Maternal, Newborn, and Child Health
MNCH Health Systems Strengthening Interventions
Maternal, Newborn, and Child Health
MNCH Health Systems Strengthening InterventionsImproving Quality: Antenatal Care
Improving the Quality of Antenatal Care
Antenatal care (ANC) is a critical component of the maternal and newborn health continuum. It provides a platform for promoting health and well-being, identifying and managing risks, and preparing for a safe delivery. Quality ANC involves more than just clinical check-ups – it ensures that pregnant women receive comprehensive, respectful, timely, and person-centered care tailored to their unique needs throughout pregnancy.
Improving the quality of ANC is vital for reducing maternal and neonatal morbidity and mortality, detecting complications early, and supporting positive pregnancy experiences. It empowers women with the knowledge and support needed to make informed health decisions for themselves and their babies.
Primary healthcare systems are central to this improvement. By strengthening service delivery at the community and facility levels, ANC can be better integrated with nutrition, immunization, mental health, family planning, and HIV services. High-quality ANC also relies on well-trained providers, the availability of essential supplies, functional referral systems, and effective engagement with women, families, and communities.
This section of the HSS toolkit provides guidance for local government leaders, health managers, and providers on delivering high-impact, equitable, and integrated ANC services – ensuring that every pregnancy is monitored with care and every woman is treated with dignity.
What Are the Benefits of Delivering Quality Antenatal Care?
How to Implement
Improving the quality of ANC service delivery at the primary healthcare level involves several evidence-based protocols. Here are the key steps:
1. Promote Early and Regular ANC Visits
Encourage pregnant women to attend their first ANC visit within the first trimester. Schedule regular follow-up visits throughout pregnancy, in line with the WHO recommendation of a minimum of eight ANC contacts.
2. Conduct Comprehensive Health Assessments
Carry out full medical histories, physical examinations, and laboratory tests to detect and manage any underlying health issues or pregnancy-related complications early.
3. Provide Nutritional Interventions
Offer dietary counseling and ensure access to iron, folic acid, and calcium supplements to address nutritional deficiencies and support healthy fetal development.
4. Administer Recommended Vaccinations
Ensure all pregnant women receive vaccines such as tetanus toxoid and influenza to protect against infections that may harm the mother or baby.
5. Screen and Manage High-Risk Conditions
Implement standardized screening protocols for conditions like gestational diabetes, hypertension, and preeclampsia, and manage or refer appropriately.
6. Offer Health Education and Counseling
Educate women on pregnancy danger signs, healthy lifestyle practices, birth preparedness, breastfeeding, and postpartum care to empower informed decision-making.
7. Support Mental Health
Incorporate mental health screening and offer counselling to address issues such as stress, anxiety, and depression during pregnancy.
8. Integrate Community-Based Care
Use community health workers and mobile outreach strategies to extend ANC access to women in remote or underserved areas.
9. Foster a Multidisciplinary Team Approach
Encourage collaboration among obstetricians, midwives, nurses, nutritionists, and mental health providers to deliver coordinated and holistic care.
10. Leverage Technology for Care Delivery
Incorporate digital tools such as telemedicine, mobile health apps, and SMS reminders to enhance service delivery, improve patient follow-up, and boost adherence to ANC visits.
Group Antenatal Care
An alternative approach being widely studied and used is Group Antenatal Care (G-ANC). It is a model of care that combines clinical assessments with group discussions and social support. Usually, 10-12 women, who live near each other and have similar estimated dates of delivery, come together for all their antenatal care facilitated by health professionals (generally midwives). Group antenatal care aims to increase the social, psychological, and informational support found to be lacking in traditional antenatal care and to facilitate increased autonomy and empowerment.
Key Resource: Group antenatal care: findings from a pilot randomised controlled trial of REACH Pregnancy Circles.
Prevention of Mother-to-Child Transmission (PMTCT)
Infections during pregnancy significantly contribute to perinatal morbidity and mortality. In utero infections can directly harm the fetus, potentially causing intrauterine deaths and stillbirths, or indirectly, leading to premature birth or fetal growth restriction (FGR) due to maternal infections. Infections that are asymptomatic at birth may manifest later in life, often within the first five years. Typically, primary infections during pregnancy cause more damage than re-infections or reactivations, and infections acquired earlier in gestation are generally more severe. HIV, syphilis, TB, HBV, malaria, and, more recently, listeriosis, all significantly impact maternal and child health outcomes. For the same reason, PMTCT is an essential part of antenatal care. While there are comprehensive guidelines and protocols for PMTCT for each of the aforementioned infections, generally, a four-pillar approach is applied to prevent the transmission:
WHO recommends the following key components of PMTCT that can be provided at primary healthcare facilities:
- Testing and Counseling: Routine testing and counselling for all pregnant women, in geographies with high burden of infection/s, during their first antenatal care (ANC) visit and repeat testing later in pregnancy if necessary.
- Provide Antiretroviral Therapy (ART): Or refer to specialized clinics/secondary care health facilities if unavailable.
- Adherence Support: Counselling and support to ensure that infected pregnant women consistently take their medications.
- Nutritional Support: Nutritional counselling and support to improve the overall health and pregnancy outcomes.
- Safe Delivery Practices: Implementation of safe delivery practices, including the option of elective caesarean section for women with high viral loads.
- Infant Prophylaxis: Administration of antiretroviral prophylaxis to newborns of HIV-positive mothers to further reduce the risk of transmission.
- Breastfeeding Counseling: Counseling on safe breastfeeding practices, including the option of exclusive breastfeeding with maternal ART or formula feeding.
- Postnatal Follow-Up: Regular postnatal follow-up visits for both the mother and the infant to monitor their health and provide ongoing support.
- Community Engagement: Engaging with the community to raise awareness about PMTCT and reduce stigma associated with HIV and other communicable diseases.
Key Indicators
Key indicators for measuring the quality of antenatal care service delivery:
- Percentage of pregnant women who initiate ANC visits within the first trimester.
- Percentage of pregnant women who attend the recommended number of ANC visits throughout their pregnancy.
- Percentage of pregnant women receiving comprehensive health assessments, including medical history, physical exams, and laboratory tests.
- Percentage of pregnant women receiving nutritional counseling and supplementation, such as iron, folic acid, and calcium.
- Percentage of pregnant women receiving recommended vaccinations, such as tetanus and influenza.
- Percentage of pregnant women screened for high-risk conditions, such as gestational diabetes, hypertension, and preeclampsia.
- Percentage of pregnant women receiving health education and counseling on topics like healthy lifestyle choices, breastfeeding, and birth preparedness.
- Percentage of pregnant women receiving mental health support and counseling for stress, anxiety, and depression.
- Percentage of pregnant women with access to ANC services within a specified distance from their residence.
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Quality of Care
Looking for practical guidance on delivering MNCH services? Visit the MNCH Service Delivery Toolkit for step-by-step instructions on Antenatal Care.
Tips
- Community Engagement: Involve the community in planning and decision-making processes to ensure that ANC services meet their needs and preferences.
- Training and Capacity Building: Provide continuous training and capacity-building programs for healthcare providers to enhance their skills and knowledge in delivering quality ANC services.
- Integrated Care: Integrate ANC services with other primary healthcare services, such as immunization, family planning, and nutrition, to provide comprehensive care.
- Feedback Mechanisms: Establish feedback mechanisms to gather input from patients and communities on the quality of ANC services and use this feedback to make improvements.
- Resource Allocation: Ensure adequate allocation of resources, including medical supplies, equipment, and personnel, to support the delivery of quality ANC services.
- Monitoring and Evaluation: Implement robust monitoring and evaluation systems to track the performance of ANC services and identify areas for improvement.
- Patient-Centered Care: Focus on providing patient-centered care that respects the dignity, preferences, and needs of pregnant women.
Challenges
- Limited Access to Care: Improve infrastructure and transportation, establish and leverage community groups, and deploy mobile health clinics to expand access in rural and underserved areas.
- Inadequate Provider Training: Provide ongoing training and capacity-building for healthcare workers to improve knowledge and implementation of ANC guidelines and best practices.
- Cultural and Social Barriers: Engage community leaders and promote culturally sensitive education campaigns to shift norms and increase ANC utilization.
- Insufficient Resource Allocation: Advocate for increased subnational investment in supplies, equipment, and staffing to support high-quality ANC at primary healthcare facilities.
Key Resources
- Guideline for Antenatal Care. WHO 2016
- Barriers and Facilitators to Delivering Effective Services. UNICEF 2022
- Primary Health Care Measurement Framework and Indicators. WHO 2022
- Group Antenatal Care in Ghana: Protocol for a Cluster Randomized Controlled Trial. JMIR Research Protocols 2022
- Group Antenatal Care: Findings from a Pilot Randomised Controlled Trial of REACH Pregnancy Circles. Pilot and Feasibility Studies 2023
- Guideline for the Prevention of Mother-to-Child Transmission of Communicable Infections. National Department of Health, South Africa 2020
- Triple Elimination Initiative of Mother-to-Child Transmission of HIV, Syphilis and Hepatitis B. WHO 2023
