Longitudinal antenatal care quality and postpartum health: findings from a prospective cohort study in Ethiopia, India, Kenya and South Africa
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Background
Effective antenatal care (ANC) requires high quality longitudinal services to provide a health benefit to mothers and newborns. Few studies have assessed the quality of care across the continuum of pregnancy or its impact on outcomes in lower income countries with high perinatal mortality.
Methods and findings
We conducted a prospective study in eight rural and urban sites in Ethiopia, India, Kenya, and South Africa that followed women from their first ANC visit until childbirth. We created a longitudinal ANC quality score that included repeated interventions in pregnancy and described ANC quality trajectories by gestational age. We also assessed associations between longitudinal ANC quality – categorized into three groups: low (0–50% of recommended care received), moderate (51%–74.9%), and higher quality (75%–100%) – and intrapartum complications and poor postpartum health using logistic regression models adjusted for sites, demographics, and baseline risk factors.
A total of 3,602 women were included in the present study. On average, women had a total of 4.3 ANC visits. Average longitudinal ANC quality was 46% in Ethiopia, 57% in Kenya, 74% in India, and 79% in South Africa, with reference to national guidelines. Only 20 of 3,602 women (0.6%) received all recommended care items. Few women received the recommended three urine and blood tests in pregnancy: only 5%–11% in Kenya and 13%–21% in Ethiopia. Timely ultrasounds (before 24 weeks’ gestation) ranged from 12% in Kenya to 54% in Ethiopia. While ANC quality remained relatively stable over the course of pregnancy in India and South Africa, it declined as pregnancy progressed in Ethiopia and Kenya. During the third trimester, only around half of women in these two countries received a blood test, and just one third received a urine test. In adjusted regression models, the odds of intrapartum complications and poor postpartum health were, respectively, 44% and 55% lower among women who received higher longitudinal ANC quality compared to those who received low quality ANC (adjusted odds ratio (aOR) 0.56, 95% CI 0.34, 0.92, and aOR 0.45, 95% CI 0.29-0.70)
Conclusions
We found important gaps in longitudinal ANC quality and poor provision of recommended anemia and gestational diabetes clinical protocols in pregnancy. These were associated with worse health outcomes. One area of concern is the decline in quality during the third trimester in two of the countries – a time when complications frequently arise that can be mitigated with quality care. Policymakers and health system managers should track longitudinal care quality during pregnancy to identify and redress persistent gaps in maternal and child health care quality. Global and national guidelines and medical education should also reinforce the importance of late-pregnancy surveillance.
AUTHORS SUMMARY
Why was this study done?
- Past studies on the quality of antenatal care (ANC) have mostly relied on cross-sectional data that offer limited insight into the continuity and consistency of care throughout pregnancy.
- These studies have generally assessed whether pregnant women receive certain services at least once in pregnancy.
- In addition, there is little evidence on the links between quality of care and outcomes.
What did the researchers do and find?
- We followed 3,602 pregnant women in Ethiopia, India, Kenya and South Africa from their first ANC visit until the end of pregnancy, described longitudinal ANC quality, the trajectory of quality by gestational age, and assessed associations with intrapartum complications and postpartum health.
- Global and national guidelines recommend at least three blood and urine tests in pregnancy. Despite attending a total of 4.3 ANC visits on average, receipt of three urine tests was only 4.8% in Kenya, 13.1% in Ethiopia, and 37.6% in India. Receipt of three blood tests was 10.9% in Kenya, 20.7% in Ethiopia and 67.4% in India. These two indicators surpassed 80% in South Africa.
- In Ethiopia and Kenya, we also found that ANC quality tended to decline as pregnancy progressed while it was relatively stable in India and South Africa.
- Our regression analyses showed that longitudinal ANC quality was associated with lower odds of self-reported intrapartum complications and lower odds of poor postpartum health.
What do these findings mean?
- The number and timing of specific interventions must be considered to adequately capture quality gaps.
- Policy makers should routine monitor longitudinal care quality to address persistent deficits in quality.
- Training programs and clinical guidelines in LMICs should also reinforce the importance of late-pregnancy surveillance.
