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What matters to women: a systematic scoping review to identify the processes and outcomes of antenatal care provision that are important to healthy pregnant women.
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Mar 2016
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Abstract
Global uptake of antenatal care (ANC) varies widely and is influenced by the value women place on the service they receive. Identifying outcomes that matter to pregnant women could inform service design and improve uptake and effectiveness.
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Why Do Women Not Use Antenatal Services in Low- and Middle-Income Countries? A Meta-Synthesis of Qualitative Studies
Kenneth Finlayson, Soo Downe (2013)
Introduction Recent estimates of global maternal mortality ratios (MMRs) suggest a substantial decline in recent years [1],[2]. However, current rates of decline will still fall well short of meeting Millennium Development Goal 5 (MDG 5): reducing maternal mortality by 75% by 2015 [3]. Data from the World Health Organization (WHO) indicate that in many low- and middle-income countries (LMICs), especially in sub-Saharan Africa, the rate of decline in MMR is less than 1% per year, and in some countries (e.g., South Africa, Nigeria, Mozambique, and Swaziland) rates even appear to be increasing [1],[4]. This slow rate of progress is starkly highlighted in the most recent “Countdown to 2015” report, which found that only nine of the 74 countries with the highest MMRs in the world were on target to achieve MDG 5 [5]. WHO reports and experts in the field consistently highlight the lack of access to local, adequately resourced health care facilities as an important reason for the relatively slow rate of progress towards achieving MDG 5 [6],[7]. Access includes ensuring comprehensive antenatal care coverage for all pregnant women. Recent estimates indicate that the number of women in LMICs attending at least one antenatal appointment increased from 64% in 1990 to 81% in 2009, and those attending four or more times rose from 35% to 51% over the same period [2]. However, major disparities exist within and between continents, between countries, and between urban and rural populations [8]. As with the MMR figures, the rate of progress is slowest in sub-Saharan Africa, where antenatal coverage rates have improved slightly during the last two decades, but the number of women visiting four or more times has remained static, at about 44% [2]. Although the correlation between “inadequate” antenatal care and high maternal mortality is complicated and contentious, it is widely accepted that antenatal care presents opportunities to identify pregnancy risks and, in a broader sense, to monitor and support the general health care of women who may be susceptible to a range of potentially fatal pathologies including HIV, anaemia, malnutrition, tuberculosis, and malaria [5]–[9]. Global implementation of strategies designed to encourage antenatal attendance tend to be based on the assumption that if high-quality services are provided, people will come to them. However, data from quantitative population-level studies suggest that this is not necessarily the case for some groups of pregnant women. Well-documented socio-demographic data indicate that women from relatively poor backgrounds, living in rural areas, and/or with low levels of education are less likely to access antenatal services, even if they are provided [10]–[12]. Other factors, including having a husband with a low level of education, living a long distance from a clinic, and having high parity, have also been identified as barriers [13]–[17]. Similar factors emerge in reviews of barriers to antenatal care in developed countries [18]–[21], which suggests that the issues for women who remain marginalised at local, national, and global levels are much the same. Based on the results of a WHO antenatal care randomised trial [22], the standard measure of adequate antenatal care delivery is a minimum of four antenatal visits (with the first occurring during the first trimester) for a woman and her foetus, if they are judged to be healthy following a standard risk assessment [23]. Although some authorities, e.g., the US Agency for International Development, have noted the need for woman-centred, individualised, culturally specific programmes [24], the recent BMJ Best Practice guidance on routine antenatal care provision lists a wide range of routine screening, testing, and health education topics, with little emphasis on individual concerns and circumstances [25]. Evidence equating risk-focused, low-frequency antenatal care with clinical outcomes in LMICs is limited, but a recent Cochrane review found that population groups in LMICs receiving fewer antenatal visits (4–6) had an increased risk of perinatal mortality and, in particular, stillbirth [26]. The author of a WHO commentary on this review hypothesizes that the excess perinatal loss for women in LMIC settings may be due to inadequate local tailoring of risk assessment, low numbers of staff, and inadequate training [27]. The WHO manual on antenatal care [23] does not specify how antenatal care should be funded, the nature and relevance of staff attitude and training, or what resources should be available at which level of care provision. However, tacit assumptions are likely to include that staff are available and have high levels of communication and interpersonal skills, and that the programme is affordable, otherwise it would be unlikely to function. Despite the findings of the review, and speculation about the components and the effectiveness of the WHO programme, it remains the standard for adequate antenatal care provision. Given the potential significance of context in mediating whether women access antenatal care, qualitative studies may provide fresh insights into pertinent issues in specific settings. In terms of LMICs, such studies suggest that some women do not attend antenatal facilities because of deeply held cultural beliefs and/or tribal traditions surrounding the nature of pregnancy and childbirth [28],[29]. Qualitative studies can also illuminate the effect of local policies and incentives, such as the use of antenatal clinic cards to guarantee intra-partum hospital access—a controversial practice in a number of African countries because of the potential for discrimination against women who don't have any record of antenatal clinic attendance [30]. However, because of the highly contextualised nature of individual qualitative studies, policy makers often overlook them, and their findings remain outside of global, national, and local health care strategies [31]. Systematic review and synthesis of qualitative studies can generate hypotheses about how successful programmes work, and why unsuccessful programmes fail certain individuals and groups [32]. To address the latter question with regards to inadequate accessing of antenatal care, we planned to locate, analyse, and synthesise qualitative studies exploring the views, beliefs, and experiences of women from LMICs who did not access antenatal care at all, or accessed it inadequately, according to the WHO definition given above. The intention was to develop hypotheses about lack of attendance that could inform policy development, based on a new understanding of why some women still don't access antenatal care, even when it is made available. Qualitative Meta-Synthesis Methodology The emphasis in meta-synthesis is on rigorous study selection and the careful interpretation of data across studies, contexts, and populations. This combination and interpretation of findings from a number of systematically selected studies in a particular subject area shares methodological similarities with its quantitative equivalent, meta-analysis. When meta-synthesis is used to explain or interpret existing knowledge, e.g., alongside meta-analysis, it can be aggregative and deductive [32]. However, when it is exploring fields where there is little prior information, it is undertaken as an inductive method, designed to generate theoretical insights and hypotheses that can be tested in future research [32]. In the latter case, the classic approach is meta-ethnography [33]. As with qualitative research, the direct findings of meta-synthesis are not usually generalisable, but the theoretical insights or hypotheses arising from the synthesis of the included studies should be transferable to other similar settings and contexts [34]–[36]. In meta-synthesis, as in grounded theory, the comprehensiveness of the analysis is determined by the concept of theoretical saturation. Theoretical saturation is reached when new studies do not change the emerging theory or hypothesis, and when a systematic search for disconfirming cases in all the included studies reinforces the theoretical insights. Given the scope and rigour of meta-synthesis reviews, there is greater potential for them to inform practice, influence policy, and underpin strategy than for individual qualitative studies [37],[38]. Methods Search Strategy and Selection Criteria The search strategy was designed to locate qualitative studies exploring the antenatal care experiences, attitudes, and/or beliefs of women from LMICs who had chosen to access antenatal care late (after 12 wk gestation), infrequently (less than four times), or not at all [7]. We searched for any studies that might include qualitative data, including survey-based studies with open-ended written responses, mixed methods studies, focus groups, and one-to-one interviews. No language restriction was imposed. All electronic searches used keywords covering the main search domains including “antenatal”, “prenatal”, “maternity”, “pregnancy”, “care”, “service”, “provision”, “access”, and “attendance”. The searches were conducted across a range of medical, sociological, and psychological databases (MEDLINE, Embase, PubMed, AMED [Allied and Complementary Medicine Database], BNI [British Nursing Index], CINAHL [Cumulative Index to Nursing and Allied Health Literature], PsycINFO, Wilson Social Science Abstracts), as well as continent-specific databases such as Latindex (Literatura Latino-Americana e do Caribe em Ciências da Saúde) for South American publications and AJOL (African Journals Online) for articles published in Africa. Where possible, we sought to narrow the search to LMICs by incorporating the World Bank's list of low- and middle-income economies in the search terms [39]. Some specific papers were recommended by colleagues, and we hand-searched relevant journals in the departmental and university libraries. Other articles were obtained from reference lists published in identified studies. The initial search included papers published between 1 January 1980 and 31 March 2011. An updated search was completed on 14–15 February 2012, after which the contents pages of relevant journals were reviewed (via Zetoc) as they were published. These updated searches have provided a means to check that the thematic structure and synthesis developed in the primary analysis continue to hold true as new studies are published (“theoretical saturation”). Both authors reviewed all of the included papers independently, and then reached a final agreement on inclusion by consensus. All of the papers meeting our eligibility criteria were assessed for quality using an appropriate published tool [40]. This tool incorporates a pragmatic grading system [41] and uses an A–D scoring system. The authors determined grades by consensus, and studies scoring C+ or higher were included in the final review (see Table S1). Analysis and Synthesis Our intention was to generate new theoretical insights that could form the basis for hypothesis testing in the future, so we used the meta-ethnographic approach developed by Noblit and Hare [33]. This approach has been used successfully in meta-synthesis studies related to several different health care settings [19],[35],[42]–[44]. It is not restricted to ethnographic studies, as the approach can incorporate the full range of qualitative methods. We began by identifying the findings from one paper and comparing them with the findings from another, to generate a “long list” of emerging concepts. These early concepts were then examined to identify similarities, in a process that is termed “reciprocal translation”. During this process, some concepts were collapsed together to create a parsimonious thematic structure. Each author then reviewed the themes independently to ensure there were no data that were at odds with our analysis and that no data remained unexplained. This stage of the process is analogous to searching for discomfirming data and is termed “refutational translation” in meta-ethnographic studies [33]. The themes were then synthesised into a “line of argument” synthesis—a phrase or statement that summarises the main findings of the study and the theoretical insights that they generate. This synthesis was then used to create a hypothetical model to explain why women fail to make adequate use of antenatal services in LMICs. Reflexive Accounting In qualitative research, the researcher is the instrument of measurement, and the final analysis is a product of the interaction between the researcher and the data. Reflexive accounting allows the reader of the final research product to assess the degree to which the prior views and experiences of the researchers may have influenced design, data collection, and data interpretation in any specific study. In this case, S. D. believed that interpersonal relationships were likely to be critical in mediating antenatal care use, and K. F. believed that whether women accessed care was most likely to be influenced by personal and/or localised socio-economic circumstances. To minimise the effect of these beliefs, both authors were particularly rigorous in looking for refutational data in these specific areas as the analysis progressed. Results Our search to 31 March 2011 generated a total of 3,622 hits, including 625 duplicates, which were removed at this stage. Of the remaining 2,997 articles, 2,892 were excluded by title and abstract because they failed to address the initial selection criteria. Most of the studies removed at this stage were excluded for one of three reasons: (1) they were conducted in high-income countries, (2) they were obviously quantitative, or (3) they were not about access to antenatal care. Of the remaining 105 papers, a further 75 were removed after independent full text review by the authors, largely because they lacked sufficient qualitative data (n = 36), were based on the experiences of women who attended antenatal services regularly rather those who didn't (n = 25), reflected the views of service providers rather than the women attending care (n = 8), or were concerned with access to health care generally as opposed to antenatal care specifically (n = 6). This left 30 papers that were taken forward for quality assessment. Following independent review, the authors agreed that nine studies failed to meet the quality requirements, leaving 21 that were taken forward for analysis and synthesis (see Figure 1 for details of the selection process). Of the nine studies excluded, three were mixed methods studies with very limited qualitative data, two reported on the views of health care providers with little emphasis on the responses of service users, two presented qualitative information in a quantitative format (frequency of responses), and two failed to meet the quality criteria for design, methodology, and/or analysis. Only one study meeting the inclusion and quality criteria was identified by the updated searches since 31 March 2011 [45], and this was used to check the explanatory power of the final thematic structure, synthesis, and interpretation. 10.1371/journal.pmed.1001373.g001 Figure 1 Flow chart summarising search strategy. Description of the Studies The 21 papers in the final full synthesis represent the views of women from 15 countries (Bangladesh [×2], Benin, Cambodia, Gambia, India, Indonesia, Kenya, Lebanon, Mexico, Mozambique, Nepal, Pakistan, South Africa [×4], Tanzania [×2], and Uganda [×2]) and include data from more than 1,239 participants (minimum 10, maximum 240) who were either interviewed directly or gave their opinion as part of a focus group (see Table S1 for full details of the included studies). Two of the studies utilised a mixed methods approach, and although these studies contained limited qualitative information, the narrative data were pertinent and reasonably well reported. Ten of the 21 studies were conducted in a rural setting, three took place in an exclusively urban environment, and the remaining eight involved both urban and rural settings. The earliest paper was published in 1992 and the most recent in 2011, with the majority (n = 17) being published within the last ten years. More than half of the included papers (n = 12) were published within the last three years, which suggests an upswing in interest in this area of research (see Table 1 for a summary of included papers). 10.1371/journal.pmed.1001373.t001 Table 1 Summary of included studies. Authors [Reference] Year of Publication Country Location—Type of Region Number of Participants Method Used Quality Grading Abrahams et al. [46] 2001 South Africa Cape Town—semi-urban 32 Interviews C+ Myer and Harrison [47] 2003 South Africa Hlabisa district—rural 29 Interviews B Pretorius and Greeff [48] 2004 South Africa Mafikeng-Mmbatho districts—rural 18 Interviews C+ Mrisho et al. [49] 2009 Tanzania Lindi and Tandahimba districts—rural 58 Focus groups B Matsuoka et al. [50] 2010 Cambodia Kampong and Cham provinces—rural 66 Interviews and focus groups B Choudhury and Ahmed [51] 2011 Bangladesh Rangpur and Kurigram districts—rural 20 Interviews C+ Chapman [52] 2003 Mozambique Vila-Gondola—semi-urban 83 Interviews A Grossmann-Kendall et al. [53] 2001 Benin Cotonou and Ouidah districts—urban and rural 19 Interviews C+ Ndyomugyenyi et al. [54] 1998 Uganda Kigorobya sub-country—rural 80–120a Focus groups C+ Gcaba and Brookes [55] 1992 South Africa Durban—urban 10 Interviews B Atuyambe et al. [56] 2009 Uganda Wakiso district—rural 92 Focus groups B Stokes et al. [57] 2008 Gambia Kiang West district—rural 83 Interviews and focus groups C+ Griffiths and Stephenson [58] 2001 India Pune and Mumbai—mix of urban and rural at each location 45 Interviews B Simkhada et al. [59] 2010 Nepal Kathmandu area—semi-urban and rural 30 Interviews B Titaley et al. [60] 2010 Indonesia Garut, Sukabumi, and Ciamis districts, West Java—semi-urban and rural 119 Interviews and focus groups B Family Care International [61] 2003 Kenya Homabay and Migori districts—mix of urban and rural in each 27–47a Interviews and focus groups B Tinoco-Ojanguren et al. [62] 2008 Mexico Chiapas—mix of urban and rural 16 Interviews C+ Mumtaz and Salway [63] 2007 Pakistan Punjab—rural 39–55a Interviews and focus groups B Chowdhury et al. [64] 2003 Bangladesh Dhaka and Upazila—urban and rural 16 Interviews B Mubyazi et al. [65] 2010 Tanzania Mkuranaga and Mufinidi districts—both rural 240 Interviews and focus groups B+ Kabakian-Khasholian et al. [66] 2000 Lebanon Bekaa, Akkar, and Beirut—rural, semi-rural, and urban 117 Interviews C+ a A range is given for these studies, as the authors list the number of focus groups conducted, with a minimum and maximum number of participants; e.g., ten focus groups with 8–12 participants. Description of the Themes The emerging concepts and themes are summarised in Table 2. We identified a total of seven emerging themes and three final themes (summarised below), two of which relate specifically to initial attendance at antenatal facilities, and a further, service-oriented, theme relating to maintaining attendance. 10.1371/journal.pmed.1001373.t002 Table 2 Summary of themes. Initial Concepts (Findings from Primary Papers) Relevant Papers (References) Emerging Themes Final Themes Awareness of signs/symptoms of pregnancy 46–51 Pregnancy awareness and disclosure—awareness of signs and symptoms of pregnancy; cultural reasons for keeping pregnancy secret Pregnancy as socially contingent and physiologically healthy—pregnancy as a normal life event—only attend antenatal care when sick; lack of awareness of pregnancy indicators; lack of understanding of antenatal care benefits; embarrassment; cultural and supernatural implications of pregnancy disclosure; preference for traditional healers and medicines (including cost savings) Cultural reasons for keeping pregnancy secret 46,48,49,52–57 Don't recognise/understand Western approaches to health care 46,47,54,56,58,60 Resistance to risk-averse care models—don't recognise/understand Western approaches to health care; lack of perceived benefits; pregnancy as a normal life event; reliance on traditional/alternative antenatal practices; influence of family members Lack of perceived benefits of attendance 46–48,51,56,58,59,62–64 Pregnancy as a normal life event 46,50–54,56,58–61,66 Reliance on traditional/alternative antenatal practices 50,52,54,58,60–62 Influence of family members 50,51,62–64 Costs (direct and indirect) 46,49,50–56,58–66 Prioritising limited resources for basic survival—costs (direct and indirect); laziness Resource use and survival in conditions of extreme poverty—costs (direct and indirect), transport, and distance; time off work and child care—may be made to wait several hours; inadequate infrastructure (especially in rural areas); potential for accident/attack en route Laziness 46,47,49,62 Lack of transport and distance to clinic 46,48,50,54–56,58,60,65 Difficult and dangerous travel —lack of transport and distance to clinic; inadequate infrastructure Inadequate infrastructure 48,49,55,58,60–62,64 Lack of staff/medicine/care at clinic 49,50,54,56,58,65 Attending clinics is not worth the effort—lack of staff/medicine/care at clinic; waiting times at clinic Not getting it right the first time—poor staff attitude; inflexibility of antenatal care services; issuing of cards for delivery at a hospital (women don't return) and staff giving card holders preferential treatment; few, poorly trained staff; lack of facilities; lack of medicines Waiting times at clinic 46,48–50,52, Attendance only to get a card (for hospital delivery) 46,47,50,52,61 Locally determined rules of access—attendance only to get a card; inflexible booking systems Inflexible booking systems 46,63 Poor staff attitude 46,48–51,53,55–57,62,65,66 Insensitivity, disrespect, and abuse —poor staff attitude; embarrassment Embarrassment (about examination or inability to pay) 46,49,56,65, Theme One: Pregnancy as Socially Contingent and Physiologically Healthy This theme incorporates two concepts (highlighted below) that emphasise some of the cultural and contextual nuances associated with pregnancy. Many women in these studies described pregnancy as a healthy physical state and saw little reason to visit health professionals when there was no perceived threat to their well-being. In some cultures this reluctance to engage with antenatal services was further compounded by a belief that pregnancy disclosure could lead to unwanted religious or spiritual complications. Pregnancy awareness and disclosure: “It's better to wait, to see if you really are pregnant” For many respondents, traditional or cultural beliefs dictated that they should wait until they had missed several periods before confirming a pregnancy [46]–[51]. Sometimes it's difficult to tell that you are pregnant. Some people have irregular periods, they miss periods for months only to find they are not pregnant, so it is better to wait, to see if you are really pregnant. [Pregnant woman, rural South Africa] [47] This belief limited early accessing of care. Even when women suspected they were pregnant, the motivation to visit an antenatal clinic was often superseded by cultural and superstitious beliefs about pregnancy disclosure [52]–[63]. In rural Pakistan, the shame (sharam) associated with pregnancy, because of the obvious relationship with sexual activity, meant women were less willing to be seen in public places [63]. The shame of being pregnant and the subsequent reluctance to be seen in public was also a factor for pregnant teenagers in Uganda [56]. In other parts of Africa and South East Asia, the potential to be “cursed” by evil spirits or jealous or vindictive contemporaries had a detrimental effect on pregnancy disclosure [52],[53],[55],[64]. One South African woman who had recently experienced a neonatal death explained her loss in the following manner: I think my boyfriend's previous girlfriends were jealous of my pregnancy and they bewitched me. [55] These kinds of beliefs appeared to be relatively common in rural communities and discouraged women from visiting public places, especially antenatal clinics, where a visit would be perceived as a public declaration of pregnancy. Resistance to risk-averse care models: “What is the point in going for a check-up in a healthy condition?” In many of the studies, women reported that they didn't feel the need to seek professional care when there was nothing wrong with their pregnancy [46]–[49],[52]–[54],[58],[63],[64]. As no-one expects to be sick during pregnancy, visiting the centre for a check-up is not necessary. What is the point in going for a check-up in a healthy condition? [Non-user of antenatal care services, rural Bangladesh] [64] Pregnancy was viewed as a normal life event rather than a medical condition requiring professional monitoring and supervision. This was especially true for multiparous women who had experienced one or more healthy pregnancies [50],[54],[58]. If a woman has always delivered well, she does not see the need for antenatal care attendance or visiting the health unit to deliver. [Pregnant woman, rural Uganda] [54] In some hierarchical cultures the decision to engage with antenatal services was made by tribal elders, husbands, mothers-in-law, or senior family members rather than the women themselves [50],[56],[59],[62]–[64]. Findings from a Nepalese study highlight the central role played by the mother-in-law when it came to making decisions about whether to go for antenatal care. My mother-in-law doesn't help. It might be due to her past experiences. She used to do all the work by herself during her time of pregnancy, so she wants me to do the same. I have lots of work here at home so I don't go for [antenatal care] check-ups. [Non-user of antenatal care services, rural Nepal] [59] Theme Two: Resource Use and Survival in Conditions of Extreme Poverty All of the studies were conducted in populations affected by poverty, and our findings suggest that, in such circumstances, limited personal resources were often directed towards immediate survival needs rather than specific pregnancy-related concerns. Even when antenatal care was offered free of charge, the cost of transport (sometimes across difficult or dangerous terrain), the loss of women's labour to the family, and the possibility of having to pay for additional medicines rendered attendance impossible. Using resources for health care or basic survival: “If there is no money, we can't go” In virtually all of the identified studies [46],[49],[50]–[56],[58]–[66], the costs (both direct and indirect) of visiting antenatal facilities were viewed as a significant factor in restricting or inhibiting access to antenatal care: It is good to go to the doctor during pregnancy, but if there is no money we can't go. I wanted to go but I didn't have the money to pay. [Limited user of antenatal care services, Mumbai, India] [58] Even in countries offering free access to antenatal care, the unanticipated costs of paying for drugs, tests, and medical cards placed an additional strain on limited family finances. The reason I did not go back there [to the antenatal clinic] is because my husband only buys what he wants when he is given the prescription. For example, when there are three things prescribed he buys only two. So, why should I take the trouble to go there for nothing? If I go to the clinic every month, he will just ask how much I think he earns to be able to buy so many medications for me. [Limited user of antenatal care services, Benin] [53] The indirect costs of getting to and from antenatal facilities were highlighted consistently in the included studies, especially those conducted in rural areas [46],[48],[50],[54]–[56],[58],[60]. The prohibitive costs of taxi and bus fares prevented some women from visiting antenatal clinics, and, in cases of extreme poverty, even the most basic forms of transport came at an unaffordable price. When I was pregnant what prevented me from seeking healthcare was lack of transport money because my legs were a problem. I used to live far away in the hills and I could not ask anyone to take me on a bicycle because I would be asked for money. [Adolescent limited user of antenatal care services, rural Uganda] [56] Some of the respondents' accounts indicated that the need for women to contribute to relatively meagre household resources was more than simply a useful contribution. It was perceived to be crucial for survival, especially at significant times in the farming cycle: When I had a third pregnancy, it was harvest season. So I wanted to help my husband, even during the pregnancy. [Non-user of antenatal care services, rural Cambodia] [50] Difficult and dangerous travel: “It is so far and the road condition is too bad” Many of the studies included in this synthesis were conducted in predominantly rural areas with relatively basic transport networks. For pregnant women living in towns and villages without community health care facilities, the need to journey to distant locations to receive antenatal care presented travelling difficulties, which they were unwilling or unable to overcome [46],[47],[50],[52],[58],[60],[62]. I never visited the health centre to check my pregnancy because it is so far and the road condition is too bad. [Non-user of antenatal care services, rural Cambodia] [50] Even in situations where women were prepared to make lengthy journeys on foot, sometimes walking for three to four hours, the associated risks and challenges occasionally prevented them from doing so. In parts of Africa, the prospect of being attacked by wild animals or aggressive men deterred women from making these journeys, whilst in South East Asia, the deterioration of the roads during the rainy season had a similar detrimental effect. This suggests that the barriers were not just nonexistent or expensive transportation, or inadequate roads, but also the fear of physical harm, which outweighed any benefits that might be gained from antenatal care: It is really hard when it is raining. We are afraid we will fall over because the road is so slippery and we are pregnant. The health centre is far and you can see that the road is poor. [Limited user of antenatal care services, West Java, Indonesia] [60] Theme Three: Not Getting It Right the First Time Given the very real and critical issues of how women perceive pregnancy, and of the economic and physical sacrifice needed from the woman and her family to get her to a central antenatal clinic, it is crucial that the services she receives when she gets there are “fit for purpose”, and that the benefits are perceived to outweigh potential harms. Unfortunately, for many of the women included in this review, this was not the case. Attending clinics is not worth the effort: “It's better to go to the TBA [traditional birth attendant]” The relatively poor economic circumstances of the countries included in this study meant that clinics were often severely under-resourced. Pregnant women who initially recognised the benefits of antenatal care and who made the often significant financial and personal sacrifices to visit health care facilities were often disappointed by the lack of resources they found when they finally got there. As a consequence, they made the decision not to return [48]–[50],[54],[56],[58],[65]. I don't visit the health centre for antenatal care because the health centre doesn't have enough medical equipment. When we have a problem, all they will probably do is refer us to the referral hospital…. [Non-user of antenatal care services, rural Cambodia] [50] The amount of time women had to wait to be seen by health professionals, especially after long and difficult journeys, was a common cause of complaint and discouraged some of them from attending again [46],[48],[49],[52],[54],[65]. Pregnant women also complained about the cursory nature of consultations in understaffed clinics and made the decision to revert to more traditional forms of antenatal care. They just touch your abdomen, it's better to go to the TBA [traditional birth attendant] because the TBA examines the mother and tells her how the baby is lying in her stomach. [Pregnant woman, rural Uganda] [54] Locally determined rules of access: “If you do not have a card, they will not accept you” Our findings suggest that in a number of cases, particularly in sub-Saharan Africa, the practice of giving antenatal cards to women attending the clinic is being poorly managed and is having a detrimental effect on continued access. Some health care providers use the clinic card as “a passport” and refuse to admit labouring women to a clinic or hospital if they do not have one [46],[49],[52],[53],[65]. This kind of negative reinforcement has created a situation in which pregnant women visit an antenatal facility only once—to get a “clinic card”. I am just afraid of being denied services when I need them, so one must just go [to antenatal care] to get the [clinic] card. If you do not have a card, they will not accept you when there is a problem…otherwise we could just rest at home. [Woman in ninth month of pregnancy, rural Tanzania] [65] Disrespect and abuse: “They don't care for patients” One of the most common reasons given for delaying or restricting antenatal visits was the poor attitude of staff at health care facilities [46],[48],[50],[51],[53],[56],[62],[63],[65],[66]. Findings from countries in Africa, Asia, and South America highlight insensitivity, rudeness, humiliation, neglect, abuse, and even physical violence by health centre staff as key factors in limiting women's accessing of antenatal care. Sometimes the poor attitude of health care providers was described by what they failed to do, as recounted by a young woman in Uganda: They [health care workers at an antenatal clinic] don't care for patients, for example when you go in the morning they will ask you “at your home don't you sleep”. When you go at lunch time they will ask you whether at your place you don't take lunch. And when you go in the evening they will tell you they have closed up. [56] Authors also reported that women felt intimidated because of the potential for abuse: When you see the health agent yelling at women who are not feeling well, you are afraid of telling them what is wrong with you too…. [Pregnant woman, Benin] [53] In other contexts, women recounted being punished or humiliated because of some perceived minor misdemeanour: If you arrive late at the clinic, the staff rebukes and punishes you with a fine or they order you to clean the floor or sweep the surroundings. [Limited user of antenatal care services, rural Tanzania] [65] In all of these examples, women reported feeling reluctant to return for another appointment, and some reverted to more traditional forms of antenatal care as a consequence. Line-of-Argument Synthesis Antenatal care provision that is based on a concept of pregnancy as a potentially risky biomedical state, and that, as a consequence, provides mechanisms focused mainly on surveillance in more or less centralised locations, is contextually at odds with the theories, beliefs, and socio-economic situations of pregnant women and their families in a range of LMICs. This situation is compounded when accessing services presents additional risks to women and their families, in terms of lost labour or income, or physical danger; when the promised care is not delivered because of resource constraints; and when women experience covert or overt abuse in care settings. Hypothesis Based on the Findings Following the claim by Pawson [67] that “programmes are theory incarnate”, our data can illuminate the potential inconsistencies between theories underpinning antenatal care programmes based on the WHO antenatal care model [23] and the themes that underpin the beliefs, actions, and experiences (the local context) of those to whom these programmes are targeted (see Figure 2). We hypothesize that the dissonance between these two frames of reference might explain the lack of initial attendance at antenatal clinics, as described in the first row of Figure 2. The second row of the figure illustrates a second misalignment, this time between the principles assumed to underpin antenatal care provision, and the experiences of women who use them. We hypothesize that this misalignment may explain the lack of return visits for antenatal care after the first encounter. 10.1371/journal.pmed.1001373.g002 Figure 2 Hypothetical model of inadequate access to antenatal care in low and middle income countries. Testing for Theoretical Saturation The data from the one paper [45] we identified after the end of our formal search phase in March 2011 can be incorporated into our explanatory model, suggesting theoretical saturation. We would argue that future studies should therefore focus on testing our hypothesis, and designing specific solutions to the problem of inadequate attendance building on this summary of all the relevant qualitative data to date. This approach would avoid the problem of “analytic interruptus” described by Statham in relation to the continual reproduction of single-site qualitative studies with no attempt to translate the emerging theoretical insights into action [68]. Discussion Some of the issues identified by this meta-synthesis are common to other areas of maternity care and health care in general. At the family level, these include lack of household resources, especially when faced with the problem of formal and informal payment or services [69],[70], and the problems inherent in travel to centralised health care services [46],[51]–[54],[71]. Restricted autonomy for women has been identified as a factor underpinning inability to make personal decisions about health service use [72], and this factor is one of the underlying elements of the “three delays” hypothesis relating to lack of accessing of emergency care in labour [73]. There is also an increasing recognition of the problem of human rights abuses in health care in general [74]–[76]. From a theoretical perspective our findings suggest the hypothesis that, in certain contexts, there may be a misalignment between the theories that underpin the provision of antenatal care and the beliefs and socio-economic contexts of women who access services irregularly or not at all. The dissonance between these two frames of reference might explain the lack of initial access to antenatal care. A second disparity, this time between the nature of antenatal provision and the expectations of the women who use the services, may explain the lack of continued engagement. We are not aware of previous studies that have integrated these factors into an analysis of antenatal care use based on women's views and experiences, or that have identified pregnancy as a socially risky but physically healthy state. Minimising social stigma and risk requires care provision that is discrete and certainly not provided in public places subject to long queues for services. Strategies incorporating culturally appropriate understandings of maternity care tailored to individual communities are rare, but participatory programmes where local women and community leaders are actively engaged in the planning of local antenatal services have been shown to be effective in increasing antenatal coverage and reducing maternal and infant mortality [77]. This approach is well illustrated by a recent Cambodian study, which showed a 22% increase in antenatal attendance when service users and influential stakeholders became involved in the planning of community maternity services [78]. From a socio-economic perspective our findings suggest that, even in situations where women recognise the benefits of antenatal care and are willing, in principle, to attend, the physical barriers and even physical risks of getting to and from the clinic, coupled with the potential loss of crucial family resources, can be prohibitive. Even if services are free (with no covert point-of-care costs) and safe transport systems are provided, taking women from essential farming duties on long trips to and from central clinics might, at the extreme, still present a risk to family food supplies. In this case, the benefits of antenatal care must weigh strongly in the balance for service users before uptake will increase. Also, even where women do have a degree of personal autonomy, those who see pregnancy as a healthy state, but as socially risky, are still unlikely to value and attend programmes that expose their pregnant state, and that are largely focused on identifying and averting risk. This is especially pertinent when both the direct and opportunity costs are high, travel to central locations is difficult and dangerous, and the services they receive are of poor quality and overtly or covertly abusive. Projects designed to incentivise pregnant women to attend antenatal care have been implemented successfully in some LMICs. The Janani Suraksha Yojana cash transfer programme in India, where women are paid a small amount to attend antenatal care and give birth in a recognised health care facility, has had a significant effect on antenatal attendance and subsequent levels of neonatal and perinatal mortality [79]. An alternative, transport-based project in eastern Uganda, where local motorcycle riders were contracted to take women to and from antenatal clinics throughout their pregnancy, also showed a significant increase in antenatal attendance [80]. However, doubts remain about the practicality and sustainability of these kinds of initiatives, and, as our findings illustrate, many pregnant women remain unconvinced by the focus and quality of antenatal programmes, and seem unlikely to make full use of antenatal facilities unless care quality is improved. Given that data were not available from every region of every LMIC, it is possible that our line-of-argument synthesis, and our model, do not apply to all contexts in which antenatal care is underused. However, the comprehensiveness of our analysis is reinforced by evidence of theoretical saturation, both from our refutational analysis, and from the paper [45] published after the end of our formal search phase in March 2011. Our hypothetical model can explain the findings of this study, including the influence of cultural beliefs and lack of respect from health care professionals. In addition, the findings of the meta-synthesis are similar to those of a parallel review of women's accounts of non-accessing or limited accessing of antenatal care in resource-rich countries [19]. Given the range of countries that were represented in the meta-synthesis, and the date range of the publications (over nearly two decades), the issues seem to be universal and persistent. We hope that our synthesis illustrates the need to move from small repeated studies of the same problem in local contexts towards a more comprehensive understanding of the potential dissonance between context and service delivery mechanism across all of these settings. A more thorough evaluation using the realist review approach could test this hypothesis, and contribute towards a more detailed understanding of this issue [81]. This could provide the basis for a new approach to the design and delivery of antenatal care, founded on a careful analysis of distinctive local beliefs, values, and resource availability. Such an approach could identify a way of moving services away from broad population-based solutions, towards new service designs based on what works, for whom, in what circumstances [81]. Conclusion Despite moderate success in reducing MMRs and increasing antenatal care coverage, the global targets associated with MDG 5 seem unlikely to be attained by 2015, especially in many LMICs. So far, practical initiatives to address these issues have tended to adopt centralised, public provision of antenatal care based on utilitarian strategies designed to minimise clinical risk. This approach benefits some women and infants, but it marginalises others, as the programme design does not take into account necessary survival decisions, beliefs, attitudes, or cultural theories that may be intrinsic to the local context. Measures designed to sustain and maintain access in LMICs are likely to be more effective when policy makers and service providers align their programmes with the theoretical and philosophical constructs and the severe practical constraints that underpin the local community context. Such programmes must ensure that, once they access services, all pregnant women are treated with dignity, respect, and compassion. If programme delivery is not aligned with local contexts in this way, the findings from this meta-synthesis suggest, even the best and most physically accessible services may remain underused by some local pregnant women. Supporting Information Table S1 Assessment of quality of included studies. (RTF) Click here for additional data file.
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Appraising the quality of qualitative research.
Soo Downe, Denis Walsh (2006)
In the process of undertaking a meta-synthesis of qualitative studies of free-standing midwife-led units, the authors of this paper encountered a number of methodologically and epistemologically unresolved issues. One of these related to the assessment of the quality of qualitative research. In an iterative approach to scoping this issue, we identified eight existing checklists and summary frameworks. Some of these publications were opinion based, and some involved a synthesis of pre-existing frameworks. None of them provide a clear map of the criteria used in all their reviewed papers, and of the commonalities and differences between them. We critically review these frameworks and conclude that, although they are epistemologically and theoretically dense, they are excessively detailed for most uses. In order to reach a workable solution to the problem of the quality assessment of qualitative research, the findings from these frameworks and checklists were mapped together. Using a technique we have termed a 'redundancy approach' to eliminate non-essential criteria, we developed our own summary framework. The final synthesis was achieved through reflexive debate and discussion. Aspects of this discussion are detailed here. The synthesis is clearly rooted in a subjectivist epistemology, which views knowledge as constructed and hermeneutic in intent, encompassing individual, cultural and structural representations of reality.
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The quality–coverage gap in antenatal care: toward better measurement of effective coverage
Stephen Hodgins, Alexis D'Agostino (2014)
INTRODUCTION The proportion of pregnant women receiving 4 or more antenatal care visits (ANC 4+) has pride of place as a global benchmark indicator, standing in as a proxy for adequacy of antenatal care (ANC). It has been used as an indicator both for Millennium Development Goal 5 (improve maternal health) 1 and for the United Nations Secretary General's Commission for Information and Accountability for Women's and Children's Health. 2 In the late 1990s, José Villar led a multicountry study, 3 under the auspices of the World Health Organization (WHO), comparing a more goal-oriented, abbreviated, 4-visit schedule with conventional ANC. Conventional ANC comprised about 12 visits (one visit each month during the first 6 months of pregnancy, once every 2–3 weeks for the next 2 months, and once a week thereafter until delivery). On most measures, there were no differences in maternal or perinatal outcomes. These findings have been the basis for adoption of the ANC 4+ indicator as a marker of receipt of adequate antenatal care. Since that time, along with skilled birth attendance, ANC 4+ has been the most frequently used summary measure of maternal health program performance. This has had the unfortunate consequence of drawing the attention of program managers away from the content and process of care and toward mere contact. But content and process of care matter. As Bhutta and colleagues have documented in their comprehensive review, 4 there is significant scope for improving health outcomes, even with a simple package of antenatal interventions that can be delivered by health auxiliaries consisting of: Tetanus toxoid Intermittent presumptive/preventive treatment of malaria Iron–folate and calcium supplementation Deworming Detection and treatment of preeclampsia, syphilis, and asymptomatic bacteriuria Counseling about essential newborn care practices (immediate and exclusive breastfeeding, clean delivery, and thermal protection) and care-seeking for institutional delivery and danger signs Focusing on the proportion of pregnant women making at least 4 antenatal visits to measure program performance has drawn the attention away from the content of care to mere contact. Clearly, it is not mere contact that results in better outcomes; it is the actual substance of care delivered. Using data from the Demographic and Health Surveys (DHS), this paper explores the extent to which the ANC 4+ indicator tells us anything useful about the substance of care and proposes an alternative indicator to measure program performance. METHODS Recent DHS data from 41 countries were analyzed, retaining information on pregnancies during the preceding 2 years for which the mother reported receiving 4 or more ANC visits. From these data, we determined the proportion of survey respondents who reported receipt of 8 specific clinical preventive services: Blood pressure measurement Full protection against tetanus First antenatal visit at less than 4 months gestation Urine testing Counseling about danger signs HIV counseling and testing Iron–folate supplementation for at least 90 days At least 2 doses of sulfadoxine/pyramethamine (SP) for presumptive/preventive malaria treatment Surveys retained for this analysis had to have values for at least 5 of these interventions of interest. Among the surveys retained, the main distinction in which data were included was the presence or absence of HIV- and malaria-related indicators. A “quality–coverage gap” was calculated for each of these services—across the 41 surveys—as the difference between expected (100%) and actual coverage. We also present additional DHS analysis on coverage for this set of services using, as the denominator, all women having a birth in the 2 years preceding the survey (regardless of the number of ANC visits received). For each country survey, a simple mean was calculated across the set of retained antenatal indicators listed above as well as the proportion of women who reported receiving all the interventions. The country surveys were conducted by MEASURE DHS, a project of the Bureau for Global Health at the U.S. Agency for International Development (USAID). All the datasets are available online at www.dhsprogram.com. Analysis was done using Stata 12.1. In line with DHS practice, women not providing a response or answering “do not know” to questions on services received were retained in the denominators for calculation of the indicators (that is, it was assumed that they did not receive those services). 5 Results from each country were calculated using the weighting and sampling information and procedures specified in the DHS datasets and documentation. RESULTS Quality of Care Among Those Receiving 4+ Visits The analysis presented in Table 1 can be considered as characterizing the quality of care received, among women who reported receiving 4 or more ANC visits. Colombia, the Dominican Republic, and Nepal performed well; average coverage across the indicators measured in those surveys was 83%–85% (a quality–coverage gap of 15%–17%). Although Nepal performed as well as the other 2 countries with regard to average coverage, a considerably smaller proportion of pregnant women in Nepal reported 4+ visits (53% versus 87% in Colombia and 96% in the Dominican Republic). Timor-Leste, Indonesia, and Lesotho were the median performers across the 41 countries, with average coverage across indicators of 58% (average quality–coverage gap of 42%). The poorest performing countries were the Democratic Republic of Congo and Burundi, with an average coverage across indicators of 32% and 36% (quality–coverage gaps of 68% and 64%, respectively). TABLE 1. Receipt of Specific Services Among Pregnant Women With 4+ ANC Visitsa (%) Survey ANC4+ ANC<4mo IFA90+ TT2+ DSs BP Ur HIV SP2+ AVG Colombia 2010 87 82 62 83 100 98 85 85 Dominican Rep 2007 96 84 66 92 70 99 97 86 85 Nepal 2011 53 72 78 97 87 94 72 83 Maldives 2009 87 93 65 86 51 97 95 81 Honduras 2005–06 79 79 73 75 68 97 79 78 Rwanda 2010 36 73 74 88 43 96 75 Peru 2007–08 88 75 17 69 84 98 81 71 India 2005–06 36 80 32 93 34 89 85 69 Philippines 2008 76 61 35 80 75 96 60 68 Senegal 2010–11 48 78 68 75 48 98 88 39 47 68 Burkina Faso 2010 33 65 50 91 56 97 89 41 50 67 Ghana 2008 76 65 44 77 75 98 93 32 51 67 Bolivia 2008 72 76 10 66 70 98 77 66 Cambodia 2010 64 81 14 94 83 96 42 48 65 Guyana 2009 77 53 30 42 64 96 94 78 65 Haiti 2005–06 51 73 32 76 50 98 76 36 63 Pakistan 2006–07 29 70 29 84 33 92 70 63 Cameroon 2011 59 47 65 87 50 96 89 30 35 62 Swaziland 2006–07 77 27 30 82 54 98 91 53 62 Malawi 2010 43 23 27 90 81 85 31 88 61 61 Timor-Leste 2009–10 54 64 20 91 61 95 20 58 Indonesia 2007 81 84 31 56 43 95 42 58 Lesotho 2009 66 40 9 84 59 97 73 46 58 Namibia 2006–07 70 36 29 56 63 97 92 73 11 57 Benin 2006 59 61 61 74 42 99 93 20 4 57 Ethiopia 2011 17 40 81 29 83 56 49 56 Zambia 2007 57 26 41 83 75 79 21 39 74 55 Kenya 2008–09 44 26 3 83 53 89 76 83 20 54 Liberia 2007 66 72 13 86 40 87 52 14 52 Tanzania 2010 39 26 2 93 56 71 58 75 34 52 Guinea 2005 46 49 35 86 29 93 65 5 52 Zimbabwe 2010–11 59 25 5 64 66 88 60 82 10 50 Uganda 2011 46 33 6 90 57 66 28 78 31 49 Nigeria 2008 44 28 22 77 64 86 75 26 10 48 Congo (Brazzaville) 2005 72 55 17 54 40 95 95 8 3 46 Mali 2006 36 57 24 78 32 92 53 11 17 46 Sierra Leone 2008 56 39 15 87 60 87 42 12 14 44 Madagascar 2008–09 46 42 8 79 52 83 34 8 8 39 Niger 2006 15 46 25 57 28 90 46 5 13 39 Burundi 2010 33 39 7 91 40 50 12 46 1 36 Dem Rep Congo 2007 47 28 2 47 42 73 51 8 8 32 Mean 57 55 30 79 58 91 67 49 25 60 Abbreviations: ANC4+, 4 or more antenatal care visits; 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. AVG: Average coverage across the 8 interventions (or fewer, if specific intervention(s) not included in the survey). Country data are presented in order, from highest average coverage to lowest. a Self-reported receipt of services among women delivering during the 2 years preceding the survey and reporting 4+ ANC visits. As seen in the Figure, with the exception of blood pressure measurement, there were marked quality–coverage gaps for each of these elements of care for most countries, ranging from 18% to 86%. The greatest gap was for 2 commodity-dependent functions—iron–folate supplementation (72%) and presumptive/preventive treatment for malaria with SP (86%). (HIV testing and tetanus toxoid are also commodity-dependent, but supply is commonly managed under separate, vertical systems; iron–folate and SP provision normally does not benefit from such special logistical arrangements.) 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. The greatest quality–coverage gaps were for iron–folate supplementation and preventive treatment for malaria, both of which depend on reliable commodity supplies. Effective Coverage at Population Level Whereas Table 1 presented intervention-specific coverage among those reporting 4 or more ANC visits (that is, those who are supposedly “covered” with respect to ANC services), Table 2 presents data calculated for all women delivering over the previous 2 years as the denominator, reflecting effective coverage at the population level. Specifically, mean coverage across all the antenatal indicators offers an alternative summary measure that could be considered for antenatal program performance. TABLE 2. Receipt of Specific Services Among All Pregnanciesa (%) Survey ANC4+ ANC<4mo IFA90+ TT2+ DSs BP Ur HIV SP2+ AVG ALL Dominican Rep 2007 96 81 65 91 69 99 96 86 84 34 Maldives 2009 87 90 64 86 51 97 95 81 28 Colombia 2010 87 74 59 79 96 94 80 80 34 Honduras 2005–06 79 65 61 71 60 89 68 69 10 Rwanda 2010 36 40 84 71 84 36 92 68 8 Peru 2007–08 88 68 15 66 78 93 75 66 7 Nepal 2011 53 50 52 84 66 76 51 63 22 Guyana 2009 77 46 29 42 62 94 91 71 62 4 Philippines 2008 76 50 28 74 67 89 52 60 10 Ghana 2008 76 54 36 70 67 94 86 27 46 60 5 Senegal 2010–11 48 58 56 70 42 93 80 30 40 59 3 Swaziland 2006–07 77 22 25 78 50 96 86 50 58 2 Burkina Faso 2010 33 40 34 86 50 93 81 31 39 57 1 Bolivia 2008 72 60 8 58 60 89 65 57 3 Cambodia 2010 64 63 10 88 73 84 34 38 56 2 Malawi 2010 43 12 15 87 78 82 27 85 55 55 1 Namibia 2006–07 70 30 24 56 58 92 88 68 11 53 0 Indonesia 2007 81 74 25 50 39 88 37 52 4 Lesotho 2009 66 30 6 75 49 88 63 42 50 1 Zambia 2007 57 18 28 79 70 75 19 39 66 49 1 Cameroon 2011 59 32 43 74 40 79 72 23 26 49 2 Haiti 2005–06 51 61 18 62 38 82 55 24 49 8 Timor-Leste 2009–10 54 43 12 78 48 82 15 46 1 Benin 2006 59 40 42 61 34 88 81 14 3 45 0 Tanzania 2010 39 14 1 91 50 64 47 68 27 45 0 Liberia 2007 66 59 11 77 38 79 46 0 44 2 Kenya 2008–09 44 14 1 72 40 77 61 70 15 44 0 Uganda 2011 46 20 3 85 49 55 21 72 27 42 0 Zimbabwe 2010–11 59 16 3 54 55 75 50 68 8 41 0 India 2005–06 36 43 15 76 19 48 44 41 4 Sierra Leone 2008 56 29 13 81 56 81 37 10 12 40 0 Congo (Brazzaville) 2005 72 42 13 45 34 82 82 7 0 38 0 Guinea 2005 46 32 19 22 72 47 4 32 0 Madagascar 2008–09 46 25 4 68 43 71 23 6 7 31 0 Burundi 2010 33 19 3 87 35 44 9 40 0 30 0 Nigeria 2008 44 16 12 48 38 53 46 15 6 29 0 Mali 2006 36 30 12 57 21 64 31 6 11 29 0 Dem Rep Congo 2007 47 18 1 37 33 62 42 6 7 26 0 Pakistan 2006–07 29 31 12 60 17 52 32 0 0 25 2 Ethiopia 2011 17 10 49 9 31 17 16 22 1 Niger 2006 15 13 7 23 12 41 18 1 0 14 0 Mean 57 40 21 69 49 78 55 43 20 50 Abbreviations: ANC4+, 4 or more antenatal care visits; 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. AVG: Average coverage across the 8 interventions (or fewer, if specific intervention(s) not included in the survey). Country data are presented in order, from highest average coverage to lowest. a Self-reported receipt of services among all women delivering during the 2 years preceding the survey. The 2 tables (Table 1, reflecting ANC quality, and Table 2, reflecting population effective coverage) show somewhat similar rankings. For example, the top 7 performers are the same on these 2 measures. Most countries were underperformers—in the sense that average population effective coverage for actual content was lower than for ANC 4+. For only 8 of the 41 countries was average coverage higher than the proportion of women reporting 4 or more visits (Table 2). (This is reflected in the generally large quality–coverage gaps for individual interventions.) Four of the 10 highest-performing countries, with respect to average coverage across the specific elements of care, also had ANC 4+ values greater than 85% (Dominican Republic, Maldives, Colombia, and Peru) (Table 2). On the other hand, 2 of these 10 countries had comparatively low ANC 4+ values: Rwanda (36%) and Nepal (53%). Very low average coverage was generally associated with low ANC 4+. However, there were several cases of relatively low coverage on specific antenatal content in countries with relatively high ANC 4+ (for example, Congo Brazzaville, with average coverage of 38% and ANC 4+ of 72%; Indonesia, with average coverage of 52% and ANC 4+ of 81%; and Namibia, with average coverage of 53% and ANC 4+ of 70%). Correlation Between Number of Visits and Care Received Certainly, in general, the more ANC visits one has, the higher the likelihood of receiving specific elements of care. So, not surprisingly, ANC 4+ and mean coverage across the 8 elements of care correlate relatively well (Pearson r2 = 0.56). In other words, 56% of the variance in mean coverage is accounted for by the value of ANC 4+. The number of visits does matter, in the sense that each visit provides an opportunity for provision of needed care. Fewer visits means fewer opportunities. Mean number of visits correlates similarly well (r2 = 0.53), and has the advantage that its use as an indicator would not (inappropriately) signal that any particular number of visits is automatically sufficient. Regardless of degree of association, whether with ANC 4+ or mean number of visits, as is evident in the data presented here, there is no necessary relationship with reliable delivery of the content of care. Receipt of the Full Set of Interventions Among all pregnancies during the 2 years preceding the survey, the proportion of women who reported receiving all 8 services (or fewer, if a particular indicator was not included in the survey) was zero in over one-third of the surveys (15 of 41) (Table 2). In only 4 countries was the proportion 20% or higher (Dominican Republic, Maldives, Colombia, and Nepal). In Honduras and the Philippines, the proportion was 10%; in Rwanda and Haiti, 8%; and in Peru, 7%. In none of the other countries was it above 5%. DISCUSSION As this analysis demonstrates, there are large quality–coverage gaps for most of the antenatal interventions assessed. Such gaps mean ineffective care, and ineffective care means missed opportunities to achieve better outcomes. Focusing on mere contact rather than on the content of care means that we have taken our eye off what really matters. Most ANC services assessed had large quality–coverage gaps, reflecting ineffective care. ANC 1 (any ANC) and ANC visit within the first 4 months of gestation are programmatically useful indicators (although not sufficient, in themselves, as summary measures of program performance); they point to how adequately services are reaching intended beneficiaries. The same cannot be said for ANC 4+. This indicator has been used as an overall proxy for delivery of a package of needed antenatal care. As demonstrated by the analysis here, it serves this role poorly. For most of the elements of care, there were marked quality–coverage gaps. And high ANC 4+ coverage can be completely compatible with a large quality–coverage gap (for example, see Congo Brazzaville, Indonesia, Namibia, and Swaziland, in Table 1). Furthermore, its widespread use as the single benchmark indicator for antenatal care has the very unwelcome effect of directing the attention of clinicians and program managers toward optimizing the number of antenatal visits rather than ensuring delivery of the important substance of that care. This effect is exacerbated when attendance at 4 ANC visits is incentivized under conditional cash transfer programs, or when it serves as part of the basis for performance-based financing schemes. Furthermore, continued use of this indicator reinforces the impression that an abbreviated schedule of antenatal visits is adequate. Recent further analysis 6 of the original WHO research that gave rise to the 4-visit recommendation has demonstrated a 27% higher risk of fetal death among those randomized to the abbreviated schedule. Moreover, with eclampsia/preeclampsia emerging as the leading cause of maternal death in certain countries, there is renewed recognition of the importance of more vigilant routine screening and timely response to worsening preeclampsia, which cannot be accomplished with only 4 visits over the entire pregnancy. Commenting on the secondary analysis of the WHO antenatal care trial, Justus Hofmeyr 7 makes the case that: An increased number of routine visits may detect asymptomatic conditions such as preeclampsia, fetal growth restriction or reduced fetal movements earlier, allowing more timely intervention. The importance of the content and quality of routine antenatal care should not be lost to policy makers when decisions about numbers of visits with the available resources are being made. Recent analysis found higher risk of fetal death with the abbreviated ANC schedule of visits. It is time to drop the use of ANC 4+. It does not reliably tell us how adequate ANC services are, and relying on it encourages program managers and clinicians to focus on mere contact rather than on the content of care. Furthermore, as we have noted, 4 visits are not enough. Alternative Indicators to Measure ANC Program Performance ANC 4+ has been retained, to date, as the key global benchmark indicator for antenatal care not because there are passionate defenders of its validity but because there is a perception that there is no readily available alternative. But there is. In principle, an attractive option would be the proportion of women who report receiving the full set of specific elements of care measured. This can be readily determined from survey data. Kyei and colleagues 8 have done such analysis based on data from the 2007 Zambia DHS, using an overlapping, but not identical, set of ANC-related indicators to those used here.* In their study, “good-quality ANC” was defined as attending at least 4 ANC visits with a skilled provider and receiving at least 8 of the 10 antenatal interventions used in their analysis; “moderate-quality ANC” required 4 visits and 5–7 of the 10 antenatal interventions. In this paper, similar analysis found that in about one-third of the surveys (15 of 41), the proportion of women receiving all 8 services (or fewer, if a particular indicator was not included in the survey) was zero. So the utility of this specific measure is constrained by its lack of discriminating power. A further limitation is that, unlike a simple average across indicators—which can be easily calculated from corresponding indicators already tracked by routine health information systems—a measure of receipt of a full set of services at the level of the individual woman would, for the foreseeable future, only be feasible in periodic population surveys and special studies. So we propose adopting, as a summary measure of antenatal program performance at the population level, the simple average of a set of available indicators for receipt of specific services (such as presented in this paper). For use at the global level, to ensure strict comparability, it may be necessary to restrict this composite indicator to content elements that are common across all countries. This would imply retaining HIV- and malaria-related interventions in the summary measure only for within-country use, in settings where this is warranted by local epidemiology and public health priorities. We propose that the same approach be used for periodic population surveys and for ongoing monitoring using routine health information systems. An alternative indicator to ANC 4+ to measure program performance could be a simple average of receipt of a set of key antenatal services. Certainly, the specific components of an average measure merit further debate and discussion. There may be other interventions tracked by health management information systems and measured by DHS or other periodic surveys that could be included (for example, those in the analysis done by Kyei and colleagues 8 ). Likewise, average total number of ANC visits could be included in the summary average measure. Such an average coverage measure would reflect much better how well the needs of the population are actually being met, with regard to the substance of antenatal care, than does the ANC 4+ indicator. This brings us to an important issue of terminology. Shengelia and colleagues 9 have provided a formal description of “effective coverage,” which comprises individual-level need, utilization, and quality. Bryce and colleagues 10 have criticized this concept as unnecessarily complex and not readily measurable. In the global child health sphere, use of the term “coverage” is relatively unproblematic, as it is normally used to refer to delivery of specific technical interventions. However, in global maternal health discourse, “coverage” commonly refers to mere contact (notably ANC 4+ and skilled birth attendance), and these measures are used as proxies for adequate delivery of needed care to a population. For maternal health, a shift toward use of indicators of overall program performance that take account of the actual substance of care provided is certainly called for. For that purpose, we would endorse use of indicators that track “effective coverage,” as the term is used by Kyei and colleagues 8 —“the proportion of the population who need a service that receive it with sufficient quality [for it] to be effective.” In the case of antenatal care, using a more appropriate summary metric for overall program performance, as proposed here, would help effect a much-needed shift in focus, putting the content back into contact.
Author and article information
Journal
Journal ID (iso-abbrev): BJOG
Title:
BJOG : an international journal of obstetrics and gynaecology
ISSN
(Electronic):
1471-0528
ISSN
(Print):
1470-0328
Publication date
(Electronic):
Mar 2016
Volume: 123
Issue: 4
Affiliations
Article
DOI: 10.1111/1471-0528.13819
PubMed ID: 26701735
SO-VID: 6bac0d83-6cfd-4120-98fc-bdd06a7ee3a6
Copyright © © 2015 The Authors. BJOG An International Journal of Obstetrics and Gynaecology published
by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.
History
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