|The quality–coverage gap in antenatal care: toward better measurement of effective coverage|
||Stephen Hodgins, Alexis D’Agostino
||Global Health: Science and Practice, First published online April 8, 2014, doi: 10.9745/GHSP-D-13-00176
More than one region
||Background: The proportion of pregnant women receiving 4 or more antenatal care visits (ANC 4+) is used
prominently as a global benchmark indicator to track maternal health program performance. This has contributed to an
inappropriate focus on the number of contacts rather than on the content and process of care. This paper presents
analysis of specific elements of care received among women reporting 4 or more ANC visits.
Methods: We conducted secondary analysis using Demographic and Health Survey data from 41 countries to
determine coverage for specific elements of antenatal care. The analysis was conducted for: (1) women who delivered
during the 2 years preceding the survey and who reported receiving 4 or more ANC visits, and (2) all women who
delivered during the preceding 2 years. The specific ANC services that we assessed comprised: blood pressure
measurement, tetanus toxoid vaccination, first ANC visit at less than 4 months gestation, urine testing, counseling about
danger signs, HIV counseling and testing, iron-folate supplementation (> 90 days), and at least 2 doses of sulfadoxine/
pyramethamine for malaria prevention. The difference between expected (100%) and actual coverage (the quality–
coverage gap) was calculated for each service across the 41 surveys.
Results: Coverage for specific elements of care among women reporting 4 or more ANC visits was generally low for
most of the specific elements assessed. Blood pressure and tetanus toxoid performed best, with median quality–coverage
gaps of 5% and 18%, respectively. The greatest gaps were for iron–folate supplementation (72%) and malaria
prevention (86%). Coverage for specific interventions was generally much lower among all pregnant women (reflecting
population effective coverage) than among only those who had received ANC 4+ visits. Although ANC 4+ and average
coverage across the elements of care correlated relatively well (Pearson r2 5 0.56), most countries had lower average
coverage for the content of care than for ANC 4+ (among all pregnant women).
Conclusion: We argue for the adoption of a summary indicator that better reflects the content of care in maternal
health programs than does the current ANC 4+ indicator. We propose, as an alternative, the simple average of a set of
ANC content indicators available through surveys and routine health information systems.