A Fresh Look at the Adequacy of Antenatal Health Care

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By Jacquelyn Caglia, Associate Director, Women and Health Initiative, Harvard T.H. Chan School of Public Health

10698178843_7de36e6228_zHigh quality care during pregnancy is a critical part of the continuum of reproductive, maternal, newborn and child health care.  Antenatal care (ANC) provides an opportunity to promote healthy behaviors during pregnancy, identify and treat health problems, and raise awareness of danger signs that may arise throughout pregnancy. Most efforts to measure the effectiveness of ANC, however, are limited by only tracking the number of visits a woman has during pregnancy, without incorporating key measures of the quality of that care or the content of the visits.

Heredia-Pi and colleagues published a study in this month’s Bulletin of the World Health Organization in which they propose a new way to look at antenatal care. The authors note that historically, studies have analyzed antenatal care indicators – such as timeliness, sufficiency, and adequacy – independently, which may result in high average levels that do not convey an accurate depiction of care. To better measure the adequacy and continuity of antenatal care, the authors propose a comprehensive approach that incorporates several dimensions of the health care process.

Four Proposed Dimensions of the Adequacy of Antenatal Care:

  1. Skilled – Was antenatal care provided by a nurse or physician?
  2. Timely – Was the first antenatal care visit during the first trimester of pregnancy?
  3. Sufficient – Were there at least four antenatal care visits during the pregnancy?
  4. Appropriate – Was the content of the antenatal care visits mostly correct?

For the measure of appropriateness, the authors investigated whether at least seven of the following eight procedures or processes were included: measurement of height, weight, and blood pressure; urine analysis; blood examination; tetanus vaccine; prescription of folic acid; and prescription of vitamins, iron, or dietary supplements.

Using data from the Mexican National Health and Nutrition Survey conducted in 2012, Heredia-Pi and colleagues divided the study sample into three outcome categories: adequate antenatal care (conditions 1-4 above met), inadequate antenatal care (some but not all criteria met), and no antenatal care. Their study revealed that while 98.4% of women in the sample received at least one antenatal care visit from a skilled health provider, only 71.5% of these women received antenatal care that was adequate. Their study also detected socioeconomic disparities across the three outcome categories with women at the higher ends of income and with better housing conditions more likely to receive adequate antenatal care.

While the findings of the study in Mexico are important in their own right, I am most excited about the possibility of a new composite measure of antenatal care that focuses on quality and context just as much as it captures access and frequency that is comparable within and across countries. Is the time for a comprehensive, woman-centered measure of health care during pregnancy finally here?


What do you think of the proposed new measure of adequate antenatal care? If you are working to improve maternal newborn health through antenatal care, are you measuring beyond the number of visits? We would love to hear from you at mhtf@hsph.harvard.edu.

Photo: “Maternal care, Hargeisa, Somalia 2007” © 2007 Sarah Bones/CARE, used under a Creative Commons Attribution license 2.0