Research Article: A reassessment of global antenatal care coverage for improving maternal health using sub-Saharan Africa as a case study

Date Published: October 5, 2018

Publisher: Public Library of Science

Author(s): John Ele-Ojo Ataguba, Olalekan Uthman.


Antenatal period is an opportunity for reaching pregnant women with vital interventions. In fact, antenatal care (ANC) coverage was an indicator for assessing progress towards the Millennium Development Goals. This paper applies a novel index of service coverage using ANC, which accounts for every ANC visit. An index of service coverage gap is also proposed. These indices are additively decomposable by population groups and they are sensitive to the receipt of more ANC visits below a defined threshold. These indices have also been generalised to account for the quality of services.

Data from recent rounds of the Demographic and Health Survey (DHS) are used to reassess ANC service coverage in 35 sub-Saharan African countries. An index of ANC coverage was estimated. These countries were ranked, and their ranks are compared with those based on attaining at least four ANC visits (ANC4+).

The index of ANC coverage reflected the level of service coverage in countries. Further, disparities exist in country ranking as some countries, e.g. Cameroon, Benin Republic and Nigeria are ranked better using the ANC4+ indicator but poorly using the proposed index. Also, Rwanda and Malawi are ranked better using the proposed index.

The proposed ANC index allows for the assessment of progressive realisation, rooted in the move towards universal health coverage. In fact, the index reflects progress that countries make in increasing service coverage. This is because every ANC visit counts. Beyond ANC coverage, the proposed index is applicable to assessing service coverage generally including quality education.

Partial Text

There is a growing concern globally, especially within developing countries, to improve maternal and child health outcome indicators [1, 2]. The antenatal period provides an opportunity for reaching pregnant women with interventions that may be vital to their health and wellbeing and that of their children. In fact, evidence shows that “women from high-, medium- and low-resource settings valued having a positive pregnancy experience” ([3] p.86). While such a positive pregnancy experience is multidimensional, within the health system, women have expressed concern for flexible appointment systems and ensuring continuity in the provision of care with emphasis placed on ensuring privacy and providing quality time to build trust and a good relationship with health service providers. They also value having culturally sensitive, safe and effective health services [3, 4].

This paper builds on the traditional indicators of ANC coverage, particularly the ‘reduced’ ANC model (see Table 1) and proposes an index of ANC coverage that uses the number of ANC contacts over the “entire” distribution (0–4+ visits in this case. For noting, this can be extended easily to the “standard” ANC model of 0–8+ contacts). The proposed index is designed to be very simple to compute and to explain to policymakers and can be useful to compare countries and for monitoring progress in ANC coverage over time. The properties of this index are also presented in S1 Appendix. In the light of the debates around effective coverage [21], the paper also proposes an extension by developing a generalised index of ANC coverage that analysts can use to account for the quality of each ANC received and not just the number of ANC contacts.

Let vij represet the ith ANC visit for woman j aged 15–49 with a live birth within a given period such that:

The ANC coverage statistics shown in Table 2 indicate that the coverage of only one ANC visit is very low (<3%) in Uganda in 2016. Coverage with at least four ANC visits is slightly greater than 60%. Also, about 28% had only 3 visits while about 2% did not record any ANC visit. Basically, data from 2016 show that about 88% of the women (aged 15–49 years) with a live birth in the past 5 years had attained at least 3 ANC visits based on the most recent live birth experience. The proposed ANC coverage index (IANC) was estimated for African countries with available DHS data. In total, relatively recent DHS data from 35 African counties were used to estimate IANC. Because the traditional indicator of reporting at least four ANC visits (ANC4+) cannot be directly comparable to the IANC, country rankings are presented to compare both indictors and to illustrate differences between them. Globally, antenatal care remains an important intervention for improving maternal and child health. While there are debates about the minimum number of ANC visits required for pregnant women to ensure their health and that of their children, the WHO had previously recommended at least four visits (i.e. the ‘reduced’ ANC model) and more recently, the standard ANC model of at least eight ANC contacts, especially in the case of uncomplicated pregnancies. In fact, the WHO’s proposed indicator of attaining at least four ANC visits was used to assess progress towards the MDGs. Although this indicator may be relevant, it does not account for the quality of ANC services received by women. Also, it is not sensitive to any improvements or initiatives that have increased the proportion of pregnant women that attain less than four ANC visits. This paper, using a modified measure of ANC coverage that is additively decomposable by population groups, has shown the importance of accounting for the entire population of pregnant women irrespective of the number of ANC visits. This presents an initial attempt and it allows for an assessment of ANC coverage that tallies with the notion of progressive realisation as entrenched in debates for moving towards UHC. It is envisaged that this paper will, among other things, open the space for rigorous debates about methodologies that are able to demonstrate a country’s progress in (especially by incorporating quality) health service coverage as this represents a very important dimension of UHC.   Source:


0 0 vote
Article Rating
Notify of
Inline Feedbacks
View all comments