Gaps and challenges underpinning the first analysis of global coverage of early antenatal care
Authors: Camille Raynes-Greenow
Journal: The Lancet Global Health (2017)

The importance of antenatal care cannot be underestimated. Antenatal care coverage, defined as a minimum of four antenatal care visits, has been used globally as a benchmark of performance of maternal health programmes, was included in the Millennium Development Goals (MDG),1UNMillennium Development Goals Report 2015. United Nations, New York2015http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20(July%201).pdfGoogle Scholar and is key to goal 3 of the Sustainable Development Goals. However, despite the recognition of the importance of initiation of antenatal care in the first trimester (known as early antenatal care), this provision has not been used as an indicator nor previously evaluated.2Family Care InternationalSafe Motherhood A Review: The Safe Motherhood Initiative 1987–2005. Family Care International, New York2007Google Scholar The updated 2016 WHO guidelines for antenatal care3WHOWHO recommendations on antenatal care for a postitive pregnancy experience. World Health Organization, Geneva2016Google Scholar now recommend eight contacts with initiation of early antenatal care between 8 and 12 weeks' gestation. In The Lancet Global Health, Ann-Beth Moller and colleagues4Moller A-B Petzold M Chou D Say L Early antenatal care visit: a systematic analysis of regional and global levels and trends of coverage from 1990 to 2013.Lancet Glob Health. 2017; 5: e977-e983Summary Full Text Full Text PDF PubMed Scopus (141) Google Scholar describe for the first time a global analysis of the coverage of early antenatal care. They systematically searched for data at the national level, including an exhaustive review of population-based survey data, routine health information system reports, perinatal surveys, and a hand search for perinatal studies. Women aged 15–49 years who had a livebirth and who had had an antenatal care visit at less than 14 weeks' gestation were included in the analysis. The investigators compared national and regional estimates across both the World Bank income groups and the MDG regions. A major limitation was the heterogeneity of the data collected, with wide variability in quality and availability. Nevertheless, using data from 183 countries they found a relative increase of 43·3% in the global coverage of early antenatal care visits, from 41% in 1990 to 59% in 2013. However, and unsurprisingly, there were great disparities between developed and developing regions, with low coverage in Oceania (19%) and sub-Saharan Africa (25%) and high coverage in eastern Asia (97%). Both the very low coverage and the great disparity are concerning, and despite the MDG improvements, women who are already disadvantaged and at the greatest risk of poor pregnancy outcomes seem not to be accessing early antenatal care. Although these descriptive data are important, two messages underpinning these findings are key in this paper. The first message is the important opportunity that early antenatal care offers to the health-care sector to engage women for health promotion, prevention, screening, and disease detection. The second message is the critical need for strengthening data collection. The incorporation of health promotion, prevention, screening, and disease detection into routine antenatal care requires an evolution of antenatal care and adoption of an approach that is underpinned by a more public health approach. The early antenatal care visit is the ideal time for multidisciplinary care providers to intervene with health promotion activities and establish a baseline understanding of the pregnant woman's pre-existing health conditions. This intervention is particularly important with the emerging prevalence of non-communicable diseases in women of reproductive age, known as the "obstetric transition".5Souza JP Tunçalp Ö Vogel JP et al.Obstetric transition: the pathway towards ending preventable maternal deaths.BJOG. 2014; 121: 1-4Crossref PubMed Scopus (140) Google Scholar This change in the underlying morbidity of women is recognised in high-income countries6WHOGlobal status report on noncommunicable diseases 2010. World Health Organization, Geneva2011Google Scholar but has also been reported in low-income and middle-income countries such as India where, for example, the prevalence of overweight and obesity in women of reproductive age living in urban settings is greater than 23%.7Gouda J Prusty RK Overweight and Obesity among Women by Economic Stratum in Urban India.J Health Popul Nutr. 2014; 32: 79-88PubMed Google Scholar Early antenatal care can be used to monitor the morbidity transition and preempt the modifications in provision of health-care services that are required to manage this change. This monitoring will also require high-quality data. Gaps and inconsistencies in data persist at all levels, yet investment in data collection can lead to improved outcomes at the population level.8Phillips DE AbouZahr C Lopez AD et al.Are well functioning civil registration and vital statistics systems associated with better health outcomes?.Lancet. 2015; 386: 1386-1394Summary Full Text Full Text PDF PubMed Scopus (88) Google Scholar In many countries, demographic and health surveys are the best and only health and demographic data available. However, for many measures such as stillbirths, the gaps and inconsistencies make these data difficult to use and limit evaluation of health-care services, thus diminishing opportunities for programmatic intervention and resulting in a poor return on investment.9Christou A Dibley MJ Raynes-Greenow C Beyond counting stillbirths to understanding their determinants in low- and middle-income countries: a systematic assessment of stillbirth data availability in household surveys.Trop Med Int Health. 2017; 22: 294-311Crossref PubMed Scopus (18) Google Scholar Moller and colleagues4Moller A-B Petzold M Chou D Say L Early antenatal care visit: a systematic analysis of regional and global levels and trends of coverage from 1990 to 2013.Lancet Glob Health. 2017; 5: e977-e983Summary Full Text Full Text PDF PubMed Scopus (141) Google Scholar are the first to estimate global coverage of early antenatal care, but there remain many unanswered questions. We do not know whether early antenatal care leads to continued antenatal care throughout pregnancy. Global coverage of four antenatal care visits, the pre-2016 recommendation, was higher than coverage of early antenatal care (64% vs 59%), suggesting that many women were starting antenatal care late but at least attending for four visits. Identifying the barriers to early antenatal care is crucial, and a conceptual approach similar to the theoretical model used for referral (ie, the three-delays model) is needed.10Thaddeus S Maine D Too far to walk: Maternal mortality in context.Soc Sci Med. 1994; 38: 1091-1110Crossref PubMed Scopus (1709) Google Scholar The major challenge now is to provide high-quality care and collect high-quality data. Neither starting early nor receiving all of the recommended number of antenatal care visits is indicative of receiving good quality care. The new antenatal care guidelines have a strong focus on quality, which includes "the ability of health-care practitioners to explain and deliver biomedical tests and effective preventive care in a knowledgeable, supportive and respectful manner".3WHOWHO recommendations on antenatal care for a postitive pregnancy experience. World Health Organization, Geneva2016Google Scholar Engaging women with respect in early antenatal care is a basic human right but also the beginning of the continuum of care for mother and child to improve their health over the life course.11UNThe Global Strategy for Women's, Children's and Adolescents' Health (2016–2030). United Nations, New York2010Google Scholar I declare no competing interests. Early antenatal care visit: a systematic analysis of regional and global levels and trends of coverage from 1990 to 2013Progress in the coverage of early antenatal care visits has been achieved but coverage is still far from universal. Substantial inequity exists in coverage both within regions and between income groups. The absence of data in many countries is of concern and efforts should be made to collect and report coverage of early antenatal care visits to enable better monitoring and evaluation. Full-Text PDF Open Access