Quality of antenatal care and perinatal outcomes: evidence from a cohort study in Ethiopia, Kenya, South Africa, and India

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Abstract
Background Antenatal care (ANC) is crucial for ensuring the health of pregnant women and their newborns. Although ANC coverage has improved globally, ANC quality remains suboptimal in some settings. Evidence on the association between ANC quality and perinatal outcomes in low-resource countries is still limited. Hence, this study assessed ANC quality and its relationship with fetal loss and low birth weight (LBW) newborns. Methods and findings We used data from the eCohort study that collected longitudinal data on ANC utilization and quality until the end of pregnancy across eight sites in Ethiopia, Kenya, South Africa, and India. Women were enrolled from public government-owned facilities only in India and South Africa and from both public and private facilities in Ethiopia and Kenya. Primary outcomes included fetal loss (≥13 weeks of gestation) and LBW. Good quality ANC was defined as receiving six essential care components during the first ANC visit: blood pressure measurement, blood and urine tests, ultrasound, iron and folic acid supplementation, and counseling on pregnancy danger signs. We conducted mixed-effect logistic regressions to assess the association between good quality ANC and perinatal outcomes, with a sensitivity analysis where good quality ANC excluded ultrasound scans. Among 3,597 pregnant women followed until the end of pregnancy, only 5.8% received all six essential care components during their first ANC visit (ranging from 1.4% in India to 14.0% in Ethiopia) and 30.7% received five care components (excluding ultrasounds) ranging from 5.7% in India to 52.5% in Kenya. Fetal loss prevalence was 3.7% in Ethiopia, 3.8% in Kenya, 4.0% in South Africa, and 6.0% in India. India and South Africa had higher rates of LBW newborns (among neonates who were alive at the time of the survey): 16.3% and 13.1%, respectively, compared to 8.6% in Ethiopia and 8.5% in Kenya. Multiple pregnancies were rarely detected at the first ANC visit. Good quality ANC was associated with a 22% to 58% lower risk of fetal loss (RR 0.78, 95% CI 0.61 – 0.95 to RR 0.42, 95% CI 0.10 – 0.73). No statistically significant associations were observed between good quality ANC and LBW. Conclusions This study identified important gaps in ANC quality and found that receiving essential ANC services was associated with a lower risk of fetal loss. With increasing global ANC coverage, future research should continue assessing quality, and programs should prioritize quality improvement, ensuring the delivery of good clinical practice and proven evidence-based interventions in pregnancy. Why was this study done? ANC utilization has significantly increased in low-resource settings; however, the quality of care received remains insufficient. Most prior research investigating the associations between ANC and perinatal outcomes has focused on ANC utilization or the number of visits. While the global dialogue has gradually shifted to ANC quality rather than merely ANC utilization, limited evidence has explored the association between ANC quality and critical perinatal outcomes, including fetal loss and LBW newborns. What did the researchers do and find? We used data from a longitudinal study that collected information on the utilization and quality of ANC throughout pregnancy and assessed the care received and its relationship with fetal and neonatal outcomes. Our study found that ANC quality was overall poor. Only 6% of pregnant women received all six care components (blood pressure measurement, blood and urine tests, ultrasound examination, iron and folic acid given or prescribed, and counseling on pregnancy danger signs) at their first ANC visits and only 31% received five care components (excluding ultrasounds). Good quality ANC was significantly associated with a lower risk of fetal loss (including late miscarriage and stillbirth), while no significant association was found between the receipt of good quality ANC and LBW newborns. What do these findings mean? Poor-quality antenatal care is not only inefficient but can also be harmful. This issue is particularly concerning as increasing numbers of women in low-resource settings seek ANC services. Efforts at the national level should ensure the delivery of good clinical practice and essential care components for high quality ANC to improve perinatal outcomes.

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