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

• Published in: PLoS Medicine 2024, Vol.21 (8)
• Main Authors: Arsenault, Catherine, Mfeka-Nkabinde, Nompumelelo Gloria, Chaudhry, Monica, Jarhyan, Prashant, Taddele, Tefera, Mugenya, Irene, Sabwa, Shalom, Wright, Katherine, Amboko, Beatrice, Baensch, Laura, Molla Wondim, Gebeyaw, Mthethwa, Londiwe, Clarke-Deelder, Emma, Yang, Wen-Chien, Kosgei, Rose J, Purohit, Priyanka, Mzolo, Nokuzola Cynthia, Derseh Mebratie, Anagaw, Shaw, Subhojit, Nega, Adiam, Tlou, Boikhutso, Fink, Günther, Moshabela, Mosa, Prabhakaran, Dorairaj, Mohan, Sailesh, Haile Mariam, Damen, Nzinga, Jacinta, Getachew, Theodros, Kruk, Margaret E
• Format: Report
• Language: English
• Subjects: Anemia; Antidepressants; Chronic diseases; Comorbidity; Depression, Mental; Health aspects; Infants; Infants (Newborn); Obstetrics; Patient outcomes; Pregnant women; Risk factors
• ISSN: 1549-1277
• DOI: 10.1371/journal.pmed.1004446

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 heal