Antenatal care quality assessment methods in India: a systematic review

INTRODUCTION

Antenatal care (ANC) is one of the most important pillars in improving maternal health. Within the continuum of reproductive health care, ANC provides a platform for important health-care functions, including health promotion, screening and diagnosis, and disease prevention. In addition, ANC also provides the opportunity to communicate with and support women, families and communities at a critical time in the course of a woman’s life.¹ The World Health Organisation (WHO) gave positive pregnancy experience the guidelines in 2016.¹

Recently the need for quality improvement of ANC has been identified and is being considered as a priority. The basic ANC should not just be limited to the number of visits but the quality of care in those visits as well as patients' experience during the entire antenatal period should be a priority to achieve the goals set for maternal health outcomes. WHO has also very recently highlighted emerging priorities and unfinished agenda for improving the quality of care in low and middle-income countries, regarding maternal, newborn and child health.²

Improving the ability to consistently provide good quality care-care that is effective, safe, people centered, timely, equitable, integrated, and efficient-is fundamental to universal health coverage.² Quality of care is dependent on the provision and content of ANC, as well as women’s experiences of ANC, which rely on the availability of the health provider and physical resources.³ Continuous monitoring of ANC visits is necessary to monitor the overall quality of antenatal services that are being provided by the health care facilities. Although monitoring the number of visits or contacts remains important, the new WHO ANC guidelines’ focus is on the quality and content of the care received.⁴

While increased ANC coverage is a welcome development, ANC coverage alone cannot guarantee success of ANC services. Besides increase in coverage, provision of Quality ANC (QANC) services will have the greatest impact on women accessing these services.⁵ There is a considerable gap between the coverage of ANC and quality of ANC in India. The words coverage and quality cannot be used interchangeably, as coverage does not provide any detail of quality of services provided by the health system. Furthermore, achieving minimum number of ANC visits also does not ensure that necessary routine services have been provided in terms of good quality as well as timeliness. It is not mere contact that results in better outcomes; it is actual substance of care delivered.⁶ ANC quality (ANC-Q) is not one-dimensional. Therefore, while assessing the ANC-Q, content and quality of services must be considered, not just number of visits.

We did review of literature regarding quality of ANC assessment in India published from 2017 (after WHO’s positive pregnancy guidelines recommendations in 2016) to 2023.

METHODS

Literature review done by 2 researchers independently, to search quality assessment studies for ANC in India with the aim to identify methods (tools or criteria or scoring system) that are being followed for assessment.

Search strategy

Searched electronic database: PubMed/Medline, PubMed central, Embase and ScienceDirect. Search terms: 'antenatal care’, ‘prenatal care', ‘quality of antenatal care', ‘quality of prenatal care’, ‘quality of care’, ‘India’, ‘quality assessment of antenatal or prenatal care in India’. These keywords were combined to locate the relevant literatures by using “or” to broaden the searches and using “and” to narrow down the searches specifically relevant to our aim. We searched for the articles published from January 2017 to the December 2023. Search terms could be found in title or abstract of article.

Inclusion criteria

We included studies assessing quality of ANC specifically in India. Research articles in which a specific-criteria or scoring system or tool for quality of ANC was mentioned and studies from January 2017-December 2023 (After WHO’s positive pregnancy experience guidelines, 2016) were included.

Exclusion criteria

Articles that had described quality of ANC in a descriptive manner and articles published in languages other than English were excluded from the study.

Routine ANC indicators are already there but what should be the value of those indicators to be called ANC as a good QANC is not clear. Therefore precisely, we did a search for criteria and not for the indicators. There was no restriction to particular study design. Primary or secondary data-based studies, both were included. Studies which had described ANC in descriptive manner (i.e. proportions of women) were excluded as main purpose of this review was to identify various tools/criteria of ANC quality assessment in India. After reviewing databases, we found 13 studies that fit in our inclusion criteria (studies from January 2017-December 2023, conducted in India, measuring quality of ANC by certain criteria).

Analysis

The information extracted included title, author, year of publication and specifically, method of assessment for quality of ANC (descriptive explanation, specific criteria or scoring system). Two authors extracted the information independently. Both created a separate collection/folder of articles titled, ‘ANC-Q papers’ in their PubMed accounts. We used the Mendeley reference manager to keep track of references. We differentiated the services that are being considered for assessment and the criteria that is describing the ANC-Q. After discussion among authors, it was decided to present results under headings ‘author and year of publication’, ‘content of ANC’ and ‘quality assessment criteria’ in a tabular form.

RESULTS

Results have been presented in the form of a Table. Separate columns have been made for ‘content’ of ANC and the quality assessment ‘criteria’ in Table 1.

Key findings

This review identified the ANC quality assessment methods in India. We have differentiated the ‘content’ considered and ‘criteria’ set of defining QANC. The studies mentioned in Table 1 provide a comprehensive overview of the assessment of ANC in terms of both quantity and quality across different regions of India.

Dimensions of ANC-Q: We found two dimensions for assessing ANC Quality: 1) ANC visits-their number and time of registration. 2) The services provided during ANC visits (their quality, timing etc.)

In reviewed studies, the authors have assessed ANCQ in both dimensions.

Quality assessment criteria: We found broadly three types of approaches for quality assessment of ANC: 1) Making categories depending on the content of ANC visits and number of visits. (e.g. adequate ANC, inadequate ANC, no ANC etc.).^7,9,17 2) A scoring system approach where authors have given scores to various ANC services and then set a particular cut off to be called as QANC.^8,11,16 3) Combination of both (categories formed on the basis of a range of score).^18,19

Some studies have assessed in the form of quality and quantity, as presented as ‘low quantity-low quality’, ‘low quantity-high quality’ and so on.^12,18

DISCUSSION

ANC is a multidimensional concept. It is much more than the minimum number of visits. The overall experience of women and services being provided by healthcare facility during those ANC visits are equally important. We have divided the discussion in three subheadings-ANC visits, content of ANC and terminology used during ANCQ assessment.

ANC visits

ANC visits are essential for keeping an eye on the developing fetus's health as well as the pregnant woman's. During these appointments, medical professionals can evaluate the mother's health, identify any possible issues early on, and administer the required treatments to guarantee a safe pregnancy and birth. Different health systems propose different numbers of ANC visits. Nonetheless, the majority advise a minimal quantity of visits to guarantee sufficient observation during the entire pregnancy. For instance, certain country guidelines may suggest fewer ANC visits than the WHO's minimum recommendation of eight visits.

The number and timing of ANC visits both equally matter. Among the studies included, only one study has considered 8 or more antenatal visits⁷ (which is suggested in WHO guidelines for positive pregnancy experience, 2016). There is still a need for improvement in the number of routine ANC visits in India, where 4 or more visits are considered as the minimum number of visits required in the antenatal period. Apparently, because of this reason, all other studies have considered 4 or more visits for quality assessment. The timing of registration of pregnancy is also an important factor in ANC. Rustagi et al and Singh et al considered early registration of pregnancy as content for ANC-Q assessment.^13,15

Number of ANC visits cannot be used as proxy for ANC-Q. Quality of care provided during these visits (e.g. how the patient was attended, counselling services, timing of immunization services, ultrasounds etc.) should be considered for better quality assessment. Almost every study included services during ANC visits which we have summarized under heading ‘content of ANC’ (Table 1).

ANC content

Here, the term "ANC content" describes the particular services offered during antenatal visits. These elements usually consist of a variety of interventions, screenings, tests, and preventive measures meant to improve the health of both the mother and the fetus. Physical examinations (such as blood pressure monitoring and weight measurement), diagnostic tests (such as collecting urine and blood samples), preventive measures (such as tetanus toxoid immunization and iron/folic acid supplementation), and health education and counseling on pregnancy-related topics (such as breastfeeding, nutrition, and complications) are considered as ANC content. However, different studies have considered different groups of these elements as content of ANC visits for quality assessment. For example, Rustagi et al has called early pregnancy registration, tetanus toxoid immunization, and iron/folic acid supplementation for at least 100 days, as ‘complete ANC’ where as Dixit et al has included a set of services, where ‘full ANC’ was considered as the combination of at least eight ANC visits and procedures like- tetanus vaccination, collection urine, and blood, weight, height and blood pressure measurement, counseling on pregnancy-related complications and breastfeeding for quality assessment.^7,13 One factor that only few studies have included is the counselling services with mention of specific areas like mental health, breast feeding, nutritional counselling etc. E.g. Singh et al considered whether counseling was given regarding specific symptoms of pregnancy complications and information about the place to approach for, if any complications arise.¹⁵ Number of ultrasounds done in the antenatal period was also missing in the ‘content’ of some studies.⁹

Terminology

Terms like, ‘full ANC, ’complete ANC, ‘comprehensive ANC, ‘appropriate ANC, ‘adequate ANC, ‘quality ANC are being used in the literature. To keep things simple and uniform, we believe that a standard term should be set which is then used uniformly throughout the country regarding quality of ANC services. Furthermore, the researchers must have clarity on the term ‘coverage’, ‘utilisation’ and ‘quality’ regarding ANC.

Though there can be some overlap between terms ‘utilisation’ and ‘quality’ of ANC, quality of care is more related to the healthcare system. It tells the performance from the provider's end. Contents like working of the equipments, record keeping etc. are more relevant for ANC quality assessment as compared to utilisation.

Overall, most of the studies have considered a particular set of services suggested by WHO guidelines, though the set of services varies among studies. Furthermore, every group of authors have made their own criteria and terminology for defining ANC-Q. This is apparently because there is no standardized criteria and definition for antenatal quality assessment in India.

Strengths and limitations

The strength of this review is a systematic search of studies for a clearly defined aim. We were very specific regarding inclusion of studies that measure ‘quality’ of ANC and not the ‘coverage’ and ‘utilisation’. We have reviewed and presented the quality assessment approaches in a comprehensive yet concise way. However, there are several limitations to this review. As there may be an overlap between the terms ‘utilisation’ and ‘quality’, this review may not have captured studies that have indirectly measured quality but were titled as ‘utilisation of ANC services’. In addition, because of being country specific, the key findings do not represent other low-and middle- income countries. This review also suffers from language bias as studies published in English language only were included.

CONCLUSION

The literature on quality assessment of ANC in India is scarce. Quality of care has been one of the top priorities in healthcare. A number of studies are done on ANC ‘coverage’ and ANC ‘utilisation’, both of which are different from ANC ‘quality’. More studies should be done specifically on ANC-Q assessment using a standardized criterion. Other than routine services, infrastructure of health facilities, working equipment and record maintenance should also be included while assessing the quality of ANC services. Furthermore, we believe that there should be a standard quality of care assessment method to assess ANC-Q that can be applied to the country in both public as well private sectors. A uniform standard criterion that is applicable throughout India shall be a simpler way for quality assessment. It will be quick and easy to compare and interpret.

This systematic review has summarised several quality assessment methods of ANC in India. It shall help other researchers to consult the approaches mentioned in this article for further quality assessment studies. It clearly is evidence that emphasizes need for setting a standard terminology and criteria that can be used and followed throughout country (public as well as private sectors). A standard criterion shall help in assessment and monitoring of ANC-Q in a simpler manner. This will be a great step in raising quality of ANC standards in the country.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. World Health Organisation. WHO recommendations on antenatal care for a positive pregnancy experience, 2016. WHO, Geneva. Available at: https://www.who.int/publications/i/item/9789241549912. Accessed on 2 January 2024.
2. 2. World Health Organisation. Health service quality must be a priority, not an afterthought: New Collection on quality of care. Available at: https://www.who.int/news/item/11-12-2023-health-service-quality-must-be-a-priority--not-an-afterthought--new-collection-on-quality-of-care. Assessed on 28 December, 2023.
3. 3. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Provision and uptake of routine antenatal services: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2019;6(6):CD012392.
4. 4. Lattof SR, Moran AC, Kidula N, Ann-Beth M, Chandani AJ, Theresa D, et al. Implementation of the new WHO antenatal care model for a positive pregnancy experience: a monitoring framework. BMJ Global Health. 2020;5(6):e002605.
5. 5. Fagbamigbe AF, Idemudia ES. Assessment of quality of antenatal care services in Nigeria: evidence from a population-based survey. Reprod Health. 2015;12:88.
6. 6. Hodgins S, D’Agostino A. The quality-coverage gap in antenatal care: toward better measurement of effective coverage. Glob Health Sci Pract. 2014;2(2):173-81.
7. 7. Dixit P, Khan J, Dwivedi LK, Gupta A. Dimensions of antenatal care service and the alacrity of mothers towards institutional delivery in South and South East Asia. PLoS One. 2017;12(7):e0181793.
8. 8. Pricilla RA, David KV, Siva R, Vimala TJ, Rahman SP, Angeline N. Quality of Antenatal Care Provided by Nurse Midwives in an Urban Health Centre with Regard to Low-Risk Antenatal Mothers. Indian J Community Med. 2017;42(1):37-42.
9. 9. Singh L, Dubey R, Singh S, Goel R, Nair S, Singh PK. Measuring quality of antenatal care: a secondary analysis of national survey data from India. BJOG. 2019;126(4):7-13.
10. 10. Kumar G, Choudhary TS, Srivastava A, Upadhyay RP, Taneja S, Bahl R, et al. Utilisation, equity and determinants of full antenatal care in India: analysis from the National Family Health Survey 4. BMC Pregnancy Childbirth. 2019;19(1):327.
11. 11. Silverman JG, Fonseka RW, Dehingia N, Boyce SC, Chandurkar D, Singh K, et al. Associations between recent intimate partner violence and receipt and quality of perinatal health services in Uttar Pradesh. PLoS One. 2020;15(5):e0232079.
12. 12. Sumanta N, Samuel S, Nguyen P, Menon P. Both Quantity and Quality of Antenatal Care Matter for Child Birthweight: An Analysis of Nationally Representative Data from Bangladesh, India, Nepal, and Pakistan. Current Develop Nutrit. 2021;5:794.
13. 13. Rustagi R, Basu S, Garg S, Singh MM, Mala YM. Utilization of antenatal care services and its sociodemographic correlates in urban and rural areas in Delhi, India. Eur J Midwifery. 2021;10(5):40.
14. 14. Dandona R, Majumder M, Akbar M, Bhattacharya D, Nanda P, Kumar GA, et al. Assessment of quality of antenatal care services in public sector facilities in India. BMJ Open. 2022;12(12):e065200.
15. 15. Singh L, Bubey R, Singh PK, Nair S, Rai RK, Vardhana Rao MV, et al. Coverage of Quality Maternal and Newborn Healthcare Services in India: Examining Dropouts, Disparity and Determinants. Ann Glob Health. 2022;88(1):39.
16. 16. Lee HY, Rana MJ, Kim R, Subramanian SV. Small Area Variation in the Quality of Maternal and Newborn Care in India. JAMA Netw Open. 2022;5(11):e2242666.
17. 17. Nagdev N, Ogbo FA, Dhami MV, Diallo T, Lim D, Agho KE et al. Factors associated with inadequate receipt of components and non-use of antenatal care services in India: a regional analysis. BMC Public Health. 2023;23(1):6.
18. 18. Neupane S, Scott S, Piwoz E, Kim SS, Menon P, Nguyen PH. More is not enough: High quantity and high quality antenatal care are both needed to prevent low birthweight in South Asia. PLOS Glob Public Health. 2023;3(6):e0001991.
19. 19. Girotra S, Malik M, Roy S, Basu S. Utilization and determinants of adequate quality antenatal care services in India: evidence from the National Family Health Survey (NFHS-5) (2019-21). BMC Pregnancy Childbirth. 2023;23(1):800.