Early antenatal care visit as indicator for health equity monitoring
Authors: Oliver Razum, Jürgen Breckenkamp, Theda Borde, Matthias David, Kayvan Bozorgmehr
Journal: The Lancet Global Health (2017)

Early antenatal care visits can be used as an indicator for health equity monitoring in the context of the Sustainable Development Goals (SDGs). National-level surveys, health information system data, and perinatal studies demonstrate substantial differences between countries grouped by income in the proportion of women initiating the first antenatal care visit in the first trimester of pregnancy. In the analysis by Ann-Beth Moller and colleagues (October, 2017),1Moller AB 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 early antenatal care coverage showed an inverse association with country-level income, ranging from more than 80% in high-income countries to 52% in lower-middle-income and 24% in low-income countries in 2013.1Moller AB 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 Mothers' education, other individual socioeconomic factors such as income, and health system factors such as accessibility are also known determinants of early antenatal care attendance. The SDGs are often interpreted as relating mainly to low-income and middle-income countries, based on the argument that high-income countries such as Germany provide universal access to health care.2Busse R Blümel M Knieps F Bärnighausen T Statutory health insurance in Germany: a health system shaped by 135 years of solidarity, self-governance, and competition.Lancet. 2017; 390: 882-897Summary Full Text Full Text PDF PubMed Scopus (151) Google Scholar In an age of increasing migration and population heterogeneity, however, variance in health indicators might be high and underlying determinants more diverse than previously considered. We demonstrate this high variance and increased diversity using data from a perinatal study in Berlin, Germany,3David M Borde T Brenne S et al.Obstetric and perinatal outcomes among immigrant and non-immigrant women in Berlin, Germany.Arch Gynecol Obstet. 2017; 296: 745-762Crossref PubMed Scopus (19) Google Scholar covering 6466 births. 52% of these births are to first-generation immigrant or second-generation women of whom many originate from middle-income countries such as Turkey and Lebanon. Although early antenatal care coverage among non-immigrant, second-generation, and first-generation women who arrived in Germany 5 or more years before is more than 80%, it is only 51% among first-generation women who arrived less than 2 years before (table). Adjustment for age and parity leads to similar findings. The dimension of the differences between local population groups is comparable to that between high-income and lower-middle-income countries described by Moller and colleagues.1Moller AB 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 ScholarTableEarly antenatal care (ANC) coverage and number of visits by migrant status, Berlin, Germany, 2011–12Number of womenMean age in years (SD)Proportion with first ANC visit <12 weeks of gestationAge-adjusted and parity-adjusted odds ratio (95% CI) for first antenatal care visit <12 weeks of gestationFirst-generation immigrant women, arrival in Germany <2 years before41427·0 (5·7)51·0%0·25 (0·20–0·31); p<0·0001First-generation immigrant women, arrival in Germany 2–<5 years before45428·6 (5·8)69·8%0·60 (0·48–0·75); p<0·0001First-generation immigrant women, arrival in Germany ≥5 years before161630·8 (5·5)80·5%1·05 (0·90–1·23); p=0·52Second-generation women87127·7 (5·8)80·9%1·10 (0·90–1·34); p=0·34Non-immigrant women (including third generation)311130·7 (5·8)81·6%1 (ref) Open table in a new tab The notion underlying the SDGs of leaving nobody behind requires increased attention to disadvantaged population subgroups, including those in high-income countries. Although established indicators such as education are important,3David M Borde T Brenne S et al.Obstetric and perinatal outcomes among immigrant and non-immigrant women in Berlin, Germany.Arch Gynecol Obstet. 2017; 296: 745-762Crossref PubMed Scopus (19) Google Scholar factors such as time since arrival need to be considered in high-income countries experiencing immigration from low-income and middle-income countries; however, these parameters are not yet routinely reported in Germany.1Moller AB 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 Moreover, there are no dedicated data on antenatal care in asylum seekers who, due to their recent arrival, might be at particularly high risk of late initiation of antenatal care. Equity-oriented monitoring systems focusing on the magnitude of health inequalities between social groups, and respective changes over time, are essential to identify and amend the underlying structural mechanisms.4Hosseinpoor AR Bergen N Koller T et al.Equity-oriented monitoring in the context of universal health coverage.PLoS Med. 2014; 11: e1001727Crossref PubMed Scopus (75) Google Scholar However, such monitoring systems are not yet established even in many high-income countries.5Bozorgmehr K Razum O Social inequalities and health: monitoring in the era of non-communicable diseases.Public Health Forum. 2016; 24: 70-72Crossref Scopus (1) Google Scholar We declare no competing interests. The Berlin Perinatal Study was supported by Deutsche Forschungsgemeinschaft (DFG), grant number DA 1199/2-1. The Charité Ethics Committee, Berlin, approved the Berlin Perinatal Study on Feb 18, 2009, reference EA1/235/08. Data protection regulations were observed in the survey and in the linkage to hospital data. 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