A new content-qualified antenatal care coverage indicator: development and validation of a score using national health surveys
Authors: Arroyave Luisa , Saad Ghada E , Victora Cesar G , Barros Aluisio J D 
Published: February 2020

AbstractIntroductionGood quality antenatal care (ANC) helps reduce maternal and newborn mortality and morbidity, especially in low and middle-income countries (LMICs). Most studies that attempted to measure ANC quality proposed categorical indicators considering either contact with services or based on content, sometimes both. We aimed to create and validate a new indicator measured as a score, considering both contact and content.MethodsWe used Demographic and Health Surveys and Multiple Indicator Cluster Surveys. Information on ANC contact and content was used to build an adequacy score 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 with neonatal mortality.ResultsThe proposed indicator (ANCq) is derived from the number of visits, timing of the first visit, skill level of the attendant, blood pressure measurement, tetanus toxoid vaccination and collection of blood and urine samples. The validity assessment showed satisfactory results with Cronbach’s alpha coefficient equal to 0.82. ANCq score ranges from 0 to 10. The overall mean of ANCq in 63 LMICs with data was 6.7, ranging from 3.5 in Afghanistan to 9.3 in Cuba and the Dominican Republic. In most countries, higher scores of ANCq were associated with lower neonatal mortality, with pooled odds ratio of 0.90 (95% CI: 0.88-0.92).ConclusionANCq allows the assessment of ANC in LMICs considering contact with services and content of care. ANCq presented good validity properties, being a useful tool for assessing ANC coverage and adequacy of care in monitoring and accountability exercises.Key questionsWhat is already known?Antenatal care (ANC) is an important part of primary healthcare, being associated with reductions in maternal and new-born morbidity and mortality, mainly in low and middle-income countries (LMICs).Several indicators have been proposed to measured ANC quality either through contacts with services or based on content of care, or sometimes both. Several of the proposed indicators are applicable only to women who had at least one ANC visit, and measured quality as a categorical indicator.Consensus on the need for a more comprehensive ANC indicator that is suitable for monitoring progress, including aspects of quality of care.What are the new findings?We proposed a content-qualified ANC indicator in the form of a score, called ANCq. It includes seven different variables related to contact with services and content of care received during pregnancy. The indicator is applicable to all pregnant women.The indicator has good validity properties and was inversely associated with neonatal mortality.There is wide variation across countries regarding the average ANCq score, and large within-country variation at individual level. Latin America and the Caribbean and East Asia and the Pacific are the best performing regions.What do the new findings imply?The proposed indicator provides a standardized and comparable measure of ANC adequacy, allowing for comparisons between and within countries.The indicator can help monitoring ANC progress to all women in need of ANC, with several advantages over currently existing indicators: it is applicable to all pregnant women independent of having accessed ANC services, it includes serval aspects of ANC content and, being a score, provides a gradation of how suitable ANC was.