Antenatal care quality and detection of risk among pregnant women: An observational study in Ethiopia, India, Kenya, and South Africa

Catherine Arsenault, Department of Global Health, The George Washington University Milken Institute School of Public Health, Washington, DC, United States of America.
Nompumelelo Gloria Mfeka-Nkabinde, Department of Family Medicine, Howard College campus, University of KwaZulu-Natal, KwaZulu-Natal, South Africa.
Monica Chaudhry, Public Health Foundation of India, New Delhi, India.
Prashant Jarhyan, Public Health Foundation of India, New Delhi, India.
Tefera Taddele, Ethiopian Public Health Institute, Addis Ababa, Ethiopia.
Irene Mugenya, Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.
Shalom Sabwa, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America.
Katherine Wright, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America.
Beatrice Amboko, Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.
Laura Baensch, Laterite Kenya, Nairobi, Kenya.
Gebeyaw Molla Wondim, Ethiopian Public Health Institute, Addis Ababa, Ethiopia.
Londiwe Mthethwa, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.
Emma Clarke-Deelder, Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland.
Wen-Chien Yang, Department of Global Health, The George Washington University Milken Institute School of Public Health, Washington, DC, United States of America.
Rose J. Kosgei, Department of Obstetrics and Gynecology, University of Nairobi, Nairobi, Kenya.
Priyanka Purohit, Public Health Foundation of India, New Delhi, India.
Nokuzola Cynthia Mzolo, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.
Anagaw Derseh Mebratie, Department of Health Systems Management and Health Policy, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
Subhojit Shaw, Public Health Foundation of India, New Delhi, India.
Adiam Nega, Department of Health Systems Management and Health Policy, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
Boikhutso Tlou, Department of Public Health Medicine, Howard College campus, University of KwaZulu-Natal, KwaZulu-Natal, South Africa.
Günther Fink, Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland.
Mosa Moshabela, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.
Dorairaj Prabhakaran, Public Health Foundation of India, New Delhi, India.
Sailesh Mohan, Public Health Foundation of India, New Delhi, India.
Damen Haile Mariam, Department of Health Systems Management and Health Policy, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
Jacinta Nzinga, Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.
Theodros Getachew, Ethiopian Public Health Institute, Addis Ababa, Ethiopia.
Margaret E. Kruk, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America.

Document Type

Journal Article

Publication Date

8-1-2024

Journal

PLoS medicine

Volume

21

Issue

8

DOI

10.1371/journal.pmed.1004446

Abstract

BACKGROUND: Antenatal care (ANC) is an essential platform to improve maternal and newborn health (MNH). While several articles have described the content of ANC in low- and middle-income countries (LMICs), few have investigated the quality of detection and management of pregnancy risk factors during ANC. It remains unclear whether women with pregnancy risk factors receive targeted management and additional ANC. METHODS AND FINDINGS: This observational study uses baseline data from the MNH eCohort study conducted in 8 sites in Ethiopia, India, Kenya, and South Africa from April 2023 to January 2024. A total of 4,068 pregnant women seeking ANC for the first time in their pregnancy were surveyed. We built country-specific ANC completeness indices that measured provision of 16 to 22 recommended clinical actions in 5 domains: physical examinations, diagnostic tests, history taking and screening, counselling, and treatment and prevention. We investigated whether women with pregnancy risks tended to receive higher quality care and we assessed the quality of detection and management of 7 concurrent illnesses and pregnancy risk factors (anemia, undernutrition, obesity, chronic illnesses, depression, prior obstetric complications, and danger signs). ANC completeness ranged from 43% in Ethiopia, 66% in Kenya, 73% in India, and 76% in South Africa, with large gaps in history taking, screening, and counselling. Most women in Ethiopia, Kenya, and South Africa initiated ANC in second or third trimesters. We used country-specific multivariable mixed-effects linear regression models to investigate factors associated with ANC completeness. Models included individual demographics, health status, presence of risk factors, health facility characteristics, and fixed effects for the study site. We found that some facility characteristics (staffing, patient volume, structural readiness) were associated with variation in ANC completeness. In contrast, pregnancy risk factors were only associated with a 1.7 percentage points increase in ANC completeness (95% confidence interval 0.3, 3.0, p-value 0.014) in Kenya only. Poor self-reported health was associated with higher ANC completeness in India and South Africa and with lower ANC completeness in Ethiopia. Some concurrent illnesses and risk factors were overlooked during the ANC visit. Between 0% and 6% of undernourished women were prescribed food supplementation and only 1% to 3% of women with depression were referred to a mental health provider or prescribed antidepressants. Only 36% to 73% of women who had previously experienced an obstetric complication (a miscarriage, preterm birth, stillbirth, or newborn death) discussed their obstetric history with the provider during the first ANC visit. Although we aimed to validate self-reported information on health status and content of care with data from health cards, our findings may be affected by recall or other information biases. CONCLUSIONS: In this study, we observed gaps in adherence to ANC standards, particularly for women in need of specialized management. Strategies to maximize the potential health benefits of ANC should target women at risk of poor pregnancy outcomes and improve early initiation of ANC in the first trimester.

Department

Global Health

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