Improving quality of antenatal care through provision of medical supply kits
Authors: Chigozie Jesse Uneke, Henry Chukwuemeka Uro-Chukwu
Journal: The Lancet Global Health (2017)

Recent statistics from WHO show that the global maternal health situation is deplorable: up to 830 women died of pregnancy and childbirth-related complications every day in 2015.1WHOMaternal mortality. Global Health Observatory (GHO) data.http://www.who.int/gho/maternal_health/mortality/maternal_mortality_text/en/Date: 2017Google Scholar According to the report, nearly all of these deaths occurred in resource-poor settings where health systems are weak and most deaths could have been prevented.1WHOMaternal mortality. Global Health Observatory (GHO) data.http://www.who.int/gho/maternal_health/mortality/maternal_mortality_text/en/Date: 2017Google Scholar The WHO African Region is reported to bear the highest burden of global maternal deaths, with almost two-thirds of global maternal deaths in 2015 recorded in the region.1WHOMaternal mortality. Global Health Observatory (GHO) data.http://www.who.int/gho/maternal_health/mortality/maternal_mortality_text/en/Date: 2017Google Scholar, 2WHOMaternal mortality Data by WHO region. Global Health Observatory data repository.http://apps.who.int/gho/data/view.main.1370?lang=enDate: 2017Google Scholar Although the maternal mortality ratio in the WHO African Region reduced from 620 per 100 000 livebirths in 2010 to 542 per 100 000 livebirths in 2015,2WHOMaternal mortality Data by WHO region. Global Health Observatory data repository.http://apps.who.int/gho/data/view.main.1370?lang=enDate: 2017Google Scholar this figure is still unacceptably high. Since most causes of maternal deaths are preventable, there is an urgent need for deployment of interventions that are not only robustly informed by high-quality research evidence but also take into account the contextual requirements of low-income settings. Quality health care delivered during pregnancy and childbirth have been shown to prevent most of the adverse outcomes of pregnancy, and antenatal care provides an important platform to achieve a reduction in pregnancy-related mortality and morbidity.3Tunçalp Ö Pena-Rosas JP Lawrie T et al.WHO recommendations on antenatal care for a positive pregnancy experience-going beyond survival.BJOG. 2017; 124: 860-862Crossref PubMed Scopus (147) Google Scholar WHO notes that antenatal care not only serves as a platform for health promotion, prevention, screening, and diagnosis of diseases but also as an opportunity to provide pregnant women with the social and psychological support necessary for healthy motherhood.4WHOWHO recommendations on antenatal care for a positive pregnancy experience. World Health Organization, Geneva2016Google Scholar In a report, Tunçalp and colleagues3Tunçalp Ö Pena-Rosas JP Lawrie T et al.WHO recommendations on antenatal care for a positive pregnancy experience-going beyond survival.BJOG. 2017; 124: 860-862Crossref PubMed Scopus (147) Google Scholar argue that whenever timely and appropriate evidence-based health-care practices are implemented during antenatal care, they can lead to improvements in maternal and fetal health outcomes. By doing a stepped-wedge cluster-randomised, controlled trial in ten clinics in Mozambique, Ana Pilar Betrán and colleagues5Betrán AP Bergel E Griffin S et al.Provision of medical supply kits to improve quality of antenatal care in Mozambique: a stepped-wedge cluster randomised trial.Lancet Glob Health. 2018; 6: e57-e65Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar evaluated whether a supply chain strategy based on the provision of kits delivered during antenatal care can improve quality of care. With a maternal mortality ratio of 489 per 100 000 livebirths in 2015,2WHOMaternal mortality Data by WHO region. Global Health Observatory data repository.http://apps.who.int/gho/data/view.main.1370?lang=enDate: 2017Google Scholar maternal health outcomes in Mozambique remain unacceptably high. The results of this study, published in The Lancet Global Health, are therefore very timely because Mozambique and other low-income countries are in dire need of context-specific evidence that can improve antenatal care, since antenatal care visits represent the major or perhaps only opportunity to deliver quality health services to pregnant women in most of these settings. Until now, there has been a scarcity of evidence on the effect of the delivery of supply kits at point of care on antenatal care visits. Betrán and colleagues5Betrán AP Bergel E Griffin S et al.Provision of medical supply kits to improve quality of antenatal care in Mozambique: a stepped-wedge cluster randomised trial.Lancet Glob Health. 2018; 6: e57-e65Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar show that a supply chain strategy that resolves stockouts at point of care can result in a vast improvement in quality during antenatal care visits, compared with the routine national process for procurement and distribution of supplies. Among the important findings of their study is that the effect was found to be immediate, sustained over time, and with negligible heterogeneity between sites.5Betrán AP Bergel E Griffin S et al.Provision of medical supply kits to improve quality of antenatal care in Mozambique: a stepped-wedge cluster randomised trial.Lancet Glob Health. 2018; 6: e57-e65Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar Although the authors noted that their intervention improved care for the main drivers of maternal and infant morbidity and mortality, including hypertensive disorders of pregnancy, anaemia, and maternal infections,5Betrán AP Bergel E Griffin S et al.Provision of medical supply kits to improve quality of antenatal care in Mozambique: a stepped-wedge cluster randomised trial.Lancet Glob Health. 2018; 6: e57-e65Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar it is not clear whether the same result will be obtained in other low-income countries with different socioeconomic and cultural characteristics. Furthermore, delivery of antenatal care supply kits at point of care is a complex intervention package with multiple components, and the individual effects of the various components can have a far-reaching effect on the outcome of the intervention. One clear limitation of the study was that it did not assess the contributory role of some of the essential factors affecting the delivery of supply kits at point of care. Apart from availability of test kits, factors such as low levels of coverage of antenatal care and the low quality of care—which are prominent features of the Mozambique health system6Biza A Jille-Traas I Colomar M et al.Challenges and opportunities for implementing evidence-based antenatal care in Mozambique: a qualitative study.BMC Pregnancy Childbirth. 2015; 15: 200Crossref PubMed Scopus (27) Google Scholar—were not taken into account in the study. Another important limitation of the study is that the authors did not collect data on final maternal and newborn outcomes and so they could not assess the ultimate effect of the antenatal care practices on mortality or morbidity. These aspects merit full consideration in future studies. Finally, despite the value of the stepped-wedge design used,5Betrán AP Bergel E Griffin S et al.Provision of medical supply kits to improve quality of antenatal care in Mozambique: a stepped-wedge cluster randomised trial.Lancet Glob Health. 2018; 6: e57-e65Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar Prost and co-workers7Prost A Binik A Abubakar I et al.Logistic, ethical, and political dimensions of stepped wedge trials: critical review and case studies.Trials. 2015; 16: 351Crossref PubMed Scopus (58) Google Scholar have pointed out that findings from studies applying this technique should be interpreted with some caution because the technique is particularly susceptible to bias introduced through secular changes in main outcomes. Citing the works of Hussey and Hughes8Hussey MA Hughes JP Design and analysis of stepped wedge cluster randomized trials.Contemp Clin Trials. 2007; 28: 182-191Summary Full Text Full Text PDF PubMed Scopus (780) Google Scholar and of Kotz and colleagues,9Kotz D Spigt M Arts ICW Crutzen R Viechtbauer W Use of the stepped wedge design cannot be recommended: a critical appraisal and comparison with the classic cluster randomized controlled trial design.J Clin Epidemiol. 2012; 65: 1249-1252Summary Full Text Full Text PDF PubMed Scopus (58) Google Scholar Prost and co-workers7Prost A Binik A Abubakar I et al.Logistic, ethical, and political dimensions of stepped wedge trials: critical review and case studies.Trials. 2015; 16: 351Crossref PubMed Scopus (58) Google Scholar have argued that the technique usually takes longer than parallel-group trials to achieve equivalent statistical power. These limitations notwithstanding, this study makes an important contribution to research and clinical practice because the authors have combined a robust experimental design with a large sample size and large effect size to provide a strong level of evidence supporting the effectiveness of the delivery of antenatal care supply kits at point of care. Additional studies are recommended in other low-income settings with health-system and resource challenges similar to those of Mozambique. We declare no competing interests. Provision of medical supply kits to improve quality of antenatal care in Mozambique: a stepped-wedge cluster randomised trialA supply chain strategy that resolves stockouts at point of care can result in a vast improvement in quality during antenatal care visits, when compared with the routine national process for procurement and distribution of supplies. Full-Text PDF Open Access