The world is in a ‘Decade of Action’ to attain the Sustainable Development Goals (SDGs) by 2030. Despite several limiting factors like rising conflicts across the world, climatic threats, a fragile global economy, and the COVID-19 pandemic, there have been notable improvements in critical areas in the form of reduction of poverty, reduction of child mortality, improvement in access to electricity, improvements in the prevention and treatment of diseases, etc [1]. Maternal health indicators also show a positive trend as globally, approximately 84 per cent of all births during 2015-21 occurred in the presence of skilled birth attendants, marking a significant increase from 64 per cent in the 2001-07 period [2]. However, the progress in the SDG era has remained slow. In 2020, almost 800 women died every day due to preventable pregnancy-related complications, with nearly 95 per cent of maternal deaths occurring in low- and lower-middle-income countries [3]. The world is moving towards broader coverage, but quality remains a significant constraint on achieving the SDG targets by 2030.
The Programme of Action proposed at the International Conference on Population and Development (ICPD) in 1994 emphasised the need to meet the needs of individuals and improve quality of life within a universally recognised framework of human rights rather than merely meeting the demographic targets. The prime objective of the Programme of Action was that all people should have access to comprehensive reproductive healthcare, including voluntary family planning, safe pregnancy and childbirth services, and prevention as well as treatment of sexually transmitted infections [4]. In alignment with the ICPD, the World Health Organisation (WHO) strives to create a world where ‘every pregnant woman and newborn receives quality care throughout the pregnancy, childbirth and postnatal period’ [5].
Antenatal care (ANC), provided by the healthcare system, is the initial set of interventions pregnant women receive to promote a positive pregnancy experience and ensure a healthy start for their newborns. It is a crucial part of the continuum of care as it allows for early detection of obstetric conditions, education on the intricacies of pregnancy, initiation of immediate breastfeeding, and the importance of family planning [6, 7]. Studies have found that failure to use antenatal care and inadequate receipt of the components of ANC pose a significant risk to the pregnant woman and the newborn [8]. The burden of maternal morbidity and mortality due to the lack of quality ANC services can be tackled by the strategic and effective implementation of healthcare services, promotion of utilisation of quality ANC, and provision of healthcare education during routine ANC visits, all of which go beyond ensuring coverage [3].
The WHO guidelines on antenatal care initially stated that at least four antenatal care visits are required for pregnant women, which was later increased in 2016 to a minimum of eight antenatal care visits for safe motherhood. The WHO also emphasised that to make ANC visits an effective preventive measure, it is important to focus on the content and quality of ANC, which incorporates nutritional interventions, maternal and foetal assessment, preventive measures in terms of vaccinations, interventions for common physiological symptoms, and health system interventions to improve utilisation and quality of antenatal care [9]. The WHO provides a core set of recommendations to guide policymakers, following which, every country develops its own guidelines [10]. In India, the National Health Mission (NHM) defines quality antenatal care as care provided by skilled healthcare providers to pregnant women, which consists of a minimum of four antenatal care visits, timely pregnancy registration, physical examination, identification and referral for danger signs, consumption of at least 100 days of IFA (Iron and Folic Acid) tablets, essential lab investigations, tetanus toxoid immunisation, and counselling [11].
In India, continuous attempts have been made to increase antenatal care coverage, that is, to ensure four or more ANC visits. However, mere visits or timely initiation of ANC are not fully helpful in the long run. Quality of care is a significant concern, as reflected in the country’s maternal mortality ratio. As per the Sample Registration System (SRS) report, the maternal mortality ratio (MMR) in India was 103 maternal deaths per 100,000 live births in 2017–2019 [12], which is way off the target set by Sustainable Development Goal 3 to reduce MMR to less than 70 per 100,000 live births. Therefore, there is a need to expand maternal and infant healthcare services to all regions and communities. However, the aim should not be limited to making healthcare services delivered by skilled personnel, which is available and accessible during pregnancy; it should include improving the quality of the services as well [13].
The coverage of antenatal care services depends on various socio-demographic factors. It is significantly associated with women’s empowerment, maternal education, maternal health status, birth order, economic status, and availability of health facilities [14, 15]. There have been many studies on the factors associated with the low utilisation of ANC in different parts of India. However, the literature shows limited attempts to understand the factors associated with utilising quality ANC in India and other low- and middle-income countries. Despite the efforts to bring quality to the forefront of programmes and policies, interventions are geared towards increasing coverage. As a result, quality is compromised, particularly in countries like India, where millions of women become pregnant each year.
Measurement of quality
Several efforts have been made to measure the quality of ANC in different parts of the world. As early as the 1970s, Kessner et al. constructed an index to measure the timeliness of the initial antenatal care intervention [16]. Similarly, by combining several indicators, other authors also tried to develop a quality measure. Unfortunately, while some failed to provide comprehensiveness, others overlooked the process measures [17, 18]. In the Indian context, only a limited number of studies [19] have attempted to understand quality ANC across all its necessary dimensions, often overlooked by most of the previous studies on quality ANC [8, 20,21,22,23]. The present study is an extension of those efforts. It uses the most recent data from the National Family Health Survey (NFHS) and adds some additional dimensions that were lacking in the previous studies. The study is based on the methodology developed by Heredia-Pi et al., who analysed the Demographic and Health Surveys data (DHS) for Mexico, introduced four dimensions to measure the quality of antenatal care and overcome the previous methodological limitations [24].
In the present study, adequate quality ANC refers to the timely and sufficient delivery of services by skilled healthcare providers without ignoring the appropriateness of the content. To our knowledge, this study is one of the initial efforts in the Indian context to quantify adequate quality antenatal care, assess the progress of each component and dimension of adequate quality antenatal care in the last five years (2015-21), and identify the components that are a barrier to achieving quality antenatal care and positive pregnancy experiences for mothers. Also, this study reaffirms that the load of maternal and newborn deaths can be reduced if the quality aspect is brought to the forefront of all maternal health policies. Therefore, it highlights the states of India that must be prioritised and identifies the vulnerable population segments. The rationale for conducting this study is to fill a significant research gap, generate evidence to inform policy decisions, enhance healthcare practices, support global sustainable development goals, and empower women and communities through improved maternal healthcare services.
The present study is an attempt to provide an overview of the change in the levels of components of quality ANC, analyse the state- and district-level distribution of adequate quality ANC, and identify the determinants of adequate quality ANC, with an aim to bridge the gap between the coverage of ANC and the provision of adequate quality in maternal health policy formulation.
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