Integration of antenatal care services with health programmes in low– and middle–income countries: systematic review

Abstract

BackgroundAntenatal care (ANC) presents a potentially valuable platform for integrated delivery of additional health services for pregnant women–services that are vital to reduce the persistently high rates of maternal and neonatal mortality in low– and middle–income countries (LMICs). However, there is limited evidence on the impact of integrating health services with ANC to guide policy. This review assesses the impact of integration of postnatal and other health services with ANC on health services uptake and utilisation, health outcomes and user experience of care in LMICs.MethodsCochrane Library, MEDLINE, Embase, CINAHL Plus, POPLINE and Global Health were searched for studies that compared integrated models for delivery of postnatal and other health services with ANC to non–integrated models. Risk of bias of included studies was assessed using the Cochrane Effective Practice and Organisation of Care (EPOC) criteria and the Newcastle–Ottawa Scale, depending on the study design. Due to high heterogeneity no meta–analysis could be conducted. Results are presented narratively.Findings12 studies were included in the review. Limited evidence, with moderate– to high–risk of bias, suggests that integrated service delivery results in improved uptake of essential health services for women, earlier initiation of treatment, and better health outcomes. Women also reported improved satisfaction with integrated services.ConclusionsThe reported evidence is largely based on non–randomised studies with poor generalizability, and therefore offers very limited policy guidance. More rigorously conducted and geographically diverse studies are needed to better ascertain and quantify the health and economic benefits of integrating health services with ANC.

Birth asphyxia at a district hospital in Kigali, Rwanda

“…Two other studies address normal term neonates and BA prevalence. [9,26,] Though poor ANC attendance has been associated with poor pregnancy outcomes, [27,28] in this study population, women who had <4 ANC visits had a lower BA rate (36.8%) than those attending 4 ANC visits who had a higher BA rate (45.5%). Therefore, the higher number of ANC visits offered no apparent protective effect.…”

A framework for healthcare interventions to address maternal morbidity

“…WHO has long recognized that integration of antenatal care with other health services is a key strategy to reduce missed opportunities for patient contact, and to effectively address the comprehensive health needs of women. About 70% of pregnant women in LMICs have at least one antenatal visit, providing a crucial opportunity for providing integrated services …”

“…Antenatal care has traditionally been bundled with prevention of mother‐to‐child HIV transmission services and syphilis screening . Countries can capitalize on the relatively high ANC coverage in many LMICs by further integrating services related to chronic diseases.…”

“…About 70% of pregnant women in LMICs have at least one antenatal visit, providing a crucial opportunity for providing integrated services. 46 Antenatal care has traditionally been bundled with prevention of mother-to-child HIV transmission services and syphilis screening. 46 Countries can capitalize on the relatively high ANC coverage in many LMICs by further integrating services related to chronic diseases.…”

“…46 Antenatal care has traditionally been bundled with prevention of mother-to-child HIV transmission services and syphilis screening. 46 Countries can capitalize on the relatively high ANC coverage in many LMICs by further integrating services related to chronic diseases. A successful example comes from a collaboration between the Colombian government, Accenture Development Partnerships, and the World Diabetes Foundation, and the project has raised NCD awareness and capacity building to integrate GDM care into existing antenatal services.…”