Measuring the quality of antenatal care in a context of high utilisation: evidence from Telangana, India

Abstract

Background Antenatal care coverage has dramatically increased in many low-and middle-income settings, including in the state of Telangana, India. However, there is increasing evidence of shortfalls in the quality of care women receive during their pregnancies. This study aims to examine dimensions of antenatal care quality in Telangana, India using four primary and secondary data sources. Methods Data from two secondary statewide data sources (National Family Health Survey (NFHS-5), 2019–21; Health Management Information System (HMIS), 2019–20) and two primary data sources (a facility survey in 19 primary health centres and sub-centres in selected districts of Telangana; and observations of 36 antenatal care consultations at these facilities) were descriptively analysed. Results NFHS-5 data showed about 73% of women in Telangana received all six assessed antenatal care components during pregnancy. HMIS data showed high coverage of antenatal care visits but differences in levels of screening, with high coverage of haemoglobin tests for anaemia but low coverage of testing for gestational diabetes and syphilis. The facility survey found missing equipment for several key antenatal care services. Antenatal care observations found blood pressure measurement and physical examinations had high coverage and were generally performed correctly. There were substantial deficiencies in symptom checking and communication between the woman and provider. Women were asked if they had any questions in 22% of consultations. Only one woman was asked about her mental health. Counselling of women on at least one of the ten items relating to birth preparedness and on at least one of six danger signs occurred in 58% and 36% of consultations, respectively. Conclusion Despite high coverage of antenatal care services and some essential maternal and foetal assessments, substantial quality gaps remained, particularly in communication between healthcare providers and pregnant women and in availability of key services. Progress towards achieving high quality in both content and experience of antenatal care requires addressing service gaps and developing better measures to capture and improve women’s experiences of care.

Prevalence and Determinants of Low Birth Weight in India: Findings From a Nationally Representative Cross-Sectional Survey (2019-21)

“…The country's northeastern, eastern, and southern parts had better birth-weight outcomes compared to other regions, which is consistent with the evidence from the fourth round of the NFHS in India [ 24 ]. Higher utilization and quality of ANC services, higher maternal literacy rates correlating with improved awareness, lower parity, and the varied sociocultural phenomenon could be attributed to this phenomenon [ 25 ]. Furthermore, in this study, having no health insurance increased the likelihood of having an LBW newborn, a finding akin to that in a study in Mexico although most health insurance in India does not cover outpatient expenses while regardless of insurance status, all government facilities are obliged to provide universal free-of-cost antenatal services to all beneficiaries [ 26 ].…”

A realist approach to implementation fidelity in a mixed-method evaluation of electronic decision support systems to improve the quality of antenatal care in Nepal

“…The mIRA project took place in four predominantly rural districts in Bagmati Province, Nepal (Kavrepalanchok, Sindhupalchowk, Sindhuli and Dolakha) between April and December 2022. Twenty facilities-government Health Posts and Primary Health Care Centers and non-governmental Dhulikhel Hospital Outreach Centers-were selected to receive tablets with the EDSS software installed (20). Facilities were paired by type and reported ANC client volume for the previous year and then randomly allocated to receive either the mIRA or the WHO EDSS.…”

“…The implementation fidelity study used a mixed-method convergent design where quantitative and qualitative data were collected simultaneously (24). The intent was to offer a more complete understanding of implementation in all 19 facilities, drawing on quantitative and qualitative data from in-person monitoring visits, quantitative information captured in the backend data of the EDSS software, and repeat, unstructured observations and in-depth interviews conducted in four case study facilities (20).…”

“…EDSS are information systems, often delivered through computers or tablets, that integrate clinical and demographic data to support healthcare providers' decisionmaking and improve adherence to guidelines via checklists, alerts or information provided at the point of care (16,17). The mIRA project evaluated two tablet-based EDSS: the newly developed mIRA EDSS (18) and the World Health Organization (WHO) digital ANC module (19), using a two-phase outcome assessment, comparing quality scores pre-and post-EDSS implementation from observations of ANC consultations, alongside a robust process evaluation (20,21). The mIRA project evaluation results are reported in detail elsewhere (21), but for the most part, the EDSS intervention did not improve quality of care outcomes.…”

Bridging the Gap: Examining the level, trends and determinants of Adequacy of Quality Antenatal Care in India

“…As per our knowledge, in the Indian context there has been only one major nationwide study, utilising data from NFHS-4 that attempted to understand the adequacy of quality ANC, consisting each of necessary dimension [16] , which has been missing in other previous or subsequent studies [5,[17][18][19][20] . The present study is an extension to their efforts as it used the most recent data of NFHS-5, shown the trends and added some additional dimensions in looking up for determinants, which were lacking in the previous study.…”