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

Abstract

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.

Figure 1

Antenatal care quality in 91 low-income and middle-income countries Non-coloured regions had no data available or were not relevant to this analysis. Antenatal care quality is defined as the proportion of women who report blood pressure monitoring and urine and blood testing at any point during the pregnancy among those who had at least one visit with a skilled provider.

Figure 2

Antenatal care quality and coverage by GDP per capita in 91 low-income and middle-income countries Countries are represented with International Organization for Standardization country codes. Antenatal care quality is defined as the proportion of women who report blood pressure monitoring and urine and blood testing at any point during the pregnancy among those who had at least one visit with a skilled antenatal care provider. Antenatal care coverage is defined as the proportion of women with at least one livebirth in the past 2 or 5 years who had at least one visit with a skilled provider. GDP=gross domestic product.

Figure 3

Slope and relative indices of inequality in antenatal care quality by country income group Dots represent country-specific point estimates of the slope and relative indices of inequality in antenatal care quality. Countries at the extremes of the scales are named. Shaded boxes represent the IQR of inequality across countries and horizontal lines delineate the median. Country-specific estimates and confidence intervals are shown in the appendix.

Figure 4

Antenatal care coverage, quality, and equity in 91 low-income and middle-income countries Countries are ranked by level of antenatal care coverage. Dark green indicates high coverage and equity (ie, smaller inequalities) and red indicates low coverage and equity (ie, greater inequalities). DHS=Demographic and Health Surveys. MICS=Multiple Indicator Cluster Surveys. SII=slope index of inequality. *Recall period is limited to 2 years in MICS and to 5 years in DHS. †Antenatal care coverage is defined as the proportion of women with at least one livebirth in the past 2 or 5 years who had at least one visit with a skilled provider. ‡Antenatal care quality is defined as the proportion of women who report blood pressure monitoring and urine and blood testing at any point during the pregnancy among those who had at least one visit with a skilled antenatal care provider.