In 2010, about 287,000 maternal deaths occurred worldwide (WHO 2012a). Despite considerable efforts to curb maternal mortality, close to 800 women continue to die every day due to complications of pregnancy and childbirth, and about 99% of these deaths occur in developing countries (WHO 2012c). In these settings, neonatal mortality rates are also high, despite the availability of evidence-based interventions that could avert up to 72% of neonatal deaths (Darmstadt 2005). Interventions such as maternal immunisation against tetanus and skilled care at delivery can reduce both maternal and neonatal deaths (Lassi 2010).
Interventions to reduce maternal mortality may focus on three periods. The first is during pregnancy (antenatal care (ANC)), the second is the intrapartum period,(i.e. during labour and delivery) and the third is in the post-partum period (after delivery). The intrapartum period is much shorter and less predictable than the longer more stable pregnancy period (Mbuagbaw 2011). It is also more challenging to provide adequate care in this period, especially in developing countries where human resource shortages and other health system weaknesses limit the availability of emergency obstetric care (Dogba 2009). ANC, on the other hand, is less resource-intensive and its provision can be spread throughout the pregnancy period.
ANC generally comprises the following interventions (Kinzie 2004).
Health promotion: ANC is an opportunity to educate the woman about her health, pregnancy and child birth, recognising danger signs, the benefits of good nutrition, the harms of alcohol, tobacco and drugs, exclusive breast feeding and other relevant issues.
Disease prevention: immunisation against tetanus, prophylactic treatment against malaria, protection against iron deficiency anaemia are some conditions that can de addressed during ANC visits.
Early detection and treatment for complications and diseases: pregnant women would be screened for syphilis, human immunodeficiency virus (HIV) and other sexually transmitted infections (STI). Complications of pregnancy such as pre-eclampsia and eclampsia, infection and vaginal bleeding among others can be addressed.
Birth preparedness: the pregnant woman is counselled on her decision about where to deliver, choice of a skilled birth attendant and a care-giver (for herself or her other children at home). The ANC visit may cover planning for transportation to the hospital, costs of care and supplies for delivery.
Complication readiness: women are encouraged to have an emergency plan for complicated deliveries. This plan should include money for extra medical or surgical care and potential blood donors.
ANC may not address all the causes of maternal deaths; however, it is positively associated with receiving professional assistance at delivery (Bloom 1999; Mbuagbaw 2011; Mishra 2006; Oakley 2009) and improved pregnancy outcomes such as normal birthweight (Mbuagbaw 2011). In different regions, the effects of ANC on enhancing rates of delivery in a health facility are disparate (Mbuagbaw 2011; Raatikainen 2007).
Description of the condition
The World Health Organization (WHO) recommends at least four ANC visits for all pregnant women (WHO 2013).The first visit should take place during the first trimester (before the 12th week but no later than the 16th week), the second visit between the 24th and 28th week, and the third and fourth visits at 32 weeks and 36 weeks respectively. Reports indicate that only 53% of pregnant women worldwide receive this amount of care (WHO 2013). Coverage is lower in developing countries where the use of maternal health care in general is limited and varies widely within and between countries (Say 2007). Poor attendance of ANC is associated with delivery of low birthweight infants (Mbuagbaw 2011; Raatikainen 2007; Showstack 1984; Siza 2008) and more neonatal deaths (Raatikainen 2007). ANC models with reduced visits may also be linked to higher perinatal mortality (Dowswell 2010; Vogel 2013).
Measuring antenatal care
Even though the WHO recommends four ANC visits during pregnancy, this is not a very informative measure (WHO 2013), as it gives no indication of the quality or timing of the visits. Furthermore, there is no measure of access. A comprehensive measure of ANC should include a measure of personal health-seeking behaviour and also a measure of the availability of ANC services, as both are integral to effective ANC. More comprehensive measures have been proposed, which include the number and timing of visits, the provider of care and the adequacy of care provided (Delgado-Rodriguez 1996; Mbuagbaw 2011). Well-timed ANC visits are critical to the success of some interventions, as a systematic review has shown that adverse outcomes from syphilis can best be prevented by intervening in the first two trimesters (Hawkes 2013).The content of each ANC visit is also important, as some ANC interventions may not be beneficial, such as routine aspirin to prevent pre-eclampsia in low-risk women or external version for breech lie (Bergsjo 1997; Villar 1997). Irrespective of how it is measured, ANC is beneficial and represents an important point of contact with the health system for communication and pregnancy preparedness (Lassi 2010).
For the purposes of this review, coverage will be considered as the proportion of pregnant women who attend at least four ANC visits.
Description of the intervention
The fifth United Nations' Millenium Development Goal (MDG5) targets maternal health and explicitly calls for more ANC (United Nations 2013). The WHO now recommends a package of reduced visits with evidence-based interventions through goal-oriented clinic visits (WHO 2011). A variety of interventions can be used to increase the number of women who receive ANC. A systematic review on the effectiveness of interventions to improve early initiation of ANC in vulnerable populations identified two broad categories of interventions: outreach/community-based interventions and alternative models of clinic-based ANC. The former included the use of lay health workers and mobile health clinics, while the latter included adaptations of clinic-based ANC to be more collaborative and comprehensive, and also to accommodate teens (Oakley 2009).
Community-based interventions such as community support, mobilisation, education and home visits by trained community health workers can lead to significant reductions in maternal morbidity and neonatal mortality, and an increase in referrals to a health facility (Lassi 2010). In underserved areas, a community health van may improve access to adequate ANC (Edgerley 2007).
Other interventions, such as mass media campaigns, social mobilisation, information-education-communication (IEC) interventions, financial incentives, behaviour change interventions and policy interventions targeting health workers or pregnant women will also be investigated.
How the intervention might work
Interventions targeting the factors that reduce antenatal care coverage may be beneficial.
Health policy is a critical component of any health system and guides how resources (man power, money and material) are used. Policy can be applied at any level of the health system. Regional health managers are capable of making policy changes that influence the use of ANC services. Recent papers suggest that the effects of policy change in health outcomes should be explored in more detail (Dettrick 2013). Such policy changes may include capacity building in ANC to improve quality of care (Lassi 2010; Say 2007; van Eijk 2006), re-organisation of services to include more midwives providing ANC (Dowswell 2010; Khan-Neelofur 1998), and reduction of user fees to eliminate financial barriers (Lassi 2010; Mbuagbaw 2011; Say 2007; Titaley 2010; van Eijk 2006). Where coverage is better in the private sector (Cesar 2012), adopting their (private sector) model of care may be beneficial. Switching to individual counselling sessions may also improve the number of high-risk women delivering in hospitals (Ballard 2013).
Mass media campaigns can be used to improve the utilisation of health services (Grilli 2002), and may also help to improve the use of ANC services. Social mobilisation- engaging multiple stakeholders - is an important way of bringing change in communities. If pregnant women receive the same consistent message on the benefits of ANC from health workers, community health workers and in other social gatherings, they may be more likely to take heed. Lack of awareness (Lassi 2010; Titaley 2010) and misconceptions (Agus 2012; Say 2007) about ANC can be addressed using IEC sessions. Financial incentives can be used to encourage pregnant women to attend ANC and cover costs including user fees and transportation costs where these problems exist (Lassi 2010; Mbuagbaw 2011; Say 2007; Titaley 2010; van Eijk 2006). They are most effective in the short term, and in resource-limited settings (Marteau 2009). Behavior change interventions are interventions derived from a specific model or theory of behaviour change and can play a role in improving health outcomes (Marteau 2006). Such interventions could play an important role in encouraging women to attend ANC.
Why it is important to do this review
Regions of the world with low ANC coverage can benefit from a comprehensive synthesis of the evidence surrounding the ways in which ANC coverage can be improved. In these places, low ANC coverage comes with low rates of deliveries in health facilities and assistance by skilled birth attendants. The latter two factors are associated with high materno-fetal morbidity. This review will have important implications for reproductive health policy, the provision of services to women in reproductive ages and may highlight gaps in current evidence or openings for further research.