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Background: Antenatal care (ANC) is one of the recommended interventions to reduce maternal and neonatal mortality. Yet in most Sub-Saharan African countries, high rates of ANC coverage coexist with high maternal and neonatal mortality. This disconnect has fueled calls to focus on the quality of ANC services. However, little conceptual or empirical work exists on the measurement of ANC quality at health facilities in low-income countries. We developed a classification tool and assessed the level of ANC service provision at health facilities in Zambia on a national scale and compared this to the quality of ANC received by expectant mothers.Methods: We analysed two national datasets with detailed antenatal provider and user information, the 2005 Zambia Health Facility Census and the 2007 Zambia Demographic and Health Survey (DHS), to describe the level of ANC service provision at 1,299 antenatal facilities in 2005 and the quality of ANC received by 4,148 mothers between 2002 and 2007.Results: We found that only 45 antenatal facilities (3%) fulfilled our developed criteria for optimum ANC service, while 47% of facilities provided adequate service, and the remaining 50% offered inadequate service. Although 94% of mothers reported at least one ANC visit with a skilled health worker and 60% attended at least four visits, only 29% of mothers received good quality ANC, and only 8% of mothers received good quality ANC and attended in the first trimester.Conclusions: DHS data can be used to monitor ” effective ANC coverage” which can be far below ANC coverage as estimated by current indicators. This ” quality gap” indicates missed opportunities at ANC for delivering effective interventions. Evaluating the level of ANC provision at health facilities is an efficient way to detect where deficiencies are located in the system and could serve as a monitoring tool to evaluate country progress. © 2012 Kyei et al.; licensee BioMed Central Ltd.
The Health Facility Census (HFC), developed by the Japan International Cooperation Agency, is a national-level assessment of the functionality of health system assets, providing extensive information useful for health system planning [32]. There is no sampling; instead, information is collected on every facility. The 2005 Zambia HFC [33] covered all public and missionary health facilities at all levels in the country, as well as major private facilities, in total over 1400 facilities. The assessment included self-reported availability of interventions, a head count of health workers and verification of the condition of the infrastructure and certain utilities. The Zambian HFC has been used previously to study access to delivery care [34,35]. The 2007 Zambia Demographic and Health Survey (DHS), a nationally representative household cluster survey, interviewed 7,146 women aged 15–49 years and 6,500 men aged 15–59 years across Zambia. All women who had given birth in the five years preceding the survey were asked a range of questions about maternal care. Detailed information about antenatal care was only collected for the last live birth in that period [15]. The dataset contains antenatal information on 4,148 births (counting multiple pregnancies as one birth) that occurred between 2002 and 2007. We adopted a definition of quality based on the frameworks of Donabedian [20-22] and Maxwell [23] and focused on the process attributes of ANC, particularly on the technical aspects of the provider-client interaction, in order to judge whether the new focused ANC requirements [12,36] were fulfilled. Since “structure” is mainly considered as the conduit through which care takes place, rather than a true component of quality of care [37], we only included the availability of skilled health workers into our definition. The availability of certain equipment and drugs are implicit in the performance of certain functions. Information collected on ANC provision in a health facility included the availability of the service, the number of ANC days per week, performance of screening tests for anaemia, syphilis, urine protein and urine sugar, tetanus toxoid vaccination, folate/iron supplementation, intermittent presumptive treatment (IPT) of malaria, voluntary counseling and testing (VCT) for HIV, prevention of mother-to-child transmission (PMTCT) of HIV, routine discussion of family planning with pregnant women, and ANC outreach services. Based on the recommended interventions for pregnancy care [38], initial data analysis and professional judgment, including feedback from several maternal health researchers and medical practitioners with experience in low-income countries, we developed a framework for assessing the level of ANC provision. This combined availability of five key antenatal functions, five relevant screening tests, availability of skilled health workers according to country definition (doctors, midwives/nurses & clinical officers) [15], as well as availability of other pertinent services in the continuum of care (delivery care, PMTCT), thus representing various dimensions of quality of care as suggested by Maxwell and adopted by WHO [23-25]. In this study, we refer to the quality aspects of ANC provision at health facilities as “level of service provision” to avoid confusion with the quality aspects of ANC received by women as reported in the DHS (next sub-chapter). We first evaluated the level of service provision for four core ANC quality attributes individually (days per week with ANC provision, availability of skilled health workers, ANC functions, and ANC screening tests) and then combined them to assess the overall level of ANC provision at all Zambian ANC facilities. Table Table11 shows the framework used to classify levels of service provision. Although we considered them important, we were unable to include provision of postnatal care, blood group and rhesus testing, provision of ANC outreach services and routine family planning information at ANC due to problems with how the questions were recorded or because these questions were not asked in all facility types in the HFC. Framework for the classification of level of ANC provision in Zambian health facilities a Doctor, nurse/midwife, clinical officer. VCT, voluntary counseling and testing; IPT, intermittent preventive treatment; PMTCT, prevention of mother to child transmission. A facility was considered to provide an optimum level of ANC service if providing at least three days of ANC per week, performing at least three screening tests including urine protein testing, offering all five key ANC functions and having three or more skilled health workers registered at the facility, in addition to offering Emergency Obstetric Care (EmOC) referral and delivery services. A facility was classified as providing an adequate level of service if failing in any of the criteria for optimum level but providing at least one day of ANC per week, performing at least one screening test, at least three ANC functions and having at least one registered skilled worker. Failing in any of these criteria, a facility was considered offering an inadequate level of ANC services. The 2007 Zambia DHS collected details on ANC received in the five years prior to the survey for all last births to the mothers interviewed [15]. Information was available on 4148 births and was used to describe the characteristics of ANC received by expectant mothers in Zambia. This included information on ANC use, type of ANC provider, place of ANC provision, number of ANC visits, timing of first ANC visit and on the interventions received. Information was available on the following interventions [15]: weight measurement, height measurement, blood pressure measurement, urine sample taken for analysis, blood sample taken for analysis, offered VCT, iron supplementation provided, antimalarial drug provided for IPT, birth preparedness plan discussed, treatment provided for intestinal parasites and tetanus toxoid vaccination. In the few instances where information was missing on an item or mothers did not know, we assumed a skilled provider was not seen, the intervention was not received, etc. Having received “good quality ANC” was defined as having attended at least the recommended four ANC visits with a skilled provider and received at least eight antenatal interventions, while our definition of “moderate quality ANC” required four visits with a skilled provider and five to seven antenatal interventions.
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