Quality of antenatal care in Zambia: A national assessment

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Study Justification:
The study aimed to assess the quality of antenatal care (ANC) services in Zambia on a national scale. This was important because although ANC coverage was high, maternal and neonatal mortality rates remained high. The study aimed to address the disconnect between high coverage and high mortality rates by focusing on the quality of ANC services.
Highlights:
– Only 3% of antenatal facilities in Zambia provided optimum ANC service, while 47% provided adequate service, and 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% received good quality ANC and attended in the first trimester.
– The study highlighted the “quality gap” in ANC services, indicating missed opportunities for delivering effective interventions.
– The study emphasized the importance of evaluating the level of ANC provision at health facilities as a monitoring tool to evaluate country progress.
Recommendations:
– Improve the quality of ANC services at health facilities to ensure that all facilities meet the criteria for optimum ANC service provision.
– Increase the percentage of mothers receiving good quality ANC by promoting early attendance and ensuring that all recommended interventions are provided.
– Strengthen ANC outreach services and routine family planning information at ANC facilities.
– Enhance the availability of skilled health workers, particularly doctors, midwives/nurses, and clinical officers, at ANC facilities.
Key Role Players:
– Ministry of Health: Responsible for implementing and overseeing improvements in ANC service quality.
– Health Facility Managers: Responsible for ensuring that ANC facilities meet the criteria for optimum service provision.
– Skilled Health Workers: Doctors, midwives/nurses, and clinical officers who provide ANC services.
– Community Health Workers: Involved in ANC outreach services and promoting early attendance.
– Maternal Health Researchers: Provide expertise and guidance in improving ANC service quality.
Cost Items for Planning Recommendations:
– Training and Capacity Building: Budget for training health workers to improve their skills in providing quality ANC services.
– Infrastructure and Equipment: Budget for improving the infrastructure and ensuring the availability of necessary equipment at ANC facilities.
– Recruitment and Retention: Budget for hiring and retaining skilled health workers, particularly doctors, midwives/nurses, and clinical officers.
– Outreach Services: Budget for expanding ANC outreach services to reach more expectant mothers.
– Information and Education: Budget for developing and disseminating educational materials on ANC and family planning.
– Monitoring and Evaluation: Budget for monitoring and evaluating the implementation and impact of the recommendations.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is strong, but there are some areas for improvement. The study utilized two national datasets to assess the level of antenatal care (ANC) service provision in Zambia and the quality of ANC received by expectant mothers. The study found that only 3% of antenatal facilities fulfilled the criteria for optimum ANC service, indicating a significant quality gap. However, the abstract does not provide specific details about the methodology used to assess ANC quality or the criteria for determining the level of service provision. To improve the evidence, the abstract should include more information about the study design, data collection methods, and the specific criteria used to assess ANC quality. This would provide readers with a clearer understanding of the study’s findings and increase the transparency and replicability of the research.

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.

The study “Quality of antenatal care in Zambia: A national assessment” recommends focusing on improving the quality of antenatal care (ANC) services to improve access to maternal health. The study found that although ANC coverage in Zambia was high, the quality of care received by expectant mothers was inadequate. The following recommendations were made based on the study:

1. Develop and implement a comprehensive ANC quality improvement program: This program should focus on improving the technical aspects of the provider-client interaction during ANC visits. It should include training for healthcare providers on best practices for ANC, including conducting screening tests, providing vaccinations, and offering counseling and testing for HIV and other relevant services.

2. Strengthen the availability of skilled health workers: Efforts should be made to ensure an adequate number of skilled health workers, such as doctors, midwives, and nurses, are available at ANC facilities. This may involve recruiting and training more healthcare professionals or improving the distribution of existing staff.

3. Enhance the availability of essential equipment and supplies: ANC facilities should have access to screening tests, medications, and other essential equipment needed to provide quality care. This may involve improving supply chain management and strengthening procurement systems.

4. Promote early initiation of ANC: Initiatives should be implemented to encourage women to seek ANC early in their pregnancies. This may involve community awareness campaigns, providing incentives for early ANC visits, and improving access to ANC services in rural and remote areas.

5. Monitor and evaluate ANC service provision: Regular monitoring and evaluation should be conducted to ensure that ANC services are meeting the required standards and to identify areas for improvement. This may involve the use of standardized assessment tools and regular data collection.

These recommendations aim to improve the quality of ANC services in Zambia, leading to better maternal and neonatal health outcomes.
AI Innovations Description
The recommendation to improve access to maternal health based on the study “Quality of antenatal care in Zambia: A national assessment” is to focus on improving the quality of antenatal care (ANC) services. The study found that although ANC coverage in Zambia was high, the quality of care received by expectant mothers was inadequate.

To address this issue, the following steps can be taken:

1. Develop and implement a comprehensive ANC quality improvement program: This program should focus on improving the technical aspects of the provider-client interaction during ANC visits. It should include training for healthcare providers on best practices for ANC, including conducting screening tests, providing vaccinations, and offering counseling and testing for HIV and other relevant services.

2. Strengthen the availability of skilled health workers: The study found that the availability of skilled health workers was a key factor in determining the quality of ANC services. Efforts should be made to ensure an adequate number of skilled health workers, such as doctors, midwives, and nurses, are available at ANC facilities. This may involve recruiting and training more healthcare professionals or improving the distribution of existing staff.

3. Enhance the availability of essential equipment and supplies: The study highlighted the importance of having the necessary equipment and supplies for ANC services. Efforts should be made to ensure that ANC facilities have access to screening tests, medications, and other essential equipment needed to provide quality care. This may involve improving supply chain management and strengthening procurement systems.

4. Promote early initiation of ANC: The study found that only a small percentage of expectant mothers received ANC in the first trimester. Initiatives should be implemented to encourage women to seek ANC early in their pregnancies, as early initiation of ANC has been shown to improve maternal and neonatal outcomes. This may involve community awareness campaigns, providing incentives for early ANC visits, and improving access to ANC services in rural and remote areas.

5. Monitor and evaluate ANC service provision: The study emphasized the importance of monitoring the level of ANC provision at health facilities to identify deficiencies and track progress. Regular monitoring and evaluation should be conducted to ensure that ANC services are meeting the required standards and to identify areas for improvement. This may involve the use of standardized assessment tools and regular data collection.

By implementing these recommendations, it is expected that the quality of ANC services in Zambia will improve, leading to better maternal and neonatal health outcomes.
AI Innovations Methodology
To simulate the impact of the main recommendations on improving access to maternal health based on the study “Quality of antenatal care in Zambia: A national assessment,” the following methodology can be used:

1. Data collection: Collect data on the current status of ANC services in Zambia, including the availability of skilled health workers, equipment and supplies, and the timing and quality of ANC visits. This can be done through surveys, interviews, and data analysis of existing health facility and household surveys.

2. Baseline assessment: Assess the current level of ANC service provision at health facilities using the framework developed in the study. This will help identify deficiencies and areas for improvement.

3. Intervention implementation: Implement the recommended interventions, including the development and implementation of a comprehensive ANC quality improvement program, strengthening the availability of skilled health workers, enhancing the availability of essential equipment and supplies, promoting early initiation of ANC, and monitoring and evaluating ANC service provision.

4. Monitoring and evaluation: Regularly monitor and evaluate the implementation of the interventions to assess their impact on improving access to maternal health. This can be done through data collection, analysis, and reporting on key indicators such as ANC coverage, quality of ANC services, timing of ANC visits, and maternal and neonatal health outcomes.

5. Analysis and interpretation: Analyze the data collected to assess the impact of the interventions on improving access to maternal health. Compare the baseline assessment with the post-intervention data to identify any improvements or changes in ANC service provision and maternal health outcomes.

6. Recommendations and action plan: Based on the findings of the analysis, make recommendations for further improvements and develop an action plan for implementing these recommendations. This may involve scaling up successful interventions, addressing remaining gaps, and ensuring sustainability of the improvements.

7. Continuous monitoring and improvement: Continuously monitor and evaluate the implementation of the action plan to ensure that progress is being made and to make any necessary adjustments or modifications. This will help ensure that access to maternal health continues to improve over time.

By following this methodology, policymakers and stakeholders can assess the impact of the recommended interventions on improving access to maternal health in Zambia and make informed decisions for further improvements.

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