Antenatal care has long been viewed as a critical component of comprehensive maternal and newborn health care, together with care at the time of delivery and during the postnatal period. Yet, in low-income countries, only 38% of pregnant women attended the recommended four or more ANC visits during 2006-2013. Since numerous life-saving interventions can be delivered in the weeks and months leading up to birth, what is holding the global maternal health community back from successfully delivering high quality ANC to all pregnant women around the world? Further, what does high quality ANC actually entail? What innovative models for delivering ANC exist, and might be scaled up to reach more women in more settings?
To begin to answer these questions—and their policy implications—the MHTF recently worked together with the Wilson Center, as part of the Advancing dialogue on maternal health, series to facilitate the policy dialogue, “Delivering Quality Antenatal Care in Low Resource Settings: Examining Innovative Models and Planning For Scale up.”
The panel for this policy dialogue consisted of Dr. A. Metin Gülmezolgu of the World Health Organization (WHO), Carrie Klima, PhD of the University of Illinois at Chicago, and Faith Muigai of Jacaranda Health. The three experts on this panel offered insight into both gaps and solutions to the current ANC environment. Their expertise focused around three main topics: continued rigorous research, creating more effective and efficient models of care, and delivering quality care through investing in the health workforce.
Global standards for ANC have experienced numerous iterations, and the World Health Organization (WHO) continues to examine the best schedule and content for ANC. The second iteration of WHO’s ANC model, Focused Antenatal Care (FANC), was released in 2001 and outlines key interventions to be delivered in four visits that are critically timed. But a WHO trial in Zimbabwe showed an increase in perinatal death, specifically fetal deaths, in those who had only four ANC visits.This model is currently under reevaluation by the WHO and we can look forward to new guidelines in the coming year.
Dr. Gülmezolgu emphasized the continual need of rigorous research like randomized control trials (RCTs) to evaluate two questions—what should be delivered and how. This is being accomplished partially through the joint WHO and MHTF project, Adding Content to Contact, which systematically assesses the obstacles that prevent and the factors that enable the adoption and implementation of cost-effective interventions for antenatal and postnatal care along the care continuum. Research and interventions for ensuring a healthy pregnancy and delivery should occur on several levels: individual interventions, barriers and facilitators to access to and provision of care, large-scale program evaluation to address policy issues, and health systems interventions. The outcomes of these interventions and research are not only maternal, but should also be evaluated on the fetal and neonatal level and women-centered—creating a space where women can learn about pregnancy and not just preventing complications.
Innovative Models of Care
Public facilities in low-income countries are often overcrowded with poor provider-to-patient ratios, straining health workers and providing a barrier to sufficient ANC. Carrie Klima offers insight to a model of care that could improve the efficiency and effectiveness of health workers in low-resource settings. CenteringPregnancy is a group care model that has been implemented in the Unites States since the 1990s. In CenteringPregnancy, eight to 12 pregnant women with similar due dates receive their prenatal care, education, and support in a group setting. This model has shown an increase in weight and gestational age for mothers who deliver prematurely. But could this model, primarily used in a developed country, also work in the developing world?
Recently Klima traveled to Tanzania and Malawi to conduct a feasibility and acceptability study of this model of care. The current CenteringPregnancy model of ten visits and was pared down to four to reflect the FANC guidelines for this study. What did the results show? Both health workers and expecting mothers were accepting of this model and qualitatively reported an increase in the quality of ANC. Midwives reported that they finally felt like they were able to practice their profession as they were taught to do in midwifery school. Women were also taught how to perform self-assessments and reported feeling more empowered by better understanding the metrics of their care and options for treatment.
Invest in the Health Workforce
Jacaranda Health in Kenya provides a novel model of care not often seen in low-resource settings—quality over quantity, a valued health workforce versus one that is overworked. This health model has six areas of focus: patient-centered design, human resources, quality improvement, technology, measuring impact, and business innovation. Faith Muigai, Director of Clinical Operations, stressed the importance of supply-side incentives for ANC as she highlighted patient-centered interventions. During their stay at the facility women receive three meals, two snacks, medications, maternity pads, and other goods that the woman or her family normally must supply. At Jacaranda facilities, patients keep coming back because the quality is much better. Jacaranda also works with women to create a savings plan for delivery fees. Since some women can’t afford these fees, Jacaranda is working with the Government of Kenya to subsidize care and lower prices.
Jacaranda not only creates a quality place to receive care, but also a quality place to provide care. Jacaranda is passionate about their health workforce and has developed a career ladder for their staff to help create a sustainable health system. This allows task-shifting, which maximizes time with clients so education can be provided. Muigai concluded by emphasizing that the model of care Jacaranda implements is “a means of proving concepts that impact the delivery of cost-effective, patient-centered, quality care in low-resource settings.”
Interested in learning more about what our speakers had to say? Follow the links below:
- New Security Beat: Antenatal Care as an Instrument of Change: Innovative Models for Low-Resource Settings
- Dr. A. Metin Gülmezoglu’s Presentation
- Carrie Klima’s Presentation
- Faith Muigai’s Presentation
- Friday Podcast With Faith Muigai
- Photo Gallery
Interested in learning more about the MHTF’s ongoing work relating to antenatal care? Contact Annie Kearns, project manager of Adding Content to Contact (ACC).