A new content-qualified antenatal care coverage indicator: Development and validation of a score using national health surveys in low- and middle-income countries

Abstract

Background Good quality antenatal care (ANC) helps reduce adverse maternal and newborn outcomes, especially in low and middle-income countries (LMICs). Most of the currently used ANC indicators only measure contact with services. We aimed to create and validate a new indicator measured as a score, considering both contact and content, that can be used for monitoring. Methods We used data from national surveys conducted in LMICs. Information on ANC was used to build an adequacy score (ANCq) that would be applicable to all women in need of ANC. Cronbach's alpha and factor analysis were used to assess the proposed indicator. We also used a convergent validation approach, exploring the association of our proposed indicator with neonatal mortality. Results The ANCq score was derived from seven variables related to contact with services and content of care ranging from zero to ten. Surveys from 63 countries with all variables were used. The validity assessment showed satisfactory results based on Cronbach's alpha (0.82) and factor analysis. The overall mean of ANCq was 6.7, ranging from 3.5 in Afghanistan to 9.3 in Cuba and the Dominican Republic. In most countries, the ANCq was inversely associated with neonatal mortality and the pooled for all surveys Odds Ratio was 0.90 (95% CI = 0.88-0.92). Conclusions ANCq allows the assessment of ANC in LMICs considering contact with services and content of care. It also presented good validity properties, being a useful tool for assessing ANC coverage and adequacy of care in monitoring and accountability exercises.

Ethnic inequalities in health intervention coverage among Mexican women at the individual and municipality levels

“…The gaps are important because higher ANCq scores are associated with lower neonatal mortality in the offspring. 18 Also, higher ANCq scores have been reported for women living in urban areas, with secondary or more level of education, belonging to wealthier families and with higher empowerment, showing large inequalities across socioeconomic groups between and within countries. 41 SBA coverage showed a significant gap of 20¢8 percent points among municipalities with <10% and ≥40% indigenous population, whereas at individual level the coverage ratio was 0¢83 for indigenous women (a gap of 17¢6 percent points).…”

“…Although the ANCq definition and Mexican guidelines for antenatal care consist of at least two shots of tetanus toxoid during pregnancy. 18,44 we estimated the ANCq score for at least one shot because that was the information was recorded in the survey. Still regarding limitations of the indicators, it is unlikely that this difference would explain the observed gaps.…”

“…Antenatal care was assessed with ANC [18] a content-qualified antenatal care coverage indicator that combines aspects of contact with services with quality of care variables among who delivered a child in the five years before the survey. ANCq is a discrete score ranging from 0 to 10 based on seven variables: first visit in the first trimester of pregnancy (1 point), at least one visit with a skilled provider (2 points), total number of visits (1 point for 1–3 visits, 2 points for 4–7 visits, and 3 points for 8+ visits), blood pressure measured (1 point), blood sample collected (1 point), urine sample collected (1 point), and receiving at least one shot of tetanus toxoid (1 point).…”

“…ANCq is a discrete score ranging from 0 to 10 based on seven variables: first visit in the first trimester of pregnancy (1 point), at least one visit with a skilled provider (2 points), total number of visits (1 point for 1–3 visits, 2 points for 4–7 visits, and 3 points for 8+ visits), blood pressure measured (1 point), blood sample collected (1 point), urine sample collected (1 point), and receiving at least one shot of tetanus toxoid (1 point). The ANCq has been validated, showing significant inverse associations with neonatal mortality [18] . We coded ANCq as a binary variable considering 9 or more ANCq points as an indicator of adequate antenatal care coverage because the national average was 9·1 points.…”

“…The ANCq has been validated, showing significant inverse associations with neonatal mortality. 18 We coded ANCq as a binary variable considering 9 or more ANCq points as an indicator of adequate antenatal care coverage because the national average was 9¢1 points.…”