Focused antenatal care acceptable, tricky to implement.

Appropriate antenatal care is a key element of programs to improve the health of mothers and newborns. Recently the Population Council and partners studied antenatal care in Ghana, Kenya, and South Africa. These investigations showed that a focused approach, emphasizing quality of care over quantity, is acceptable, but can be difficult to implement because of scarce resources and staff turnover.

Approaches to antenatal care

On the whole, antenatal care programs in developing countries have been modeled on those in developed countries. These programs, however, have been poorly implemented and largely ineffective. In response, the World Health Organization (WHO) designed and tested a focused antenatal care package that includes only counseling, examinations, and tests that serve an immediate purpose and have a proven health benefit. For example, many antenatal care programs screen for suspected risk factors for pregnancy complications. However, this approach has been challenged and WHO's focused approach does not use it. The WHO recommends reducing the number of antenatal care visits to four, and this has not been found to pose a risk to the health of mother or baby.

South Africa

The Maternal, Child and Women's Health Unit of the KwaZulu-Natal Department of Health wanted to improve the quality of antenatal care provided in its clinics. To this end, it collaborated with the Population Council's USAIO-funded Frontiers in Reproductive Health program, the Reproductive Health Research Unit of the University of Witwatersrand, and the Department of Medical Microbiology and Infectious Diseases of the Nelson Mandela School of Medicine at the University of Natal. These groups developed and pilot-tested a version of the WHO-recommended package of care, involving five (rather than four) antenatal care visits and two postnatal care visits. The focused package also included counseling on the prevention of sexually transmitted infections, onsite syphilis screening with same-day results, and HIV prevention information and referral.

The teams used a pre- and post-test comparison group design, comparing the current standard of care in six clinics with focused care in another six clinics. They found that the introduction of the programs was feasible. However, patient care did not improve as much as hoped. Not as many women as planned received counseling on nutrition in pregnancy, breastfeeding, and postpartum family planning. Nor were women adequately educated about pregnancy danger signs. Such disappointing results might be attributable to high staff turnover. By the time of the endline survey, only two of the six intervention clinics had at least one staff member who had covered all the training modules. Thus, interventions such as this, which rely heavily on teaching staff new ways of organizing and providing services, must develop strategies that allow for relatively rapid rates of staff turnover.

Frontiers has been working with the Department of Health in KwaZulu-Natal province to develop a comprehensive package of policies, tools, and job aides to strengthen antenatal care services; the national Department of Health is also interested in adapting these products.

Ghana and Kenya

In Ghana, Frontiers collaborated with the Noguchi Memorial Institute for Medical Research and the Ghana Health Service to examine the extent to which adaptation of the package influenced the quality of care received by pregnant women and its acceptability to both providers and clients. The study took place at ten intervention clinics and four comparison clinics.

The researchers found that the new model is well accepted by clients and providers because of its comprehensiveness and individualized care. But some components of the package were lacking in several clinics, in particular procedures for disease detection, including syphilis and HIV/MDS. Existing opportunities for referral were not fully used. Client privacy was sometimes compromised, as many clinics partition their consulting rooms. And essential drugs and supplies were not always available. Nevertheless, the focused antenatal care model did result in improved quality and continuity of care in Ghana. Clients visiting the intervention clinics obtained more comprehensive care than those visiting comparison clinics.

In Kenya, the Frontiers program collaborated with the Ministry of Health to determine whether focused antenatal care has increased the coverage and quality of services. The study compared clinics in two intervention districts with clinics in a control district. The researchers found support for the focused services among policymakers. But, as in the other countries studied, inadequate staff training and shortages of equipment and supplies inhibit the full provision of services. Despite these challenges, the new model did increase the quality of specific components of care, such as detection of diseases and counseling on family planning use postpartum. Further, clients report satisfaction with most aspects of the new model of antenatal care provision.

"Focused antenatal care is acceptable to both clients and providers and can improve care," said Council researcher Harriet Birungi. "However, to optimize the introduction of the new model, program managers and other key stakeholders need to develop strategies to deal with high staff turnover and a scarcity of needed supplies."

SOURCES

Birungi, Harriet and W. Onyango-Quma. 2006. "Acceptability and sustainability of the WHO focused antenatal care package in Kenya," FRONTIERS Final Report. Washington, DC: Population Council.

Chege, Jane N., lan Askew, Nzwakie Mosery, Mbali Ndube-Nxumalo, Busi Kunene, Mags Beksinska, Janet Dalton, Ester Snyman, Wilem Sturm, and Preshny Moodley. 2005. "Feasibility of introducing a comprehensive integrated package of antenatal care services in rural public clinics in South Africa," FRONTIERS Final Report. Washington, DC: Population Council.

Nyarko, Philomena, Harriet Birungi, Margaret Armar-Klemesu, Daniel Arhinful, Sylvia Deganus, Henrietta Qdoi-Agyarko, and Gladys Brew. 2006. "Acceptability and feasibility of introducing the WHO focused antenatal care package in Ghana," FRONTIERS Final Report. Washington, DC: Population Council.

OUTSIDE FUNDING

United States Agency for International Development