Abstract
BackgroundAntenatal care (ANC) is one of the recommended interventions to reduce maternal and neonatal mortality. Yet in most Sub-Saharan African countries, high rates of ANC coverage coexist with high maternal and neonatal mortality. This disconnect has fueled calls to focus on the quality of ANC services. However, little conceptual or empirical work exists on the measurement of ANC quality at health facilities in low-income countries. We developed a classification tool and assessed the level of ANC service provision at health facilities in Zambia on a national scale and compared this to the quality of ANC received by expectant mothers.MethodsWe analysed two national datasets with detailed antenatal provider and user information, the 2005 Zambia Health Facility Census and the 2007 Zambia Demographic and Health Survey (DHS), to describe the level of ANC service provision at 1,299 antenatal facilities in 2005 and the quality of ANC received by 4,148 mothers between 2002 and 2007.ResultsWe found that only 45 antenatal facilities (3%) fulfilled our developed criteria for optimum ANC service, while 47% of facilities provided adequate service, and the remaining 50% offered inadequate service. Although 94% of mothers reported at least one ANC visit with a skilled health worker and 60% attended at least four visits, only 29% of mothers received good quality ANC, and only 8% of mothers received good quality ANC and attended in the first trimester.ConclusionsDHS data can be used to monitor “effective ANC coverage” which can be far below ANC coverage as estimated by current indicators. This “quality gap” indicates missed opportunities at ANC for delivering effective interventions. Evaluating the level of ANC provision at health facilities is an efficient way to detect where deficiencies are located in the system and could serve as a monitoring tool to evaluate country progress.
Highlights
Antenatal care (ANC) is one of the recommended interventions to reduce maternal and neonatal mortality
Drawing upon two national datasets with detailed provider and user information, the Zambia 2005 Health Facility Census (HFC) and the Zambia 2007 Demographic and Health Survey (DHS), we demonstrated that ANC attendance in Zambia was high, insufficient provision of important antenatal screening tests and interventions were limiting the level of ANC delivered, which was reflected in the high proportion of women not receiving good quality ANC
This is the first study to present data on ANC quality at health facilities on a national scale and the first to develop a tool for classifying the level of ANC service provision in health facilities in low-income settings that includes several quality dimensions
Summary
Antenatal care (ANC) is one of the recommended interventions to reduce maternal and neonatal mortality. In most Sub-Saharan African countries, high rates of ANC coverage coexist with high maternal and neonatal mortality This disconnect has fueled calls to focus on the quality of ANC services. In Zambia, for example, 94% of women attend ANC at least once, while maternal mortality is estimated at 591 maternal deaths per 100,000 live births, and neonatal mortality at 34 neonatal deaths per 1,000 live births [15] This weak relationship between ANC use and maternal and newborn survival has motivated a recent call to focus on content and quality of care provided rather than mere ANC attendance as we aim at achieving MDG 4 and MDG 5 [16]. Researchers frequently highlight the importance of quality of maternal care in improving maternal and newborn health [17,18,19], the quality of ANC remains insufficiently studied
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