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The desired results of increasing access and availability of antenatal care (ANC) services may not be realized if the quality of care offered is not adequate. We analyzed the content/ quality of antenatal care to determine whether there are socioeconomic (education and wealth) inequalities in the services provided in 59 low and middle income countries in six WHO regions–Africa, East Asia and Pacific, Europe and Central Asia, Latin America and Caribbean, Middle East and South Asia. We aggregated the most recent (2005–2015) Demographic and Health Survey for each country. The quality of content was measured on eight recommended ANC services–(1) monitoring of blood pressure; (2) tetanus injection; (3) urine analysis for protein; (4) blood test; (5) information about danger signs (6); weight (7); height measurements and (8) provision of iron-folate supplement. Descriptive and Poisson regression techniques were applied to analyse the data. We found considerable wealth and educational differences prior to controlling for known covariates. Between wealth and education, however, the disparities in the latter are larger than the former. Whereas the socioeconomic differences remained at post adjusting for residence, place and number of antenatal care, parity and region, the magnitude of change was minimal. Higher number of ANC content was provided in “other” forms of private facilities; the Latin America and Caribbean region recorded the highest number of content compared to the other regions. The hypothesized socioeconomic status on content/number of ANC services was generally supported, although the associations are substantially constrained to other variables. Efforts are made to increase the number and timing of ANC services; due recognition is needed for the content offered.
We extracted the most recent nation-wide household demographic and health survey (DHS) data from 59 countries in Africa, East Asia and Pacific, Europe and Central Asia, Latin America and Caribbean, Middle East and South Asia, categorizes based on WHO regions. Our analysis was restricted to live births that occurred either in the three or five years to the survey. From the 5th round of the surveys, the DHS programme extended the collection of records on births to those occurring in five, instead of three years. We also limited the analysis of ANC records to the most recent births among women who reported more than one birth in the either three or five year period before the survey. The DHS uses similar sampling processes and interview modules, making cross-country comparability feasible. The methods are documented in previous studies [19,20]. Our dependent variable was the quality of ANC derived from the WHO clinical guidelines for focused ANC, spread across a minimum of four visits [21], which has recently been revised upwards to eight by the WHO [22]. The quality of content was measured on eight WHO recommended ANC service elements–(1) monitoring of blood pressure, (2) tetanus injection, (3) urine analysis for protein, (4) blood test, (5) information about danger signs (6), weight and (7) height measurements and (8) provision of iron-folate supplement. From these eight variables, we created a count score, ranging from 0–8 with eight indicating that the woman received care on all the indicators. Intermittent preventive therapy for malaria was excluded from the analysis since it is not endemic in all the 59 countries considered for our analysis. Following some previous studies [23,24–26], we used household quintile (poorest, poorer, average, richer and richest) and maternal education (no education, primary, secondary and higher) as measures of SES. Apart from these factors, we controlled for residence (urban-rural), parity (nulliparous, multiparous and grandparous), place of ANC–dummy for home, government hospital, government center, maternity clinic, village health unit, other public facility, other private facility, private health center, and religious hospital, timing of first ANC (first trimester; after first trimester) and number of ANC visits (less than 4 and 4 or more), region–grouped based on WHO categorisation. These are: Africa, East Asia and Pacific, Europe and Central Asia, Latin America and Caribbean, Middle East and South Asia. We utilised graphs and Poisson regression to present the data. Specifically, we show mean number of ANC services women received by regions, educational attainment of women as well as their wealth status. We then applied a Poisson regression because the main outcome variable was constructed as count. The coefficients were then Exponentiated into odds ratios since the coefficients say very little in respect of explanation. To adequately explicate the SES inequalities in the quality of service provided, we estimated two models with the first one involving only SES variables while a second was modelled to include the control variables. Next, we computed marginal effects of wealth and education alone and a second set of marginal effects with wealth, education and all the control variables. We applied individual weighting factors to the analysis. The weighting factors are derived from the household weight multiplied by the inverse of the individual response rate of the individual response rate group [27].
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