antenatal care visits who

TYLER S. ROGERS, MD, MBA, FAAFP, AND BRENDAN LUSHBOUGH, DO, Martin Army Community Hospital, Fort Benning, Georgia

Am Fam Physician. 2023;107(2):187-190

Author disclosure: No relevant financial relationships.

Key Clinical Issue

What are the risks and benefits of less frequent antenatal in-person visits vs. traditional visit schedules and televisits replacing some in-person antenatal appointments?

Evidence-Based Answer

Compared with traditional schedules of antenatal appointments, reducing the number of appointments showed no difference in gestational age at birth (mean difference = 0 days), likelihood of being small for gestational age (odds ratio [OR] = 1.08; 95% CI, 0.70 to 1.66), likelihood of a low Apgar score (mean difference = 0 at one and five minutes), likelihood of neonatal intensive care unit (NICU) admission (OR = 1.05; 95% CI, 0.74 to 1.50), maternal anxiety, likelihood of preterm birth (nonsignificant OR), and likelihood of low birth weight (OR = 1.02; 95% CI, 0.82 to 1.25). (Strength of Recommendation [SOR]: B, inconsistent or limited-quality patient-oriented evidence.) Studies comparing hybrid visits (i.e., televisits and in-person) with in-person visits only did not find differences in rates of preterm births (OR = 0.93; 95% CI, 0.84 to 1.03; P = .18) or rates of NICU admissions (OR = 1.02; 95% CI, 0.82 to 1.28). (SOR: B, inconsistent or limited-quality patient-oriented evidence.) There was insufficient evidence to assess other outcomes. 1

Practice Pointers

Antenatal care is a cornerstone of obstetric practice in the United States, and millions of patients receive counseling, screening, and medical care in these visits. 2 , 3 There is clear evidence supporting the benefits of antenatal care; however, the number of appointments needed and setting of visits is less understood.

The American College of Obstetricians and Gynecologists recommends antenatal visits every four weeks until 28 weeks' gestation, every two weeks until 36 weeks' gestation, and weekly thereafter, which typically involves 10 to 12 visits. 4

Expert consensus and past meta-analyses have favored fewer antenatal care visits given similar maternal and neonatal outcomes. In 1989, the U.S. Public Health Service suggested a reduction in the antenatal visit schedule based on a multidisciplinary panel and expert opinion in conjunction with a literature review; however, the American College of Obstetricians and Gynecologists has not updated its guidelines, and practices have not changed. 5 A 2010 Cochrane review found no differences in perinatal mortality between patients randomized to higher vs. reduced antenatal care groups in high-income countries, and a 2015 Cochrane review showed no difference in neonatal outcomes for women in high-income countries. 6 , 7

The Agency for Healthcare Research and Quality (AHRQ) review showed moderate- and low-strength evidence and did not find significant differences between traditional and abbreviated schedules when looking at many outcomes, such as gestational age at birth, low birth weight, Apgar scores, NICU admission, preterm birth, and maternal anxiety. The review was limited by a small evidence base with studies that are difficult to compare. The randomized controlled trials that were eligible were adjusted for confounding, whereas the nonrandomized controlled studies were not adjusted and were at high risk for confounding.

Telemedicine, defined as the use of electronic information and telecommunication to support health care among patients, clinicians, and administrators, is a new option for antenatal care delivery. 8 Televisits, the real-time communication between patients and clinicians via phone or the internet, are the specific interactions that encompass telemedicine. Recent literature suggests that supplementing in-person visits with televisits in low-risk pregnancies resulted in similar clinical outcomes and higher patient satisfaction scores. 9 The AHRQ review found no significant differences between rates of preterm births or NICU admissions for a hybrid model of televisits and in-person visits compared with in-person visits only. The review was limited due to the lack of adjustments for potential confounders in the study. For example, some of the studies were conducted during the COVID-19 pandemic, which adds multiple confounders and potential for bias.

The AHRQ review offers limited opportunity for conclusions to suggest changes in current practice. The current evidence supports past evidence, suggesting that fewer visits are not associated with neonatal or maternal harm, and televisits may have a role in antenatal care. Many of the other outcomes of interest had insufficient evidence to generate conclusions.

Editor's Note:   American Family Physician SOR ratings are different from the AHRQ Strength of Evidence ratings.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army, the U.S. Department of Defense, or the U.S. government.

For the full review, go to https://effectivehealthcare.ahrq.gov/sites/default/files/product/pdf/cer-257-antenatal-care.pdf .

Balk EM, Konnyu KJ, Cao W, et al. Schedule of visits and televisits for routine antenatal care: a systematic review. Comparative effectiveness review no. 257. (Prepared by the Brown Evidence-Based Practice Center under contract no. 75Q80120D00001.) AHRQ publication no. 22-EHC031. Agency for Healthcare Research and Quality; June 2022. Accessed October 1, 2022. https://effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-257-antenatal-care-evidence-summary.pdf

Kirkham C, Harris S, Grzybowski S. Evidence-based prenatal care: part I. General prenatal care and counseling issues. Am Fam Physician. 2005;71(7):1307-1316.

Zolotor AJ, Carlough MC. Update on prenatal care. Am Fam Physician. 2014;89(3):199-208.

Kriebs JM. Guidelines for perinatal care, sixth edition: by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. J Midwifery Womens Health. 2010;55(2):e37.

Rosen MG, Merkatz IR, Hill JG. Caring for our future: a report by the expert panel on the content of prenatal care. Obstet Gynecol. 1991;77(5):782-787.

Dowswell T, Carroli G, Duley L, et al. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst Rev. 2010(10):CD000934.

Dowswell T, Carroli G, Duley L, et al. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst Rev. 2015(7):CD000934.

Fatehi F, Samadbeik M, Kazemi A. What is digital health? Review of definitions. Stud Health Technol Inform. 2020;275:67-71.

Cantor AG, Jungbauer RM, Totten AM, et al. Telehealth strategies for the delivery of maternal health care: a rapid review. Ann Intern Med. 2022;175(9):1285-1297.

The Agency for Healthcare Research and Quality (AHRQ) conducts the Effective Health Care Program as part of its mission to produce evidence to improve health care and to make sure the evidence is understood and used. A key clinical question based on the AHRQ Effective Health Care Program systematic review of the literature is presented, followed by an evidence-based answer based on the review. AHRQ’s summary is accompanied by an interpretation by an AFP author that will help guide clinicians in making treatment decisions.

This series is coordinated by Joanna Drowos, DO, MPH, MBA, contributing editor. A collection of Implementing AHRQ Effective Health Care Reviews published in AFP is available at https://www.aafp.org/afp/ahrq .

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National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

• Chapter 2: Antenatal care

Introduction

Antenatal care aims to improve health and prevent disease for both the pregnant woman and her baby. While many Aboriginal and Torres Strait Islander women have healthy babies, poor maternal health and social disadvantage contribute to higher risks of having problems during pregnancy and an adverse pregnancy outcome. 1,2 The reasons for these adverse outcomes are complex and multi factorial (Figure 1), and together with other measures of health disparity provide an imperative for all involved in caring for Aboriginal and Torres Strait Islander women to ensure they receive the highest quality antenatal care, and, in particular, care that is woman-centred, evidence-based and culturally competent. This chapter reflects recommendations for Aboriginal and Torres Strait Islander women from two modules of Australian evidence-based antenatal care guidelines 3,4 and incorporates new evidence published subsequently. For selected antenatal care topics, narrative summaries of evidence relevant to Aboriginal and Torres Strait women are presented below. These are:

• screening for genitourinary and blood-borne viral infections
• nutrition and nutritional supplementation

Antenatal care – General features

Antenatal care includes providing support, information and advice to women during pregnancy, undertaking regular clinical assessments, and screening for a range of infections and other conditions as well as following up and managing screen-detected problems. 4 The key feature of high-quality antenatal care for all women is that it is woman-centred, 4 meaning care that includes:

• focusing on each woman’s individual needs, expectations and aspirations, including her physical, psychological, emotional, spiritual, social and cultural needs
• being culturally safe
• supporting women to make informed choices and decisions  involving the woman’s partner, family and community, as identified by the woman herself.

High-quality antenatal care for Aboriginal and Torres Strait Islander women includes holistic care that is consistent with the Aboriginal definition of health, being the physical, social, emotional and cultural wellbeing of both an individual and their community. 6

Aboriginal and Torres Strait Islander women are cared for by a range of health professionals during pregnancy, and the cultural competence of healthcare providers is of critical importance to women’s engagement with antenatal care and the delivery of high-quality care. Healthcare providers need an awareness of the higher levels of social and economic disadvantage experienced by many Aboriginal and Torres Strait Islander people and to prioritise doing what they can to address these social determinants of health at both individual and system levels. 7 Building trust, and respectful communication and developing effective therapeutic relationships are also key features of providing high-quality antenatal care to Aboriginal and Torres Strait Islander women. 8 In Australia, antenatal care is delivered in a range of organisational settings including hospitals, general and specialist private practices, government clinics, and Aboriginal Community Controlled Health Services. The involvement of Aboriginal and Torres Strait Islander people in the delivery of care, and in the design and management of services, will improve the quality of care for Aboriginal and Torres Islander women in all settings. 4 The ‘first visit’ is an important focus in antenatal care, as provision of advice and a range of assessment and screening activities is best undertaken early in pregnancy to maximise the benefits. It is recommended that the first antenatal care visit occurs before 10 weeks’ gestation. 4 While there is some evidence of recent improvements, Aboriginal and Torres Strait Islander women are still less likely than other Australian women to receive antenatal care early in pregnancy. 1,9 According to age-standardised national data from 2014, 53% of Aboriginal and Torres Strait Islander women attended antenatal care in the first trimester, compared to 60% of non-Indigenous women, and among Aboriginal and Torres Strait Islander women first trimester attendance was higher for women in outer regional areas (62%) compared to women living in major cities (48%) or very remote areas (51%). 1 This suggests the need for ongoing attention by the healthcare system to promoting and facilitating early engagement of pregnant Aboriginal and Torres Strait Islander women, including strengthening cultural safety and addressing local barriers identified by Aboriginal and Torres Strait Islander women. Current recommendations for antenatal care have shifted from a ‘traditional’ fixed schedule of visits towards a more flexible tailored plan of visits that is developed in consultation with each woman in early pregnancy and designed to meet her individual needs. 4 Ten antenatal care visits are recommended for a woman without complications having her first pregnancy, and seven visits for a woman having a subsequent pregnancy. 4 Antenatal care frequently involves screening that aims to improve outcomes for the pregnant woman and her baby. For all screening conducted during pregnancy, women must be provided with information and an opportunity to ask questions about the tests and potential treatments beforehand, so that they are able to provide informed consent. Screening test results need to be communicated to women whether they are positive or negative, and appropriate management and follow-up of positive results is critical if the potential benefits of screening are to be realised.

Smoking tobacco during pregnancy has a range of negative impacts on the health of women and babies. Adverse birth outcomes are more common among women who smoke during pregnancy and include an increased risk of pre term birth, low birth weight, and stillbirth. Children of women who smoked during pregnancy have higher rates of Sudden Infant Death Syndrome (SIDS), asthma, ear infections and respiratory infections. Quitting smoking before or during pregnancy can reduce these risks. At a national level, an estimated 44% of Aboriginal and Torres Strait Islander women smoked during pregnancy in 2014. 1 The prevalence of smoking during pregnancy for Aboriginal and Torres Strait Islander women is decreasing (down from 52% in 2003 10 ); however, it remains much higher than that of non-Indigenous women who are pregnant (12% in 2014). Smoking during pregnancy is more common among young women, those living in rural and remote areas, and those who experience socio-economic disadvantage. 1 Factors associated with high smoking rates and low quit rates among Aboriginal and Torres Strait Islander populations include the normalisation of smoking within Aboriginal communities; the presence of social health determinants such as unemployment, poverty, removal from family, and incarceration; personal stressors such as violence, grief and loss; concurrent use of alcohol and cannabis; and lack of access to culturally appropriate support for quitting. 11–14 Aboriginal and Torres Strait Islander women have expressed the view that smoking during pregnancy can help them cope with stress and relieve boredom, and that quitting may be of lower priority compared to the many other personal and community problems they face. 15 Pregnancy is a particularly opportune time for an intensive focus on the delivery of smoking cessation advice and support to women, because of the potential for improving the health of both mother and baby, and because women are more likely to quit smoking during pregnancy. Aboriginal and Torres Strait Islander women have indicated their support for receiving information, advice and support for quitting from caregivers during pregnancy. 16,17 Health professionals, therefore, have an important role to play in providing information and support to women during pregnancy. There is systematic review evidence that psychosocial interventions for smoking cessation during pregnancy are effective at increasing quit rates and improving birth outcomes such as low birth weight. 18 Only one randomised controlled trial has assessed the effectiveness of a tailored smoking cessation intervention for Aboriginal and Torres Strait Islander women. 19 It did not find a significant difference in quit rates between the intervention group and those receiving usual care, suggesting that more work is needed to optimise smoking cessation strategies in pregnancy for Aboriginal and Torres Strait Islander women. All pregnant women should be asked about their smoking history and practices, and it is recommended that those who currently smoke or have recently quit be provided with information about the effects of smoking during pregnancy, advised to quit smoking and stay quit, and offered ongoing and tailored support to do so. 4 Efforts by health professionals to address smoking during pregnancy for Aboriginal women are more likely to be effective when relationships are non-judgemental, trusting and respectful, as well as empowering and supportive of women’s self-efficacy and agency. 12,20 The social context of Aboriginal and Torres Strait Islander women’s lives is very important to consider when designing and delivering smoking cessation advice and support during pregnancy; it has been suggested that addressing stressors, and building skills and coping strategies, are likely to increase the efficacy of smoking cessation efforts. 14,15 Involvement of partners and families, as well as community-wide efforts to de normalise and reduce smoking in Aboriginal communities, are also recommended as strategies to address smoking in pregnancy for Aboriginal and Torres Strait Islander women. While evidence for the effectiveness of nicotine replacement therapies (NRT) during pregnancy is currently limited, trial results suggest NRT can have positive impacts on quit rates and child development outcomes, and there is no evidence of associated harms. 21 The use of NRT during pregnancy is recommended when initial quit attempts have not been successful, with preference being for the use of an intermittent mode of delivery (such as lozenges, gum or spray) rather than continuous (such as patches). 4 The safety of oral (such as buprenorphine and varenicline) and e-cigarettes, and their effectiveness as measures to support quitting during pregnancy, is not known and therefore they are not recommended for use. 21

Screening for genitourinary and blood-borne infections

Urinary tract infections.

Asymptomatic bacteriuria is common during pregnancy, and may be more common among Aboriginal and Torres Strait Islander women. 22–24 Ascending urinary tract infection during pregnancy may lead to pyelonephritis, and an association with pre term birth and low birth weight has been suggested. 4 A Cochrane review has demonstrated that treatment with antibiotics is effective at clearing asymptomatic bacteriuria during pregnancy, and results in a reduced risk of pyelonephritis as well as providing suggestive evidence about a reduced risk of adverse pregnancy outcomes such as pre term birth and low birth weight. 25 All women should be routinely offered testing for asymptomatic bacteriuria early in pregnancy using a midstream urine culture. 4 Urine dipstick for nitrites is not a suitable test for diagnosing infection, as false positives are frequent; however, a negative dipstick result means infection is unlikely. Appropriate storage of dipsticks is essential, as high humidity and temperature can impact on their accuracy.

Chlamydia is a common sexually transmitted infection (STI) that can be asymptomatic and can lead to pelvic inflammatory disease, infertility and ectopic pregnancy. Chlamydia infection during pregnancy has been associated with higher rates of pre term birth and growth restriction, and can result in neonatal conjunctivitis and respiratory tract infections. 4 Antibiotics are effective at treating Chlamydia, and there is some evidence that treatment during pregnancy reduces the incidence of pre term birth and low birth weight. 26,27 Chlamydia prevalence estimates for pregnant Aboriginal and Torres Strait Islander women vary from 2.9% to 14.4%. 30,31 Chlamydia is most common among young people, with 80% of diagnoses among Aboriginal and Torres Strait Islander people being in this group. 30 Notification rates for Chlamydia are eight times higher for Aboriginal and Torres Strait Islander people living in remote regions. 30 Australian national evidence-based antenatal care guidelines recommend that Chlamydia testing is routinely offered during pregnancy at the first antenatal care visit to pregnant women aged less than 25 years, and to all women who live in areas where Chlamydia and other STIs have a high prevalence. 4 Pregnant women who test positive to Chlamydia, and their partners, need follow-up, assessment for other STIs and treatment.

Gonorrhoea is a sexually acquired infection that can cause pelvic inflammatory disease and chronic pelvic pain in women. Gonorrhoea infection during pregnancy is associated with adverse outcomes including ectopic pregnancy, miscarriage, pre term birth and maternal sepsis during and after pregnancy. 4 Transmission at the time of birth can lead to neonatal conjunctivitis, which may cause blindness. Gonorrhoea is most commonly diagnosed in young people, and is more common for Aboriginal and Torres Strait Islander people living in outer regional and remote areas. 30 Rates of diagnosis have been declining but remain high in these regions. 30 Australian national evidence-based antenatal care guidelines recommend against screening all pregnant women for gonorrhoea, because there is a relatively low prevalence of disease and there is potential for harms associated with false positive test results, particularly in low-risk populations. 4 Screening for gonorrhoea is recommended for pregnant women who live in, or come from, areas of high prevalence (outer regional and remote areas), or who have risk factors for STIs. Pregnant women who test positive to gonorrhoea, and their partners, need follow-up, assessment for other STIs and treatment.

Trichomoniasis

Trichomoniasis is a sexually transmitted vaginitis that is commonly asymptomatic, but can cause a yellow–green vaginal discharge and vulval irritation, and may be associated with infertility and pelvic inflammatory disease. 3 The implications of trichomoniasis during pregnancy remain unclear; while an association between trichomoniasis and pre term birth and low birth weight has been demonstrated, evidence of a cause and effect relationship is currently lacking. 31 The benefits of screening asymptomatic women for trichomonas during pregnancy are uncertain, because there is no evidence that antibiotic treatment improves pregnancy outcomes, 3,31 with one trial suggesting a higher rate of pre term birth among pregnant women who were treated for asymptomatic trichomoniasis with metronidazole. 31 For this reason screening of asymptomatic, pregnant women is not recommended. 3

Bacterial vaginosis

Bacterial vaginosis (BV) is a deficiency of normal vaginal flora (Lactobacilli) and a relative overgrowth of anaerobic bacteria. BV occurs commonly and is often asymptomatic, although it can also cause a greyish vaginal discharge. 4 In epidemiological studies, BV has been associated with a higher rate of pre term birth. While antibiotics for BV have been found to be effective at eradicating BV microbiologically, they have not resulted in a reduction in the preterm birth rate. 32 For this reason, routine screening of asymptomatic pregnant women for BV is not recommended. 4,32 Symptomatic women diagnosed with BV, however, should be treated.

Group B streptococcus

Group B streptococcus (GBS) is a bacteria that commonly colonises the gastrointestinal tract, vagina and urethra, and has the potential to increase the risk of preterm birth and cause serious neonatal infection after birth. 4 For women who are colonised with GBS, intravenous antibiotics during labour can prevent more than 80% of neonatal infection. 4 Australian estimates suggest a prevalence of GBS colonisation among all pregnant women of around 20%. 4 Prevention strategies can involve two main approaches: antenatal screening for GBS in late pregnancy  (at 35–37 weeks’ gestation), or an assessment of risk factors for GBS transmission during labour (including preterm birth, maternal fever and prolonged rupture of membranes). As there is currently no clear evidence supporting one strategy over the other, Australian national evidence-based antenatal care guidelines recommend either strategy can be used. 4

Syphilis is an STI with serious systemic sequelae. During pregnancy, syphilis can cause spontaneous miscarriage or stillbirth, or lead to congenital infection that is commonly fatal or results in severe and permanent impairment. Congenital syphilis can be prevented by effective treatment of maternal syphilis  with antibiotics. 33 In Australia, notifications of infectious syphilis have been declining but have remained more common for Aboriginal and Torres Strait Islander peoples compared to non-Indigenous populations. 30 However, since 2010 there has been a marked increase in notifications of infectious syphilis, driven by an outbreak in northern Australia, including Western Australia, the Northern Territory and Queensland. 34 This outbreak has included a total of 22 cases of congenital syphilis being notified nationally between 2011 and 2015, with  14 of these cases being Aboriginal and Torres Strait Islander babies, 30 and several infant deaths from syphilis have occurred. 34 All pregnant women should be routinely offered testing to screen for syphilis at the first antenatal visit, and repeat screening later in pregnancy may be appropriate in regions of high prevalence. 4 The interpretation of syphilis serology can be complex. To ensure diagnosis, treatment and follow-up are consistent with evidencebased best practice, it is recommended that expert advice is sought if a pregnant woman tests positive for syphilis on an initial screen. 4

While human immunodeficiency virus (HIV) infection is uncommon in Australia, screening during pregnancy for all women at the first antenatal visit is recommended because of the serious consequences of mother-to-child transmission and the availability of treatments effective at reducing this risk. 4 These treatments include caesarean section, short courses of selected antiretroviral medications, and the avoidance of breastfeeding. HIV infection currently occurs at similar rates for Aboriginal and Torres Strait Islander and non-Indigenous population groups in Australia. 30 Women who test positive for HIV require careful and confidential follow-up, including repeat confirmatory testing, assessment and specialist management.

Hepatitis C

Hepatitis C is a blood-borne virus with the potential for causing serious long-term sequelae, including cirrhosis, hepatocellular carcinoma and liver failure through chronic infection. Hepatitis C infection is diagnosed up to four times more often among Aboriginal and Torres Strait Islander women than nonIndigenous women, and is increasing. 30 Perinatal transmission occurs for 4–6% of babies born to women who are positive to both hepatitis C antibody and hepatitis C RNA during pregnancy, and this risk is higher with increasing viral load. 4 In recent years, the increased availability of effective anti-viral therapies with fewer adverse impacts than previously available treatments has greatly improved treatment options and outcomes for people with chronic hepatitis C infection. 35 However, at the time of writing, anti-viral therapies used for treating for hepatitis C are not approved or recommended for use during pregnancy. 35 The lack of antenatal treatment options and the potential psychological harms associated with false positive results of screening tests are the main reasons that routine screening of all women for hepatitis C during pregnancy is not recommended. 4 Testing during pregnancy may be considered, however, for women with identifiable risk factors, including intravenous drug use, tattooing and body piercing, and incarceration. 4 If an initial hepatitis C antibody test is positive, a confirmatory hepatitis C RNA test is required to assess risks and guide management for the woman and baby, and both should be appropriately followed up.

Hepatitis B

Aboriginal and Torres Strait Islander populations have higher rates of diagnosis of hepatitis B infection than non-Indigenous population groups, and available evidence suggests this pattern is also true of hepatitis B surface antigen positivity during pregnancy. 30,36,37 All pregnant women should be offered screening for hepatitis B infection by testing for hepatitis B surface antigen at their first antenatal care visit, and those that test positive should be appropriately followed up. 4 Newborn children of women with current hepatitis B infection (hepatitis B surface antigen positive) can be vaccinated after delivery. Vaccination and the provision of immunoglobulin to the baby at birth is approximately 95% effective at preventing perinatal transmission. 4

Nutrition and nutritional supplementation

Good nutrition during pregnancy is important for the health of the woman, and the development and growth of the baby. Providing women with information and advice about nutritional needs during pregnancy is an important part of routine antenatal care. In providing this advice to Aboriginal and Torres Strait Islander women, it is important to consider the significance of barriers to accessing nutritious foods (eg fresh fruit, vegetables) because of costs and lack of availability in rural and remote regions (refer to Chapter 1: Lifestyle, ‘Overweight and obesity’ ).

Weight and body mass index

Overweight and obesity is becoming increasingly common in Australia, and is more common in Aboriginal and Torres Strait Islander population groups. 9 In 2014, obesity during pregnancy was documented for 33% of Aboriginal and Torres Strait Islander women compared to 20% of non-Indigenous women. 1 Being overweight (body mass index [BMI] ≥25 kg/m 2 ) or underweight (BMI <18.5 kg/m 2 ) before pregnancy are each associated with an increased risk of adverse birth outcomes. Being overweight before pregnancy or having a high weight gain during pregnancy is associated with higher rates of preterm birth, caesarean section, gestational high blood pressure or pre-eclampsia, gestational diabetes, postpartum haemorrhage, and depression, as well as a baby being more likely to be of low birthweight or large for gestational age. Being underweight before pregnancy or having a low weight gain during pregnancy is associated with an increased risk of preterm birth, low birthweight and being small for gestational age. The national evidence-based antenatal care guidelines recommend routine assessment of a woman’s weight and height, and calculation of BMI at the first antenatal care visit. 4 Weighing women at subsequent visits is recommended only when it is likely to influence clinical management. Recommended weight gain during pregnancy varies with a woman’s estimated pre-pregnancy BMI from a total of 6 kg to 18 kg ( Box 1 ). While weight loss is not an appropriate aim during pregnancy, strong evidence suggests interventions for women who are overweight based on increased physical activity and dietary counselling combined with weight monitoring can reduce inappropriate weight gain during pregnancy, as well as reduce the risks of caesarean section, macrosomia and neonatal respiratory morbidity. 38–40

Aboriginal and Torres Strait Islander populations are at greater risk of anaemia, 41 and iron deficiency is the most common cause of anaemia. Routine iron supplementation for all pregnant women is not recommended, because evidence of improved pregnancy outcomes is lacking and there may be adverse impacts. 4 However, it is recommended that all women be screened for anaemia at the first and subsequent visits during pregnancy, and that iron supplementation be used to treat iron deficiency if it is detected. 4 Management of iron deficiency anaemia during pregnancy includes dietary advice, iron supplementation and follow-up. Pregnant women can potentially benefit by being advised about iron-rich foods and that iron absorption can be aided by vitamin C– rich foods, such as fresh fruit and fruit juice, and reduced by tea and coffee. 4,42

Routine folic acid supplementation before and during pregnancy is recommended for all women as it is effective in reducing the risk of neural tube defects. 4 The incidence of this group of congenital abnormalities decreased in Australia among non-Indigenous women after folic acid supplementation during pregnancy became widespread. 43 However, Aboriginal and Torres Strait Islander women were still experiencing high rates of neural tube defects. 43,44 Following mandatory folic acid fortification of bread, which has occurred since 2009, rates of neural tube defects among Aboriginal and Torres Strait Islander women have dropped significantly and are now lower than those of other Australian women. 45

Increased thyroid activity during pregnancy results in increased maternal requirements for iodine, which is essential for neuropsychological development. While severe iodine deficiency during pregnancy is uncommon in Australia, recent evidence suggests that mild and moderate levels of iodine deficiency during pregnancy may result in negative impacts on the neurological and cognitive development of the child. 47 While mandatory iodine fortification of bread since 2009 has improved iodine levels in the general Australian population, available evidence suggests that for many women dietary intake of iodine will not be sufficient to meet needs during pregnancy and breastfeeding. 45 As a consequence, it is recommended that all pregnant women take an iodine supplement of 150 mcg daily. 4,47

Vitamin D is essential for skeletal development, and vitamin D deficiency may have a range of negative health impacts, including during pregnancy. 4,48 The prevalence of vitamin D deficiency varies geographically and between different population groups, and there have been few estimates of prevalence among Aboriginal and Torres Strait Islander populations. 49,50 Risk factors for vitamin D deficiency include limited exposure to sunlight, dark skin and a high BMI. Vitamin D supplementation for women with vitamin D deficiency increases maternal levels of vitamin D, but there is currently no evidence that it improves pregnancy outcomes. 4,48 Screening pregnant women for vitamin D deficiency is recommended only if they have risk factors, and women who are found to be vitamin D deficient should be treated with supplementation because of the potential benefits to their long-term health. 4,48

Diabetes in pregnancy includes type 1 or type 2 diabetes diagnosed before pregnancy, undiagnosed pre-existing diabetes, and gestational diabetes, where glucose intolerance develops in the second half of pregnancy. All forms of diabetes in pregnancy are associated with increased risks for both the pregnant woman and the baby, with the level of risk depending on the level of hyperglycaemia. 3,51–53 Diabetes in pregnancy is associated with an increased risk of induced labour, preterm birth, caesarean section and pre-eclampsia. Babies of mothers with diabetes in pregnancy have higher rates of stillbirth, fetal macrosomia, low APGAR (Appearance, Pulse, Grimace, Activity, Respiration) scores, neonatal hypoglycaemia, and admission to special care/neonatal intensive care units. Babies born to mothers with pre-existing diabetes also have a higher risk of congenital malformations of the spine, heart and kidneys. In addition, raised maternal glycaemic levels are associated with a child having increased adiposity in childhood and other adverse metabolic factors that may increase the risks of later cardiovascular disease and diabetes. Women with gestational diabetes also have an increased risk of developing type 2 diabetes later in life. The number of women with all types of diabetes in pregnancy is increasing. At a national level in 2014, an estimated 4% of Aboriginal and Torres Strait Islander women had diabetes in pregnancy and 13% had gestational diabetes, and each of these rates was higher than those of non-Indigenous women (3.5 times higher for diabetes and 1.6 times higher for gestational diabetes). 1 Given the high prevalence of diabetes in Aboriginal and Torres Strait Islander populations, a significant number of Aboriginal and Torres Strait Islander women are likely to have undiagnosed diabetes at the time they become pregnant. Consequently, screening all Aboriginal and Torres Strait Islander women for pre-existing diabetes is recommended at the first antenatal care visit. 3,54 Tests recommended for screening for undiagnosed diabetes are fasting plasma glucose, plasma glucose after a 75 g glucose load, or random plasma glucose. 3 The use of HbA1C levels to screen for diabetes during pregnancy has not yet been fully evaluated, but has been proposed as an alternative test to consider for early pregnancy screening if other tests such as an oral glucose tolerance test are not feasible; an HbA1C level above 6.5% suggests pre-existing diabetes. 54 Internationally, screening guidelines for gestational diabetes vary in their recommendations about whether screening should be offered to all pregnant women or only to women with risk factors for diabetes. However, given the higher risk of diabetes experienced by Aboriginal and Torres Strait Islander populations, it is recommended that all pregnant Aboriginal and Torres Strait Islander women without pre-existing diabetes are offered screening for gestational diabetes. The recommended timing for gestational diabetes screening to occur is 24–28 weeks’ gestation, and recommended tests include fasting plasma glucose, or plasma glucose one hour and two hours after a 75 g glucose load. 3,54 While diagnostic criteria for gestational diabetes continue to be debated, Australian national evidence-based antenatal care guidelines 3 and the Australasian Diabetes in Pregnancy Society 54 both recommend the use of criteria endorsed by the World Health Organization (WHO) and International Association of Diabetes and Pregnancy Study Group (refer to ‘Recommendations: Diabetes’). In discussions about screening for diabetes and gestational diabetes, women need information about the risks associated with these conditions and the effectiveness of management in reducing and mitigating these risks. 56,57 In general terms, management strategies for diabetes in pregnancy and gestational diabetes include optimising nutrition, increasing physical activity, monitoring and controlling weight gain, additional monitoring activities including of fetal growth and wellbeing, and the use of medications. Medications include insulin and, increasingly, oral hypoglycaemics for women where adequate glycaemic control is not achieved using non-pharmacological measures. Optimising control of gestational diabetes is important to reduce pregnancy-related risks for the woman and baby, and may also have longer term implications on the health of the infant into adulthood. For women with gestational diabetes, screening for diabetes after delivery is also important as it provides an opportunity for intervention to improve women’s future health. 57

• Australian Institute of Health and Welfare. Australia’s mothers and babies 2014. Perinatal statistics series no. 32. Canberra: AIHW, 2016.
• Humphrey MD, Bonello M, Chughtai A, Macaldowie A, Harris K, Chambers G. Maternal deaths in Australia 2008–12. Canberra: AIHW, 2015.
• Australian Health Ministers’ Advisory Council. Clinical practice guidelines: Antenatal care – Module II. Canberra: Department of Health, 2014.
• Australian Health Ministers’ Advisory Council. Clinical practice guidelines: Antenatal care – Module 1. Canberra: Department of Health and Ageing, 2012.
• Clarke M, Boyle J. Antenatal care for Aboriginal and Torres Strait Islander women. Aus Fam Physician 2014;43(1/2):20–24.
• National Aboriginal Health Strategy Working Party. National Aboriginal Health Strategy. Canberra, 1989.
• Wilson G. What do Aboriginal women think is good antenatal care? Consultation Report. Darwin: Cooperative Research Centre for Aboriginal Health, 2009.
• McHugh AM, Hornbuckle J. Maternal and child health model of care in the Aboriginal community controlled health sector. Perth: Aboriginal Health Council of Western Australia, 2011.
• Australian Health Ministers’ Advisory Council. Aboriginal and Torres Strait Islander health performance framework 2014 report. Canberra: Department of Health, 2015.
• Laws PG, Sullivan EA. Smoking and pregnancy. Sydney: Australian Institute of Health and Welfare National Perinatal Statistics Unit, 2006.
• Thomas DP, Briggs V, Anderson IP, Cunningham J. The social determinants of being an Indigenous non‐smoker. Aust N Z J Public Health 2008;32(2):110–16.
• Bond C, Brough M, Spurling G, Hayman N. ‘It had to be my choice’. Indigenous smoking cessation and negotiations of risk, resistance and resilience. Health Risk Soc 2012;14(6):565–81.
• Passey ME, Sanson-Fisher RW, D’Este CA, Stirling JM. Tobacco, alcohol and cannabis use during pregnancy: Clustering of risks. Drug Alcohol Depend 2014;134:44–50.
• Passey ME, D’Este CA, Stirling JM, Sanson‐Fisher RW. Factors associated with antenatal smoking among Aboriginal and Torres Strait Islander women in two jurisdictions. Drug Alcohol Rev 2012;31(5):608–16.
• Gould GS, Munn J, Watters T, McEwen A, Clough AR. Knowledge and views about maternal tobacco smoking and barriers for cessation in Aboriginal and Torres Strait Islanders: A systematic review and meta-ethnography. Nicotine Tob Res 2013;15(5):863–74.
• Passey ME, Sanson-Fisher RW. Provision of antenatal smoking cessation support: A survey with pregnant Aboriginal and Torres Strait Islander women. Nicotine Tob Res 2015;17(6):746–49.
• Passey ME, Sanson-Fisher RW, Stirling JM. Supporting pregnant Aboriginal and Torres Strait Islander women to quit smoking: Views of antenatal care providers and pregnant Indigenous women. Maternal Child Health J 2014;18(10):2293–99.
• Chamberlain C, O’Mara‐Eves A, Porter J, et al. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database Syst Rev 2017;2:CD001055.
• Eades SJ, Sanson-Fisher RW, Wenitong M, et al. An intensive smoking intervention for pregnant Aboriginal and Torres Strait Islander women: A randomised controlled trial. Med J Aust 2012;197(1):42.
• Gould GS, Bittoun R, Clarke MJ. Guidance for culturally competent approaches to smoking cessation for Aboriginal and Torres Strait Islander pregnant women. Nicotine Tob Res 2016;18(1):104.
• Coleman T, Chamberlain C, Davey MA, Cooper SE, Leonardi‐Bee J. Pharmacological interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev 2015;(12):CD010078.
• Bookallil M, Chalmers E, Andrew B. Challenges in preventing pyelonephritis in pregnant women in Indigenous communities. Rural Remote Health 2005;5(3):395.
• Panaretto KS, Lee HM, Mitchell MR, et al. Prevalence of STIs in pregnant urban Aboriginal and Torres Strait Islander women in northern Australia. Aust N Z J Obstet Gynaecol 2006;46(3):217–24.
• Hunt J. Pregnancy care and problems for women giving birth at Royal Darwin Hospital. Melbourne: Centre for the Study of Mothers’ and Children’s Health, La Trobe University, 2004.
• Smaill FM, Vazquez JC. Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database Syst Rev 2015;(8):CD000490.
• Ryan GM Jr, Abdella TN, McNeeley SG, Baselski VS, Drummond DE. Chlamydia trachomatis infection in pregnancy and effect of treatment on outcome. Am J Obstet Gynecol 1990;162(1):34–39.
• McMillan JA, Weiner LB, Lamberson HV, et al. Efficacy of maternal screening and therapy in the prevention of chlamydia infection of the newborn. Infection 1985;13(6):263–66.
• Lewis D, Newton DC, Guy RJ, et al. The prevalence of chlamydia trachomatis infection in Australia: A systematic review and metaanalysis. BMC Infect Dis 2012;12(1):113.
• Graham S, Smith LW, Fairley CK, Hocking J. Prevalence of chlamydia, gonorrhoea, syphilis and trichomonas in Aboriginal and Torres Strait Islander Australians: A systematic review and meta-analysis. Sex Health 2016;13(2):99–113.
• The Kirby Institute. Bloodborne viral and sexually transmissible infections in Aboriginal and Torres Strait Islander people: Surveillance and evaluation report 2015. Sydney: The Kirby Institute, 2016.
• Gülmezoglu AM, Azhar M. Interventions for trichomoniasis in pregnancy. Cochrane Database Syst Rev 2011;(5):CD000220.
• Brocklehurst P, Gordon A, Heatley E, Milan SJ. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database Syst Rev 2013;(1):CD000262.
• Walker GJ. Antibiotics for syphilis diagnosed during pregnancy. Cochrane Database Syst Rev 2001;(3):CD001143.
• Bright A, Dups J. Infectious and congenital syphilis notifications associated with an ongoing outbreak in northern Australia. Commun Dis Intell Q Rep 2016;40(1):E7–10.
• Thompson A. Australian recommendations for the management of hepatitis C virus infection: A consensus statement. Med J Aust 2016;204(7):268–72.
• Graham S, Guy RJ, Cowie B, et al. Chronic hepatitis B prevalence among Aboriginal and Torres Strait Islander Australians since universal vaccination: A systematic review and meta-analysis. BMC Infect Dis 2013;13(1):403.
• Schultz R. Hepatitis B screening among women birthing in Alice Springs Hospital, and immunisation of infants at risk. Northern Territory Disease Control Bulletin 2007;14(2):1–5.
• Campbell F, Johnson M, Messina J, Guillaume L, Goyder E. Behavioural interventions for weight management in pregnancy: A systematic review of quantitative and qualitative data. BMC Public Health 2011;11(1):491.
• National Health and Medical Research Council. Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. Melbourne: NHMRC, 2013.
• Muktabhant B, Lawrie TA, Lumbiganon P, Laopaiboon M. Diet or exercise, or both, for preventing excessive weight gain in pregnancy. Cochrane Database Syst Rev 2015;(6):CD007145.
• Australian Bureau of Statistics. Australian Aboriginal and Torres Strait Islander health survey: Biomedical results, 2012–13. Canberra: ABS, 2014. 
• National Blood Authority. Patient blood management guidelines: Module 5 – Obstetrics and maternity. Canberra: NBA, 2015.
• Bower C, D’Antoine H, Stanley FJ. Neural tube defects in Australia: Trends in encephaloceles and other neural tube defects before and after promotion of folic acid supplementation and voluntary food fortification. Birth Defects Res A Clin Mol Teratol 2009;85(4):269–73.
• Macaldowie A. Neural tube defects in Australia: Prevalence before mandatory folic acid fortification. Canberra: AIHW, 2011.
• Australian Institute of Health and Welfare. Monitoring the health impacts of mandatory folic acid and iodine fortification. Canberra: AIHW, 2016.
• National Health and Medical Research Council. Iodine supplementation during pregnancy and lactation – A literature review. Canberra: NHMRC, 2009.
• National Health and Medical Research Council. Iodine supplementation: Public statement. Canberra: NHMRC, 2010.
• Paxton GA, Teale GR, Nowson CA, et al. Vitamin D and health in pregnancy, infants, children and adolescents in Australia and New Zealand: A position statement. Med J Aust 2013;198(3):142–43.
• Benson J, Wilson A, Stocks N, Moulding N. Muscle pain as an indicator of vitamin D deficiency in an urban Australian Aboriginal population. Med J Aust 2006;185(2):76–77.
• Vanlint SJ, Morris HA, Newbury JW, Crockett AJ. Vitamin D insufficiency in Aboriginal Australians. Med J Aust 2011;194(3):131–34.
• Lowe LP, Metzger BE, Dyer AR, et al. Hyperglycemia and adverse pregnancy outcome (HAPO) study. Diabetes Care 2012;35(3):574–80.
• Contreras M, Sacks DA, Bowling FG, et al. The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study. Int J Gynaecol Obstet 2002;78(1):69–77.
• McElduff A, Cheung NW, McIntyre HD, et al. The Australasian Diabetes in Pregnancy Society consensus guidelines for the management of type 1 and type 2 diabetes in relation to pregnancy. Med J Aust 2005;183(7):373–77.
• Nankervis A, McIntyre H, Moses R, et al. ADIPS consensus guidelines for the testing and diagnosis of hyperglycaemia in pregnancy in Australia and New Zealand. Sydney: Australasian Diabetes in Pregnancy Society, 2014.
• Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005;352(24):2477–86.
• Landon MB, Spong CY, Thom E, et al. A multicenter, randomized trial of treatment for mild gestational diabetes. N Engl J Med 2009;361(14):1339–48.
• Chamberlain C, McLean A, Oats J, et al. Low rates of postpartum glucose screening among indigenous and non-indigenous women in Australia with gestational diabetes. Maternal Child Health J 2015;19(3):651–63.
• Cancer Council Australia Cervical Cancer Screening Guidelines Working Party. National Cervical Screening Program: Guidelines for the management of screen-detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding. Sydney: Cancer Council Australia, 2016.
• Woolcock J, Grivell R. Noninvasive prenatal testing. Aust Fam Physician 2014;43(7):432–34.
• beyondblue. Clinical practice guidelines for depression and related disorders – anxiety, bipolar disorder and puerperal psychosis – in the perinatal period: A guideline for primary care health professionals. Melbourne: beyondblue, 2011.
• Australian Technical Advisory Group on Immunisation. The Australian immunisation handbook. 10th edn. Canberra: Department of Health, 2017.
• The Royal Australian and New Zealand College of Obtetricians and Gynaecologists. Measurement of cervical length for prediction of preterm birth. Sydney: RANZCOG; 2017 . [Accessed 10 November 2017].

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Peer-reviewed

Research Article

A comprehensive assessment of care competence and maternal experience of first antenatal care visits in Mexico: Insights from the baseline survey of an observational cohort study

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Unidad de Investigación Epidemiológica y Servicios de Salud del CMN SXXI, Instituto Mexicano del Seguro Social, Ciudad de México, México

Roles Conceptualization, Methodology, Writing – review & editing

Affiliation Dirección de Prestaciones Médicas, Instituto Mexicano del Seguro Social, Ciudad de México, México

Roles Conceptualization, Supervision, Writing – review & editing

Affiliation Division of Social Protection and Health, Interamerican Development Bank, Washington, DC, United States of America

Roles Investigation, Methodology, Writing – review & editing

Affiliation Unidad de medicina Familiar 31, Instituto Mexicano del Seguro Social, Ciudad de México, México

Affiliation OOAD Estado de México Oriente, Instituto Mexicano del Seguro Social, Tlalnepantla de Baz, Estado de México, México

Roles Supervision, Writing – review & editing

Affiliation OOAD Coahuila, Instituto Mexicano del Seguro Social, Saltillo, Coahuila, México

Affiliation Unidad Médica de Alta Especialidad, Hospital de Gineco obstetricia N°23 Dr. Ignacio Morones Prieto, Instituto Mexicano del Seguro Social, Monterrey, Nuevo León, México

Roles Investigation, Supervision, Writing – review & editing

Affiliation Jefatura de Prestaciones Médicas, Instituto Mexicano del Seguro Social, Monterrey, Nuevo León, México

Affiliation OOAD DF Sur, Instituto Mexicano del Seguro Social, Ciudad de México, México

Affiliation OOAD Veracruz Norte, Instituto Mexicano del Seguro Social, Veracruz, México

Affiliation OOAD Aguascalientes, Instituto Mexicano del Seguro Social, Aguascalientes, México

Affiliation OOAD Jalisco, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México

Affiliation Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America

•  [ ... ],

Affiliation Department of Global Health, Milken Institute School of Public Health, The George Washington University, Washington, DC, United States of America

• [ view all ]
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• Svetlana V. Doubova, 
• Claudio Quinzaños Fresnedo, 
• Martín Paredes Cruz, 
• Diana Perez-Moran, 
• Ricardo Pérez-Cuevas, 
• Verónica Meneses Gallardo, 
• Luis Rey Garcia Cortes, 
• Megan Carolina Cerda Mancillas, 
• Victoria Martínez Gaytan, 

• Published: September 3, 2024
• https://doi.org/10.1371/journal.pmed.1004456
• Reader Comments

Comprehensive antenatal care (ANC) must prioritize competent, evidence-based medical attention to ensure a positive experience and value for its users. Unfortunately, there is scarce evidence of implementing this holistic approach to ANC in low- and middle-income countries, leading to gaps in quality and accountability. This study assessed care competence, women’s experiences during the first ANC visit, and the factors associated with these care attributes.

Methods and findings

The study analyzed cross-sectional baseline data from the maternal eCohort study conducted in Mexico from August to December 2023. The study adapted the Quality Evidence for Health System Transformation (QuEST) network questionnaires to the Mexican context and validated them through expert group and cognitive interviews with women. Pregnant women aged 18 to 49 who had their first ANC visit with a family physician were enrolled in 48 primary clinics of the Instituto Mexicano del Seguro Social across 8 states. Care competence and women’s experiences with care were the primary outcomes. The statistical analysis comprised descriptive statistics, multivariable linear and Poisson regressions.

A total of 1,390 pregnant women were included in the study. During their first ANC visit, women received only 67.7% of necessary clinical actions on average, and 52% rated their ANC experience as fair or poor. Women with previous pregnancies (adjusted regression coefficient [aCoef.] −3.55; (95% confidence intervals [95% CIs]): −4.88, −2.22, p < 0.001), at risk of depression (aCoef. −3.02; 95% CIs: −5.61, −0.43, p = 0.023), those with warning signs (aCoef. −2.84; 95% CIs: −4.65, −1.03, p = 0.003), common pregnancy discomforts (aCoef. −1.91; 95% CIs: −3.81, −0.02, p = 0.048), or those who had a visit duration of less than 20 minutes (<15 minutes: aCoef. −7.58; 95% CIs: −10.21, −4.95, p < 0.001 and 15 to 19 minutes: aCoef. −2.73; 95% CIs: −4.79, −0.67, p = 0.010) and received ANC in the West and Southeast regions (aCoef. −5.15; 95% CIs: −7.64, −2.66, p < 0.001 and aCoef. −5.33; 95% CIs: −7.85, −2.82, p < 0.001, respectively) had a higher probability of experiencing poorer care competence. Higher care competence (adjusted prevalence ratio [aPR] 1.004; 95% CIs:1.002, 1.005, p < 0.001) and receiving care in a small clinic (aPR 1.19; 95% CIs: 1.06, 1.34, p = 0.003) compared to a medium-sized clinic were associated with a better first ANC visit experience, while common pregnancy discomforts (aPR 0.94; 95% CIs: 0.89, 0.98, p = 0.005) and shorter visit length (aPR 0.94; 95% CIs: 0.88, 0.99, p = 0.039) were associated with lower women’s experience. The primary limitation of the study is that participants’ responses may be influenced by social desirability bias, leading them to provide socially acceptable responses.

Conclusions

We found important gaps in adherence to ANC standards and that care competence during the first ANC visit is an important predictor of positive user experience. To inform quality improvement efforts, IMSS should institutionalize the routine monitoring of ANC competencies and ANC user experience. This will help identify poorly performing facilities and providers and address gaps in the provision of evidence-based and women-centered care.

Author summary

Why was this study done.

• High-quality antenatal care (ANC) is crucial for preventing, detecting, and managing maternal and newborn complications. It involves providing comprehensive care, prioritizing evidence-based medical attention, and ensuring positive experiences for women. How healthcare providers treat women during the first ANC visit is vital in determining their satisfaction and subsequent use of health services.
• There is little evidence of the implementation of this holistic approach to ANC in Latin America and other low- and middle-income countries.

What did the researchers do and find?

• The study used baseline data from the maternal eCohort in Mexico, collected through validated global QuEST network questionnaires adapted to the local context.
• The study gathered and analyzed an extensive number of user-reported experience measures and multiple health status variables to comprehensively assess women’s experiences and healthcare competency during the first ANC visit, serving as a valuable model for other Latin American and low- and middle-income countries.
• Compared to prior studies in this field, which typically gather information within a 1-year recall period, we used a 2-week data collection timeline to minimize recall bias.
• We found that higher care competence was associated with a higher likelihood of women rating their care as high quality and reporting positive experiences during the first ANC visit.
• The study’s main limitation is the potential for participants’ answers to be influenced by social desirability bias (i.e., what they think others want to hear), leading to responses they believe are socially acceptable.

What do these findings mean?

• Evidence on care competence and women’s experiences should inform efforts to improve ANC quality in Mexico and Latin America.
• Care competence is an important determinant of client satisfaction.
• The gaps in care competence should be addressed to ensure positive experiences during pregnancy.

Citation: Doubova SV, Quinzaños Fresnedo C, Paredes Cruz M, Perez-Moran D, Pérez-Cuevas R, Meneses Gallardo V, et al. (2024) A comprehensive assessment of care competence and maternal experience of first antenatal care visits in Mexico: Insights from the baseline survey of an observational cohort study. PLoS Med 21(9): e1004456. https://doi.org/10.1371/journal.pmed.1004456

Received: April 14, 2024; Accepted: July 31, 2024; Published: September 3, 2024

Copyright: © 2024 Doubova et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The entire dataset and codebook are available at https://github.com/svetlanadoubova/ANC1Mex .

Funding: This work was supported by the Convocatoria para el Financiamiento de Protocolos de Investigación Propuestos de Redes Transversales de Investigación En Salud del Instituto Mexicano Del Seguro Social Para El Ejercicio 2023-2024. [Call for Funding of the Research Protocols of Transversal Health Research Networks of the Mexican Institute of Social Security for the fiscal year 2023-2024] (R-2022-785-064; grant-recipient-SVD; https://www.imss.gob.mx/profesionales-salud/investigacion/convocatorias ). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: MEK is a member of the Editorial Board of PLOS Medicine. SVD, CQF, MPC, DPM, VMG, LRGC, MCCM, VMG, MARG, GEA, CEPR, CAPA, and ASD are employed by the IMSS, yet IMSS played no role in the design and conduct of the study, in the collection, management, analysis, and interpretation of the data, or in the preparation, review, or approval of the manuscript. RPC and CA have declared that no competing interests exist.

Abbreviations: 95% CI, 95% confidence interval; aCoef., adjusted regression coefficient; AMIIMSS, IMSS Comprehensive Women-Centered Maternal Care Model; ANC, antenatal care; aPR, adjusted prevalence ratio; CVI, content validity index; FMC, family medicine clinic; IMSS, Mexican Institute of Social Security; IPW, inverse probability weight; MI, multiple imputation; PR, prevalence ratio; QuEST, Quality Evidence for Health System Transformation; WHO, World Health Organization

Introduction

Women who receive continuous, supervised, quality care throughout their pregnancy, childbirth, and delivery have a 16% lower probability of neonatal death and a 24% lower probability of premature birth [ 1 ]. High-quality care improves the likelihood of preventing, detecting, and managing maternal and newborn complications in a timely manner [ 2 ]. In addition to technical care competence, women value respectful and empathetic healthcare, regardless of sociocultural and economic background [ 3 ]. How healthcare providers treat women is significant in determining their satisfaction and utilization of health services throughout the perinatal care continuum [ 3 ]. However, as many as 44% of women worldwide report experiencing negative experiences during pregnancy and childbirth care [ 4 ].

The traditional approach to obstetric care, which prioritizes the technical aspects of care and often overlooks the importance of the user–provider relationship, has been found to have adverse effects on the physical and mental health of pregnant women, leading to low levels of satisfaction, increased rates of maternal and neonatal morbidity and mortality, and a lack of trust in healthcare providers [ 3 ]. Providing evidence-based interventions and respectful antenatal and intrapartum care focusing on care quality, content of care, and women-centeredness are critical strategies to lower maternal morbidity and mortality rates [ 2 , 5 ].

In Mexico, gaps in clinical competence and empathetic and respectful care in the perinatal period have been reported. The 2018–2019 National Health and Nutrition Survey found that average compliance for the process of care indicators during antenatal, delivery, and postpartum care for women with obstetric risk factors was only 56.9% [ 6 ]. About 33.4% of women aged 15 to 49 experienced obstetric violence during the last childbirth [ 7 ]. There are mental health needs that should be addressed through comprehensive perinatal care. For instance, up to 20% of women develop depression during pregnancy and the postnatal period, but 75% do not receive depression care [ 8 ]. Untreated depression in pregnancy is associated with a higher probability of preterm birth, stillbirth, low birth weight, and maternal morbidity [ 9 ]. Furthermore, the high prevalence of domestic violence during pregnancy (ranging from 5.4% to 43.8% in Mexico) [ 10 , 11 ] puts women’s and newborns’ health at additional risk and requires appropriate care [ 12 ].

The Mexican Institute of Social Security (IMSS, Spanish acronym) is Mexico’s largest healthcare provider, with 74 million affiliated members, mainly formal labor market workers and their families [ 13 ]. Approximately 410,000 babies are born in IMSS hospitals each year. The perinatal care processes involve various healthcare providers, as stated in IMSS guidelines [ 14 ]. At primary care family medicine clinics (FMCs), family physicians and nurses are responsible for providing antenatal care (ANC), identifying obstetric risk factors, requesting laboratory and ultrasound tests, and administering vaccines and supplements. If the pregnant woman has no obstetric risks, the family doctor and nurse continue to monitor her progress. However, if there are complications or comorbidities during pregnancy, the woman must be referred to obstetrician/gynecologist specialists in second-care hospitals for further ANC. Delivery occurs in a hospital setting under the supervision of obstetrician/gynecologist specialists and neonatologists. After delivery, the woman is counter-referred to the family physician for postnatal care.

IMSS has released clinical standards for ANC. However, gaps in ANC quality remain. According to a 2014 retrospective cohort study that included 5,342 women who received ANC at IMSS, the quality of care for pregnant women was substandard [ 15 ]. Only 40.6% of women began ANC in the first trimester, and 63.5% attended 4 or more ANC visits. On average, these women received only 32.7% of the ANC recommended by IMSS clinical guidelines [ 15 ].

IMSS has recognized gaps in ANC quality and is taking steps to improve it. In March 2022, it launched the “IMSS Comprehensive Women-Centered Maternal Care Model” (AMIIMSS acronym in Spanish), a nationwide program designed to improve women’s perinatal care. AMIIMS aims to provide quality, timely, safe, and women-centered comprehensive care to women throughout their reproductive lives—from contraception to postnatal care. The program intends for healthcare to be provided in a safe and respectful environment, free of obstetric violence, and with effective communication, considering cultural differences between healthcare providers and women.

To guide the program, IMSS released technical guidelines and provided mandatory “Friendly Obstetric Care” training to hospital staff to implement the AMIIMSS model, prioritizing obstetric care improvement in hospital settings.

Although AMIIMSS’s focus is on improving obstetric care in hospitals, family physicians can voluntarily enroll in an online training program that addresses the technical aspects of ANC but does not offer person-centered care training. Additionally, there have been no change management interventions, infrastructure improvements, or process of care enhancements in FMCs as part of the AMIIMSS.

Given IMSS’s goal to improve respectful maternity care, we undertook a longitudinal eCohort study to assess women-reported experiences of care across the maternal health continuum among IMSS users. Findings from this study should provide evidence to develop actionable recommendations for decision-makers to enhance ongoing interventions aimed at delivering high-quality, comprehensive women-centered ANC.

The present study describes the adaptation and validation processes of study questionnaires in the Mexican context. Using the baseline survey, we also describe women’s characteristics, care competence, and their experience during the first ANC visit, and assess the factors associated with care competence and users’ experience.

The study used the maternal and newborn health eCohort baseline data and questionnaires developed by the Quality Evidence for Health System Transformation (QuEST) network to longitudinally evaluate the quality of care from the women’s perspective during their pregnancy, childbirth, and postnatal period through telephone interviews [ 16 ].

Stage 1. Adaptation and validation of the study questionnaires

The study involved adapting and validating 4 questionnaires/modules designed by the QuEST network for their use in the Mexican context. These included a baseline survey with pregnant women after their first ANC visit and follow-up surveys during pregnancy, after delivery, and postnatal periods.

The study questionnaires were translated from English to Spanish. The translation process followed the recommendations of the World Health Organization (WHO) to ensure semantic equivalence, quality, and consistency of meaning with the questionnaires’ original version. IMSS experts validated their content and conducted cognitive interviews with women during the perinatal care continuum to ensure the questionnaires were appropriate for the institutional and Mexican-culture context. The group of experts comprised 3 nurses who specialized in family medicine and maternal–child care, 2 medical doctors who were chiefs of family medicine services, 2 specialists in gynecology and obstetrics, 2 health services researchers, and a clinical psychologist, all with 10 or more years of clinical and research experience in maternal and child health. The experts reviewed and rated all questions of the 4 questionnaires based on their relevance to the study’s objectives. They also identified questions and response options difficult to understand for women and proposed clarity improvements. After 3 rounds of content validation, the experts reached a consensus on the content and wording of the questionnaire.

The content validity index (CVI) was calculated for each item, considering the expert ratings. All ratings were grouped into the following categories: relevant/very relevant, and not relevant/useful but not relevant. The CVI was calculated using the formula and methodology proposed by Lawshe and improved by Veneziano and Hooper, which quantifies the expert panel’s consensus regarding each item in the questionnaire and considers CVI equal to or greater than 0.70 as valid [ 17 ].

Two rounds of cognitive interviews were conducted with pregnant women affiliated with 2 IMSS FMCs to assess the clarity and comprehension of the study questionnaires. We applied purposive sampling to obtain a diverse schooling and pregnancy status sample and used registries of pregnant women to identify and invite women to the interviews. We completed 44 interviews, with 11 interviews per questionnaire. Of these, 12 interviews were conducted with women holding college degrees, 12 with high school graduates, 12 with secondary school graduates, and 8 with primary school education or lower. A previously elaborated guide was used to conduct the interviews.

Stage 2. Women recruitment and baseline—First antenatal visit—Evaluation

From August 10 to December 15, 2023, pregnant women were enrolled to participate in the study.

Selection criteria

The study included women aged 18 to 49 who attended their first ANC appointment with an IMSS family physician and signed the informed consent form. Women who planned to receive ANC and childbirth care elsewhere (for instance, private sector), those without a contact telephone number for follow-up, or those with disabilities preventing them from completing a phone survey (for instance, mental, hearing disability) were excluded from participating in the study.

Sample size

Settings and sampling

The study included 48 FMCs across 8 Mexican states in 4 regions (North, West, Center, and Southeast). Two states were selected in each region based on their higher number of ANC visits. The states chosen were Aguascalientes and Jalisco in the West, Coahuila and Nuevo León in the North, Veracruz and Yucatán in the Southeast, and the State of Mexico and Mexico City in the Central region. Six FMCs were then selected from each state: 2 small, 2 medium, and 2 large. The size of the FMC was defined using the formula proposed by the IMSS Coordination of Information and Strategic Analysis and calculated as Total FMC affiliates / Total delegation affiliates × 100. A proportion of less than 5 was considered a small FMC, 5 to 15 a medium FMC, and more than 15 a large FMC. In each FMC, the sample of women was defined using the Lahiri method [ 18 ] based on probability proportional to the number of first-time ANC visits 4 months before the study and the goal to recruit a minimum of 163 women in each delegation to obtain 1,300 women (also see S1 and S2 Appendices files).

Women who had their first ANC appointment at study FMCs were invited by trained interviewers to participate in the study. They were informed about the study’s purpose, duration, ethical considerations (for instance, voluntary participation, potential risks and benefits, data security, and confidentiality), and contact details for the principal investigator and the IMSS Ethics Committee. All participants gave their informed consent before joining the study.

After consenting, participants could either complete a baseline questionnaire immediately or schedule a phone interview later on. Most participants (86%) preferred to conduct the baseline interviews over the phone. They often did not have time to answer the questionnaire immediately after the ANC visit but agreed to schedule a phone call for a later time. All baseline questionnaires conducted by phone were completed between the day of the first ANC visit and no more than 2 weeks afterward. The baseline interview lasted between 30 and 40 minutes. Participants received no in-kind or economic compensation for their participation in the study. For data storage and security, see S3 Appendix .

At the baseline, information was gathered on participants’ sociodemographic and clinical characteristics, content of care, their experiences with the first ANC visit, and their ratings of the quality of healthcare they received.

The variables comprised the following:

• The general attributes that included (i) sociodemographic characteristics such as age, level of education, occupation, and marital status; (ii) risky health behaviors such as alcohol and tobacco consumption in the last month, and (iii) Intimate partner violence measured with the violence scale and severity index validated in Mexico [ 19 ]. This scale has 19 items and evaluates psychological, physical, and sexual violence and allows calculating the severity index of intimate partner violence through the sum of the weighted scores of the 19 items, which varies from 0 to 369, where the highest score indicates greater violence.
• Obstetric and medical history comprised the total number of pregnancies (including the current pregnancy), number of children born alive, history of abortion/miscarriage, premature birth (<37 weeks of gestation), obstetric hemorrhage, cesarean section, neonatal death; history of pregestational chronic diseases, such as previously diagnosed diabetes, prediabetes/insulin resistance, hypertension or cardiovascular disease, depression or anxiety, epilepsy, anemia, thyroid disease, respiratory diseases, gastrointestinal diseases, gynecological diseases or other chronic diseases, medication, and supplements consumption.
• Current pregnancy and health status included weeks of gestation and trimester of pregnancy at the first antenatal visit, reasons for not seeking/receiving ANC in the first trimester, planned pregnancy, multiple pregnancies, common pregnancy discomforts (dizziness, nausea, paresthesia, or back pain); emergency warning signs: severe headache, vaginal bleeding, severe abdominal pain, difficulty breathing, fever, and others such as seizures, repeated fainting, or loss of consciousness; reduced or stopped fetal movement in the second or third trimester of pregnancy; systolic and diastolic blood pressure recorded in the woman’s health card and high blood pressure (>140/>90 mm Hg); the presence of one or more obstetric risk factors: age ≥35 years old, history of fetal death, preterm birth, pregestational diabetes, high blood pressure, current multiple pregnancies, decreased fetal movements; and self-rated health (excellent/very good, good, fair/bad). The risk of depression was evaluated with the widely used Patient Health Questionnaire (PHQ-9) validated in Mexico [ 20 , 21 ]. This scale has 9 questions and 4 response options ranging from 0 (none of the days) to 3 (almost every day), with an overall total between 0 and 27. The severity of the symptoms is organized into 6 risk categories of depression: 0 to 4 (minimal), 5 to 9 (mild), 10 to 14 (moderate), 15 to 19 (moderate to severe), and 20–27 (severe) [ 22 ]. For this study and considering the low prevalence of cases with a risk of depression ≥10, the last 3 categories were grouped into a single one of moderate to severe risk.
• Content of care during the first ANC visit comprised waiting time and visit duration and the following clinical actions during the visit, including history taking: assessing the date of the last menstruation, taking history about previous pregnancies, (including asking about miscarriages, stillbirths, premature births, previous cesarean sections, or neonatal deaths), assessing the presence of warning signs during the current pregnancy; history of pregestational chronic diseases and their treatments, including mental health disorders. Examinations, laboratory and imaging studies, and preventive care included measurements of blood pressure, weight, height, and fetal heartbeat (for women with ≥12 weeks of gestation); referral to a general urine test, full blood count testing for anemia screening, rapid test for HIV, glucose measurement for diabetes detection, syphilis testing; ultrasound scan before 24 weeks; referral for tetanus vaccination in unvaccinated women or those with more than 10 years since the last immunization. Provision of information about the number of babies expected, the delivery date, the delivery plan, the possibility, and reasons for needing a cesarean section. Counseling during the first ANC visit about nutrition, physical exercise during pregnancy, situations that cause stress, quitting risky health behaviors such as smoking and/or drinking alcohol in women with these habits, and information on where to seek help in case of intimate partner violence in women who suffered violence, and counseling about common pregnancy discomforts and signs of emergency. Referral to a consultation or follow-up with a specialist in obstetrics and gynecology and scheduling the next antenatal appointment.
• Women’s experiences during the first ANC visit were measured by asking women to rate 8 components of their care on a scale from 1 to 5 (poor, fair, good, very good, and excellent): (i) knowledge and skills of their healthcare provider; (ii) the level of respect showed by the provider; (iii) availability of medical equipment or access to lab tests; (iv) clarity of the provider’s explanations; (v) degree to which the provider involved women in decisions about their care; (vi) courtesy and helpfulness of the healthcare facility staff, other than healthcare provider; (vii) the amount of time the provider spent with the woman and (viii) the waiting time.
• We also created 2 summary variables. (6.1) A summative measure of care competence was defined as the percentage of clinical actions performed by the healthcare provider during the first ANC visit out of the total number of actions the woman required based on her medical and obstetric history. To construct this variable, we considered all previously mentioned clinical actions, including taking an obstetric and medical history, physical examinations, laboratory tests and imaging, preventive care, and counseling. (6.2) A user experience score was defined as the sum of the response scores of the 8 user experience indicators described in the fifth subsection.

Statistical analysis (also see S4 Appendix )

We first conducted descriptive analyses of the study population, the content of care, and women’s experiences during the first antenatal visit. The categorical variables were presented as percentages, while numerical variables with a normal distribution were presented as mean and standard deviation; numerical variables without normal distribution were presented as median with minimum and maximum.

Second, we investigated the factors associated with care competence using a multivariable linear regression model. Our modeling strategy was based on VanderWeele and Shpitser criterion for confounder selection [ 23 , 24 ]. These authors recommend including all conceptually and clinically relevant covariates to ensure the final model adjusts for even slight confounding (and is not subject to potential p -value hacking). Through a literature review, we identified relevant sociodemographic obstetric and medical history variables that previous studies linked to user experiences, satisfaction with healthcare, perception of the quality of care, and providers’ competence. Finally, we analyzed factors associated with better user experience during the first antenatal visit. For this purpose, we considered the distribution of the user experience score and conducted multivariable Poisson regression analyses, including all conceptually or clinically relevant covariates in the model and considering the health facilities as a cluster variable. In addition, 19% of women had missing data for the user experience score or other variables.

To avoid bias related to the missing data in the participants’ responses, we corrected this by fitting the final multivariable Poisson regression model using stabilized inverse probability weights (IPWs) [ 25 ]. The denominator of stabilized IPWs was the probability of “having missing data” given the available covariates without missing data. These covariates were the participants’ age, education, presence of risky health behaviors, chronic disease, and number of pregnancies. The numerator was the probability of “having missing data” regardless of the covariates. The IPW approach tends to be simpler than multiple imputation (MI) because, unlike MI, which requires the creation and analysis of multiple imputed datasets, IPW involves only a single weighted dataset. IPW can provide a straightforward way to obtain unbiased estimates if the model for the missing data mechanism is correctly specified [ 26 ]. Results from the regression analysis without IPWs are provided in S5 Appendix .

Before performing the multivariable regression analyses, we estimated crude coefficients through bivariate linear regression and crude prevalence ratios (PRs) through bivariate Poisson regression ( S6 and S7 Appendices). We also confirmed the absence of multicollinearity and interactions among the study covariates. In addition, the standard errors of both regression models were adjusted for the clustered sampling approach. We used the unique ID of the FMCs where women received ANC to adjust the standard errors. A p -value of ≤0.05 was considered statistically significant.

We analyzed data using the statistical software Stata 14 (Stata Corp LP; College Station, Texas). The study is reported as per the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline ( S8 Appendix ).

Ethics approval

The study was approved by the IMSS National Research and Ethics Committees (R-2022-785-064). Before participating in the study, all women signed the informed consent form.

As part of the adaptation process, all 4 study questionnaires underwent changes to enhance the questions’ clarity, sequence, and relevance. In each questionnaire, irrelevant questions were removed, and unclear questions were improved to ensure better understanding. For example, 7 questions were eliminated in the first questionnaire as they did not apply to the health providers activities during the first ANC visit in IMSS FMCs. Additionally, 16 questions and 8 response options were modified to improve clarity. Moreover, questions related to partner violence were replaced with questions from a validated scale in Mexico.

A total of 1,555 pregnant women were invited to participate in a study after their first ANC visit. Out of those, 1,390 women (89.4%) agreed to participate. The 2 main reasons for not participating were lack of time (66.1%) and lack of interest because they would not receive any in-kind or economic incentive (33.9%). When comparing the characteristics of those who agreed and those who did not, we found that the women who declined to participate had higher education levels than those who agreed (64.2% of acceptors had high school or higher education, while 76.2% of non-acceptors had high school or higher education).

Participants’ characteristics

A total of 1,390 women participated in the study ( Table 1 ). Most were between 18 and 34 years old (86.4%), with high school or higher (64.2%), and had a paid job (61.0%). Only 3.8% reported consuming alcoholic beverages and 1.7% smoking. The majority lived in a common law union (43.7%) or were married (38.4%); 9.6% reported suffering from intimate partner violence, with psychological violence being the most frequent (8.3%) and the severity of violence being mild, with a median of 6 and a range between 4 and 127 points.

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https://doi.org/10.1371/journal.pmed.1004456.t001

Of all the women surveyed, 36.6% had their first pregnancy, while the remaining 63.4% had already experienced pregnancy. Among those who had previous pregnancies, 8.3% had reported having a miscarriage, 7.6% had experienced premature birth, 3.7% had obstetric hemorrhage, 39.4% had undergone cesarean section, and 2.4% had to face neonatal death. As for medical history, 19% reported having a chronic illness before pregnancy. The top 5 medical diagnoses were depression or anxiety (5.6%), followed by high blood pressure and diabetes/prediabetes (2.7% both), thyroid disease (2.6%), and gynecological diseases (2.2%). Additionally, 34% mentioned taking medication.

Regarding the current pregnancy, 45.8% began ANC during the first trimester, 42.5% during the second trimester, and 11.7% during the third trimester. The main reasons for not initiating ANC during the first trimester were not knowing they were pregnant (61.2%), not having social security at the beginning of pregnancy (28.2%), or not finding available appointments (12.5%). Only 48.8% reported planning their pregnancy, and multiple pregnancies were reported by 1.2%; 73.2% experienced common pregnancy discomforts, such as dizziness, nausea, or back pain, while 35.8% reported experiencing some emergency warning signs. The most frequent emergency symptoms were headache (22.5%), vaginal bleeding (11.0%), and severe abdominal pain (9.3%). Of the women with blood pressure recorded ( n = 800), 6.9% had elevated blood pressure. According to the institutional guideline, 26.9% presented one or more obstetric risk factors. Most women rated their health as good or excellent, while only 16.3% rated it as fair or poor. The evaluation of the depression risk with the PHQ9 scale revealed that 15.7% had a mild risk of depression, while 3.4% had a moderate to severe risk of depression ( Table 2 ).

https://doi.org/10.1371/journal.pmed.1004456.t002

Care during the first ANC visit

The median waiting time for the first ANC visit was 30 minutes (range 0 to 540) and the median duration of the visit was 20 minutes. Only 20.9% waited less than 15 minutes. Only half reported that their first ANC visit lasted 20 minutes or longer, while 16.7% had a visit lasting less than 15 minutes ( Table 3 ).

https://doi.org/10.1371/journal.pmed.1004456.t003

Regarding the clinical actions during the first ANC visit, in most cases (97.9%), the physicians asked women about the date of their last menstruation. However, only 7.9% of women were asked about their previous pregnancy. Among these women, 95.9% were asked if they had experienced miscarriages and stillborn babies. Only 13.4% were asked about their history of preterm births. Only 6.6% of women with a previous cesarean section and only 14.3% of women with a previous neonatal death were asked about this history. Out of the total number of women, only 48.1% were asked about warning symptoms during their current pregnancy.

A relatively high percentage of women with diabetes (76%) and hypertension (69.4%) were asked about their medical history by their physicians, as opposed to only 19.2% of women with previously diagnosed depression. Furthermore, only 20.8% of women at risk of depression were asked about their mood, and 76.5% were asked about their medication consumption.

Out of the women surveyed, 93.2% reported having their blood pressure measured, but only 57.6% had it recorded on their personal health cards; 97.3% reported that their weight was measured, while 81.7% reported that their height was measured. Half of the women (53.2%) with ≥12 weeks of gestation reported that their physician measured the fetal heartbeat. Additionally, 93.7% were referred to a general urine test, 93% for a blood test, 87.1% for the rapid HIV test, 78.3% for rapid glucose measurement to screen for diabetes, and 73.6% for the Venereal Diseases Research Laboratory measurement for syphilis detection. Only 54.6% of the women were referred to ultrasound scan before 24 weeks, and 59.1% of women not vaccinated against tetanus or those with more than 10 years after the last vaccination were referred to tetanus vaccination. Less than half (43.2%) of women who were 8 or more weeks pregnant were informed by their physicians about the number of babies they were carrying, while 79.3% received information about the probable delivery date. Only 29.0% were informed about their birth plans, and just 12.8% were told about the possibility of having a cesarean section. The main reasons for the cesarean section were a previous one (53.9%) or the mother’s health issues (25.3%).

Regarding health-related counseling, 57.9% of women were counseled about nutrition, 44% about physical activity, and 16.8% about stress management. Also, 72.2% of women with a history of smoking or alcohol use were advised to quit these habits. Only 5.3% of women who reported experiencing intimate partner violence received information about where to seek help. Also, 72.2% of women were counseled about warning signs of emergency, and 42.9% of women received recommendations and treatment to address common discomforts during pregnancy. Four hundred and thirty women (30.9%) were referred to a gynecologist for consultation or follow-up, and 96% had the next antenatal visit scheduled.

On average, only 67.7% of the necessary clinical actions were performed based on women’s medical and obstetric history. Overall, 26.6% of women received poor care competence, with less than 60% of activities performed.

The 3 main reasons for receiving ANC at the IMSS FMC were healthcare covered by social security and being affiliated with a specific FMC (57.5%), proximity to home (19.8%), or need for maternity leave (6.3%), while only 4% said it was due to the good skills of IMSS physicians.

When specifically asked about women’s perceptions of different aspects of the first ANC visit, the results showed that 30% of women rated the level of respect they received from their physician as regular or poor, and 36.1% rated the clarity of the explanations as regular or poor. Additionally, about 40% rated the degree to which the physician involved them in decision-making about their care and the physician’s knowledge and skills in caring for pregnant women as fair or poor. Furthermore, 41.8% rated the courtesy and friendliness of the healthcare facility staff as fair or poor, while 52.1% rated the time the provider spent with them as fair or poor. Finally, 52.7% rated the availability of equipment and lab tests as fair or poor ( Fig 1 ).

https://doi.org/10.1371/journal.pmed.1004456.g001

Overall user experience during the first ANC visit, defined as the sum of the 8 previously reported indicators, ranging from a score of 8 (poor experiences) to 40 points (excellent experience), revealed that, on average, women scored only 23 points, indicating general regular experience.

Table 4 presents the factors associated with care competence score during the first ANC visit. Women’s characteristics, such as multiple pregnancies, risk of depression, warning signs, common pregnancy discomforts, and initiating ANC in the first or second trimester, were associated with poorer care competence during the first ANC visit. Additionally, receiving ANC in the West and Southeast regions or having an ANC consultation length under 20 minutes were associated with lower competence scores.

https://doi.org/10.1371/journal.pmed.1004456.t004

Table 5 shows that higher care competence and the size of the clinic (small) were variables associated with better user experience, while common pregnancy discomforts and visit length of less than 15 minutes were associated with lower women’s overall experience score during the first ANC visit.

https://doi.org/10.1371/journal.pmed.1004456.t005

The study comprehensively assessed provider competence and women’s experiences during the first ANC visit across 48 IMSS primary care clinics in 8 states of Mexico. The key findings show that, on average, women received less than 70% of the necessary clinical actions, indicating suboptimal health providers’ proficiency. Several characteristics were associated with poorer care competence, including women’s health status and obstetric history, shorter visit length, and being in the West or South East regions of Mexico. The findings also show that almost half of the pregnant women rated their experience during the first ANC visit as fair or poor. Higher care competence and receiving care in a small clinic as compared to a medium size clinic were factors associated with a better first ANC visit experience, while common pregnancy discomforts and shorter visit length were associated with lower women’s experience.

The first ANC visit is important for identifying obstetric risks and building trusting relationships between women and healthcare providers to ensure positive pregnancy outcomes. Comprehensive ANC is essential to achieve these objectives and ensure pregnant women’s and their babies’ well-being [ 2 ]. This type of care should prioritize competent, evidence-based medical attention and produce positive experiences for women. Therefore, assessing the quality of ANC should include measuring the experiences and opinions of women who receive it. Unfortunately, this holistic approach to ANC and its evaluation is not widely implemented, leading to significant information gaps and missed opportunities for improvement.

Provider competency in ANC refers to the knowledge and implementation of institutional evidence-based practice guidelines and WHO recommendations on ANC tailored to women’s needs [ 2 ]. A competent provider should be able to conduct thorough maternal and fetal assessment and counseling. IMSS has evidence-based practice guidelines, but health providers do not use them regularly, and there are no clear metrics to ascertain their use. Our results indicate deficient obstetric and medical history taking, physical examinations, and laboratory and ultrasound screenings. For instance, less than 1 in 10 women who had been pregnant before were asked about their previous pregnancies, and less than half were screened for warning symptoms during the current pregnancy. Additionally, only half of the women received a referral for an ultrasound scan before 24 weeks of gestation. These clinical activities are essential to identify and manage high-risk pregnancies and to prevent complications during childbirth. For instance, previous studies have indicated that women who have had 2 or more miscarriages face twice the risk of experiencing very preterm delivery, placenta previa, preterm premature rupture of membranes, and low birth weight [ 27 ]. Moreover, women with a history of fetal death are at high risk for subsequent pregnancy loss with less than 1 in 4 pregnancies resulting in infant survival [ 28 ]. At the same time, routine second-trimester ultrasound before 24 weeks can enhance the detection of major fetal abnormalities and increase the number of women opting for termination of pregnancy due to this reason [ 29 ].

Counseling about obstetric danger signs would help identify and treat severe pregnancy complications in a timely manner [ 2 ], yet in our study, only 7 in 10 women received counseling for danger signs. However, it was documented that in developing countries like Mexico, pregnant women have low to medium awareness of obstetric danger signs [ 30 ]. This lack of awareness can lead to delays in seeking urgent healthcare [ 31 ]. Providing counseling on warning signs during ANC visits can increase the likelihood of recognizing pregnancy danger signs by 8 times [ 32 ]. Therefore, healthcare providers should prioritize counseling on obstetric warning signs.

It is also important to counsel pregnant women about unhealthy habits and provide nutrition and physical activity advice to ensure healthy pregnancy outcomes. A meta-analysis of 34 studies on the effect of nutrition counseling targeting maternal diet and supplement intakes during pregnancy revealed significant improvements in health outcomes. The interventions led to a 30% reduction in the risk of anemia in late pregnancy, a 105 g increase in birth weight, and a 19% decrease in the risk of preterm delivery [ 33 ]. Furthermore, dietary and physical activity interventions and a combination of both were also associated with a 26% reduction in the risk of preeclampsia and a 9% reduction in cesarean section [ 34 , 35 ]. However, in the present study, only 4 out of 10 women received physical activity counseling, and 6 out of 10 received nutritional counseling, revealing the need to reinforce these activities.

Existing studies on ANC provider competency, including counseling, are primarily from low-income countries in Africa and Asia [ 33 – 35 ]. In Latin America, research on healthcare provider competency in ANC is scarce. Studies mainly focus on the adequacy of care in terms of the timing of ANC initiation, the number of attended appointments, and antenatal procedures, reporting that the percentage of women who received adequate ANC ranges from 21% to 71% in different settings [ 36 – 40 ].

In our study, we found that better care competence was strongly correlated with better women’s experiences. This suggests that pregnant women are able to recognize good quality care. Gathering women’s feedback about their initial ANC visit can offer significant insights and valuable information. Therefore, a comprehensive assessment of ANC should include feedback from women about their first ANC visit, including the provider’s level of knowledge and respect, the clarity of the information given, the involvement of the woman in decision-making, the courtesy of the staff, the duration of the visit, and the availability of necessary equipment. These characteristics of care are essential to ensure women-centered care and to encourage women to continue using ANC [ 41 ]. However, most research in Latin America and other low- and middle-income countries focuses on women’s satisfaction [ 42 – 46 ]. It lacks detailed information on specific experiences that could help identify gaps in care and design improvement strategies. In our study, lower-rated experiences included limited access to lab tests and medical equipment, long wait times before being seen, and short provider–patient interactions. Additionally, women reported perceived gaps in the knowledge and skills of healthcare providers and a lack of involvement in decisions about their care. Importantly, higher healthcare providers’ competence was associated with better women’s overall opinions about their experiences during the first antenatal visit. However, we identified that care competence varied across states, with the Southeast (Veracruz and Yucatán) and the West (Aguascalientes and Jalisco) regions showing lower provider competency than the Northern region (Coahuila and Nuevo León). Variations in the quality of maternal care at IMSS across states were previously reported, revealing low quality in both poor and wealthy states [ 47 ]. Additionally, women’s experiences varied based on the size of FMCs, with better experiences in small FMCs compared to medium-sized ones. Similar findings were observed in the United Kingdom [ 48 , 49 ], where small clinics provided more personalized care. This variation in care emphasizes the need for standardizing IMSS care across the country to ensure consistent quality of care across facilities and states.

The association between poor ANC competence and women’s overall opinions of their experiences during the first ANC visit underscores the need to address systemic barriers contributing to this issue. Institutional, structural, and provider-related barriers must be identified and addressed to implement evidence-based practices in primary care.

From an institutional perspective, common barriers include shortages of healthcare providers, heavy workloads, and time constraints [ 50 ]. Several studies at IMSS have reported these barriers, emphasizing the need for strengthening human resources [ 51 , 52 ]. For example, family physicians at IMSS work 6-hour shifts with up to 24 patients, allowing an average of 15 minutes per patient consultation. However, our study suggests that to better meet women’s specific needs, the first ANC visit should be at least 20 to 30 minutes long. This duration ensures sufficient time for necessary assessments and counseling, thereby creating positive experiences for women.

Another barrier is the lack of providers’ competency and monitoring of user experiences. IMSS should institutionalize regular monitoring and feedback of ANC providers’ competency and women’s experiences at FMCs. Monitoring these indicators could serve as benchmarks for performance against best practices and offer succinct feedback to health providers. This could help identify and address gaps between evidence-based practices and the care women receive. Incorporating pregnant women’s feedback about the ANC they receive, tailoring ANC to their needs, and ensuring their preferences and values are considered could be pivotal in developing a women-centered model of ANC. Additionally, the information gathered from monitoring can be integral in devising simulation-based training and e-learning platforms customized to address the identified educational needs of health providers delivering ANC.

Regarding healthcare providers, common barriers include inadequate training, and insufficient knowledge and skills related to evidence-based practices, poor communication skills, and unclear delineation of roles and responsibilities. Implementing comprehensive training strategies for primary care teams—including physicians, nurses, social workers, and nutritionists—is crucial. These strategies should focus on enhancing providers’ technical, communication, and user-centered skills, as suggested by the present study findings and existing literature on this topic [ 50 ]. These strategies should prioritize the provision of appropriate assessment and counseling to pregnant women, especially those who have had previous pregnancies, who are experiencing warning signs, and who are at risk of depression or suffering from domestic violence. These recommendations align with the WHO and IMSS ANC guidelines [ 2 , 14 ]. The training should focus on underperformed activities in the Southeast and West regions where lower care competence and women’s experiences were reported. This is especially important as a recent study revealed that the user’s overall perception of public healthcare providers’ low quality is associated with a higher likelihood of private sector use [ 53 ]; therefore, if women do not receive competent person-centered ANC at IMSS, they will choose to use private sector care, which could lead to their catastrophic health expenditures.

Additionally, all members of the primary care teams should educate women on danger signs, diet, and physical health during pregnancy, childbirth, and the postnatal period to raise women’s awareness of the importance of early identification and treatment of danger signs, as well as healthy behaviors for the health of the mother and her baby.

The present study has several strengths and limitations. One of its strengths is the comprehensive evaluation of the first ANC visit, including both patient-reported experience and healthcare competency measures. Our study also benefited from adapting and validating the questionnaires designed by international experts from the QuEST network for global use. The translated version of this questionnaire was content validated by experts from IMSS, and patient input was taken into account during the questionnaire codevelopment through cognitive interviews. Another strength is the large sample of women from 8 Mexican states and a 2-week timeline for data collection to avoid recall bias, as previous studies collected information over a year or more after the healthcare visit took place.

Nevertheless, our study has limitations. First, the content of care was self-reported by participants who may not be able to accurately report what was done during the visit. More educated or multipara women may report specific ANC clinical items better. Some measures (for instance, blood pressure) were extracted from maternal health cards, but these cards were often incomplete. There is also a possibility that participants’ ratings of their experiences can be prone to social desirability bias when participants provide responses that they think are socially acceptable; however, the physical distance between the interviewer and respondent, along with the respondent’s inability to see nonverbal signs of the interviewer, can lead to more sincere responses. The cross-sectional analysis of baseline information does not allow causal inference. There was also a high prevalence of missing data for the user experience score, which we addressed using stabilized IPWs. Moreover, the present paper only addresses the first ANC visit. Additional clinical care items may be performed in follow-up visits. Finally, the study only focused on pregnant women who received ANC at IMSS and did not include other public healthcare providers in Mexico. This limits the generalizability of the findings. However, it is worth noting that IMSS is the largest health institution in Mexico, providing healthcare to over 57% of the national population.

In conclusion, care competence during the first ANC visit is an important predictor of positive user experience. Improvements in care competence and respectful and patient-centered care are needed for pregnant women at IMSS. Our study provides evidence on the attributes of ANC that need to be improved, calling for action from stakeholders, including policymakers, healthcare providers, and researchers.

Supporting information

S1 appendix. protocol sections on the sampling method and data collection procedures..

https://doi.org/10.1371/journal.pmed.1004456.s001

S2 Appendix. Flowchart of the sampling process.

https://doi.org/10.1371/journal.pmed.1004456.s002

S3 Appendix. Data storage and security.

https://doi.org/10.1371/journal.pmed.1004456.s003

S4 Appendix. Predefined analysis plan.

https://doi.org/10.1371/journal.pmed.1004456.s004

S5 Appendix. Regression analysis without IPWs.

https://doi.org/10.1371/journal.pmed.1004456.s005

S6 Appendix. Results of a bivariate linear regression for the factors associated with the care competence score during the first ANC visit.

https://doi.org/10.1371/journal.pmed.1004456.s006

S7 Appendix. Results of an IP-weighted bivariate Poisson regression analysis for the factors associated with women’s experiences during the first ANC visit.

https://doi.org/10.1371/journal.pmed.1004456.s007

S8 Appendix. STROBE checklist.

https://doi.org/10.1371/journal.pmed.1004456.s008

Acknowledgments

The authors would like to thank the following health professionals for their support in the study fieldwork: Kryssna Mendoza Murillo, Luz Maria Martinez Lemus, Alfonso Israel Sandoval Rabia, Flor Araceli Nava Ayala, Gabriela Flores Gutierrez, Maria De La Paz Sarahi Marquez Gomez, Alejandro Tapia Galicia, Berenice Cornejo Vázquez, Rosario Elizabeth Rojas Soto, Jazmín Guarneros Carrasco, Josué Crisanto Crisanto, Alma Rosa Cano Paez, Verónica Maribel Hernández Jiménez, Sabino Carlos Haro Marabel, Cinthya Flores García, Gloria Mendoza López, Ana Lilia González Ramírez, Ana Karen Fatima Aguilar Paredes, Elizabeth García Cortés, Dulce Anahí Quiroz Díaz, Nallely Leonor Rosas Juárez, Lizbeth Hernández Salto, Thalia Sánchez Guillén, Karina Cárdenas García, Gerónimo Rodrigo Ahumada Ocaranza, Rosalba Angulo Cruz, Clara Castillo Cruz, Alejandro Raúl Guzmán López, José Luis Pérez Estupiñan, Manuel Alejandro Treviño Jiménez, Omar Juárez Rodríguez, Ernesto Nava Escobedo, Monica Enriquez Gandara, Laura Alicia Medina Verástegui, Gabriela Escott Pérez, David Vicente Barrientos Cardona, Laura Velia Flores Arambula, José Eduardo Guajardo Iruegas, Victor Arturo Mendez Oseguera, Salma Saray Rodríguez Sandoval, Carol Nozuri Zul Rendón, Alejandra Martínez Alvarado, Rocío Guadalupe Galván Hernández, Jazzel Guadalupe Hernández Reyes, Yanet Guadalupe Padilla Arroyo, Alejandra Guadalupe Sánchez Molina, Dr José Angel González Gónzalez.

• 1. Organización Mundial de la Salud. (19 de septiembre de 2020). Mejorar la supervivencia y el bienestar de los recién nacidos. [cited 2023 Oct 10]. https://www.who.int/es/news-room/fact-sheets/detail/newborns-reducing-mortality
• 2. World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: World Health Organization; 2016. [cited 2024 Feb 5]. https://www.who.int/publications/i/item/9789241549912
• View Article
• PubMed/NCBI
• Google Scholar
• 5. WHO Recommendations: Intrapartum Care for a Positive Childbirth Experience. Geneva: World Health Organization; 2018. [cited 2024 Feb 5]. https://www.who.int/publications/i/item/9789241550215
• 7. Castro R, Frías SM. Violencia obstétrica en México: hallazgos de una encuesta nacional de violencia contra mujeres. In: Quattrocchi P, Magnone N. Violencia obstétrica en América Latina: conceptualización, experiencias, medición y estrategias, Remedios de Escalada. México: Universidad Nacional de Lanús; 2020.
• 8. Secretaría de Salud. Prensa122. En México, dos de cada 10 mujeres presentan depresión durante el embarazo o después del parto. México: Secretaría de Salud; 2023. [cited 2024 Jan 16]. https://www.gob.mx/salud/prensa/122-en-mexico-dos-de-cada-10-mujeres-presentan-depresion-durante-el-embarazo-o-despues-del-parto?idiom=es
• 13. Instituto Mexicano del Seguro social. El Informe al Ejecutivo Federal y al Congreso de la Unión sobre la Situación Financiera y los Riesgos del Instituto Mexicano del Seguro Social 2022–2023. Mexico: IMSS; 2023. [cited 2024 Jan 16]. https://www.imss.gob.mx/conoce-al-imss/informes-estadisticas
• 14. Instituto Mexicano del Seguro social. Control prenatal con atención centrada en la paciente. Guía de Evidencias y Recomendaciones: Guía de Práctica Clínica. [Prenatal control with patient-centered care. Evidence and Recommendations Guide: Clinical Practice Guide]. México: IMSS; 2017. [cited 2023 Oct 10]. https://www.imss.gob.mx/sites/all/statics/guiasclinicas/028GER.pdf
• 16. Quality Evidence for Health systems Transformation network. ECohort s to Track Longitudinal Care Quality. [cited 2024 Feb 1]. https://questnetwork.org/eCohorts-longitudinal-care-quality
• 25. Hernan MA, Robins JM. Causal Inference: What If. Boca Raton: Chapman & Hall/CRC; 2020.

• Open access
• Published: 04 September 2024

Trends and inequalities in antenatal care coverage in Benin (2006–2017): an application of World Health Organization’s Health Equity Assessment Toolkit

• Richard Gyan Aboagye 1 , 2 ,
• Joshua Okyere 3 ,
• Josephine Akua Ackah 4 ,
• Edward Kwabena Ameyaw 5 , 6 ,
• Abdul-Aziz Seidu 7 , 8 &
• Bright Opoku Ahinkorah 8 , 9 , 10  

BMC Health Services Research volume  24 , Article number:  1026 ( 2024 ) Cite this article

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Introduction

Between 2006 and 2017, antenatal care (ANC) coverage in Benin declined, potentially exacerbating inequalities and substantiating the need for health inequality monitoring. This study examines inequalities in ANC attendance in Benin, disaggregated by women’s age, educational level, economic status, place of residence, region of residence, and the extent to which they have changed over time.

Three rounds of the Benin Demographic and Health Surveys (2006, 2011–12, and 2017–18) were analyzed to examine inequalities in ANC coverage. An exploratory descriptive approach was adopted for the analysis. Simple [difference (D) and ratio (R)] and complex [population attributable risk (PAR) and population attributable fraction (PAF)] measures of inequalities were computed using the World Health Organization’s Health Equity Assessment Toolkit (WHO’s HEAT) online platform. The measures were computed separately for each of the three surveys, and their estimates were compared.

The findings revealed an 8.4% decline in at least four ANC visits between 2006 and 2017–18. The decline occurred irrespective of age, educational status, economic status, place of residence, and region. Region-related inequalities were the largest and increased slightly between 2006 (D = 54.6; R  = 2.6; PAF = 47.8, PAR = 29.0) and 2017–18 (D = 55.8; R  = 3.1; PAF = 57.2, PAR = 29.8). Education ( 2006 : D = 31.3, R  = 1.6, PAF = 40.5, PAR = 24.5; 2017–18 : D = 25.2, R  = 1.6, PAF = 34.9, PAR = 18.1) and rural-urban ( 2006 : D = 16.8, R  = 1.3, PAF = 17.8, PAR = 10.8; 2017–18 : D = 11.2, R  = 1.2, PAF = 13.1, PAR = 6.8) inequalities reduced while economic status inequalities did not improve ( 2006 : D = 48, R  = 2.2, PAF = 44.5, PAR = 26.9; 2017–18 : D = 43.9, R  = 2.4, PAF = 45.0, PAR = 23.4). Age inequalities were very minimal.

ANC inequalities remain deeply ingrained in Benin. Addressing their varying levels requires comprehensive strategies that encompass both supply—and demand-side interventions, focusing on reaching uneducated women in the poorest households and those residing in rural areas and Atacora.

Peer Review reports

Over the past decades, several studies have provided evidence to support the importance and positive impact of antenatal care (ANC) on maternal, newborn, and child health outcomes [ 1 , 2 , 3 , 4 , 5 ]. ANC is considered as an important element in the maternal continuum of care [ 6 , 7 , 8 ] with several models proposing recommended guidelines. Notable are the standard “Western” model of 12 visits, the 2002 World Health Organization (WHO) Focused Antenatal Care model of four visits, and the latest 2016 WHO ANC model of eight visits to ensure positive pregnancy outcomes [ 5 ] and applicability in resource-deprived settings. Efforts following these guidelines and their updates have contributed to the current global estimates of 88% for at least one ANC and 66% for at least four ANC visits [ 9 ], but with sharp regional differences. The percentage of women aged 15–49 who attend at least four ANC visits was lowest for Western and Central Africa (53%), South Asia (55%), and Eastern and Southern Africa (54%) [ 9 ]. The disparities are further exacerbated by women’s socio-economic and demographic characteristics, where lower coverage of ANC attendance is skewed towards those residing in rural areas or specific administrative regions, poor, not educated, and in specific age groups [ 10 , 11 ].

Within sub-Saharan Africa, countries like Benin have witnessed a decline in ANC coverage. Though an estimated 90% of women (15–49 years) have had at least one ANC visit in Benin [ 12 ], values were far lower for those who met the recommended four visits. The proportion reduced from 61.4% in 2006 [ 13 ] to 52% in 2018 [ 12 ]. For ANC visits of at least eight, Ekholuenetale and colleagues only found the national coverage to be 8 per 100 women, implying a rather slow progress toward institutionalizing the new guideline [ 14 ]. As part of ANC, mothers receive the needed micro supplementation, immunization against tetanus, detection of early signs of complications, and medications for endemic health conditions to reduce the risk of pregnancy complications as well as maternal/child deaths [ 2 , 5 , 9 , 15 , 16 ]. This is particularly important in Benin, where the rates of maternal/child mortality are already high; maternal, infant, and under-five mortality rates stand at 405 deaths per 100,000 live births, 55 deaths per 1000 live births, and 83.5 per 1000 live births, respectively [ 17 , 18 ]. Benin is also far from reaching the Sustainable Development Goal (SDG) targets for maternal and under-five survival by 2030. As a result, the decline in Benin’s ANC (at least four visits) coverage raises dire public health concerns, highlighting the need to explore underlying factors and inequalities to guide targeted interventions.

Exploring inequalities in the proportion of women who have had at least four ANC visits presents three opportunities – (1) tracking the impact of existing ANC-related health programs, strategies, interventions, and policies on marginalized groups; (2) identifying who to target in new programs and interventions, and (3) guiding research to provide socio-cultural and contextual explanations to the differences observed within groups. Within the context of this study, we prioritize the concept of “health inequality” to highlight differences in health outcomes (at least four ANC visits) within and between social groups. The differences could be a product of avoidable systematic, unjust, and unfair processes or circumstances [ 19 ]. For ANC, observed inequalities have been reported for women in different educational, age, wealth, and residential groups [ 10 , 13 , 20 , 21 , 22 ]. According to the United Nations Children’s Fund [ 23 ], in Benin, an estimated 66% of women in urban areas had at least four ANC visits compared to 54% in rural areas. Only 35% of women in the poorest households also made at least four ANC visits compared to 83% among those in the richest households. The proportion of women aged 20–34 years who made at least four ANC visits (60%) was 7% more than those aged less than 20 years (53%), while for educated women (87%), the proportion was 36% more than that of uneducated women (51%). Among the regions of residence, ANC coverage of at least four was lowest in Atacora (27%) and Alibori (36%) compared to Littoral (86%). The observed decelerating trends in ANC visits among women in Benin imply that inherent patterns of low uptake will be concentrated in some social groups compared to others. The magnitude of the inequalities and the extent to which they differ with time are important to explain the observed patterns at the national level, relevant for health monitoring. Of greater interest is the need to determine whether the prevalence of ANC among disadvantaged sub-groups (those aged less than 20, uneducated, in the poorest households, residing in rural areas, and in Alibori or Atacora) continues to worsen over time and whether that partly explains the decelerating trends.

Given its strong commitment to achieving equity in health, the WHO has developed several tools and resources to build and strengthen capacity for health inequality monitoring [ 24 , 25 ]. Notable is a free and open-source software - Health Equity Assessment Toolkit (HEAT) - that facilitates the assessment and monitoring of within-country inequalities for several health outcomes, including ANC visits of at least four and with special emphasis on low-and-middle-income countries [ 25 ]. A set of simple and complex inequality measures can be computed with this software, and several documents and updates have been drafted for public use [ 25 , 26 ]. This study applies HEAT by using selected simple and complex inequality measures to provide an in-depth understanding and perspectives on ANC patterns and their inherent disparities over time. Using data from three rounds of the Benin Demographic and Health Surveys (BDHS) (2006, 2011–12, 2017–18), the study seeks to answer two questions – (1) Are there inequalities in ANC coverage among women by age, place, region of residence, education, and economic status? (2) Have the levels of inequalities widened over time alongside the decline in Benin’s ANC coverage?

Our research investigates the trends of ANC coverage over time and its associated socio-demographic and economic inequalities in Benin. The findings are relevant to track the impact of existing programs and interventions on ANC and whether it is reaching the targeted audience. ANC is an essential element in the continuum of care for maternal and child health. Efforts could be strengthened to increase its uptake to ensure the attainment of the SDG targets for maternal, neonatal, infant and under-five mortality.

Study setting and data source

Data from the 2006, 2011–12, and 2017–18 BDHS was used for the study. The survey datasets are freely available to download via https://dhsprogram.com/data/dataset_admin/index.cfm . The BDHS is a nationwide survey conducted to ascertain periodic trends and changes in demographic indicators, health indicators, and social issues among men, women, and children [ 27 ]. A cross-sectional design was adopted for the BDHS, with the respondents sampled using a stratified multi-stage cluster sampling approach. The detailed sampling methodology has been highlighted in the BDHS report [ 27 ]. This study included women with a history of live birth five years before the survey. A sample of 10,522, 8,994, and 9,031 were extracted from the 2006, 2011–12, and 2017–18 BDHS, respectively, for inclusion in the study. The data from the 2006, 2011–12, and 2017–18 BDHS were available for use directly through the WHO HEAT online platform [ 26 ]. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was considered when writing this paper [ 28 ].

Outcome variable

The outcome variable of interest was four or more ANC visits. In the BDHS, childbearing women of reproductive age (aged 15–49) were asked about the number of visits made to the ANC clinic at a health facility for their recent pregnancy. A dichotomised variable with 0–3 ANC visits and four or more ANC visits was created and used in the analysis.

Dimension stratifiers

Five variables - age of the women, level of education, economic status (wealth quintile), type of place of residence, and sub-national region - were the inequality stratifiers used in the study, as found in existing literature [ 29 ]. These stratifiers were available in the WHO HEAT software for assessing inequalities in several health and social indicators [ 26 ]. The categories of each stratifier included women’s age (15–19 and 20–49), level of education (no education, primary, and secondary and above), economic status (poorest, poorer, middle, richer, and richest), place of residence (rural and urban), and sub-national region (Alibori, Atacora, Atlantique, Borgou, Collines, Couffo, Donga, Littoral, Mono, Oueme, Plateau, and Zou). For women’s age, the age groups were dichotomized to ascertain the extent to which inequalities in ANC visits are skewed against adolescents since they often face several forms of social and economic barriers compared to older women.

Statistical analyses

We used the WHO HEAT online version [ 26 ] for all analyses. The WHO HEAT is an online statistical tool for analyzing health disparities within and between countries based on a variety of health and social indicators [ 26 ]. Detailed description of the WHO HEAT statistical package can be found in the literature [ 24 , 25 , 26 ]. Using four inequality measures, we examined the coverage of four or more ANC visits across the five inequality stratifiers: age, place of residence, economic status, level of education, and sub-national region. The four measures include difference (D), ratio (R), population attributable fraction (PAF), and population attributable risk (PAR). The formulas are shown below. D and PAR are absolute measures of inequality while R and PAF are relative measures. D and R double are simple measures, while PAR and PAF are complex measures.

Where \(\mu\) is Benin’s national average estimate for ANC visits of four or more.

The inequalities between the extremes were prioritized for stratifiers with more than two categories. For instance, between no education and secondary or higher; between poorest and richest quintiles; and between Littoral and Atacora. The most advantaged in the formulas above correspond to age group 20–49, urban, secondary/higher education, richest, and Littoral, following evidence reported in existing literature on at least four ANC visits in Benin [ 13 , 21 , 23 ]. PAR and PAF were of utmost interest as they account for distribution across all subgroups (essential for stratifiers such as education, wealth, and sub-regions with more than two categories). The inequality metrics’ precise significance, calculation, and interpretation have been highlighted in the literature [ 24 , 26 ]. All figures were generated using R programming.

Ethical consideration

No ethical clearance was sought for this study because the BDHS dataset is freely available in the public domain. Permission to use the dataset for publication was obtained from the Monitoring and Evaluation to Assess and Use Results Demographic and Health Surveys (MEASURE DHS). The detailed ethical issues per the BDHS can be accessed via https://dhsprogram.com/Methodology/Protecting-the-Privacy-of-DHS-Survey-Respondents.cfm .

Trends in antenatal care coverage of at least four visits

Table  1 shows the trends in ANC coverage by the various inequality dimensions considered in this study, spanning 2006 to 2017–18. In all, ANC coverage declined from 60.5% (in 2006) to 52.1% (in 2017–18). ANC coverage was relatively high among women aged 20–49 in 2006 (60.9%). This declined to 52.7% in 2017–18 but was still higher than the proportion for women aged 15–19 who had ANC in 2017–18 (47.3%). Women in richest households dominated in ANC coverage in all the survey waves (i.e. 87.5%, 76.6% and 75.5% in 2006, 2011 and 2017 respectively), whereas those in the lowest quintile had the least coverage in the same period (39.5%, 38.2%, and 31.6% in 2006, 2011–12 and 2017–18 respectively). Most women with at least secondary education had higher ANC coverage in 2006 (85.1%) and 2017–18 (70.2%). Conversely, those without formal education recorded the lowest prevalence in 2006 (53.7%) and 2017–18 (45%). Urban residents had more ANC visits throughout the period studied (i.e. 71.3%, 65.9% and 58.9% for 2006, 2011–12 and 2017–18, correspondingly). For region, the highest ANC visits occurred in Littoral region, both in 2006 (89.5%) and 2017–18 (81.9%).

Inequalities in antenatal care coverage of at least four visits (2006–2017–18)

The following sections delve into the differences in ANC visits of at least four by key demographic and socioeconomic factors: age, economic status, education, place of residence and sub-national region. The sections below reveal inherent inequalities and the extent to which they have changed over the years.

Figure  1 shows the coverage of ANC visits of at least four and how the inequalities that exist between age groups have changed over time. In both age groups, there has been a decline in ANC visits and the inequality measures reveal that the disparities have not been substantial. The difference (D) between age groups was only 3.2% in 2006 and 5.4% in 2017–18. The ratio (R) was 1.1 in both 2006 and 2017. The PAF reveals the potential improvement in the national coverage of ANC of at least four that could be achieved if women aged 15–19 had the same level of coverage as those aged 20–49 years. The national average could have only been 0.6% higher in 2006 and 1.2% higher in 2017–18. The PAR also showed similar trends. Despite the decrease in ANC coverage in Benin, the evidence showed that age-related inequalities are very minimal.

Trends and inequalities in ANC of at least four in Benin by age groups

Economic status

Figure  2 shows results on ANC visits of at least four disaggregated by economic status for three years (2006, 2011–12, and 2017–18). Large disparities existed between women in the poorest and richest households. The difference in ANC visits between women in the richest and poorest households was almost 50% in 2006. This reduced to 38.4% in 2011–12 and increased to 43.9% in 2017. The PAR also followed similar trends, showing that Benin’s ANC coverage could have been 26.9% points higher in 2006, 18.4% points higher in 2011–12, and 23.4% points higher in 2017–18 if economic-related inequalities were eliminated. The PAF estimate for 2017–18 (45%) was not very different from the estimate in 2006 (44.5%). The ratio indicated that ANC attendance for women in the richest households was 2.2 times higher than those in the poorest households in 2006. It slightly increased to 2.4 times in 2017–18. The 95% confidence intervals for all four measures revealed that the patterns have been stable and highlight that economic-related inequalities have not improved over the period and could partly contribute to the decelerating national average trends.

Trends and inequalities in ANC of at least four in Benin by economic status

Education-related inequalities in ANC visits are highlighted in Fig.  3 . In 2006 and 2017–18, ANC visits of at least four was 1.6 times higher for women with secondary or higher education than those without. The difference in ANC visits between women with secondary education or higher and those without education was 31.2% in 2006 but decreased to 25.2% in 2017–18. The national average of ANC visits could have been 40.5% higher in 2006 and 35% higher in 2017 if there were no education related inequalities (PAF). The PAR followed a similar decreasing trend over time. While there has been a decline, the magnitude of education-related inequalities is still high, and efforts need to be strengthened to reduce them.

Trends and inequalities in ANC of at least four in Benin by education

Place of residence

As illustrated in Fig.  4 , inequalities in ANC visits disaggregated by women’s place of residence show substantial differences between rural and urban areas, despite a decline between 2006 and 2017–18. In 2006, an additional 13 per 100 women in urban areas had attended ANC on at least four counts compared to those in rural areas. This decreased to 11 per 100 in 2017. ANC among women in urban areas was 1.3 and 1.2 times higher compared to those in rural areas in 2006 and 2017–18, respectively. If the national average were to improve to a level where ANC coverage for rural women was at par with those in urban areas, the 2006 national estimate needed to be 24.5% points higher and for 2017–18, 18.1% points higher (PAR). The PAF also showed similar trends. The 95% confidence intervals emphasize that the PAR and PAF estimates for the 2006 and 2017–18 surveys are distinctively different, indicating a significant decline with time.

Trends and inequalities in ANC of at least four in Benin by place of residence

Region of residence

Region-related inequalities are shown in Fig.  5 . Littoral had the highest coverage of ANC visits and Atacora, the lowest. Other regions had varying patterns. Alibori and Zou saw an increase in coverage from 34.9 to 69.5% in 2006 to 45.1 and 75.7% in 2017–18, respectively, while others such as Mono, Oueme, and Couffo saw an initial increase between 2006 and 2011–12 and a decrease afterward. The four measures revealed large region-related inequalities. The difference in the coverage of ANC between Littoral and Atacora was 54.6% in 2006 and 55.8% in 2017–18. The ratio of Litorral to Atacora increased from 2.6 in 2006 to 3.1 in 2017–18. The PAF and PAR had similar patterns, showing that region-based inequalities have increased over time. Without such inequalities, the national estimate could have been 47.8% higher in 2006 and 57.2% higher in 2017–18. Though the relative measures show an increase over time, the 95% confidence intervals reveal the differences across surveys could only be due to chance and perhaps the existing inequalities have stalled within a defined range.

Trends and inequalities in ANC of at least four in Benin by region of residence

In this study, we assessed the trends and inequalities in ANC coverage among women in Benin. The results show an 8.4% decline in ANC attendance (at least four) between 2006 and 2017–18. Unlike Benin’s performance, other sub-Saharan African countries such as Ghana [ 29 ] and Ethiopia [ 30 ] experienced substantial improvements. The decline highlights weakened maternal healthcare efforts, especially ANC interventions and programs. Given ANC’s relevance for monitoring maternal/ fetal health, providing vital health education, and identifying potential complications early in pregnancy [ 5 ], its decline connotes missed opportunities for timely intervention that could contribute to adverse maternal and neonatal health outcomes.

We found evidence for varying inequalities disaggregated by selected demographic and socioeconomic characteristics – age, economic status, education, place of residence, and region of residence. Sub-groups with low coverage of ANC visits in 2006 continued to experience the lowest uptake compared to their counterparts in 2017–18, in the face of the overall national decline. They included women aged 15–19, those with no education, in the poorest households, in rural areas, and in Atacora. Deviating from this decline was the Alibori region, which had the second lowest coverage in 2006 (34.9%) but saw a substantial 10% increase in 2017–18 (45.1%) and surpassing other regions such as Borgou and Donga. Inequality measures for the selected demographic and socioeconomic characteristics revealed two major patterns – an increase or a decrease. Region-related inequalities slightly increased over time, while education and rural-urban inequalities decreased. The patterns of economic-related inequalities were unclear, while age-related inequalities were negligible.

Region-related inequalities were the largest compared to the other socioeconomic and demographic factors, slightly increasing between 2006 and 2017–18. Though we report an overall decline in ANC, we found that Atacora had a slightly steeper decline between 2006 and 2017–18 (10%), compared to Littoral (7.6%) showing that women in the former region had been more affected. The magnitude of the inequalities is underpinned by several economic, social, and health factors that characterize the various regions. Littoral is majorly urban and houses Cotonou, the largest city in Benin. According to Benin‘s SDG monitoring report, Littoral ranks highest for access to public services [ 31 ] - accessibility and quality of health and education services, drinking water, electricity, internet, and civil registry. In fact, 99.2% of all childbirth deliveries were assisted by qualified health personnel and only 1.5% of its population were below the poverty line [ 31 ]. The region presents itself as a prime safety net for quality life and consequently reflects in its consistently high ANC coverage. On the other hand, Atacora (located in the Northern part of Benin) scored low on almost all public service indices while housing a substantial proportion of its population in extreme poverty [ 31 ], reflecting in the subsequent low coverage of ANC. Addressing the inequality gaps will, therefore, require public and health facility facelifts (structural and non-structural) in deprived regions such as Atacora. The facelifts could also be accompanied by additional research inquiries into socio-cultural and economic issues that reflect the social realities in various regions, and which underpin their respective ANC performance. The findings from such research can feed into implementing locally feasible and acceptable interventions to women in respective regions.

Our study revealed that women who belonged to the richest wealth quintile consistently had the highest ANC coverage compared to those in the poorest wealth quintile. The difference (D), ratio (R), PAR, and PAF also showed substantial economic-related inequalities in ANC coverage. The absolute measures (D and PAR) revealed a decline between 2006 and 2017–18 while the relative measures indicated a marginal increase, inferring well-grounded disparities. Our findings echo results from other studies that report favourable ANC outcomes for economically well-off women [ 10 , 13 , 20 , 21 , 22 , 32 ] and further add that the disparities have not reduced over the period. Indirect maternal healthcare costs often serve as a disincentive for poorer women to seek ANC services [ 33 ] and constitute a major economic barrier. This underscores the need for the Benin government to enforce adequate measures to make maternal care not only more affordable but also easily accessible. Costs associated with traveling to health facilities constitute a higher proportion of indirect costs. They can be greatly reduced if health facilities are closer to women, especially those in deprived areas. Primary healthcare initiatives such as the Community-Based Health Planning and Services, which has been implemented in countries like Ghana [ 29 ], could be a great roadmap.

The trend analysis, consistent with previous studies [ 29 , 30 , 34 ], indicated that women with secondary or higher education had higher ANC coverage than those without or only primary education. Education empowers women by enhancing their knowledge about maternal health, reproductive rights, and the importance of seeking ANC services [ 35 ]. Educated women may also have better access to information through media and other channels, leading to increased awareness of the benefits of ANC, thereby informing their healthcare decision-making [ 30 ]. Conversely, women with no or only primary education may face barriers in accessing ANC services due to limited awareness, lower health literacy, and reduced decision-making power within their households. Although ANC coverage was consistently low among those with no formal education, the findings suggest an improvement in the inequality gap, as seen in the inequality estimates. The reduced gap is partly because the decline in ANC attendance between 2006 and 2017–18 was more rapid for women with secondary or higher education (~ 15%: 85.1% in 2006 and 70.2% in 2017–18) than those with no education (~ 9%: 53.7% in 2006 and 45.0% in 2017–18). More women with secondary or higher education are missing out on ANC visits, driving the inequality gap downwards. We recommend additional research to understand why this is the case and call for more concerted efforts to facilitate further narrowing of the inequality gap.

Across the three surveys, urban dwelling women had higher ANC coverage than their counterparts in rural areas. This finding aligns with evidence from prior studies conducted in Benin [ 13 ], Ethiopia [ 30 ] and Ghana [ 29 , 32 ]. A possible explanation is that women in rural areas often face challenges related to inadequate and poorly equipped health facilities, often located far from their communities [ 13 , 36 ]. These limited resources result in a shortage of skilled health attendants, leading to higher ANC dropouts. Another perspective is that rural dwelling women may exhibit a higher susceptibility to the impact of cultural norms and social beliefs, which in turn may discourage their engagement with skilled maternal care services including ANC [ 37 ]. The inequality estimates reveal a seemingly marginal decline in rural-urban inequalities between 2006 and 2017–18. Similar to what we observed for women’s education, we find that the difference in the proportion of urban women that attended ANC of four visits or more between 2006 and 2017–18 was higher (~ 12%: 71.3% in 2006 and 58.9% in 2017) than what was reported for rural dwelling women (~ 7%: 54.6% in 2006 and 47.7% in 2017–18). The resulting lower inequality gap over time could be partly driven by the fact that proportionally, more urban women are failing to meet the recommended four visits. Further research is needed to uncover the dynamics, while exploring its intersectionality with women’s education.

Even though adolescents have been considered a vulnerable group in maternal healthcare utilization due to limited autonomy and social stigmatization, the results from our analysis showed negligible inequalities in comparison to older women. Yaya et al.’s study corroborates our findings [ 13 ]. Though the odds of ANC visits were higher for women aged 20–49 compared to adolescents [ 15 , 16 , 17 , 18 , 19 ] in their study, the findings were insignificant [ 13 ]. In other contexts, the results were mixed [ 20 , 22 , 34 ] with associative effects ranging between weak and moderate. Our findings infer that Benin’s efforts to enhance adolescent-friendly services are paying off. At least for ANC, the gap isn’t extremely wide between those aged 20 years and above and adolescents.

Beyond the inequalities observed, our study highlights a decline in ANC coverage not only at the national level but also across subgroups. This could be an indication of national-level structural or financing barriers affecting maternal healthcare utilization in general. Efforts to address such barriers through policy design, implementation research, and health interventions need to be strengthened and sensitive to existing inequalities that make some women disadvantaged.

Implications for policy and practice

Our findings underscore the urgent need for targeted policy interventions to reverse the decline in ANC coverage observed in Benin. Policymakers should prioritize maternal health and allocate sufficient resources to strengthen ANC interventions and programs. Specifically, investments should be directed towards improving access to ANC services in rural and economically disadvantaged regions such as Atacora. This may entail infrastructure upgrades, such as the construction of health facilities and the deployment of skilled health personnel to ensure equitable access to quality ANC services across all regions.

The substantial socioeconomic inequalities in ANC coverage revealed in our study necessitate interventions to reduce financial barriers to maternal healthcare access. To address the socioeconomic inequalities, the government of Benin should consider implementing policies to make maternal care more affordable and accessible, especially for women from low-income households. Measures such as subsidizing healthcare costs and expanding coverage of health insurance schemes could help alleviate the financial burden on disadvantaged women and improve their utilization of ANC services. Additionally, initiatives like the Community-Based Health Planning and Services, as successfully implemented in Ghana [ 29 ], could serve as a blueprint for community-based primary healthcare delivery in Benin, particularly in rural areas.

Efforts to promote girls’ education and literacy should be prioritized as part of broader strategies to improve maternal healthcare utilization. Investing in educational programs that enhance women’s knowledge about maternal health, reproductive rights, and the importance of ANC can empower women to make informed healthcare decisions and seek timely ANC services. Furthermore, targeted health education campaigns, utilizing various media channels, can raise awareness about the benefits of ANC among women with lower levels of education, thereby reducing disparities in ANC coverage.

Strengths and limitations

Estimating inequalities is a cumbersome task; however, using the WHO HEAT software provides an appropriate medium for effective estimation. The DHS was based on a two-stage sampling methodology that ensures that the data is representative at regional and national levels. Hence, we extrapolate the findings to the wider population of women of reproductive age in Benin. Nevertheless, there were some limitations. Although the HEAT estimates inequalities, it cannot explain why inequalities exist [ 38 ]. This means that the reasons provided for the observed inequalities are based on prior literature and assumptions. Also, this study utilized data on available variables in the WHO HEAT software. Other factors such as cultural disparities that could influence ANC coverage were not accounted for. Hence, the inferences made from this study should be based on the available variables or inequality stratifiers. To mitigate this limitation, future research could incorporate qualitative methodologies such as interviews or focus groups to explore the socio-economic, cultural, and systemic factors contributing to the observed inequalities. We acknowledge that our study’s descriptive nature precludes the establishment of causal relationships. Moving forward, longitudinal studies or randomized controlled trials could be employed to elucidate causal pathways and better understand the mechanisms driving disparities in ANC coverage among women in Benin.

ANC coverage in Benin has declined over the years by 8.4%, with pervasive inequalities by wealth index, educational levels, rural-urban, and regional residence that are favorable to those in the richest wealth quintile, urban dwelling women, and those with secondary or higher education. A one-size-fit approach to narrow inequalities related to ANC coverage would not be feasible in Benin. Rather, the Benin government could devise comprehensive strategies encompassing both supply and demand-side interventions, focusing on reaching the uneducated population residing in rural areas and Atacora as well as those in the poorest households.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Antenatal Care

Benin Demographic and Health Survey

Health Equity Assessment Toolkit

Population Attributable Fraction

Population Attributable Risk

Sustainable Development Goal

Strengthening the Reporting of Observational Studies in Epidemiology

World Health Organization

Kuhnt J, Vollmer S. Antenatal care services and its implications for vital and health outcomes of children: evidence from 193 surveys in 69 low-income and middle-income countries. BMJ Open. 2017;7(11):e017122.

Article   PubMed   PubMed Central   Google Scholar  

Tekelab T, Chojenta C, Smith R, Loxton D. The impact of antenatal care on neonatal mortality in sub-saharan Africa: a systematic review and meta-analysis. PLoS One. 2019;14(9):e0222566.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Turi E, Fekadu G, Taye B, Kejela G, Desalegn M, Mosisa G, et al. The impact of antenatal care on maternal near-miss events in Ethiopia: a systematic review and meta-analysis. Int J Afr Nurs Sci. 2020;13:100246.

Google Scholar  

Wondemagegn AT, Alebel A, Tesema C, Abie W. The effect of antenatal care follow-up on neonatal health outcomes: a systematic review and meta-analysis. Public Health Rev. 2018;39(1):33.

World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience [Internet]. Geneva: World Health Organization. 2016 [cited 2023 May 2]. 152 p. https://apps.who.int/iris/handle/10665/250796 .

Cherie N, Abdulkerim M, Abegaz Z, Walle Baze G. Maternity continuum of care and its determinants among mothers who gave birth in Legambo district, South Wollo, northeast Ethiopia. Health Sci Rep. 2021;4(4):e409.

Kerber KJ, de Graft-Johnson JE, Bhutta ZA, Okong P, Starrs A, Lawn JE. Continuum of care for maternal, newborn, and child health: from slogan to service delivery. Lancet. 2007;370(9595):1358–69.

Article   PubMed   Google Scholar  

Seidu AA, Ahinkorah BO, Aboagye RG, Okyere J, Budu E, Yaya S. Continuum of care for maternal, newborn, and child health in 17 sub-saharan African countries. BMC Health Serv Res. 2022;22(1):1394.

United Nations Children’s Fund. UNICEF DATA. 2022 [cited 2023 May 2]. Antenatal care. https://data.unicef.org/topic/maternal-health/antenatal-care/ .

Adedokun ST, Yaya S. Correlates of antenatal care utilization among women of reproductive age in sub-saharan Africa: evidence from multinomial analysis of demographic and health surveys (2010–2018) from 31 countries. Arch Public Health. 2020;78(1):134.

Tessema ZT, Tesema GA, Yazachew L. Individual-level and community-level factors associated with eight or more antenatal care contacts in sub-saharan Africa: evidence from 36 sub-saharan African countries. BMJ Open. 2022;12(3):e049379.

Gryseels C, Dossou JP, Vigan A, Boyi Hounsou C, Kanhonou L, Benova L, et al. Where and why do we lose women from the continuum of care in maternal health? A mixed-methods study in Southern Benin. Trop Med Int Health. 2022;27(3):236–43.

Yaya S, Uthman OA, Amouzou A, Ekholuenetale M, Bishwajit G. Inequalities in maternal health care utilization in Benin: a population based cross-sectional study. BMC Pregnancy Childbirth. 2018;18(1):194.

Ekholuenetale M, Nzoputam CI, Barrow A, Onikan A. Women’s enlightenment and early antenatal care initiation are determining factors for the use of eight or more antenatal visits in Benin: further analysis of the demographic and Health Survey. J Egypt Public Health Assoc. 2020;95(1):13.

Alvarez JL, Gil R, Hernández V, Gil A. Factors associated with maternal mortality in Sub-saharan Africa: an ecological study. BMC Public Health. 2009;9(1):462.

Tesema GA, Teshale AB, Tessema ZT. Incidence and predictors of under-five mortality in East Africa using multilevel Weibull regression modeling. Arch Public Health. 2021;79(1):196.

Konnon R, Semyatov S, Soyunov M, Sokhova Z, Zulumyan T. Trends on maternal mortality in the Republic of Benin and comparison with the neighboring countries. Med Law Soc. 2020;13(2):197–216.

Article   Google Scholar  

United Nations Children’s Fund. UNICEF DATA. 2023 [cited 2023 Oct 30]. Benin - Demographics, Health & Infant Mortality. https://data.unicef.org/country/ben/ .

McCartney G, Popham F, McMaster R, Cumbers A. Defining health and health inequalities. Public Health. 2019;172:22–30.

Article   CAS   PubMed   Google Scholar  

Andegiorgish AK, Elhoumed M, Qi Q, Zhu Z, Zeng L. Determinants of antenatal care use in nine sub-saharan African countries: a statistical analysis of cross-sectional data from demographic and health surveys. BMJ Open. 2022;12(2):e051675.

Dansou J, Adekunle AO, Arowojolu AO. Factors Associated with Antenatal Care services utilisation patterns amongst Reproductive Age women in Benin Republic: an analysis of 2011/2012 Benin Republic’s demographic and Health Survey Data. Niger Postgrad Med J. 2017;24(2):67.

Mamuye Azanaw M, Gebremariam AD, Teshome Dagnaw F, Yisak H, Atikilt G, Minuye B, et al. Factors Associated with numbers of Antenatal Care visits in Rural Ethiopia. J Multidiscip Healthc. 2021;14:1403–11.

United Nations Children’s Fund. Maternal and newborn health disparities - Benin. New York: UNICEF; 2018.

World Health Organization. Handbook on health inequality monitoring: with a special focus on low-and-middle income countries. Geneva: World Health Organization; 2013.

World Health Organization. Health Equity Assessment Toolkit Plus (HEAT plus): Software for exploring and comparing health inequalities in countries. Upload database edition. Geneva: World Health Organization; 2021.

Hosseinpoor AR, Nambiar D, Schlotheuber A, Reidpath D, Ross Z. Health Equity Assessment Toolkit (HEAT): software for exploring and comparing health inequalities in countries. BMC Med Res Methodol. 2016;16(1):1–10.

INSAE ICF, Enquête Démographique. et de Santé au Bénin, 2017–2018 [Internet]. Cotonou, Bénin; Rockville, Maryland, USA: Institut National de la Statistique et de l’Analyse Économique (INSAE) et ICF; 2019 [cited 2023 Oct 30]. https://dhsprogram.com/pubs/pdf/FR350/FR350.pdf .

Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The strengthening the reporting of Observational studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. Int J Surg. 2014;12(12):1495–9.

Seidu AA, Okyere J, Budu E, Duah HO, Ahinkorah BO. Inequalities in antenatal care in Ghana, 1998–2014. BMC Pregnancy Childbirth. 2022a;22(1):478.

Tsegaye S, Yibeltal K, Zelealem H, Worku W, Demissie M, Worku A, et al. The unfinished agenda and inequality gaps in antenatal care coverage in Ethiopia. BMC Pregnancy Childbirth. 2022;22(1):82.

UN Sustainable Development Solutions Network. Benin Sustainable Development Report 2022 [Internet]. Paris: UN Sustainable Development Solutions Network; 2022 [cited 2023 Oct 16]. https://s3.amazonaws.com/sustainabledevelopment.report/2022/2022-benin-sustainable-development-report-english.pdf .

Asamoah BO, Agardh A, Pettersson KO, Östergren PO. Magnitude and trends of inequalities in antenatal care and delivery under skilled care among different socio-demographic groups in Ghana from 1988–2008. BMC Pregnancy Childbirth. 2014;14(1):295.

Shibre G, Zegeye B, Idriss-Wheeler D, Ahinkorah BO, Oladimeji O, Yaya S. Socioeconomic and geographic variations in antenatal care coverage in Angola: further analysis of the 2015 demographic and health survey. BMC Public Health. 2020;20(1):1243.

Sakeah E, Okawa S, Rexford Oduro A, Shibanuma A, Ansah E, Kikuchi K, et al. Determinants of attending antenatal care at least four times in rural Ghana: analysis of a cross-sectional survey. Glob Health Action. 2017;10(1):1291879.

Ahuru RR. The influence of women empowerment on maternal and childcare use in Nigeria. Int J Healthc Manag. 2021;14(3):690–9.

Bobo FT, Yesuf EA, Woldie M. Inequities in utilization of reproductive and maternal health services in Ethiopia. Int J Equity Health. 2017;16(1):105.

Mekonnen T, Dune T, Perz J. Maternal health service utilisation of adolescent women in sub-saharan Africa: a systematic scoping review. BMC Pregnancy Childbirth. 2019;19(1):366.

Kirkby K, Schlotheuber A, Vidal Fuertes C, Ross Z, Hosseinpoor AR. Health Equity Assessment Toolkit (HEAT and HEAT plus): exploring inequalities in the COVID-19 pandemic era. Int J Equity Health. 2022;21(3):172.

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Acknowledgements

We are grateful to the MEASURE DHS and the World Health Organization for making the dataset and the HEAT software freely accessible to use.

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BOA and RGA conceived the study. RGA, JAA, and BOA wrote the methods section and performed the data analysis. RGA, JO, JAA, EKA, AS, and BOA were responsible for the initial draft of the manuscript. All the authors reviewed and approved the final version of the manuscript.

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Aboagye, R.G., Okyere, J., Ackah, J.A. et al. Trends and inequalities in antenatal care coverage in Benin (2006–2017): an application of World Health Organization’s Health Equity Assessment Toolkit. BMC Health Serv Res 24 , 1026 (2024). https://doi.org/10.1186/s12913-024-11261-z

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Status of the WHO recommended timing and frequency of antenatal care visits in Northern Bangladesh

Bidhan krishna sarker.

1 Maternal and Child Health Division, icddr,b, Dhaka, Bangladesh

Musfikur Rahman

Tanjina rahman, tawhidur rahman, jubaida jahan khalil, mehedi hasan, fariya rahman, anisuddin ahmed, dipak kumar mitra.

2 Department of Public Health, North South University, Dhaka, Bangladesh

Malay Kanti Mridha

3 Professor and Director of Centre of Excellence for Non-Communicable Disease, James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh

Anisur Rahman

Associated data.

All relevant data are within the manuscript and its Supporting information files.

There is dearth of information on the timeliness of antenatal care (ANC) uptake. This study aimed to determine the timely ANC uptake by a medically trained provider (MTP) as per the World Health Organization (WHO) recommendations and the country guideline.

Cross-sectional survey was done with 2,731 women having livebirth outcome in last one year in Dinajpur, Nilphamari and Rajshahi districts, Bangladesh from August-November,2016.

About 82%(2,232) women received at least one ANC from a MTP. Overall, 78%(2,142) women received 4 or more ANCs by any provider and 43%(1168) from a MTP. Only 14%(378) women received their first ANC at the 1 st trimester by a MTP. As per 4 schedule visits by the WHO FANC model and the country guideline 8%(203) and 20%(543) women respectively received the first 2 timely ANC by a MTP; where only 1%(32) and 3%(72) received the first 3 visits timely and 0.6%(17) and 1%(29) received all the four timely visits. Factors significantly associated with the first two timely visits are: 10 or above years of schooling of women [adj. OR 2.13 (CI: 1.05, 4.30)] and their husbands [adj. OR 2.40 (CI: 1.31, 4.38)], women’s employment [adj. OR 2.32 (CI: 1.43, 3.76)], urban residential status [adj. OR 3.49 (CI: 2.46, 4.95)] and exposure to mass media [adj. OR 1.58 (CI: 1.07, 2.34)] at 95% confidence interval. According to the 2016 WHO ANC model, only 1.5%(40) women could comply with the first two ANC contacts timely by a MTP and no one could comply with all the timely 8 contacts.

Despite high coverage of ANC utilization, timely ANC visit is low as per both the WHO recommendations and the country guideline. For better understanding, further studies on the timeliness of ANC coverage are required to design feasible intervention for improving maternal and child health.

Introduction

Approximately, 300,000 women die annually from pregnancy or childbirth-related complications around the world and almost all of these deaths occur in low-resource settings, and most of these deaths are preventable [ 1 , 2 ]. The South Asian region alone accounts for approximately one-third of the global maternal and child deaths annually [ 3 ]. The global strategy for Women’s, Children’s and Adolescents’ Health under the Sustainable Development Goal (SDG) 3 has set the targets to reduce maternal mortality ratio (MMR) to less than 70 per 100,000 live births, and the neonatal mortality to 12 per 1,000 live births or lower by 2030 [ 4 ].

High coverage of quality Antenatal Care (ANC) can play a crucial role to decrease maternal and child mortality rates and achieve national and global targets related to maternal and child health [ 5 – 7 ]. Studies found ANC received from skilled provider reduces the risk of pregnancy complications and adverse pregnancy outcomes such as- stillbirths, intrauterine growth retardation, preterm births, low-birth weight, fetal abnormalities and other fetal complications, possibly mediated through health promotion, disease prevention, screening and treatment which increases maternal and newborn survival [ 2 , 8 – 15 ]. The study also emphasized on the timeliness of ANC to ensure healthy pregnancy outcomes [ 13 ].

As per the previous World Health Organization’s (WHO) recommended Focused Antenatal Care (FANC) Model; under normal circumstances, a pregnant woman should have at least four ANC visits [ 16 ]. Recently, WHO has issued “the 2016 WHO ANC model” with a new series of recommendations to improve the quality of ANC, which in turn help reducing the risk of stillbirths, complications and ensures a positive pregnancy experience. The new WHO model recommends a minimum of eight contacts. The 2016 WHO ANC Model covers 4+ ANC contacts that support the accomplishment of SDGs, which aims for reducing maternal and child mortality [ 6 , 17 , 18 ]. The 2016 WHO ANC model provides adequate knowledge to get prepared for birth or any complication, and lifesaving information for both mother and child as it reduces the delay of care-seeking for obstetric emergencies that contribute majority of the maternal mortality in a low-income area [ 7 ]. Though the recent 2016 WHO model recommends 8 contacts, the country guideline of Bangladesh still promotes 4 ANCs having slight time differences from the previously WHO recommended FANC model [ 19 , 20 ].

Globally, the coverage of early ANC visit within 14 weeks is reported to increase from 40.9% to 58.6% from the year 1990 to 2013 [ 21 ]. However, the uptake rate differs between developed and developing countries. In the year 2013, the rate of ANC uptake in developed and developing countries was 84.8% and 48.1% respectively [ 21 ].

According to the Bangladesh Demographic and Health Surveys (BDHS) the trend of ANC coverage by a medically trained provider (MTP) is increasing [ 16 , 22 – 24 ]. Since 2004 to 2017 (51%-82%) ANC coverage had increased by 31 point percentage [ 16 , 22 – 25 ]. The percentage of pregnant women who made four or more ANC visit by any provider has increased from 17% in 2004 to 47% in 2017 [ 22 – 24 ]. In terms of the ANC coverage, geographical and regional variation exist in Bangladesh where data from BDHS 2017-’18 shows at least one ANC by a MTP is the highest in the South-west region (Khulna division91%) and the lowest in the Northeast region (Sylhet division-71%) [ 24 ]. Besides, the Northern region (Rajshahi-85% and Rangpur-75%) and the Southeast region (Chattogram-83%) also showed a higher prevalence of at least one ANC uptake. However, this regional difference fluctuated quite often since the last decade [ 16 , 22 – 25 ].

Despite having a rise in ANC coverage in Bangladesh, it stands among the top ten countries those are contributing nearly 60% of global maternal mortality [ 26 , 27 ]. Maternal and neonatal mortality remained quite unchanged in the last few years [ 24 , 28 ]. Bangladesh Maternal Mortality and Health Care Survey (BMMS) shows the Maternal Mortality Ratio (MMR) is 196 per 100,000 live births in 2016 whereas it was 194 per 100,000 live births in 2010. Similar to maternal mortality, BDHS shows that neonatal deaths per 1,000 live births were 28 in 2014 and 30 in 2017–18 [ 16 , 24 , 28 , 29 ]. Bangladesh has the highest proportion of preterm births with 19% of births occurring before gestational weeks 37 [ 30 ]. The stillbirth rate in Bangladesh is 25.4 per 1,000 births [ 31 ]. According to BMMS 2016, the major causes behind the maternal deaths are hemorrhage (31%), eclampsia (24%), abortion (7%), obstructed/prolonged labor (3%), etc. [ 28 ]. To reduce pregnancy-related complications and adverse pregnancy outcomes, timely recommended ANC is imperative.

According to the BDHS-2017-18, less than 18% women received quality ANC care. Quality care is defined as receiving four or more antenatal visits, with at least one visit from a MTP and the components include measurement of weight and blood pressure, testing of blood and urine and receipt the information on potential danger signs during pregnancy [ 24 ]. In addition to the national survey, few other studies conducted in different parts of Bangladesh that also provide information of the total number of ANC visits that a woman receives during her pregnancy period [ 32 – 34 ]. However, none of the surveys showed how many women secured their visits timely as per WHO recommendations as well as a country guideline. So, there is a dearth of information in Bangladesh about the timeliness of ANC visits that a pregnant woman should adhere to WHO recommendations as well as to country guideline. It is essential to look deeper into the real status of the timely ANC uptake which has a greater impact on both mother and child’s odds of survival [ 32 , 35 ]. Therefore, we aimed to explore timely ANC uptake by MTPs as per the WHO recommendations and the country guideline from a cross-sectional survey in Northern Bangladesh.

Materials and methods

Study design and settings.

It was a community-based cross-sectional study conducted in both rural and urban areas. We had two study sites in rural areas and one in urban area from 3 northern districts of Bangladesh. Rural areas were Chirirbandar, a sub-district from Dinajpur and Saidpur, a sub-district from Nilphamari in Rangpur division and the urban area was Rajshahi City Corporation from Rajshahi division. According to the Population and Housing Census, the total population of Chirirbandar was 292,500, of which 146,619 were males, and 145,881 were female [ 36 ]. For Saidpur sub-district, the total population was 264,461, of which 133,737 were males, and 130,724 were females [ 37 ]. On the other hand, for Rajshahi City Corporation the total population was 449,756, of which 232,974 were males, and 216,782 were females [ 38 ]. According to census data, we found the female literacy rate was 42% in Dinajpur, whereas for both Nilphamari and Rajshahi, it was 39% [ 39 ]. In comparison to northern divisions (Rajshahi and Rangpur), southeast (Chattogram) and northeast (Sylhet) divisions had higher Maternal Mortality Ratio (Rajshahi-173/100,000 vs Chattogram-186/100,000 and Sylhet-425/100,000), Similar to maternal mortality, under-5Child Mortality Rate of Northern region (Rajshahi-43/1,000 and Rangpur-39/1,000) is lower than Southeast (Chattogram-50/1,000) and Northeast (Sylhet-67/1,000) regions [ 16 , 29 ].

Sampling and study participants

We applied two stages cluster sampling to select study participants in the study area. We considered some socio-demographic characteristics including age, years of schooling, occupation, religion, gravida and place of residence of study participants in the sampling frame to cover a range of information on similar issues from a variety of study participants. We considered government and non-government ‘Community-Based Health Workers’ (CBHW) catchment area as a cluster. We maintained similar population coverage for cluster selection. In Chirirbandar, we considered government CBHW’s catchment area, and for Saidpur and Rajshahi, we considered non-government CBHW’s areas as our clusters. In the first stage, we randomly selected one sub-district from two rural districts each and 10 wards (lowest administrative unit of city area) from the city corporation area. Then, we randomly selected 6 clusters (CBHW’s catchment area) out of 12 in Chirirbandar of Dinajpur district, 6 clusters out of 12 clusters in Saidpur of Nilphamari district and 6 clusters from 10 clusters in Rajshahi city area.

To recruit study participants, we applied the Expanded Program of Immunization method, which is a popular spatial sampling method named as the EPI method. We selected the starting point to start data collection in the selected cluster using the EPI method. We determined the midpoint of each cluster in consultation with the community people. To ensure the randomization process in interviewing eligible participants, we spun a bottle at the midpoint of each cluster to identify the direction from where we started searching study participants [ 40 , 41 ]. Interviewers visited every household on next door basis according to the direction of the bottle, and eligible participants were identified and interviewed. They collected data until the cluster’s sample size was met. During the household visit, if any eligible woman was absent, then data collectors tried at least two more times to interview her.

In each study area, around 900 women were interviewed, and finally, we completed 2731 interviews from the 3 study areas. Followings were the inclusion criteria for the study enrolment: (1) the woman had a live birth outcome in the last one year prior to interview (2) the woman passed 28 or more days after last delivery (3) the woman could hear, see and speak (4) the woman had permanent residence in the study area.

Data collection

We conducted this survey from August to November 2016. An expert research team from the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) was involved in preparing a survey tool based on the research question and objectives of the study. Study investigators trained all the data collectors on the data collection tool. After that, a field test was done as pre-testing to check the feasibility of the survey tool in the real field. We checked the consistency of the survey tool and incorporated the feedback into the final version after pre-testing. The survey was administered through face-to-face interviews with eligible women.

Data management and quality assurance

An efficient team with an experienced team leader was closely involved with the data collection for ensuring the quality data. The team leader checked the completeness of every interview on the spot after the data collection through day to day supervision. Furthermore, a project research physician (PRP) and a research investigator (RI) coordinated all the data collection teams and team leaders on a daily and weekly basis for ensuring quality data and completeness of the interview. Re-interview was done by the team leaders, PRP and RI in a significant amount to check the accuracy and validity of data. At the same time, a database template was designed by an expert programmer of the Maternal and Child Health Division (MCHD), icddr,b to enter all the data online. Dot net (Version-10) software was used for data template design as appropriate [ 42 ]. The data template was designed in such a way that while entering data, none of the variables could go missing. Skipping options were also maintained strictly and logically to avoid entry mistakes. The expert data management team entered all the data through an online database. During entering data, this team entered both pre-coded and postcoded data simultaneously. For post coding of data, the research team was also closely involved with the data management team.

This study had no more than minimal risk to study participants. We obtained written informed consent from each of the participants prior to the interviews. We received approval from the Institutional Review Board (IRB) of icddr,b before data collection in the field. All the participants were married, and there was no need for obtaining consent for the minors from the guardian or parents as per IRB.

All the information given by the mothers were self-reported, however, we found 27% had a pregnancy registration card (also known as ANC card) and we checked their documents for relevance. Rest of the women who did not have a pregnancy registration card, we applied the probing technique to get the actual information from them. We determined the timely ANC coverage with regards to the WHO and the country guidelines. The primary outcome variable was the first two timely ANC visits by a skilled provider as per the WHO FANC model. Our country guideline resembles with the WHO FANC model and did not yet adopt the WHO 2016 model [ 43 ]. We considered the uptake rate of the first two timely ANC visits by MTP as per the WHO FANC guideline. We collected numbers of ANC received by a woman and when as per gestational weeks; and the providers of ANC. To estimate the ANC uptake, we considered women who had received at least one ANC from any provider. If any woman reported that, she had more than one ANC in the same week from different service providers, then ANC by the highest qualified service provider was considered. We followed the criteria of skilled or unskilled provider from the Bangladesh Demographic and Health Survey (BDHS) and considered qualified doctor, nurse/midwife/paramedic, family welfare visitor (FWV) and community skilled birth attendant (CSBA) as skilled or MTP. We used skilled provider and MTP interchangeably [ 16 ].

To analyze the timely ANC visits, we followed the criteria suggested by the two WHO models and country guideline. According to “the WHO FANC model”, the timely ANC visits refer to the 1st ANC visit between 8–12 weeks of pregnancy, the 2 nd ANC visit between 24–26 weeks, the 3rd ANC visit at 32 nd week, and the 4th ANC Visit between 36–38 weeks of gestation [ 43 ].

The timely ANC visits recommended by “the WHO 2016 ANC model”, refers to 1st contact within 12 weeks, the 2nd contact at 20 th week, the 3rd contact at 26 th week, the 4th at 30 th week, the 5th at 34 th week, the 6th at 36 th week, the 7th at 38 th week and the 8th contact at 40 th week [ 43 ]. Like the WHO FANC model, the country guideline also suggests at least 4 scheduled ANC visits where the timely ANC visits refer to the 1st ANC visit within 16 weeks of pregnancy, the 2 nd ANC visit between 24–28 weeks, the 3rd ANC visit at 32 nd week, and the 4th ANC Visit at 36 th week of gestation [ 20 ].

There is a slight difference among the 2016 WHO ANC Model, the WHO FANC Model and the Bangladesh guideline for recommending the1st timing of ANC. The 2016 WHO ANC Model recommended within 12 weeks of gestation for the 1 st contact whereas the WHO FANC Model recommended the 1 st visit between 8–12 weeks of gestation and the Bangladesh guideline recommended the 1 st visit within 16 weeks of gestation.

All the guidelines mentioned about the exact timing and ranges depending on gestational age. The WHO FANC model suggests timing for 1 st , 2 nd and 4 th visits in ranges and 3 rd visit on the exact time of gestational age. The country guideline suggests timing for 1 st and 2 nd visits in ranges and 3 rd and 4 th visits on the exact time of gestational age. The recent WHO 2016 ANC model suggests only first contact in range of gestational weeks and remaining 7 contacts on the exact timing of gestational weeks.

We considered Anderson and Newman’s framework of health services utilization to select the covariates that are associated with ANC utilization. This framework consists of three individual determinants- i. Predisposing ii. Enabling iii. Illness level [ 44 , 45 ]. We adopted age, sex as demographic and years of schooling, religion, occupation, women’s partner years of schooling and his occupation as social structure from disposing factors. In addition to previous literature and known confounder, we included these socio-demographic characteristics such as age, religion, place of residence, years of schooling status, primary occupation, number of pregnancies and living children [ 32 , 33 , 46 ]. Regarding age and schooling, we considered completed years. Age was categorized into three different groups such as less than or equal to 19 years, 20 to 29 years and greater than or equal to 30 years. Similarly, years of schooling was categorized into four groups as 0 to 4 years, 5 to 7 years, 8 to 9 years and greater or equivalent to 10 years of schooling. If a woman and her husband had multiple occupations, the primary occupation was considered based on their preferences in terms of their income and time spent on that occupation. We took the information about the current occupation of the survey respondents. We ensured their primary occupation by asking “what is your primary occupation?”, “What kind of work do you mainly do?”, “Are you involved in any income generating activities?” during our interview. Point to be noted here, mothers who were on maternity leave their occupation was marked as employed during the period of data collection. The women who were housewives referred to as homemakers for their occupation. By gravida, we meant the total number of confirmed pregnancies that our participant had in her lifetime.

Statistical analysis

We performed statistical analysis using the statistical software package STATA version 13.1 [ 47 ]. To identify differences between the groups, we used the χ2 (Chi-square) test for categorical data and independent sample t-test for continuous data. We checked the linearity assumption between the predictor and the outcome variable. We found there was a non-linear relationship between the predictors and the outcome variable. Then we transformed the covariate (age and years of schooling) into categories. We estimated both unadjusted and adjusted odds ratio using simple and multiple logistic regression models considering different covariates (age, years of schooling, gravida, occupation and place of residence etc.) to see the effect of covariates on the first two timely visits by MTPs. Bivariate logistic regression analysis was conducted to examine the association between the predictor and outcome variables using the Crude Odds Ratio (COR) at a 95% confidence interval (CI). Factors that were significant with a p-value of less than 0.05 were considered for further estimation of the multiple logistic regression model. For example, the variable religion showed an insignificant relationship with the first two timely ANC visits and we excluded this variable from the regression analysis. Conventionally, p value of 0.05 is taken to indicate statistical significance. This 5% level is, however, an arbitrary minimum and p values should be much smaller to provide strong evidence. Before fitting the multiple logistic regression model, we did regression for the outcome of the first three and all four timely ANC visits by a medically trained provider, but almost all predictors were crudely insignificant for these two outcome variables separately. Furthermore, the number of observation was very low for the first three and all four timely visits by MTPs. Therefore, we considered the regression model for the first two timely visits by MTP according to the WHO FANC model.

“ Table 1 ” describes the socio-demographic characteristics of study participants living in both urban and rural areas. Result shows that almost two-third of the respondents (62%) belonged to the age group of 20 to 29 years and the majority of the respondents were Muslims (88%). A bit more than half of women (51%) passed grade 8 and higher. Years of schooling with 10 or more were higher among the respondents in the urban area (35%) than the rural area (26%). Overall, 95% of women were homemakers. In terms of the number of pregnancies, more than one-third of women (38%) had single gravida and the 50th percentile of respondents mentioned that they had experienced two pregnancies (median 2). Almost half of women’s husband had completed 8 or more years of schooling. About three-fourth of women (77%) had television exposure and only 11% of women read newspaper or magazine.

*refers Service/Business/Handicraft/Agriculture/Farm/fishing, Expatriate, and Daily Wager, etc.

* 1 refers Handicraft, Rickshaw or Van driver, Transport worker and day labor, etc.

Table 2 presents the ANC coverage of study participants by their place of residence. Almost all the women (98%) from both rural and urban sites received at least one ANC from any provider and overall 82% women (90% urban and 77% rural women) received at least one ANC from MTP. More than three-fourths of women (78%) had 4 or more ANCs by any provider while less than half of women (43%) received 4 or more ANC by a MTP. More than half of urban women (58%) and one-third of (35%) rural women reported to have received four or more ANC from MTP. However, about 17% of women received eight or more contacts by any provider and only 4% women received eight or more contacts from MTPs. Urban women (10%) were more likely to receive 8 or more ANC by MTPs than rural women (1%).

Fig 1 shows women received their 1 st ANC visit by gestational weeks from a skilled, unskilled and any provider. About one-fifth of the women (21%) received their 1st ANC within 12 weeks from any provider whereas 14% of them received from a skilled provider. The highest number of women (29%) received their 1st ANC between 13–16 weeks by any provider, whereas half of them (16%) received from a skilled provider.

“ Table 3 ” shows almost two-thirds of the women (63%) made the timely visit 2 between 24–26 weeks from any provider followed by more than one-third of the women (35%) received the visit 4 between 36–38 weeks. Overall, only 1.2% women received all the 4 timely visits and 18% women did not receive any timely ANC visit. There was a significant difference in receiving all the timely ANC visits by any provider depending on the residence.

Fig 2 shows that, only 13% women received visit 1 (between 8–12 weeks) timely, but a higher proportion of women (37%) received visit 2 (between 24–26 weeks) at the recommended time. The figure also presents that only 8% of women received the first 2 timely visits (visit 1 & 2) while less than one percent women (0.6%) received all 4 ANC visits (visit 1, 2, 3 & 4) as per recommended timing of the WHO FANC model.

“ Table 4 ” describes that the majority women (74%) received ANC visit 2 between 24–28 weeks from any provider and 46% from a skilled provider. Half of the women received ANC visit 1 within 16 weeks from any provider while almost one-third of the women (32%) received from a skilled provider. More than one-third of the women (37%) received the first 2 timely visits (visit 1 & 2) by any provider whereas one-fifth of the women (20%) received by a skilled provider. Only 2% women received all the 4 timely visits (visit 1, 2, 3 & 4) from any provider while 1% women received from a skilled provider. In terms of all the timely ANC visits, more urban women received timely ANC visits than those of rural women. There were significant differences in receiving timely ANC visits by any provider except visit 4 and for all the timely ANC visits by a skilled provider based on place of residence.

“ Table 5 ” presents that less than half of the women (43%) received contact 4 at 30 th week from any provider and near to one-third (27%) from a skilled provider. More than one-third of the women (39%) received contact 3 at 26 th week and contact 5 at 34 th week by any provider whereas one-fourth women received those contacts from a skilled provider. In line with the 2016 WHO ANC model, less than one-fifth of the women (16%) did not have any timely ANC contact from any provider and almost two-thirds of the women (63%) received at least one timing contact from a skilled provider. Only a few women (0.15%) received the timely first five contacts as per the 2016 ANC model from MTP. None of the women received all the 8 timely ANC contact either by a MTP or by any provider. Urban women were more likely to receive timely ANC contacts than those of rural women. There were significant differences in receiving timely contacts by any provider except contact 2 and 6; and by a skilled provider except contact 2 based on place of residence.

“ Table 6 ” shows that the first two timely ANC visits are estimated derived from the WHO FANC model. Results suggest that there is a strong association between the first two timely ANC visits and all the socio-demographic characteristics except religion.

*refers Service/Business/Handicraft/Agriculture/Farm/fishing, and day labor, etc.

*1 refers Handicraft, Rickshaw or Van driver, Transport worker and day labor, etc.

“ Table 7 ” shows that almost all the indicators were crudely associated with a higher prevalence of receiving the first two timely visits. After adjustment, the odds ratio of the first two timely ANC visits for the women and their husbands who had completed 10 or more years of schooling were higher than those who did not pass primary school (0–4 years of schooling). Similarly, the likelihood of receiving the first two timely visits for employed women was more than two times than the women who were homemakers. Women who had exposure to mass media (newspaper/magazine) were more likely to receive the first two timely ANC than who were not exposed. Urban women were more than three times more likely to receive the first two timely ANC from a skilled provider than those of rural women.

Significant level: 0 ‘ *** ’ 0.01 ‘ ** ’ 0.05 ‘ * ’

Model adjusted for all indicators in the Table 7

CI—Confidence interval

* 1 refers Service, Business, Handicraft, Agriculture, Farm, Fishing and Day labor, etc.

* 2 refers Handicraft, Rickshaw or Van driver, Transport worker and Day labor, etc.

This study shows that almost all the women from both rural and urban sites received at least one ANC and more than three-fourth of the women received 4 or more ANC visits by any provider in their last pregnancy. Less than one-fifth of the women received 8 or more contacts by any provider whereas only 4% women received at least 8 contacts by MTPs. However, this uptake rate significantly differs between urban and rural women.

According to the WHO FANC and the 2016 ANC model, the practice of receiving the 1 st ANC visit within recommended time is mostly delayed. There is very little difference in terms of receiving the timely 1 st ANC visit by both MTPs and any provider between the two WHO models. There is slight difference (13% Vs 14% by MTP and 20% Vs 21% by any provider) between the two models on the 1st ANC uptake and that is due to different recommended timings. The FANC model recommends first ANC between 8–12 weeks while the 2016 ANC model suggests to have the first ANC contact within 12 weeks. Therefore, when ANCs are received before 8 weeks, have been considered in the 2016 ANC model and was excluded in the FANC model. However, as per country guideline, the number of the 1st ANC uptake within 16 weeks of gestation by both MTPs and any provider was two times higher than the both WHO models. As Bangladeshi country guideline recommends an elaborated time range for the initiation of ANC, it kindles curiosity among all on the difference. Similar to our findings, three more studies were done in Bangladesh suggest that the uptake of first ANC is substantially delayed and another study revealed that the reasons could be maternal age, women’s education, residence, wealth index, pregnancy intention status, child’s birth order, and wanting more children [ 24 , 33 , 48 , 49 ]. Though no justification has found from the national guideline but our experience from working with the program in the field, we understand that culturally our women delay to disclose about their pregnancies even to their family members and relatives. They delay to seek 1 st ANC for few weeks thinking that pregnancy may terminate (abortion may occur) at an earlier stage, so they wait until 3 to 4 months of the pregnancy to report or visit healthcare centre. May be considering the cultural context, the national guideline adopted 1 st ANC by 16 weeks. Although there is no evidence, however, we are assuming that socio-cultural factors associated with delayed ANC care seeking might have been reflected on our national guideline and thus on the recommendations of the time ranges.

Though there are differences in timing, according to the WHO FANC model and the country guideline the highest proportion of the women received the timely ANC visit 2 by MTPs. Whereas according to the 2016 WHO ANC model, the highest proportion of the women complied with the contact 4 by MTPs. The country guideline mostly matches with the WHO FANC model but the 2016 WHO ANC model focused on the ANC contacts on exact weeks rather than considering ranges of weeks except ‘contact 1’ thus influences the variation of ANC uptake.

As per the WHO FANC model and the country guideline, coverage of all four timely ANC visits were extremely low and no woman could follow all the 8 timely contacts recommended by the 2016 WHO ANC model regardless of the providers. However, completing the 8 contacts is not applicable if women delivered babies before 38 weeks.

Because of the low observations for the all timely visits in both of the WHO models, the regression analysis of this study was limited to only the first two timely visits by a skilled provider as per the WHO FANC model. The regression analysis shows that women and their husbands with more years of schooling, employment, and living in the urban area were more likely to have the 1st two timely visits by MTPs.

Regarding the socio-demographic characteristics like marriage, family planning, and childbearing, Northern Bangladesh shows some variations with other Northeast and Southeast regions of Bangladesh. Early marriage (marriage before 18 years) among Northern Bangladeshi women (Rajshahi: 70% and Rangpur: 67%) is relatively higher than other parts of Bangladesh; therefore the prevalence of teenage childbearing status is also higher (Rajshahi: 33 and Rangpur: 32 vsSylhet: 14 and Chattogram: 27). However, Total Fertility Rate is lower in Northern part (Rajshahi and Rangpur: 2.1) than Northeast (Sylhet: 2.6) and Southeast (Chattogram: 2.5) regions. Regarding the modern contraceptive usage and unmet need for family planning, Rajshahi (modern method: 55%, unmet need: 10%) and Rangpur (modern method: 59%, unmet need: 8%) stand in better position than Sylhet (modern method: 45%, unmet need: 14%) and Chattogram (modern method: 45%, unmet need: 18%) divisions [ 24 ].

The BDHS 2017–18 data shows that the four or more ANC coverage raised to 47% from 31% in 2014. From the BDHS data for the Northern region, we found almost similar results with our study in terms of any ANC coverage by a MTP (BDHS: Rajshahi-84.5% and Rangpur-74.6% Vs this study-82%). The BDHS does not provide regional variation for number of ANCs, so, we couldn’t compare ANC coverage by numbers with BDHS. In addition to that, BDHS also does not present ANC coverage for 8 contacts [ 24 ]. Our study shows more ANC coverage for at least 8 ANC contacts by any provider compared to Bangladesh Multiple Indicator Cluster Survey (MICS) conducted in 2019 (17% Vs 5%) [ 50 ]. However, this difference might have induced due to having different sample size, study sites (local vs national), higher engagement of non-government organizations in providing maternal health services; especially in ANC services in our study areas, low human resource gap, access to health care, etc. [ 51 – 53 ].

In terms of four or more ANC coverage by any provider, a noticeable regional variation was observed for several South-Asian countries [ 24 , 54 – 60 ]. A national survey from Afghanistan shows that in 2015 their national ANC uptake rate for four or more ANC by any provider was 18%, likewise for Bhutan- 85% in 2015, India- 51% in 2016, Myanmar- 59% in 2016, Nepal-69% in 2016 and Pakistan-51% in 2017–2018 [ 55 , 58 , 59 ]. Despite sharing geo-economics commonalities, these South-Asian countries exhibit a good range of variation [ 61 ].

Regarding the 1 st ANC uptake by gestational age, this study found that only one-fifth of the women availed their 1 st ANC in the 1 st trimester (within 12 weeks) and more than one-fourth of the women received their 1 st ANC during 13–16 gestational weeks by any provider. Another Bangladeshi study conducted in Netrokona district found ANC uptake by a formal provider (Doctor, midwives, nurse, FWV, CHCP, health assistant, family welfare assistant, community skilled birth attendant and NGO health workers) in the 1 st trimester is 18% [ 32 ]. Although the operational definition of formal provider of that study slightly differ from our definition of any provider and MTP. If we compare it with our study findings, it shows 21% of the women received the 1 st ANC by any provider and 14% received by MTPs [ 32 ]. We assume the difference between the definition of the skilled and unskilled care provider might have influenced the difference. Many studies conducted in different parts of Asia show, there is a huge national and regional difference in terms of the 1 st ANC uptake [ 54 , 56 – 60 ]. Regarding the 1 st ANC uptake in the 1 st trimester, findings from several studies conducted in India showed the regional variation [ 56 , 57 , 60 ]. Indian national data showed, in 2016 more than half of the women received the 1 st ANC in the 1 st trimester, whereas in Andhra Pradesh more than three-fourth of the women and in eight other EAG states (Empowered Action Group) less than one-fifth of the women took the 1 st ANC uptake in the first trimester [ 56 , 57 , 60 ]. However, EAG states are defined as underprivileged and economically backward compared to other states of India and coverage from EAG states quite similar to our study findings [ 62 ].

Though we found Afghanistan’s four or more ANC uptake is lower than our study, but surprisingly; Afghanistan’s 1st ANC uptake in the 1st trimester was a bit higher than that of ours while Pakistan and Nepal showed more than double ANC uptake rate than our findings [ 54 , 58 , 59 ].

Studies show that the utilization of ANC in developing countries depends on many different factors [ 63 – 66 ]. Different studies done in Asian, European and African continents adopting Andersen behavioral model revealed that factors associated with underutilization of the ANC services in these regions are young age of the mothers, fewer years of schooling, lack of a paid job, poor language proficiency, support from a social network and lack of knowledge of the health care system [ 67 ]. Studies conducted in Bangladesh, different parts of India, Nepal, Afghanistan, Pakistan and Ethiopia explored that years of schooling and place of residence have influence over ANC uptake rate [ 32 , 54 , 56 – 60 , 68 – 70 ]. In comparison to this study; findings from the above cited studies share similarity with our findings on the findings about years of schooling and place of residence. Apart from those, geographical setting and socio-economic inequalities, cultural and normative barriers are attributing to this issue [ 71 ].

Similar to other low and middle-income countries (LMIC), Bangladesh is also improving its ANC coverage. The recommended 4 ANC visits was in a view of cost-effective model and result of extensive research, further, WHO recommended 8 ANC contacts in 2016 to expedite the improvement of Maternal and Child Health related status [ 33 , 72 ]. However, Bangladesh is still focusing on ensuring a higher uptake rate of 4 ANC visits with its government and non-government organizational initiatives [ 33 , 34 , 73 ].

Mounting all findings together from this and previous studies, we found that urban women can avail more ANC services than rural women although the ANC services are free of cost in government facilities everywhere in Bangladesh [ 74 , 75 ]. Based on those shreds of evidence, it can be asserted that ANC service inequality exists based on place of residence agreeing to the fact that 78% of people living in rural Bangladesh, while 70% doctors are stationed in urban areas [ 76 ]. In addition to unavailability of skilled provider, rural Bangladeshi women face various types of challenges to access maternal health services such as: poverty, long distance of health facility, waiting time at hospital, lack of female health staff, lack of skilled birth attendant, lack of education [ 77 – 79 ].

Even after conducting our study in high performing areas in terms of ANC coverage, extremely low prevalence of timely ANC uptake was observed maintaining the WHO and country guidelines. We can assume further worst-case scenario for low performing areas. Although we focused to discuss about ANC uptake by skilled provider in our result mostly but we found that many other national and also global studies we discussed in our paper tend to discuss the ANC uptake by any provider and used slightly different definition of skilled provider than country guideline [ 32 , 54 – 59 , 68 – 70 ]. We are assuming that it is due to low ANC uptake by skilled provider in Bangladesh and other Asian and African countries. So, to understand the countrywide situation, further evidence on timely ANC uptake is required.

Strength and limitation

Study team strictly maintained the quality of data collection in the field with close monitoring and supervision. The data derived from participants were rigorously rechecked and re-interviewed by team supervisors including a physician to minimize the scope of inaccuracy. We also checked relevant documents (such as- ANC card, pregnancy registration card, etc.) during our data collection to minimize the errors. Since this study was conducted only in part with higher ANC coverage, findings of this study hence do not represent Bangladesh uniformly. Again, the analysis was done depending on self-reported information without having a robust surveillance system; therefore, the scope of over or under-reporting may exist. Because of self-reported data, number and timing of ANC visits can be varied. According to all three guidelines, there are variations on the timing of ANC visits by exact week (e.g. 30th week) and range of weeks (e.g. 8–12 weeks); and result from range weeks will vary less but results from exact weeks may vary little bit higher. More to add, we did not explore important potential exposure variables such as household income, awareness about maternity care, cost of service, availability of healthcare services and proximity to the health facility which might have served as confounders and affected the result and the interpretation of the findings.

Conclusions

The coverage of ANC visits is quite high but the timeliness of ANC visits is very low as per both WHO models and country guideline. Initiation for the first ANC visit is also highly delayed. Government and non-government maternal health programs should focus on ensuring timely ANC visits. Ensuring at least 4 timely visits may help to make a way forward for Bangladesh endorsing 8 ANC contacts in the near future that is recommended by the recent 2016 ANC model. We suggest policy makers to promote education, women’s employment and health education through mass media as well as to ensure universal maternal healthcare coverage. Understanding the significance of timely ANC visits we further suggest to carry out more parallel studies both in countrywide and regional perspective putting emphasis on the feasibility of 8 contacts. The findings of this study will help the program and policy makers to design interventions to improve antenatal care coverage maintaining timeliness and thus reduce maternal and child mortality across Bangladesh.

Supporting information

Acknowledgments.

icddr,b acknowledges with gratitude the commitment of Bill & Melinda Gates Foundation to its research efforts. We are grateful to our study participants for their spontaneous participation and sincere commitment to fulfill the research endeavor. icddr,b is also grateful to the Government of Bangladesh, Canada, Sweden and the UK for providing core/ unrestricted support.

Funding Statement

This study funded by Bill and Melinda Gates Foundation. The awarded BMGF grant number is OPP1146943. BKS received the funding. URL of funder website is https://www.gatesfoundation.org . The sponsors had no role in the study design, data collection and analysis, decision to publish and preparing manuscript.

Data Availability

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What to expect at an annual well woman visit

Yearly visits with a gynecologist or certified nurse midwife are an opportunity to review medical history and evaluate current health through various screenings, including a breast exam, mammogram or pelvic exam. They’re also an important way women can establish a long-term, trusting relationship with their doctor.

An annual physical does not consist solely of a pelvic exam or breast exam. They’re also an opportunity for women to have open conversations with their physicians and learn helpful information about their bodies and anatomy.  

The exam and open conversation can lead to the early detection of issues ranging from benign conditions, fibroids, pelvic health issues and sexually transmitted infections, to ovarian, cervical, vaginal, skin and breast cancers and more.

Sexual health is often a topic of discussion for women of all ages. Getting to the root of sexual health concerns can be complicated, as various factors like medication, mental health and age can affect it. Approach your annual visit prepared to have a conversation about any sexual health concerns, contraceptive and preconception counseling, and safe sex practices.

“ Mary Faith Terkildsen, MD , has developed a sexual health practice that can comprehensively address patient questions and hone in on possible solutions,” said Carl Buccellato, MD , an obstetrician and gynecologist at Endeavor Health. “The solution may not be straightforward or simple, and she spends the time necessary to find it.”

Genetics are also an important topic to raise at your annual visit, as your genes and family history play a role in your level of risk for diseases like cancer. Endeavor Health’s Personalized Medicine program helps physicians build a care and treatment plan based on an individual’s unique genetic characteristics and health history. The information gathered is also fully integrated with a patient’s medical record, Dr. Buccellato said.

Naturally, pregnant patients have a lot of questions for their physicians. Some receive care from an obstetrician-gynecologist (OB-GYN) and others prefer the support of a midwife on their birth journey. Endeavor Health certified nurse midwives (CNM) are available in various locations throughout Chicagoland and can provide extended prenatal visits, general gynecology, labor support and lactation consulting. Endeavor’s certified nurse midwives in Lake County also offer group prenatal classes, known as Centering, for patients in the same stage of pregnancy, Dr. Buccellato said.

An annual well woman visit should include:

• Discussion about your state of health. Just like a yearly visit with a primary care physician, during a well woman visit, you can discuss any recent health changes, concerns from the last year and any medical history updates.
• Medication review. Bring a list of your current medications, including any birth control.
• Breast examination. A breast exam should happen at each yearly appointment starting at age 21. If you notice any changes in your breasts during a self-exam, inform your physician.
• Pelvic exam. A pelvic exam is typically performed at each annual visit and will not always include a Pap smear. A pelvic exam consists of both an external and internal visual exam as well as an evaluation of the uterus and ovaries through a manual exam, which should take no more than 2-3 minutes. You may feel some pressure and mild discomfort during this exam, but it should not be painful.
• Pap smear. You should consult with your physician on a recommended schedule for this test. The timing of a Pap smear will depend on your age, health and medical history. Physicians recommend a first Pap smear by age 21. It is then commonly performed every 3 years until age 30, and every 3-5 years thereafter.

It’s important to schedule more frequent appointments and screenings if you’ve previously had abnormal test results from a Pap smear, a family history of uterine or breast cancer, and/or any recent changes in health such as infection, pain or bleeding.

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Biden-Harris Administration Awards Over $558 Million to Improve Maternal Health, including $440 Million to Support Pregnant and New Moms, Infants, and Children through Voluntary Home Visiting Programs Proven to Improve Maternal and Child Health, Child Development, and School Readiness

HHS Also Awards $118.5 Million to Enhance Maternal Mortality Research and Prevention Efforts

Today, the U.S. Department of Health and Human Services (HHS) announced more than $558 million in funding to improve maternal health, building on the Biden-Harris Administration's commitment to reducing the nation's high maternal mortality rate through the White House Blueprint for Addressing the Maternal Health Crisis . The Health Resources and Services Administration (HRSA), an agency of HHS, is awarding more than $440 million in funding to expand voluntary, evidence-based maternal, infant, and early childhood home visiting services for eligible families across the country. In addition, the Centers for Disease Control and Prevention (CDC) announced a new investment of $118.5 million, over five years, to 46 states, six territories and freely associated statesto continue building the public health infrastructure to better identify and prevent pregnancy-related deaths.

In 2022, President Biden signed bipartisan legislation that doubles funding for the Maternal, Infant, and Early Childhood Home Visiting program over five years – the first expansion of the federal home visiting program in nearly 10 years. Through this program, local organizations can provide home visits from nurses, social workers, and other trained health workers who work with families on early and ongoing engagement in prenatal care and postpartum support. They provide support on breastfeeding, safe sleep for babies, learning and communications practices that promote early language development, developmental screening, getting children ready to succeed in school, and connecting with key services and resources in the community – like affordable childcare or job and educational opportunities. The awards announced today reflect the first opportunity for states and jurisdictions to receive federal matching funds in addition to their base grants. Every single state and U.S. territory has seen an increase in funding to their home visiting program since the start of the Biden-Harris Administration.

"As someone who has spent my entire career fighting for the health and wellbeing of women and children, I am committed to addressing a maternal health crisis in which women across America are dying before, during, and after childbirth at higher rates than in any other developed nation. That is why I called on states to extend Medicaid postpartum coverage from two months to 12 months and announced the launch of the White House Blueprint for Addressing the Maternal Health Crisis, an unprecedented whole-of-government strategy to improving maternal care," said Vice President Harris. "Today, we are building on this lifesaving work by awarding more than $558 million to improve maternal health across America. This includes a critical $440 million to support pregnant women, new mothers, and their children through home visiting programs that will improve health outcomes, child development, and access to resources for years to come."

"Bringing home a baby can be stressful. Many new parents face additional challenges such as housing, or income insecurity, which can make the whole situation even more daunting. But we know from decades of research that home visits work – from helping with school readiness and achievement for children to improving health for women," said HHS Secretary Xavier Becerra. "President Biden and Vice President Harris know how important it is to support children in their most crucial years of development so they can grow up to be healthy, happy adults. We will continue to make resources and support available, and elevate maternal health issues so that more women and families know that help is available."

"At the Health Resources and Services Administration, we are deeply committed to removing barriers to care for expectant and new moms and babies who face too many hurdles getting the support that they need," said HRSA Administrator Carole Johnson. "That's why – thanks to the leadership of the President and Vice President – we were able to work closely with bipartisan leaders in Congress to grow the home visiting program to give more moms and babies a trusted home visiting partner to help their families in ways large and small to be healthy, feel supported, access health care services, nurture their child's development, and give families every opportunity to thrive."

HRSA Administrator Carole Johnson announced the awards in conjunction with HRSA's Enhancing Maternal Health Initiative convening at Wayne State University, in Detroit, Michigan. The Initiative is bringing together moms and babies served by HRSA programs with maternal and infant health community leaders, health officials, HRSA-supported community providers, and others to advance the goals of the White House Blueprint to Address the Maternal Health Crisis.

The home visiting program funds states, jurisdictions, and tribal entities to develop and implement evidence-based, voluntary programs that best meet the needs of their communities. Families choose to participate in home visiting programs from pregnancy up to kindergarten and partner with health, social services, and child development professionals who provide resources, support, and skills to help families and children be physically, socially, and emotionally healthy. The program has demonstrated significant benefits, including improved school readiness and achievement of children, improved health for women, increased health insurance coverage, and prevented child injuries, abuse, and neglect.

For a complete list of Maternal, Infant, and Early Childhood Home Visiting Program awardees, visit https://mchb.hrsa.gov/programs-impact/programs/home-visiting/maternal-infant-early-childhood-home-visiting-miechv-program/fy24-awards .

The CDC's new $118.5 million five-year investment will continue building the public health infrastructure to better identify and prevent pregnancy-related deaths. This new investment expands support to Maternal Mortality Review Committees (MMRCs) from 46 to 52 states and U.S. territories and freely associated states . MRCs are state- and territory-based multidisciplinary groups that review deaths that have occurred within 1 year of the end of a pregnancy, determine if those pregnancy-related deaths were preventable, and recommend ways to prevent them in the future. This new investment in the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) program also advances progress on implementing the White House Blueprint for Addressing the Maternal Health Crisis . CDC began the ERASE MM program in 2019 to invest in MMRCs and to strengthen and standardize their efforts to review deaths.

"Every pregnancy-related death is a tragedy for the family and the community," said Wanda Barfield, MD, MPH, director of CDC's Division of Reproductive Health. "Thanks to MMRCs, we know more about the causes and circumstances around pregnancy-related deaths, and we have actionable recommendations to prevent future deaths. This investment will support more jurisdictions in their critical work to save mothers' lives."

Together, these efforts build on both HHS' and the broader Administration's efforts to implement the White House Blueprint to Address the Maternal Health Crisis as described in the following Fact Sheet: White House Blueprint to Address the Maternal Health Crisis: Two Years of Progress .

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Omsk Oblast, Russia

The capital city of Omsk oblast: Omsk .

Omsk Oblast - Overview

Omsk Oblast is a federal subject of Russia located in the south-eastern part of Siberia, in the Siberian Federal District. Omsk is the capital city of the region.

The population of Omsk Oblast is about 1,879,500 (2022), the area - 141,140 sq. km.

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History of Omsk Oblast

Ancient people began to settle in the area of the middle reaches of the Irtysh River about 45,000 years ago. This region became the place of numerous migrations of different peoples, of interpenetration of forest and steppe cultures. In the Middle Ages, the territory of the present Omsk region was part of the Western Turkic Khanate and the Siberian Khanate. As a result, an ethnic group of the Siberian Tatars was formed. This region was also inhabited by Kazakhs and other peoples.

The history of the development of the Irtysh by Russians is connected first of all with the legendary Yermak. Although even before him, in the 15th century, Russian merchants from the Urals visited the Siberian Khanate.

In the early 18th century, major reforms carried out by Peter the Great required large expenses. The first Russian emperor turned his attention to the east. He sent a detachment of Cossacks under the command of the lieutenant-colonel I.D.Bukhgolts from the town of Tobolsk up the Irtysh River in search of gold deposits.

More Historical Facts…

The expedition failed because of resistance from the nomads Dzhungars. Russians were forced to take a step back. In 1716, they founded a fortress at the mouth of the Om River - future Omsk. Russian peasants began to settle in the land around the fortress. To the south of Omsk, a line of outposts was constructed for protection from the nomads.

In 1782, the fortress became a town. Omsk district was formed on the basis of the southern part of Tarsky district and, in 1785, the town of Omsk was given a coat of arms. Omsk became an important center for the study of Siberia and Central Asia. This region like other parts of Siberia was used as a place for political exile.

In the 19th century, the people exiled to Siberia were the Decembrists, Petrashevts, Narodniki, representatives of other revolutionary parties and organizations, participants of the Polish national movement. These people had a major cultural impact on the local population. The great Russian writer F.M.Dostoyevsky was one of the prisoners of the Omsk jail.

In the late 19th and early 20th century, Siberia experienced significant changes. Large-scale migration of peasants led to the rapid growth of the local economy, especially agriculture. Due to its favorable economic and geographical location, at the intersection of the Trans-Siberian Railway and the Irtysh River, Omsk rapidly turned into a large transport, trade and industrial center of Western Siberia, the largest city in Siberia.

During the Second World War, about 100 industrial plants were evacuated from the European part of the USSR to Omsk. They became the basis of the local engineering industry. In 1949, the first refinery in Siberia was constructed in Omsk. In 1954-1956, during development of virgin lands, several large agricultural enterprises were built in the southern part of Omsk Oblast. In the 1970s, Omsk oblast became one of the most economically developed regions of Siberia.

Pictures of Omsk Oblast

Wooden chapel in Omsk Oblast

Author: Sedov Artem

Country house in Omsk Oblast

Author: Heinrich Jena

Provincial life in the Omsk region

Author: Baranov Pavel

Omsk Oblast - Features

Omsk Oblast is located in the south of the West Siberian Plain, in the middle reaches of the Irtysh River, with steppes in the south, which turn into forest steppes, forests and marshy tundra in the north. The territory of the region stretches for about 600 km from north to south and 300 km from west to east. In the south, Omsk Oblast borders with Kazakhstan.

The largest cities and towns of Omsk Oblast are Omsk (1,126,000), Tara (28,500), Kalachinsk (21,900), Isylkul (21,700). The main river is the Irtysh with its tributaries (the Ishim, Om, Osha, and Tara). The Trans-Siberian Railway is an important traffic artery. There is an international airport in Omsk.

The climate is continental and sharply continental. The average temperature in January is minus 19-20 degrees Celsius, in July - plus 17-18 degrees Celsius in the northern part and plus 19 degrees Celsius in the south.

Omsk Oblast has such natural resources as oil, natural gas, brown coal, iron ore, various construction materials. Main manufacturing, construction and trade are carried out in Omsk. Industrial sector is represented by military, aerospace and agricultural engineering, petrochemical, light and food industries.

Agriculture is represented by crops, dairy and beef cattle, pig and poultry farming. Cereals (wheat, rye, oats, barley), potatoes, vegetables, sunflower, and other crops are cultivated.

Attractions of Omsk Oblast

A lot of sights can be found in Omsk. The most interesting places located outside the city are:

• Achairsky Convent in the upper reaches of the Irtysh River, 50 km from Omsk;
• St. Nicholas Monastery in the village of Bolshekulache, 20 km from Omsk;
• Nature reserve “Bairovsky” created for the preservation and reproduction of rare and valuable species of birds and animals;
• Batakovo tract - a natural and archaeological park on the left bank of the Irtysh River, 150 km north of Omsk, in Bolsherechensky district;
• Znamenskiy museum of local lore dedicated to the history and nature of Omsk oblast, located in one of the oldest settlements of the region - in the village of Znamenskoye;
• Chudskaya mountain on the left bank of the Irtysh River, 3 km north of Znamenskoye;
• Lake Ulzhay - a relict water reservoir in the northwest of Kurumbelskaya steppe, in Cherlaksky district, 160 km from Omsk;
• Lake Ebeyty in the southwest of the region;
• Lake Platovskoye located to the north-east of the village of Platovo in Polstavskiy district;
• “Bird’s Haven” - a natural park located in Omsk;
• “Devil’s finger” - a rock on the right bank of the Irtysh, 2 km from the village of Serebryanoye, on the territory of Gorky district.

Omsk oblast of Russia photos

Nature of omsk oblast.

Omsk Oblast landscape

Author: Vitali Ellert

Omsk Oblast scenery

Author: Yury Ermakov

Small river in Omsk Oblast

Author: Andrey Genze

Wooden house in the Omsk region

Winter in Omsk Oblast

Wooden church in Omsk Oblast

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