maternal Mortality Ratio has significantly declined in India through a noticeable improvement in maternal health care services. However, India did not succeed to achieve the target of millennium development goal to reduced maternal mortality ratio by 2015. Also, there is substantial inequality exist at the regional, geographic, economic, and social level, and various socioeconomic factors contribute to the significantly large share in inequality in utilisation of maternal health care in India.

METHODS

Using data from the National Family Health Survey (2005 and 2015), this study examined the degree of inequality exist in maternal health care namely full antenatal care (full ANC), skilled attendants at birth (SBA), and postnatal care (PNC) in rural India. Descriptive statistics, concentration index (CI), and Wagstaff decomposition method have been performed to understand the pattern of maternal health care utilisation, and to explain the extent of inequality in maternal health care utilisation.

RESULTS

The study revealed that a substantial gap across socioeconomic groups exist in utilisation of maternal health care has significantly reduced in rural India during 2005-16. The results found a noticeable improvement in maternal health care utilisation, especially in utilisation of skilled attendants at birth (SBA). During this decade, the concentration index for SBA showed a significant decline from 0.28 in 2005-06 to 0.09 in 2015-16, while that of full ANC declined from 0.47 to 0.32 over the same period, and reduction of inequality in full ANC was least. Further, the results of decomposition analysis suggested that secondary and higher education, mass media exposure, and scheduled tribe contributed a significant share to the inequality.

CONCLUSION

The exposure to mass media is the most significant contributor to inequality, and hence, there is a need for broad dissemination of awareness regarding maternal health care schemes in rural parts of country. Based on findings of study, it is suggested that health scheme related to maternal and child health care under NRHM be continued and focused for lower socioeconomic groups and marginalized mothers to reduce maternal health services inequality, particularly in the component of full ANC.

Geographic Inequities in Coverage of Maternal and Child health Services in Haryana State of India

Introduction India aims to achieve universal health coverage, with a focus on equitable delivery of services. There is significant evidence on extent of inequities by income status, gender and caste. In this paper, we report geographic inequities in coverage of reproductive, maternal and child health (MCH) services in Haryana state of India. Methods Cross-sectional data on utilization of maternal, child health and family planning services were collected from 12,191 women who had delivered a child in the last one year, 10314 women with 12-23 months old child, and 45864 eligible couples across all districts in Haryana state. Service coverage was assessed based on eight indicators - 6 for maternal health, one for child health and one for family planning. Inter- and intra-district inequalities were compared based on four and three indicators respectively. Results Difference in coverage of full ante-natal care, full immunization and contraceptive prevalence rate between districts performing best and worst was found to be 54%, 65% and 63% respectively. More than one-thirds of the sub-centres (SCs) in Panchkula, Ambala, Gurgaon and Mewat districts had their ante-natal care coverage less than 50% of the respective district average. Similarly, a significant proportion of SCs in Mewat, Panipat and Hisar districts had full immunization rate below 50% of the district average. Conclusion Widespread inter- and intra-district inequities in utilization of MCH services exist. A comprehensive geographical targeting to identify poor performing districts, community development blocks and SCs could result in significant equity gains, besides contributing to quick achievement of sustainable development goals.

Cost-effectiveness of a mentorship and quality improvement intervention to enhance the quality of antenatal care at rural health centers in Rwanda

OBJECTIVE

To estimate cost-effectiveness of Mentorship, Enhanced Supervision for Healthcare and Quality Improvement (MESH-QI) intervention to strengthen the quality of antenatal care at rural health centers in rural Rwanda.

DESIGN

Cost-effectiveness analysis of the MESH-QI intervention using the provider perspective.

SETTING

Kirehe and Rwinkwavu District Hospital catchment areas, Rwanda.

INTERVENTION

MESH-QI.

MAIN OUTCOME MEASURES

Incremental cost per antenatal care visit with complete danger sign and vital sign assessments.

RESULTS

The total annual costs of standard antenatal care supervision was 10 777.21 USD at the baseline, whereas the total costs of MESH-QI intervention was 19 656.53 USD. Human resources (salary and benefits) and transport drove the majority of program expenses, (44.8% and 40%, respectively). Other costs included training of mentors (12.9%), data management (6.5%) and equipment (6.5%). The incremental cost per antenatal care visit attributable to MESH-QI with all assessment items completed was 0.70 USD for danger signs and 1.10 USD for vital signs.

CONCLUSIONS

MESH-QI could be an affordable and effective intervention to improve the quality of antenatal care at health centers in low-resource settings. Cost savings would increase if MESH-QI mentors were integrated into the existing healthcare systems and deployed to sites with higher volume of antenatal care visits.

Enablers and Barriers to the Utilization of Antenatal Care Services in India

Antenatal care (ANC) reduces adverse health outcomes for both mother and baby during pregnancy and childbirth. The present study investigated the enablers and barriers to ANC service use among Indian women. The study used data on 183,091 women from the 2015–2016 India Demographic and Health Survey. Multivariate multinomial logistic regression models (using generalised linear latent and mixed models (GLLAMM) with the mlogit link and binomial family) that adjusted for clustering and sampling weights were used to investigate the association between the study factors and frequency of ANC service use. More than half (51.7%, 95% confidence interval (95% CI): 51.1–52.2%) of Indian women had four or more ANC visits, 31.7% (95% CI: 31.3–32.2%) had between one and three ANC visits, and 16.6% (95% CI: 16.3–17.0%) had no ANC visit. Higher household wealth status and parental education, belonging to other tribes or castes, a woman’s autonomy to visit the health facility, residence in Southern India, and exposure to the media were enablers of the recommended ANC (≥4) visits. In contrast, lower household wealth, a lack of a woman’s autonomy, and residence in East and Central India were barriers to appropriate ANC service use. Our study suggests that barriers to the recommended ANC service use in India can be amended by socioeconomic and health policy interventions, including improvements in education and social services, as well as community health education on the importance of ANC.

Management and referral for high-risk conditions and complications during the antenatal period: knowledge, practice and attitude survey of providers in rural public healthcare in two states of India

BACKGROUND

Appropriate antenatal care improves pregnancy outcomes. Routine antenatal care is provided at primary care facilities in rural India and women at-risk of poor outcomes are referred to advanced centres in cities. The primary care facilities include Sub-health centres, Primary health centres, and Community health centres, in ascending order of level of obstetric care provided. The latter two should provide basic and comprehensive obstetric care, respectively, but they provide only partial services. In such scenario, the management and referrals during pregnancy are less understood. This study assessed rural providers' perspectives on management and referrals of antenatal women with high obstetric risk, or with complications.

METHODS

We surveyed 147 health care providers in primary level public health care from poor and better performing districts from two states. We assessed their knowledge, attitudes and practices regarding obstetric care, referral decisions and pre-referral treatments provided for commonly occurring obstetric high-risk conditions and complications.

RESULTS

Staff had sub-optimal knowledge of, and practices for, screening common high-risk conditions and assessing complications in pregnancy. Only 31% (47/147) mentioned screening for at least 10 of the 16 common high-risk conditions and early complications of pregnancy. Only 35% (17/49) of the staff at Primary health centres, and 51% (18/35) at Community health centres, mentioned that they managed these conditions and, the remaining staff referred most of such cases early in pregnancy. The staff mentioned inability to manage childbirth of women with high-risk conditions and complications. Thus in absence of efficient referral systems and communication, it was better for these women to receive antenatal care at the advanced centres (often far) where they should deliver. There were large gaps in knowledge of emergency treatment for obstetric complications in pregnancy and pre-referral first-aid. Staff generally were low on confidence and did not have adequate resources. Nurses had limited roles in decision making. Staff desired skill building, mentoring, moral support, and motivation from senior officers.

CONCLUSION

The Indian health system should improve the provision of obstetric care by standardising services at each level of health care and increasing the focus on emergency treatment for complications, appropriate decision-making for referral, and improving referral communication and staff support.

Quality of care in six sub-Saharan Africa countries: a provider-based study on adherence to WHO's antenatal care guideline

OBJECTIVE

Quality of care may help explain the high burden of disease in maternal, newborn and child health in low- and middle-income countries even as access to care is improved. We explored the determinants of quality of antenatal care (ANC) in sub-Saharan Africa (SSA).

DESIGN

Cross-sectional study. Multilevel Generalized Linear Latent Mixed-Effect models with logit link function were employed to obtain the adjusted odds ratios (AORs) and 95% confidence interval (CI).

SETTING

We used Service Provision Assessment data from six countries in SSA, including Kenya, Malawi, Namibia, Rwanda, Tanzania and Uganda.

PARTICIPANTS

Seven thousand, five hundred and seventy seven observed antenatal clients across the six countries.

MAIN OUTCOME MEASURES

Quality of ANC services, measured using indexes of quality of clinical care and quality of information provided.

RESULTS

Providers in facilities that had ANC guideline (AOR = 1.26; 95% CI, 1.08-1.48), were well-equipped (AOR = 1.65; 95% CI, 1.41-1.92), were classified as upper level facility (AOR = 1.32; 95% CI, 1.05-1.66), had central electricity supply (AOR = 2.19; 95% CI, 1.81-2.65), and piped water (AOR = 1.30; 95% CI, 1.09-1.55) were more likely to provide optimal quality of clinical care. Moreover, those having ANC guideline (AOR = 1.81; 95% CI, 1.43-2.28) and central electricity supply (AOR = 2.67; 95% CI, 2.01-3.44) were more likely to provide optimal information as well. Provider's qualification and experience were also important in information provision and clinical care independently.

CONCLUSION

The lack of some very basic facility equipment and amenities compromised quality of care in sub-Saharan countries. Policy actions and investment on facility and providers will enable provision of quality services necessary to improve maternal, newborn and child health in SSA.

Comparing summary measures of quality of care for family planning in Haiti, Malawi, and Tanzania

Measuring quality of care in family planning services is essential for policymakers and stakeholders. However, there is limited agreement on which mathematical approaches are best able to summarize quality of care. Our study used data from recent Service Provision Assessment surveys in Haiti, Malawi, and Tanzania to compare three methods commonly used to create summary indices of quality of care-a simple additive, a weighted additive that applies equal weights among domains, and principal components analysis (PCA) based methods. The PCA results indicated that the first component cannot sufficiently summarize quality of care. For each scoring method, we categorized family planning facilities into low, medium, and high quality and assessed the agreement with Cohen's kappa coefficient between pairs of scores. We found that the agreement was generally highest between the simple additive and PCA rankings. Given the limitations of simple additive measures, and the findings of the PCA, we suggest using a weighted additive method.

No time, no money, no luck: Barriers to prenatal care among dalit women in rural Nepal

In Nepal, a large gap exists between non-dalit and dalit women in regard to maternal mortality and prenatal care. Especially rural Dalits are far behind non-dalits in utilizing prenatal care. We explored rural dalit women's prenatal practices and barriers to accessing prenatal care. Interviews revealed that lack of cultural and economic capital, unequal domestic and economic burden, and gender and caste discrimination impact the use of prenatal care. The use of prenatal care might be improved by informing women about free services and incentives, better access and transportation, and heightened sensitivity to the situation of these women.

Equity in antenatal care quality: an analysis of 91 national household surveys

Background

Emerging data show that many low-income and middle-income country (LMIC) health systems struggle to consistently provide good-quality care. Although monitoring of inequalities in access to health services has been the focus of major international efforts, inequalities in health-care quality have not been systematically examined.

Methods

Using the most recent (2007–16) Demographic and Health Surveys and Multiple Indicator Cluster Surveys in 91 LMICs, we described antenatal care quality based on receipt of three essential services (blood pressure monitoring and urine and blood testing) among women who had at least one visit with a skilled antenatal-care provider. We compared quality across country income groups and quantified within-country wealth-related inequalities using the slope and relative indices of inequality. We summarised inequalities using random-effects meta-analyses and assessed the extent to which other geographical and sociodemographic factors could explain these inequalities.

Findings

Globally, 72·9% (95% CI 69·1–76·8) of women who used antenatal care reported blood pressure monitoring and urine and blood testing; this number ranged from 6·3% in Burundi to 100·0% in Belarus. Antenatal care quality lagged behind antenatal care coverage the most in low-income countries, where 86·6% (83·4–89·7) of women accessed care but only 53·8% (44·3–63·3) reported receiving the three services. Receipt of the three services was correlated with gross domestic product per capita and was 40 percentage points higher in upper-middle-income countries compared with low-income countries. Within countries, the wealthiest women were on average four times more likely to report good quality care than the poorest (relative index of inequality 4·01, 95% CI 3·90–4·13). Substantial inequality remained after adjustment for subnational region, urban residence, maternal age, education, and number of antenatal care visits (3·20, 3·11–3·30).

Interpretation

Many LMICs that have reached high levels of antenatal care coverage had much lower and inequitable levels of quality. Achieving ambitious maternal, newborn, and child health goals will require greater focus on the quality of health services and their equitable distribution. Equity in effective coverage should be used as the new metric to monitor progress towards universal health coverage.

Funding

Bill & Melinda Gates Foundation.

Determinants of frequency and contents of antenatal care visits in Bangladesh: Assessing the extent of compliance with the WHO recommendations

Background

In addition to the number of antenatal care (ANC) visits, the items of ANC services covered by ANC visits greatly influence the effectiveness of the ANC services. Recently the World Health Organization (WHO) recommended not only to achieve a minimum of eight ANC visits, but also to use a core set of items of ANC services for safe motherhood. This study examined the levels and determinants of frequency and contents of ANC visits in Bangladesh and thus assessed the level of compliance with the WHO recommended number and the content of ANC services during pregnancy in Bangladesh.

Methods

The data for the study come from the 2014 Bangladesh Demographic and Health Survey (BDHS), which covereda nationally representative sample of 17,863 ever-married women aged 15–49 years. Data derived from 4,627 mothers who gave birth in the three years preceding the survey constituted the study subjects. Descriptive, inferential and multivariate statistical techniques were used for data analysis.

Results

On average, mothers received less than three (2.7 visits) ANC visits and only 6% receive the recommended eight or more ANC visits. About 22% of the mothers received all the prescribed basic items of ANC services. About one-fifth (21%) of the mothers never received ANC visits and thus no items of ANC services. Measurement of blood pressure was the most common item received during ANC visit as reported by 69% mothers. Blood test was the least received item (43%). Significant positive association was found between frequency of ANC visits and receiving the increased number of items of ANC services. High socio-economic status, low parity, living in urban areas and certain administrative regions, planned pregnancies, having media exposure, visiting skilled providers for ANC services and visit to public or NGO health facilities are associated with frequent ANC visits and receiving higher number of items of ANC contents.

Conclusion

An unsatisfactory level of coverage of and content of ANC visits have been observed in Bangladesh. Further investigation is needed to identify the causes of under-utilization of ANC services in Bangladesh. A greater understanding of the identified risk factors and incorporating them into short and long term strategies would help improve the coverage and contents and thus quality of ANC services in Bangladesh.

Antenatal care satisfaction in a developing country: a cross-sectional study from Nigeria

Background

Utilization of Antenatal Care (ANC) is very low in Nigeria. Self-reported patient satisfaction may be useful to identify provider- and facility-specific factors that can be improved to increase ANC satisfaction and utilization.

Methods

Exit interview data collected from ANC users and facility assessment survey data from 534 systematically selected facilities in four northern Nigerian states were used. Associations between patient satisfaction (satisfied, not-satisfied) and patient ratings of the provider’s interactions, care processes, out-of-pocket costs, and quality of facility infrastructure were studied.

Results

Of 1336 mothers, 90% were satisfied with ANC. Patient satisfaction was positively associated with responsive service (prompt, unrushed service, convenient clinic hours and privacy during consultation, AOR 2.42, 95% CI 2.05–2.87), treatment-facilitation (medical care-related provider communication and ease of receiving medicines, AOR 2.03, 95% CI 1.46–2.80), equipment availability (AOR 1.10, 95% CI 1.01–1.21), staff empathy (AOR 1.82, 95% CI 1.03–3.23), non-discriminatory treatment regardless of patient’s socioeconomic status (AOR: 1.87, 95% CI 1.09–3.22), provider assurance (courtesy and patient’s confidence in provider’s competence, AOR 1.48, 95% CI 1.26–1.75), and number of clinical examinations received (AOR 1.28, 95% CI 1.10–1.50). ANC satisfaction was negatively impacted by out-of-pocket payment for care (vs. free care, AOR 0.44, 95% CI 0.23–0.82).

Conclusions

ANC satisfaction in Nigeria may be enhanced by improving responsiveness to clients, clinical care quality, ensuring equipment availability, optimizing easy access to medicines, and expanding free ANC services.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5285-0) contains supplementary material, which is available to authorized users.

Analysis of socioeconomic differences in the quality of antenatal services in low and middle-income countries (LMICs)

The desired results of increasing access and availability of antenatal care (ANC) services may not be realized if the quality of care offered is not adequate. We analyzed the content/quality of antenatal care to determine whether there are socioeconomic (education and wealth) inequalities in the services provided in 59 low and middle income countries in six WHO regions–Africa, East Asia and Pacific, Europe and Central Asia, Latin America and Caribbean, Middle East and South Asia. We aggregated the most recent (2005–2015) Demographic and Health Survey for each country. The quality of content was measured on eight recommended ANC services–(1) monitoring of blood pressure; (2) tetanus injection; (3) urine analysis for protein; (4) blood test; (5) information about danger signs (6); weight (7); height measurements and (8) provision of iron-folate supplement. Descriptive and Poisson regression techniques were applied to analyse the data. We found considerable wealth and educational differences prior to controlling for known covariates. Between wealth and education, however, the disparities in the latter are larger than the former. Whereas the socioeconomic differences remained at post adjusting for residence, place and number of antenatal care, parity and region, the magnitude of change was minimal. Higher number of ANC content was provided in “other” forms of private facilities; the Latin America and Caribbean region recorded the highest number of content compared to the other regions. The hypothesized socioeconomic status on content/number of ANC services was generally supported, although the associations are substantially constrained to other variables. Efforts are made to increase the number and timing of ANC services; due recognition is needed for the content offered.

Beyond coverage: improving the quality of antenatal care delivery through integrated mentorship and quality improvement at health centers in rural Rwanda

BACKGROUND

Inadequate antenatal care (ANC) can lead to missed diagnosis of danger signs or delayed referral to emergency obstetrical care, contributing to maternal mortality. In developing countries, ANC quality is often limited by skill and knowledge gaps of the health workforce. In 2011, the Mentorship, Enhanced Supervision for Healthcare and Quality Improvement (MESH-QI) program was implemented to strengthen providers' ANC performance at 21 rural health centers in Rwanda. We evaluated the effect of MESH-QI on the completeness of danger sign assessments.

METHODS

Completeness of danger sign assessments was measured by expert nurse mentors using standardized observation checklists. Checklists completed from October 2010 to May 2011 (n = 330) were used as baseline measurement and checklists completed between February and November 2012 (12-15 months after the start of MESH-QI implementation) were used for follow-up. We used a mixed-effects linear regression model to assess the effect of the MESH-QI intervention on the danger sign assessment score, controlling for potential confounders and the clustering of effect at the health center level.

RESULTS

Complete assessment of all danger signs improved from 2.1% at baseline to 84.2% after MESH-QI (p <  0.001). Similar improvements were found for 20 of 23 other essential ANC screening items. After controlling for potential confounders, the improvement in danger sign assessment score was significant. However, the effect of the MESH-QI was different by intervention district and type of observed ANC visit. In Southern Kayonza District, the increase in the danger sign assessment score was 6.28 (95% CI: 5.59, 6.98) for non-first ANC visits and 5.39 (95% CI: 4.62, 6.15) for first ANC visits. In Kirehe District, the increase in danger sign assessment score was 4.20 (95% CI: 3.59, 4.80) for non-first ANC visits and 3.30 (95% CI: 2.80, 3.81) for first ANC visits.

CONCLUSION

Assessment of critical danger signs improved under MESH-QI, even when controlling for nurse-mentees' education level and previous training in focused ANC. MESH-QI offers an approach to enhance quality of care after traditional training and may be an approach to support newer providers who have not yet attended content-focused courses.