Research Article: Analysis of socioeconomic differences in the quality of antenatal services in low and middle-income countries (LMICs)

Date Published: February 23, 2018

Publisher: Public Library of Science

Author(s): Joshua Amo-Adjei, Kofi Aduo-Adjei, Christiana Opoku-Nyamah, Chimaroake Izugbara, Magdalena Grce.


The desired results of increasing access and availability of antenatal care (ANC) services may not be realized if the quality of care offered is not adequate. We analyzed the content/quality of antenatal care to determine whether there are socioeconomic (education and wealth) inequalities in the services provided in 59 low and middle income countries in six WHO regions–Africa, East Asia and Pacific, Europe and Central Asia, Latin America and Caribbean, Middle East and South Asia. We aggregated the most recent (2005–2015) Demographic and Health Survey for each country. The quality of content was measured on eight recommended ANC services–(1) monitoring of blood pressure; (2) tetanus injection; (3) urine analysis for protein; (4) blood test; (5) information about danger signs (6); weight (7); height measurements and (8) provision of iron-folate supplement. Descriptive and Poisson regression techniques were applied to analyse the data. We found considerable wealth and educational differences prior to controlling for known covariates. Between wealth and education, however, the disparities in the latter are larger than the former. Whereas the socioeconomic differences remained at post adjusting for residence, place and number of antenatal care, parity and region, the magnitude of change was minimal. Higher number of ANC content was provided in “other” forms of private facilities; the Latin America and Caribbean region recorded the highest number of content compared to the other regions. The hypothesized socioeconomic status on content/number of ANC services was generally supported, although the associations are substantially constrained to other variables. Efforts are made to increase the number and timing of ANC services; due recognition is needed for the content offered.

Partial Text

The recently launched Sustainable Development Goals (SDGs) affirm the very urgent need to tackle the root causes of maternal and child morbidity and mortality. Apart from being a desirable goal in its right, improved maternal health is also a fulcrum for healthier child development, holding the key to equity, lifelong health, wellbeing, and productivity. [1]. Specifically, SDG target 3.8 aims at “achieving universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality, and affordable essential medicines and vaccines for all” [2]

There were 400,336 weighted women with recent records on births, drawn from 32 countries in Africa (N = 224,772; 56.15%), six in Europe and Central Asia (N = 11,385; 2.84%), eight Latin America and Caribbean countries (N = 45,837; 11.45%) and four each from East Asia and Pacific (N = 31.793; 7.94), Middle East (N = 35,628; 8.9%) and South Asia (N = 50,918; 12.72%). In all, women received around 4.71 (4.70–4.72) services averagely, with regional range from 3.71–6.39 in Europe and Central Asia and Latin America and Caribbean, illustrated in Fig 1.

Drawing on rich datasets that reflected nationally, we found that nearly 27% of critical ANC services were not provided to women in the countries studied. Also, in no region and country did women report obtaining all the eight recommended services. From the pooled multivariate estimates, SES differences are noted in content provided. However, in the Latin America and Caribbean region, the rich-poor gaps were not considerably substantial. In the remaining regions, it was very substantial, in excess of over 80% in some instances.

We assessed some core elements of functional/technical quality of ANC services women reported in 59 LMICs. While most countries in these regions are making tremendous efforts to increase ANC coverage by reducing structural barriers to optimum utilization, it is imperative that the quality of care provided is closely monitored in ways that do not neglect women at the lower rungs of SES. Conscious steps are needed to reach out to women who, most likely, will still not meet the required number of contacts. In fact, evidence [44–46] from advanced countries where structural issues of accessibility barely exist, the complexities of cultural diversities hinder maximum utilization (early and number). The implication is that quality should not emanate solely from frequency of contacts. Improving functional quality is imperative for better maternal health outcomes.




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