The quality-coverage gap in antenatal care: toward better measurement of effective coverage

Abstract

Background: The proportion of pregnant women receiving 4 or more antenatal care visits (ANC 4+) is used prominently as a global benchmark indicator to track maternal health program performance. This has contributed to an inappropriate focus on the number of contacts rather than on the content and process of care. This paper presents analysis of specific elements of care received among women reporting 4 or more ANC visits.

Methods: We conducted secondary analysis using Demographic and Health Survey data from 41 countries to determine coverage for specific elements of antenatal care. The analysis was conducted for: (1) women who delivered during the 2 years preceding the survey and who reported receiving 4 or more ANC visits, and (2) all women who delivered during the preceding 2 years. The specific ANC services that we assessed were: blood pressure measurement, tetanus toxoid vaccination, first ANC visit at less than 4 months gestation, urine testing, counseling about danger signs, HIV counseling and testing, iron-folate supplementation (≥ 90 days), and at least 2 doses of sulfadoxine/pyramethamine for malaria prevention. The difference between expected (100%) and actual coverage (the quality-coverage gap) was calculated for each service across the 41 surveys.

Results: Coverage for specific elements of care among women reporting 4 or more ANC visits was generally low for most of the specific elements assessed. Blood pressure and tetanus toxoid performed best, with median quality-coverage gaps of 5% and 18%, respectively. The greatest gaps were for iron-folate supplementation (72%) and malaria prevention (86%). Coverage for specific interventions was generally much lower among all pregnant women (reflecting population effective coverage) than among only those who had received ANC 4+ visits. Although ANC 4+ and average coverage across the elements of care correlated relatively well (Pearson r(2) = 0.56), most countries had lower average coverage for the content of care than for ANC 4+ (among all pregnant women).

Conclusion: We argue for the adoption of a summary indicator that better reflects the content of antenatal care than does the current ANC 4+ indicator. We propose, as an alternative, the simple average of a set of ANC content indicators available through surveys and routine health information systems.

FIGURE.

Coverage for Key ANC Services Among Pregnant Women With 4+ ANC Visits,a Across 41 Demographic and Health Surveys ^a Self-reported receipt of services among women delivering during the 2 years preceding the survey and reporting 4+ ANC visits. Abbreviations: ANC, antenatal care; ANC<4mo, first antenatal care visit before 4 months gestation; BP, blood pressure; DSs, counseled on pregnancy danger signs; HIV, HIV counseling and testing; IFA, iron–folic acid supplementation for 90+ days; SP2+, at least 2 doses of sulfadoxine/pyramethamine for malaria prevention; TT2+, protected against tetanus; Ur, urine specimen taken. The horizontal line in the middle of each solid box indicates the median; the top and bottom borders of the box mark the 75th and 25th percentiles, respectively. The “whiskers,” or lines, below and above the box mark the minimum and maximum values, respectively. Numbers in parentheses in the x-axis refer to the number of surveys providing data for that particular indicator.