Individual and community socioeconomic factors related to the quality of antenatal care: a multilevel analysis of West and Central Africa

The impact of multidimensional poverty on antenatal care service utilisation in Malawi

BACKGROUND

Poverty remains a key barrier to accessing essential maternal health services, particularly in low- and middle-income countries like Malawi. Despite the recognised importance of antenatal care (ANC) in ensuring healthy pregnancies as well as improving maternal and child health outcomes, ANC services remain underutilised by many women living in poverty. This underutilisation is not solely driven by a lack of financial resources but also by a range of non-monetary factors that constitute multidimensional poverty, such as limited access to education, healthcare services, and infrastructure. While much of the existing literature focuses on monetary poverty, this study explores how multidimensional poverty impacts ANC utilisation. By examining how various deprivations intersect to limit access to ANC, this research contributes to understanding the broader issue of healthcare inequality.

AIM

We assess the impact of multidimensional poverty (non-monetary) on antenatal care use in Malawi.

METHOD

Multidimensional poverty was constructed using the Forster-Akire method of the Oxford Poverty and Human Initiative (OPHI). We use data from the 2015-16 Demographic Health Survey (DHS), which includes information on women aged 15-49 who gave birth within five years of the survey. To mitigate selection bias, we use Propensity Score Matching (PSM) techniques for our principal analysis.

RESULTS

Our findings reveal that 52% of women adequately utilised ANC services. About 8,428 women were identified as multidimensionally poor, and 4,685 were classified as non-poor. The results of our PMS analysis show a significant negative relationship between ANC utilisation and multidimensional poverty (B = 0.52; P < 0.008), indicating that multidimensionally poor women are less likely to use ANC services. Similarly, the timing of ANC visits also showed a negative relationship with multidimensional poverty (B = 0.26; P < 0.04), highlighting that multidimensionally poor women are less likely to attend ANC visits within the recommended first trimester.

CONCLUSION

The findings suggest that there is a need for sustainable investments in poverty alleviation programs to address and reduce multidimensional poverty as well as raise awareness of sexual and reproductive health concerns among adolescents and women in Malawi to improve maternal health outcomes.

Assessing the effectiveness of the Pregnancy And Newborn Diagnostic Assessment system on the quality of antenatal care in Burkina Faso: A cluster-randomised controlled trial

Introduction

The Pregnancy and Newborn Diagnostic Assessment (PANDA) system is a mobile application designed to facilitate diagnosis and decision-making by healthcare staff in antenatal care (ANC). This study aimed to evaluate its effectiveness in improving the quality of ANC.

Methods

This randomised controlled trial implemented the PANDA system in two groups of health facilities (intervention and comparison groups) using a matched-pair method in the Koupéla health district, Burkina Faso. Six health centres were included in each group. We included pregnant women presenting with more than 20 weeks of amenorrhea during their first antenatal consultation, and we followed them up until their sixth week postpartum. The primary outcome was a binary variable derived from the ANC quality score, coded yes or no. Six components of ANC quality were identified: welcoming the woman, history taking and dietary habits, physical examination, obstetric examination, preventive care, and counselling and advice. We used Poisson regression with robust variance to compare the unadjusted and adjusted primary outcomes results between the two study arms.

Results

We included 319 and 272 women in the intervention and comparison groups, respectively. In the intervention group, 15.67% (50 out of 319) of the women had at least 75% of the total ANC quality score, compared to 6.25% (17 out of 272) in the comparison group. Adjusted results showed that women in the intervention group were 2.71 times more likely to have an excellent total ANC quality score than women in the comparison group (RR = 2.71; 95% CI [1.60-4.60]; p < .001).

Conclusion

Although the proportion of women with good ANC quality was low, this study showed that the PANDA system significantly improves the ANC quality. These results are vital because Burkina Faso has decided to use these computerised clinical decision support systems for maternal and child health.

Input, process, and output factors contributing to quality of antenatal care services: a scoping review of evidence

BACKGROUND

High-quality antenatal care (ANC) provides a lifesaving opportunity for women and their newborns through providing health promotion, disease prevention, and early diagnosis and treatment of pregnancy-related health issues. However, systematically synthesised evidence on factors influencing the quality of ANC services is lacking. This scoping review aims to systematically synthesize the factors influencing in provision and utilisation of quality ANC services.

METHODS

We conducted a scoping review of published evidence on the quality of ANC services. We searched records on four databases (PubMed, Scopus, Embase, and Google scholar) and grey literature from 1 to 2011 to 30 August 2021. We analysed data using Braun and Clarke's thematic analysis approach. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guideline for the review. We explained themes using the Donabedian healthcare quality assessment model (input-process-output).

RESULTS

Several inputs- and process-related factors contributed to suboptimal quality of ANC in many low and lower- or middle-income countries. Input factors included facility readiness (e.g., lack of infrastructure, provision of commodities and supplies, health workforce, structural and intermediary characteristics of pregnant women, and service delivery approaches). Processes-related factors included technical quality of care (e.g., lack of skilled adequate and timely care, and poor adherence to the guidelines) and social quality (lack of effective communication and poor client satisfaction). These input and process factors have also contributed to equity gaps in utilisation of quality ANC services.

CONCLUSION

Several input and process factors influenced the provision and utilization of optimum quality ANC services. Better health system inputs (e.g., availability of trained workforces, commodities, guidelines, context-specific programs) are essential to creating enabling facility environment for quality ANC services. Care processes can be improved by ensuring capacity-building activities for workforces (training, technical support visits), and mentoring staff working at peripheral facilities. Identifying coverage of quality ANC services among disadvantaged groups could be the initial step in designing and implementing targeted program approaches.

Factors associated with inadequate prenatal care service utilization in Ethiopia according to the WHO recommended standard guidelines

Background

Adequate maternal health care could prevent 54% of maternal deaths in low- and middle-income countries. In Ethiopia, the maternal mortality rate was reduced from 817 to 412 deaths per 100,000 live births between 2000 and 2016. Thus, the current study focuses on the adequacy of prenatal care (PNC) services rather than the mere prenatal contacts available to assess compliance with the WHO recommended standard guidelines.

Methods

A nationally representative cross-sectional dataset from the Ethiopian Mini Demographic and Health Survey 2019 was analyzed. Risk factors for prenatal care adequacy were assessed using a multilevel ordinal logistic regression model.

Results

About 43% of women met the old WHO recommendation of at least four prenatal contacts, while only 3.5% of women met the new WHO recommended minimum of eight prenatal contacts. The overall adequacy of prenatal care based on the four prenatal care utilization indicators was 52.1% no PNC, 37.4% received inadequate PNC and 10.5% received adequate PNC. Being a rural resident [AOR = 0.694 (95% CI: 0.557, 0.865)] and wanting no more children [AOR = 0.687 (95% CI: 0.544, 0.868)] are associated with inadequate prenatal care. Higher educational attainment of women and spouses, exposure to the media, upper wealth quintile, and a perceived shorter distance to a health facility were significantly associated with adequate prenatal care.

Conclusion

The prevalence of adequate prenatal care was lower. Multi-sectoral efforts are needed to improve maternal health targets by reducing maternal mortality through improved health care services.

Antenatal care processes in rural Southern Nepal: gaps in and quality of service provision-a cohort study

OBJECTIVES

This study aimed to compare a standard quality of care definition to one that reflected focused antenatal care (FANC) guidelines and examine associations with receipt of good quality of care.

DESIGN

This study was a longitudinal cohort study.

SETTINGS

Five government health posts in the Sarlahi district of Southern Nepal PARTICIPANTS: Pregnant women between the ages of 15 and 49 who presented for their first antenatal care (ANC) visit at the study health posts.

MAIN OUTCOMES

There were two quality of care definitions: (1) provision of seven services at least once during pregnancy (QOC1) and (2) provision of services to reflect the FANC guidelines by incorporating a frequency of care dimension for certain services (QOC4+).

RESULTS

There was variation in service provision both in terms of frequency of provision and by gestational age at the visit. There were 213 women (49.1%) that received good quality care by the first definition, but when the frequency of service provision was included for the second definition the percentage dropped to 6.2%. There were significant differences in provision of quality care by health post for both definitions. The number of visits (QOC1 adjusted risk ratio (aRR) 1.18, 95% CI 1.13 to 1.23; QOC4+ aRR 1.46, 95% CI 1.11 to 2.80) and care during the first trimester (QOC1 aRR 1.22, 95% CI 1.01 to 1.49) and maternal age (QOC1 aRR 1.27, 95% CI 1.03 to 1.58) were associated with greater likelihood of good quality ANC.

CONCLUSION

This analysis demonstrated that measuring quality of care by receipt of services at least once during pregnancy may overestimate the true coverage of quality of ANC. Future efforts should improve feasibility of including frequency of care in quality of care definitions.