Evaluating the quality of antenatal care and pregnancy outcomes using content and utilization assessment

Evaluating the quality of antenatal care and pregnancy outcomes using content and utilization... Abstract Objective To assess the adequacy of antenatal care (ANC) and its association with pregnancy outcomes using an approach that includes adequacy of both utilization and content. Design Retrospective cohort study. Setting and Participants Women attending ANC at public-funded primary health clinics where data were extracted from individual records. Methods Adequacy of utilization assessment was based on the concept of Adequacy of Prenatal Care Utilization index; adequacy of content assessed the recommended routine care received by the women according to local guidelines. Association between adequacy and pregnancy outcomes was examined using binary logistic regression. Main Outcome Measures Pregnancy outcomes included preterm birth and low birth weight. Results Sixty-three percent of women showed higher than recommended ANC utilization; 52% had <80% of recommended routine care content. Although not statistically significant, the odds of preterm birth was lower among women with adequate level of utilization compared with inadequate (adjusted odds ratios (aOR) = 2.34, 95% confidence interval (CI) 0.45–12.16) and intensive levels (aOR = 3.27, 95% CI 0.73–14.60). Regarding adequacy of content, women who received inadequate level of care content were associated with higher prevalence of preterm birth (aOR = 3.69, 95% CI 1.60–8.55). Conclusion The study shows inadequate content is associated with higher prevalence of preterm birth and suggests that inadequate utilization increases the risk of preterm birth. It demonstrates the relevance of using both utilization and content assessment in evaluating quality of ANC. Further studies are encouraged to review the methods used. antenatal care, utilization, content, quality of care, pregnancy outcomes Introduction Assessing quality of antenatal care (ANC) requires information on services utilization and indicators of content or quality of ANC [1–5]. However, the most commonly used adequacy of prenatal care utilization (APNCU) index assesses only adequacy of care initiation and adequacy of number of visits [6]. The index assesses neither content of care provided nor risk conditions of women [3, 6]. Delivery of ANC follows standards and guidelines based on bio-psycho-social needs of women [7, 8]. Definition of quality maternity care [8] and risk-oriented ANC recommended by WHO [7] imply: (i) the need for rational use of ANC according to needs and, (ii) provision of care to contribute to intended outcomes. These demand that all women be given a minimum set of care regardless of risk level and that additional care are to be given based on risk condition identified. The approach commands that evaluation of ANC needs to assess the recommended routine care received by the women and the risk condition of the women. Few studies have attempted to measure utilization and content of ANC using tools that integrated both aspects into one composite measure [4, 9]; however, these tools have limitations in this regard, in certain settings. For example, one of these tools was designed for places with low ANC attendances, for which health education was named as one ANC element without specifying the topics of health education that should be provided [9]. Therefore, application of this tool in high ANC attendance settings is challenging, while comprehensive analysis of quality of care is impossible. Also, for another tool which included three interventions (ultrasound, blood pressure and blood screening), the authors acknowledged the need to incorporate additional ANC interventions [4]; however, this is impossible owing to the tool’s design. Moreover, the tool only assessed adequacy of care initiation but not adequacy of ANC visits. Consequently, in settings with increasing number of ANC visits per pregnancy, rational use of care analysis is limited. As such, the index derived from such a tool may not be considered as more significant than others [4], since it still requires the utilization of other indices, such as the APNCU to compensate for its limitations. By analysing the complex ANC process over time, this study aimed to assess the adequacy of ANC and its association with pregnancy outcomes, using an approach that included both adequacy of utilization and adequacy of content. Background of study setting Malaysia has recorded remarkable achievement in maternal-child-health over the past decades [10]. Relevant tracers continue to be excellent [11] and the number of ANC visits have increased higher than recommended [12, 13]. Recent progress in pregnancy outcomes, however, has not improved accordingly; for over a decade, maternal mortality has stagnated [14], and the prevalence of low birth weight (LBW; compared with that of neighbouring countries) [15], and stillbirth [16] have increased. These highlight the limitations of present coverage indicators and the need to initiate assessing ANC beyond these indicators, since they are not linked to outcomes. Methods Study design and population This was a retrospective cohort study including data of women who had attended public-funded health clinics [17, 18]. The women and 6 out of 58 health clinics in Selangor state were selected by a multistage sampling. Patient records were anonymised and de-identified prior to analysis. The study was approved by the Research and Ethics Committee of University Malaya Malaysia, and the Medical Research and Ethics Committee of the Ministry of Health Malaysia. Definition of variables: evaluating quality of antenatal care Adequacy of utilization This was based on the concept of the APNCU index [6]. The index was modified in this present study by raising the cut-off points of the observed-to-expected visits ratio, to reflect the lower recommended visits of the local guidelines [18]. Figure 1 illustrates the modified visits ratio cut-off points: adequate-plus (≥130% of expected visits—intensive utilization with ≥30% higher visits than recommended), adequate (90–129%), intermediate (60–89%) and inadequate (<59%). During analysis, utilization adequacy was categorized into three categories: adequate-plus, adequate and inadequate (intermediate was grouped with inadequate). Regarding initiation of care, the modified index maintained the four categorical timing of the original APNCU index. Women who had the first visit after 17 weeks gestation were categorized as having received inadequate care (Fig. 1). Figure 1 View largeDownload slide Modified APNCU Index adjusted for Malaysian Recommended Schedule. Source: Adapted from APNCU index [6]. Figure 1 View largeDownload slide Modified APNCU Index adjusted for Malaysian Recommended Schedule. Source: Adapted from APNCU index [6]. Adequacy of content Adequacy of content assessed the level of recommended routine care received by the women according to the MOH guidelines [13]. The routine care consisted of four components—physical examination, health screening, case management and health education (Supplementary Table S1). Weighting factor, which was consulted and explained in another paper [17], was applied. Content adequacy was categorized as inadequate (<80%) or adequate (≥80%). Outcome measures The outcome measures used in this paper was pregnancy outcomes which included preterm birth (<37 gestational weeks at birth) and LBW (<2500 g at birth). Statistical analysis The association between adequacy of utilization or content and pregnancy outcomes was examined by binary logistic regression using a full model multivariate regression. The model was adjusted for maternal age, maternal education, risk status, clinic type and utilization adequacy or content adequacy. Results Respondents’ characteristics: users of ANC A total of 522 records were analysed; characteristics of the women are presented in Table 1. Table 1 Characteristics of the women (n = 522) Characteristics  n (%)  Maternal age at first visit   ≤19  11 (2.1%)   20–34  439 (84.1%)   ≥35  72 (13.8%)   Mean (SD)  28.7 (5.0)  Maternal education   Primary or no formal education  23 (4.4%)   Secondary  294 (56.3%)   Tertiary  193 (37.0%)   Unknown  12 (2.3%)  Parity   Nulliparous  195 (37.4%)   Multiparous  327 (62.6%)   Mean (SD)  1.2 (1.3)  Risk status   Low-risk  375 (71.8%)   High-risk  147 (28.2%)  Clinic type by planned daily workload   <150  98 (18.8%)   150–300  247 (47.3%)   301–500  177 (33.9%)  Pregnancy outcomes   Preterm birth  36 (6.9%)   LBW  66 (12.7%)  Characteristics  n (%)  Maternal age at first visit   ≤19  11 (2.1%)   20–34  439 (84.1%)   ≥35  72 (13.8%)   Mean (SD)  28.7 (5.0)  Maternal education   Primary or no formal education  23 (4.4%)   Secondary  294 (56.3%)   Tertiary  193 (37.0%)   Unknown  12 (2.3%)  Parity   Nulliparous  195 (37.4%)   Multiparous  327 (62.6%)   Mean (SD)  1.2 (1.3)  Risk status   Low-risk  375 (71.8%)   High-risk  147 (28.2%)  Clinic type by planned daily workload   <150  98 (18.8%)   150–300  247 (47.3%)   301–500  177 (33.9%)  Pregnancy outcomes   Preterm birth  36 (6.9%)   LBW  66 (12.7%)  Table 1 Characteristics of the women (n = 522) Characteristics  n (%)  Maternal age at first visit   ≤19  11 (2.1%)   20–34  439 (84.1%)   ≥35  72 (13.8%)   Mean (SD)  28.7 (5.0)  Maternal education   Primary or no formal education  23 (4.4%)   Secondary  294 (56.3%)   Tertiary  193 (37.0%)   Unknown  12 (2.3%)  Parity   Nulliparous  195 (37.4%)   Multiparous  327 (62.6%)   Mean (SD)  1.2 (1.3)  Risk status   Low-risk  375 (71.8%)   High-risk  147 (28.2%)  Clinic type by planned daily workload   <150  98 (18.8%)   150–300  247 (47.3%)   301–500  177 (33.9%)  Pregnancy outcomes   Preterm birth  36 (6.9%)   LBW  66 (12.7%)  Characteristics  n (%)  Maternal age at first visit   ≤19  11 (2.1%)   20–34  439 (84.1%)   ≥35  72 (13.8%)   Mean (SD)  28.7 (5.0)  Maternal education   Primary or no formal education  23 (4.4%)   Secondary  294 (56.3%)   Tertiary  193 (37.0%)   Unknown  12 (2.3%)  Parity   Nulliparous  195 (37.4%)   Multiparous  327 (62.6%)   Mean (SD)  1.2 (1.3)  Risk status   Low-risk  375 (71.8%)   High-risk  147 (28.2%)  Clinic type by planned daily workload   <150  98 (18.8%)   150–300  247 (47.3%)   301–500  177 (33.9%)  Pregnancy outcomes   Preterm birth  36 (6.9%)   LBW  66 (12.7%)  Preterm birth rate per 100 live births was ~7%, lower than official rate of 12% [11]. The lower rate was due to the role of first level health facilities in which the extreme high-risk conditions including those susceptible to preterm birth were often referred and managed at hospital level. The mean gestational age of preterm births was 34 weeks (min 29, max 36). LBW was <13%, almost similar to official rate of 11% [11]. Regarding timing of first visit, 50% of the preterm births had the first visit by 12 weeks, and 50% after 12 weeks. Forty-five percent of the LBW had the first visit by 12 weeks and 55% after. Adequacy of utilization and content Sixty-three percent had ‘adequate-plus’ utilization (Table 2), indicating a high proportion of women had higher number of ANC visits than the recommended schedule. Table 2 Distribution of women by adequacy of utilization and/or content (n = 522)   n (%)  Adequacy of utilization (APNCU-Malaysia index)   Inadequate  107 (20.5)   Adequate  85 (16.3)   Adequate-plus  330 (63.2)   Total  522 (100.0)  Adequacy of content   Inadequate (<80%)  270 (51.7)   Adequate (≥80%)  252 (48.3)   Total  522 (100.0)  Adequacy of utilization * adequacy of content   Inadequate utilization * inadequate content  62 (11.9)   Inadequate utilization * adequate content  45 (8.6)   Adequate utilization * inadequate content  208 (39.8)   Adequate utilization * adequate content  207 (39.7)   Total  522 (100.0)    n (%)  Adequacy of utilization (APNCU-Malaysia index)   Inadequate  107 (20.5)   Adequate  85 (16.3)   Adequate-plus  330 (63.2)   Total  522 (100.0)  Adequacy of content   Inadequate (<80%)  270 (51.7)   Adequate (≥80%)  252 (48.3)   Total  522 (100.0)  Adequacy of utilization * adequacy of content   Inadequate utilization * inadequate content  62 (11.9)   Inadequate utilization * adequate content  45 (8.6)   Adequate utilization * inadequate content  208 (39.8)   Adequate utilization * adequate content  207 (39.7)   Total  522 (100.0)  Table 2 Distribution of women by adequacy of utilization and/or content (n = 522)   n (%)  Adequacy of utilization (APNCU-Malaysia index)   Inadequate  107 (20.5)   Adequate  85 (16.3)   Adequate-plus  330 (63.2)   Total  522 (100.0)  Adequacy of content   Inadequate (<80%)  270 (51.7)   Adequate (≥80%)  252 (48.3)   Total  522 (100.0)  Adequacy of utilization * adequacy of content   Inadequate utilization * inadequate content  62 (11.9)   Inadequate utilization * adequate content  45 (8.6)   Adequate utilization * inadequate content  208 (39.8)   Adequate utilization * adequate content  207 (39.7)   Total  522 (100.0)    n (%)  Adequacy of utilization (APNCU-Malaysia index)   Inadequate  107 (20.5)   Adequate  85 (16.3)   Adequate-plus  330 (63.2)   Total  522 (100.0)  Adequacy of content   Inadequate (<80%)  270 (51.7)   Adequate (≥80%)  252 (48.3)   Total  522 (100.0)  Adequacy of utilization * adequacy of content   Inadequate utilization * inadequate content  62 (11.9)   Inadequate utilization * adequate content  45 (8.6)   Adequate utilization * inadequate content  208 (39.8)   Adequate utilization * adequate content  207 (39.7)   Total  522 (100.0)  Fifty-two percent of women had <80%, or inadequate level, of recommended routine ANC content (Table 2). There was a correlation between utilization level and mean content score (Table 3, P<0.001). The difference between women in ‘inadequate’ and ‘adequate’ utilization category was not statistically significant (P = 0.239). Table 3 Difference of mean for antenatal care content score in % by antenatal care utilization level (n = 522)    Mean antenatal care content score  P-value  ANC utilization level    <0.001   Inadequate  76.3     Adequate  74.6     Adequate-plus  78.1     Pairwise comparison        Inadequate and adequate-plus    0.048    Inadequate and adequate    0.239    Adequate and adequate-plus    <0.000     Mean antenatal care content score  P-value  ANC utilization level    <0.001   Inadequate  76.3     Adequate  74.6     Adequate-plus  78.1     Pairwise comparison        Inadequate and adequate-plus    0.048    Inadequate and adequate    0.239    Adequate and adequate-plus    <0.000  General linear model univariate full model analysis containing parity, risk level, clinic type, percentage of total visits attended by specific providers and antenatal care utilization adequacy. Table 3 Difference of mean for antenatal care content score in % by antenatal care utilization level (n = 522)    Mean antenatal care content score  P-value  ANC utilization level    <0.001   Inadequate  76.3     Adequate  74.6     Adequate-plus  78.1     Pairwise comparison        Inadequate and adequate-plus    0.048    Inadequate and adequate    0.239    Adequate and adequate-plus    <0.000     Mean antenatal care content score  P-value  ANC utilization level    <0.001   Inadequate  76.3     Adequate  74.6     Adequate-plus  78.1     Pairwise comparison        Inadequate and adequate-plus    0.048    Inadequate and adequate    0.239    Adequate and adequate-plus    <0.000  General linear model univariate full model analysis containing parity, risk level, clinic type, percentage of total visits attended by specific providers and antenatal care utilization adequacy. Association between adequacy of utilization or content and pregnancy outcomes Adequacy of utilization and pregnancy outcomes The odds for preterm birth in the adequate-plus category was 3.27 times that of adequate category and the odds for preterm birth in the inadequate category was 2.34 times that of the adequate category (Table 4). Although it did not reach statistical significance, the finding suggested that women with adequate utilization were associated with lower odds of preterm birth compared with those with inadequate and intensive utilization. Having intensive utilization appeared to be associated with higher prevalence of preterm birth. Table 4 Adequacy of antenatal care and pregnancy outcomes models ANC adequacy  Adjusted OR* (95% CI)  Preterm birth (n = 36)  LBW (n = 66)  ANC utilization   Inadequate  2.34 (0.45–12.16)  0.73 (0.26–2.06)   Adequate  1.00  1.00   Adequate-plus  3.27 (0.73–14.60)  1.36 (0.60–3.09)  ANC content   Inadequate  3.69 (1.60–8.55)  1.17 (0.68–2.01)   Adequate  1.00  1.00  ANC adequacy  Adjusted OR* (95% CI)  Preterm birth (n = 36)  LBW (n = 66)  ANC utilization   Inadequate  2.34 (0.45–12.16)  0.73 (0.26–2.06)   Adequate  1.00  1.00   Adequate-plus  3.27 (0.73–14.60)  1.36 (0.60–3.09)  ANC content   Inadequate  3.69 (1.60–8.55)  1.17 (0.68–2.01)   Adequate  1.00  1.00  *Full model binary logistic regression, odds ratios (ORs) for antenatal care adequacy (utilization and content) were adjusted for maternal age, maternal education, risk status, clinic type and utilization or content. Table 4 Adequacy of antenatal care and pregnancy outcomes models ANC adequacy  Adjusted OR* (95% CI)  Preterm birth (n = 36)  LBW (n = 66)  ANC utilization   Inadequate  2.34 (0.45–12.16)  0.73 (0.26–2.06)   Adequate  1.00  1.00   Adequate-plus  3.27 (0.73–14.60)  1.36 (0.60–3.09)  ANC content   Inadequate  3.69 (1.60–8.55)  1.17 (0.68–2.01)   Adequate  1.00  1.00  ANC adequacy  Adjusted OR* (95% CI)  Preterm birth (n = 36)  LBW (n = 66)  ANC utilization   Inadequate  2.34 (0.45–12.16)  0.73 (0.26–2.06)   Adequate  1.00  1.00   Adequate-plus  3.27 (0.73–14.60)  1.36 (0.60–3.09)  ANC content   Inadequate  3.69 (1.60–8.55)  1.17 (0.68–2.01)   Adequate  1.00  1.00  *Full model binary logistic regression, odds ratios (ORs) for antenatal care adequacy (utilization and content) were adjusted for maternal age, maternal education, risk status, clinic type and utilization or content. Adequacy of content and pregnancy outcomes Based on the observed significance level, ANC content was associated with preterm birth statistically. The odds of preterm birth in inadequate category were over three times that of adequate category (Table 4). ANC content did not appear to influence LBW. Discussion We analysed adequacy of utilization and adequacy of content separately, to evaluate ANC. This approach was more useful compared with a composite measure that combined both utilization and content as one variable. The composite measure cannot ascertain if the adverse pregnancy outcomes were associated with utilization or content inadequacy, and thus, would be less specific in diagnosing gaps in care delivery. Instead, we used binary logistic regression which included either utilization adequacy or content adequacy as predictors (independent variables) of adequacy and pregnancy outcomes. We also recognized the importance of including risk status of women as an independent variable, which facilitated analysis on rational use of care according to need. In many developing settings, indicators related to ANC utilization often include timing of first visit and average number of total visits, which are analysed separately. The nature of these single indicators, though commonly used, indicates only what it is defined; they are not designed to provide comprehensive measurement on quality of care. The indicator, timing of first visit, measures only what is intended and does not provide information after the first visit. Likewise, ‘average number of total ANC visits’ provides little benefit in assessing adequacy of utilization when the initiation period is not known. For example, a multiparous could be seen seven times throughout her 40-week pregnancy, which is considered adequate according to the recommended number of ANC visits for uncomplicated multipara [13]. However, if it was not known that the woman had her first ANC visit at 20 weeks gestation, it would be inappropriate to classify the woman as having adequate utilization because she fulfilled the recommended number of ANC visits. The scenario highlights the limitation in using these two indicators separately and reiterates the importance of using indicators like the APNCU index to assess ANC utilization. The finding demonstrated the absence of significant differences in terms of pregnancy outcomes between the women who had the first ANC visit by 12 weeks and after 12 weeks. Monitoring gestational age of first visit aimed to promote early initiation of care. In the case of Malaysia, the recommended initiation period is by 12 weeks of gestation [13]. It has been recognized that women who had late initiation might not have the opportunity to benefit from screening tests, antenatal health advice or supported decision making regarding choice of delivery [19, 20]. There is, however, limited evidence to establish the right period for initiation of first visit [21, 22]. For example, the Confidential Enquiry into Maternal Deaths in the UK reveals that 43% of the deceased had their ANC appointment at or before 10 weeks of gestation, 31% at 11–12 weeks, and 20% after 12 weeks (missing data 6%) [22]. In total, over 70% of women who died had their appointment by 12 weeks of gestation, compared with 20% with booking after 12 weeks. Considering the lack of evidence to determine the exact appropriate first antenatal visit, we decided to adhere to the concept of the long researched APNCU index, which categorized initiation at or before 4 months gestation in the adequate category [6]. In Malaysia, indicators for ANC content measure single procedure such as crude coverage of anti-tetanus toxoid (ATT) immunization, haemoglobin status at ±36 weeks gestation and number of medical referrals (either to medical officer, family medicine specialist or hospital). Such indicators have limitation in reflecting quality of ANC. For example, while coverage of ATT in this study has been excellent (96%), this indicator is not able to reflect the overall quality of care as evidenced by the large proportion of women (52%) who received <80% of recommended routine care content. The slightly lower mean content score among women in the ‘adequate’ utilization category compared with the ‘adequate-plus’ category was largely related to the scoring criteria of the ANC content (Supplementary Table S1). Majority of the items were adjusted for timing of initiation and birth, except for health education. Having higher utilization level (adequate-plus) implies higher number of visits than routinely recommended; this presents more opportunities for these women to receive additional health advice, than women with adequate level of utilization. Nevertheless, utilization level higher than recommended should not be encouraged especially among low-risk pregnancies. Studies have concluded that ANC for women without risk could be provided with fewer visits [21, 23]. Delivery of ANC should aim for completeness of care within the recommended schedule. Pregnancy outcomes depend on a complex network of interactions between care provided, the individuals concerned and the context in which they occur [24]. Therefore, the inclusion of only a few selected interventions may lead to a false linear relationship between the interventions and outcomes. To overcome these limitations, our study included the entire recommended routine care of the national guidelines. An advantage of the content adequacy assessment tool is that it enables modification, to include or omit other interventions according to the study context. It accounts for under-provision of care content but not over-provision. We, therefore, proposed to analyse selected interventions separately, in particular, those with high-cost implication, for example, the number of ultrasounds a woman received. The proportion of ‘adequate-plus’ category in our study was higher than that of a study in the USA, which recorded 30% classified as ‘adequate-plus’ and 45% adequate utilization [25]. The recommended ANC schedule of the USA is higher than that of the Malaysian schedule; therefore applying the US standard may result in a lower proportion of ‘adequate-plus’. However, national standards are country-specific, according to availability of technical, human and financial resources, and affordability. Therefore, adequacy of care is specific to national standards, of which each operates within a substantially different resource envelope. Our study found that over half of the women had <80% of the recommended routine ANC content documented in their antenatal records (52% vs 48%). A previous study agrees with this finding (70% vs 30%) [26]. The results from this present study appear to indicate better adherence to recommended routine content compared with the other study, in terms of proportion of women with ≥80% of ANC content (48% vs 30%). However, there are differences in assessment criteria. For example, the assessment criteria for maternal weight in the American study required that maternal weight be measured at every visit, whereas the assessment criteria for maternal weight in this present study considered the recommended number of visits. If the total visits are less than the recommended schedule, evidence of weight taken at each visit is accepted as having met the scoring criteria (Supplementary Table S1). Another study that used the APNCU index and its variants, found that the odds for preterm births were higher among those who had intensive (adequate-plus) and inadequate utilization than adequate utilization [25]. Although it did not reach statistical significance, women who had adequate-plus utilization appeared to be associated with higher prevalence of preterm births in our study. A significantly larger proportion of high-risk women were shown to have intensive utilization and poorer pregnancy outcomes [18]. This explained the association between intensive utilization and preterm birth since high-risk women, in general, were scheduled for frequent monitoring visits. ANC content adequacy was significantly associated with preterm birth but did not appear to influence LBW. This is consistent with a study which reported that low adherence to routine ANC content (<80% of recommended routine practice) was associated with increased odds of preterm birth (adjusted odds ratios (aOR) = 1.8, 95% confidence interval (CI) = 1.0–3.4), but had no effect on LBW (aOR = 1.0, 95% CI = 0.5–1.9) [26]. As discussed elsewhere, women who deliver preterm would have lesser opportunities to receive routine care which might have contributed to improved outcomes [17]. However, in this study, the scoring criteria for the ANC content considered the gestational age of birth where relevant, except for health education. Furthermore, the mean gestational age of preterm births was 34 weeks, wherein health education topics assessed in this study could have already been provided prior. The limitations associated with the study design have been discussed elsewhere [17, 18]. Though facility-based routine data have high relevance to improving quality and outcomes of care, we recognize the challenges associated with data extraction in a paper-based medical record system. Nevertheless, in the face of stagnating progress in pregnancy outcomes, we believe initiation of such assessment is crucial. The effect between ANC adequacy and pregnancy outcomes would have reached statistical significance if a larger sample size was enroled. The effects of independent variables on pregnancy outcomes were not explored since this paper specifically deals with quality of ANC and pregnancy outcomes. Our study shows inadequate ANC content is associated with higher prevalence of preterm birth and provides suggestive evidence that inadequate utilization of ANC increases the risk of preterm birth. The study demonstrates relevance of using both utilization and content assessment in evaluating quality of ANC. The findings demonstrated logical consistency as compared with other studies. In summary, the methods could be reviewed and may allow for comprehensive evaluation of technical performance, thereby, facilitating improving quality and informing policy formulation. The initiation and continuous refinement of the evaluation methods will bring about an impetus to address gaps in ANC. Supplementary material Supplementary material is available at International Journal for Quality in Health Care online. Acknowledgements The authors wish to acknowledge the contribution of Dr Ophelia Mendoza, Adjunct Prof of the Department of Epidemiology and Biostatistics, College of Public Health, University of the Philippines, for the advice on sampling and sample size estimate; Prof Dr Karuthan Chinna and Prof Dr Sanjay Rampal of Department of Social and Preventive Medicine, University of Malaya, for the advice on data analysis; and the Department of Health of Selangor, for allowing the study to be conducted. Authors’ contribution Conceived or designed the work: all. Acquired, analysed or interpreted data for the work: all. Drafted the work or revised it critically for important intellectual content: all. Approved the final version to be published: all. Agreed to be accountable for the work: all. Funding This work was supported by Mediconsult Sdn. Bhd. to PLY for a PhD study. 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Google Scholar CrossRef Search ADS PubMed  26 Handler A, Rankin K, Rosenberg D et al.  . Extent of documented adherence to recommended prenatal care content: provider site differences and effect on outcomes among low-income women. Matern Child Health J  2012; 16: 393– 405. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal for Quality in Health Care Oxford University Press

Evaluating the quality of antenatal care and pregnancy outcomes using content and utilization assessment

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
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10.1093/intqhc/mzy041
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Abstract

Abstract Objective To assess the adequacy of antenatal care (ANC) and its association with pregnancy outcomes using an approach that includes adequacy of both utilization and content. Design Retrospective cohort study. Setting and Participants Women attending ANC at public-funded primary health clinics where data were extracted from individual records. Methods Adequacy of utilization assessment was based on the concept of Adequacy of Prenatal Care Utilization index; adequacy of content assessed the recommended routine care received by the women according to local guidelines. Association between adequacy and pregnancy outcomes was examined using binary logistic regression. Main Outcome Measures Pregnancy outcomes included preterm birth and low birth weight. Results Sixty-three percent of women showed higher than recommended ANC utilization; 52% had <80% of recommended routine care content. Although not statistically significant, the odds of preterm birth was lower among women with adequate level of utilization compared with inadequate (adjusted odds ratios (aOR) = 2.34, 95% confidence interval (CI) 0.45–12.16) and intensive levels (aOR = 3.27, 95% CI 0.73–14.60). Regarding adequacy of content, women who received inadequate level of care content were associated with higher prevalence of preterm birth (aOR = 3.69, 95% CI 1.60–8.55). Conclusion The study shows inadequate content is associated with higher prevalence of preterm birth and suggests that inadequate utilization increases the risk of preterm birth. It demonstrates the relevance of using both utilization and content assessment in evaluating quality of ANC. Further studies are encouraged to review the methods used. antenatal care, utilization, content, quality of care, pregnancy outcomes Introduction Assessing quality of antenatal care (ANC) requires information on services utilization and indicators of content or quality of ANC [1–5]. However, the most commonly used adequacy of prenatal care utilization (APNCU) index assesses only adequacy of care initiation and adequacy of number of visits [6]. The index assesses neither content of care provided nor risk conditions of women [3, 6]. Delivery of ANC follows standards and guidelines based on bio-psycho-social needs of women [7, 8]. Definition of quality maternity care [8] and risk-oriented ANC recommended by WHO [7] imply: (i) the need for rational use of ANC according to needs and, (ii) provision of care to contribute to intended outcomes. These demand that all women be given a minimum set of care regardless of risk level and that additional care are to be given based on risk condition identified. The approach commands that evaluation of ANC needs to assess the recommended routine care received by the women and the risk condition of the women. Few studies have attempted to measure utilization and content of ANC using tools that integrated both aspects into one composite measure [4, 9]; however, these tools have limitations in this regard, in certain settings. For example, one of these tools was designed for places with low ANC attendances, for which health education was named as one ANC element without specifying the topics of health education that should be provided [9]. Therefore, application of this tool in high ANC attendance settings is challenging, while comprehensive analysis of quality of care is impossible. Also, for another tool which included three interventions (ultrasound, blood pressure and blood screening), the authors acknowledged the need to incorporate additional ANC interventions [4]; however, this is impossible owing to the tool’s design. Moreover, the tool only assessed adequacy of care initiation but not adequacy of ANC visits. Consequently, in settings with increasing number of ANC visits per pregnancy, rational use of care analysis is limited. As such, the index derived from such a tool may not be considered as more significant than others [4], since it still requires the utilization of other indices, such as the APNCU to compensate for its limitations. By analysing the complex ANC process over time, this study aimed to assess the adequacy of ANC and its association with pregnancy outcomes, using an approach that included both adequacy of utilization and adequacy of content. Background of study setting Malaysia has recorded remarkable achievement in maternal-child-health over the past decades [10]. Relevant tracers continue to be excellent [11] and the number of ANC visits have increased higher than recommended [12, 13]. Recent progress in pregnancy outcomes, however, has not improved accordingly; for over a decade, maternal mortality has stagnated [14], and the prevalence of low birth weight (LBW; compared with that of neighbouring countries) [15], and stillbirth [16] have increased. These highlight the limitations of present coverage indicators and the need to initiate assessing ANC beyond these indicators, since they are not linked to outcomes. Methods Study design and population This was a retrospective cohort study including data of women who had attended public-funded health clinics [17, 18]. The women and 6 out of 58 health clinics in Selangor state were selected by a multistage sampling. Patient records were anonymised and de-identified prior to analysis. The study was approved by the Research and Ethics Committee of University Malaya Malaysia, and the Medical Research and Ethics Committee of the Ministry of Health Malaysia. Definition of variables: evaluating quality of antenatal care Adequacy of utilization This was based on the concept of the APNCU index [6]. The index was modified in this present study by raising the cut-off points of the observed-to-expected visits ratio, to reflect the lower recommended visits of the local guidelines [18]. Figure 1 illustrates the modified visits ratio cut-off points: adequate-plus (≥130% of expected visits—intensive utilization with ≥30% higher visits than recommended), adequate (90–129%), intermediate (60–89%) and inadequate (<59%). During analysis, utilization adequacy was categorized into three categories: adequate-plus, adequate and inadequate (intermediate was grouped with inadequate). Regarding initiation of care, the modified index maintained the four categorical timing of the original APNCU index. Women who had the first visit after 17 weeks gestation were categorized as having received inadequate care (Fig. 1). Figure 1 View largeDownload slide Modified APNCU Index adjusted for Malaysian Recommended Schedule. Source: Adapted from APNCU index [6]. Figure 1 View largeDownload slide Modified APNCU Index adjusted for Malaysian Recommended Schedule. Source: Adapted from APNCU index [6]. Adequacy of content Adequacy of content assessed the level of recommended routine care received by the women according to the MOH guidelines [13]. The routine care consisted of four components—physical examination, health screening, case management and health education (Supplementary Table S1). Weighting factor, which was consulted and explained in another paper [17], was applied. Content adequacy was categorized as inadequate (<80%) or adequate (≥80%). Outcome measures The outcome measures used in this paper was pregnancy outcomes which included preterm birth (<37 gestational weeks at birth) and LBW (<2500 g at birth). Statistical analysis The association between adequacy of utilization or content and pregnancy outcomes was examined by binary logistic regression using a full model multivariate regression. The model was adjusted for maternal age, maternal education, risk status, clinic type and utilization adequacy or content adequacy. Results Respondents’ characteristics: users of ANC A total of 522 records were analysed; characteristics of the women are presented in Table 1. Table 1 Characteristics of the women (n = 522) Characteristics  n (%)  Maternal age at first visit   ≤19  11 (2.1%)   20–34  439 (84.1%)   ≥35  72 (13.8%)   Mean (SD)  28.7 (5.0)  Maternal education   Primary or no formal education  23 (4.4%)   Secondary  294 (56.3%)   Tertiary  193 (37.0%)   Unknown  12 (2.3%)  Parity   Nulliparous  195 (37.4%)   Multiparous  327 (62.6%)   Mean (SD)  1.2 (1.3)  Risk status   Low-risk  375 (71.8%)   High-risk  147 (28.2%)  Clinic type by planned daily workload   <150  98 (18.8%)   150–300  247 (47.3%)   301–500  177 (33.9%)  Pregnancy outcomes   Preterm birth  36 (6.9%)   LBW  66 (12.7%)  Characteristics  n (%)  Maternal age at first visit   ≤19  11 (2.1%)   20–34  439 (84.1%)   ≥35  72 (13.8%)   Mean (SD)  28.7 (5.0)  Maternal education   Primary or no formal education  23 (4.4%)   Secondary  294 (56.3%)   Tertiary  193 (37.0%)   Unknown  12 (2.3%)  Parity   Nulliparous  195 (37.4%)   Multiparous  327 (62.6%)   Mean (SD)  1.2 (1.3)  Risk status   Low-risk  375 (71.8%)   High-risk  147 (28.2%)  Clinic type by planned daily workload   <150  98 (18.8%)   150–300  247 (47.3%)   301–500  177 (33.9%)  Pregnancy outcomes   Preterm birth  36 (6.9%)   LBW  66 (12.7%)  Table 1 Characteristics of the women (n = 522) Characteristics  n (%)  Maternal age at first visit   ≤19  11 (2.1%)   20–34  439 (84.1%)   ≥35  72 (13.8%)   Mean (SD)  28.7 (5.0)  Maternal education   Primary or no formal education  23 (4.4%)   Secondary  294 (56.3%)   Tertiary  193 (37.0%)   Unknown  12 (2.3%)  Parity   Nulliparous  195 (37.4%)   Multiparous  327 (62.6%)   Mean (SD)  1.2 (1.3)  Risk status   Low-risk  375 (71.8%)   High-risk  147 (28.2%)  Clinic type by planned daily workload   <150  98 (18.8%)   150–300  247 (47.3%)   301–500  177 (33.9%)  Pregnancy outcomes   Preterm birth  36 (6.9%)   LBW  66 (12.7%)  Characteristics  n (%)  Maternal age at first visit   ≤19  11 (2.1%)   20–34  439 (84.1%)   ≥35  72 (13.8%)   Mean (SD)  28.7 (5.0)  Maternal education   Primary or no formal education  23 (4.4%)   Secondary  294 (56.3%)   Tertiary  193 (37.0%)   Unknown  12 (2.3%)  Parity   Nulliparous  195 (37.4%)   Multiparous  327 (62.6%)   Mean (SD)  1.2 (1.3)  Risk status   Low-risk  375 (71.8%)   High-risk  147 (28.2%)  Clinic type by planned daily workload   <150  98 (18.8%)   150–300  247 (47.3%)   301–500  177 (33.9%)  Pregnancy outcomes   Preterm birth  36 (6.9%)   LBW  66 (12.7%)  Preterm birth rate per 100 live births was ~7%, lower than official rate of 12% [11]. The lower rate was due to the role of first level health facilities in which the extreme high-risk conditions including those susceptible to preterm birth were often referred and managed at hospital level. The mean gestational age of preterm births was 34 weeks (min 29, max 36). LBW was <13%, almost similar to official rate of 11% [11]. Regarding timing of first visit, 50% of the preterm births had the first visit by 12 weeks, and 50% after 12 weeks. Forty-five percent of the LBW had the first visit by 12 weeks and 55% after. Adequacy of utilization and content Sixty-three percent had ‘adequate-plus’ utilization (Table 2), indicating a high proportion of women had higher number of ANC visits than the recommended schedule. Table 2 Distribution of women by adequacy of utilization and/or content (n = 522)   n (%)  Adequacy of utilization (APNCU-Malaysia index)   Inadequate  107 (20.5)   Adequate  85 (16.3)   Adequate-plus  330 (63.2)   Total  522 (100.0)  Adequacy of content   Inadequate (<80%)  270 (51.7)   Adequate (≥80%)  252 (48.3)   Total  522 (100.0)  Adequacy of utilization * adequacy of content   Inadequate utilization * inadequate content  62 (11.9)   Inadequate utilization * adequate content  45 (8.6)   Adequate utilization * inadequate content  208 (39.8)   Adequate utilization * adequate content  207 (39.7)   Total  522 (100.0)    n (%)  Adequacy of utilization (APNCU-Malaysia index)   Inadequate  107 (20.5)   Adequate  85 (16.3)   Adequate-plus  330 (63.2)   Total  522 (100.0)  Adequacy of content   Inadequate (<80%)  270 (51.7)   Adequate (≥80%)  252 (48.3)   Total  522 (100.0)  Adequacy of utilization * adequacy of content   Inadequate utilization * inadequate content  62 (11.9)   Inadequate utilization * adequate content  45 (8.6)   Adequate utilization * inadequate content  208 (39.8)   Adequate utilization * adequate content  207 (39.7)   Total  522 (100.0)  Table 2 Distribution of women by adequacy of utilization and/or content (n = 522)   n (%)  Adequacy of utilization (APNCU-Malaysia index)   Inadequate  107 (20.5)   Adequate  85 (16.3)   Adequate-plus  330 (63.2)   Total  522 (100.0)  Adequacy of content   Inadequate (<80%)  270 (51.7)   Adequate (≥80%)  252 (48.3)   Total  522 (100.0)  Adequacy of utilization * adequacy of content   Inadequate utilization * inadequate content  62 (11.9)   Inadequate utilization * adequate content  45 (8.6)   Adequate utilization * inadequate content  208 (39.8)   Adequate utilization * adequate content  207 (39.7)   Total  522 (100.0)    n (%)  Adequacy of utilization (APNCU-Malaysia index)   Inadequate  107 (20.5)   Adequate  85 (16.3)   Adequate-plus  330 (63.2)   Total  522 (100.0)  Adequacy of content   Inadequate (<80%)  270 (51.7)   Adequate (≥80%)  252 (48.3)   Total  522 (100.0)  Adequacy of utilization * adequacy of content   Inadequate utilization * inadequate content  62 (11.9)   Inadequate utilization * adequate content  45 (8.6)   Adequate utilization * inadequate content  208 (39.8)   Adequate utilization * adequate content  207 (39.7)   Total  522 (100.0)  Fifty-two percent of women had <80%, or inadequate level, of recommended routine ANC content (Table 2). There was a correlation between utilization level and mean content score (Table 3, P<0.001). The difference between women in ‘inadequate’ and ‘adequate’ utilization category was not statistically significant (P = 0.239). Table 3 Difference of mean for antenatal care content score in % by antenatal care utilization level (n = 522)    Mean antenatal care content score  P-value  ANC utilization level    <0.001   Inadequate  76.3     Adequate  74.6     Adequate-plus  78.1     Pairwise comparison        Inadequate and adequate-plus    0.048    Inadequate and adequate    0.239    Adequate and adequate-plus    <0.000     Mean antenatal care content score  P-value  ANC utilization level    <0.001   Inadequate  76.3     Adequate  74.6     Adequate-plus  78.1     Pairwise comparison        Inadequate and adequate-plus    0.048    Inadequate and adequate    0.239    Adequate and adequate-plus    <0.000  General linear model univariate full model analysis containing parity, risk level, clinic type, percentage of total visits attended by specific providers and antenatal care utilization adequacy. Table 3 Difference of mean for antenatal care content score in % by antenatal care utilization level (n = 522)    Mean antenatal care content score  P-value  ANC utilization level    <0.001   Inadequate  76.3     Adequate  74.6     Adequate-plus  78.1     Pairwise comparison        Inadequate and adequate-plus    0.048    Inadequate and adequate    0.239    Adequate and adequate-plus    <0.000     Mean antenatal care content score  P-value  ANC utilization level    <0.001   Inadequate  76.3     Adequate  74.6     Adequate-plus  78.1     Pairwise comparison        Inadequate and adequate-plus    0.048    Inadequate and adequate    0.239    Adequate and adequate-plus    <0.000  General linear model univariate full model analysis containing parity, risk level, clinic type, percentage of total visits attended by specific providers and antenatal care utilization adequacy. Association between adequacy of utilization or content and pregnancy outcomes Adequacy of utilization and pregnancy outcomes The odds for preterm birth in the adequate-plus category was 3.27 times that of adequate category and the odds for preterm birth in the inadequate category was 2.34 times that of the adequate category (Table 4). Although it did not reach statistical significance, the finding suggested that women with adequate utilization were associated with lower odds of preterm birth compared with those with inadequate and intensive utilization. Having intensive utilization appeared to be associated with higher prevalence of preterm birth. Table 4 Adequacy of antenatal care and pregnancy outcomes models ANC adequacy  Adjusted OR* (95% CI)  Preterm birth (n = 36)  LBW (n = 66)  ANC utilization   Inadequate  2.34 (0.45–12.16)  0.73 (0.26–2.06)   Adequate  1.00  1.00   Adequate-plus  3.27 (0.73–14.60)  1.36 (0.60–3.09)  ANC content   Inadequate  3.69 (1.60–8.55)  1.17 (0.68–2.01)   Adequate  1.00  1.00  ANC adequacy  Adjusted OR* (95% CI)  Preterm birth (n = 36)  LBW (n = 66)  ANC utilization   Inadequate  2.34 (0.45–12.16)  0.73 (0.26–2.06)   Adequate  1.00  1.00   Adequate-plus  3.27 (0.73–14.60)  1.36 (0.60–3.09)  ANC content   Inadequate  3.69 (1.60–8.55)  1.17 (0.68–2.01)   Adequate  1.00  1.00  *Full model binary logistic regression, odds ratios (ORs) for antenatal care adequacy (utilization and content) were adjusted for maternal age, maternal education, risk status, clinic type and utilization or content. Table 4 Adequacy of antenatal care and pregnancy outcomes models ANC adequacy  Adjusted OR* (95% CI)  Preterm birth (n = 36)  LBW (n = 66)  ANC utilization   Inadequate  2.34 (0.45–12.16)  0.73 (0.26–2.06)   Adequate  1.00  1.00   Adequate-plus  3.27 (0.73–14.60)  1.36 (0.60–3.09)  ANC content   Inadequate  3.69 (1.60–8.55)  1.17 (0.68–2.01)   Adequate  1.00  1.00  ANC adequacy  Adjusted OR* (95% CI)  Preterm birth (n = 36)  LBW (n = 66)  ANC utilization   Inadequate  2.34 (0.45–12.16)  0.73 (0.26–2.06)   Adequate  1.00  1.00   Adequate-plus  3.27 (0.73–14.60)  1.36 (0.60–3.09)  ANC content   Inadequate  3.69 (1.60–8.55)  1.17 (0.68–2.01)   Adequate  1.00  1.00  *Full model binary logistic regression, odds ratios (ORs) for antenatal care adequacy (utilization and content) were adjusted for maternal age, maternal education, risk status, clinic type and utilization or content. Adequacy of content and pregnancy outcomes Based on the observed significance level, ANC content was associated with preterm birth statistically. The odds of preterm birth in inadequate category were over three times that of adequate category (Table 4). ANC content did not appear to influence LBW. Discussion We analysed adequacy of utilization and adequacy of content separately, to evaluate ANC. This approach was more useful compared with a composite measure that combined both utilization and content as one variable. The composite measure cannot ascertain if the adverse pregnancy outcomes were associated with utilization or content inadequacy, and thus, would be less specific in diagnosing gaps in care delivery. Instead, we used binary logistic regression which included either utilization adequacy or content adequacy as predictors (independent variables) of adequacy and pregnancy outcomes. We also recognized the importance of including risk status of women as an independent variable, which facilitated analysis on rational use of care according to need. In many developing settings, indicators related to ANC utilization often include timing of first visit and average number of total visits, which are analysed separately. The nature of these single indicators, though commonly used, indicates only what it is defined; they are not designed to provide comprehensive measurement on quality of care. The indicator, timing of first visit, measures only what is intended and does not provide information after the first visit. Likewise, ‘average number of total ANC visits’ provides little benefit in assessing adequacy of utilization when the initiation period is not known. For example, a multiparous could be seen seven times throughout her 40-week pregnancy, which is considered adequate according to the recommended number of ANC visits for uncomplicated multipara [13]. However, if it was not known that the woman had her first ANC visit at 20 weeks gestation, it would be inappropriate to classify the woman as having adequate utilization because she fulfilled the recommended number of ANC visits. The scenario highlights the limitation in using these two indicators separately and reiterates the importance of using indicators like the APNCU index to assess ANC utilization. The finding demonstrated the absence of significant differences in terms of pregnancy outcomes between the women who had the first ANC visit by 12 weeks and after 12 weeks. Monitoring gestational age of first visit aimed to promote early initiation of care. In the case of Malaysia, the recommended initiation period is by 12 weeks of gestation [13]. It has been recognized that women who had late initiation might not have the opportunity to benefit from screening tests, antenatal health advice or supported decision making regarding choice of delivery [19, 20]. There is, however, limited evidence to establish the right period for initiation of first visit [21, 22]. For example, the Confidential Enquiry into Maternal Deaths in the UK reveals that 43% of the deceased had their ANC appointment at or before 10 weeks of gestation, 31% at 11–12 weeks, and 20% after 12 weeks (missing data 6%) [22]. In total, over 70% of women who died had their appointment by 12 weeks of gestation, compared with 20% with booking after 12 weeks. Considering the lack of evidence to determine the exact appropriate first antenatal visit, we decided to adhere to the concept of the long researched APNCU index, which categorized initiation at or before 4 months gestation in the adequate category [6]. In Malaysia, indicators for ANC content measure single procedure such as crude coverage of anti-tetanus toxoid (ATT) immunization, haemoglobin status at ±36 weeks gestation and number of medical referrals (either to medical officer, family medicine specialist or hospital). Such indicators have limitation in reflecting quality of ANC. For example, while coverage of ATT in this study has been excellent (96%), this indicator is not able to reflect the overall quality of care as evidenced by the large proportion of women (52%) who received <80% of recommended routine care content. The slightly lower mean content score among women in the ‘adequate’ utilization category compared with the ‘adequate-plus’ category was largely related to the scoring criteria of the ANC content (Supplementary Table S1). Majority of the items were adjusted for timing of initiation and birth, except for health education. Having higher utilization level (adequate-plus) implies higher number of visits than routinely recommended; this presents more opportunities for these women to receive additional health advice, than women with adequate level of utilization. Nevertheless, utilization level higher than recommended should not be encouraged especially among low-risk pregnancies. Studies have concluded that ANC for women without risk could be provided with fewer visits [21, 23]. Delivery of ANC should aim for completeness of care within the recommended schedule. Pregnancy outcomes depend on a complex network of interactions between care provided, the individuals concerned and the context in which they occur [24]. Therefore, the inclusion of only a few selected interventions may lead to a false linear relationship between the interventions and outcomes. To overcome these limitations, our study included the entire recommended routine care of the national guidelines. An advantage of the content adequacy assessment tool is that it enables modification, to include or omit other interventions according to the study context. It accounts for under-provision of care content but not over-provision. We, therefore, proposed to analyse selected interventions separately, in particular, those with high-cost implication, for example, the number of ultrasounds a woman received. The proportion of ‘adequate-plus’ category in our study was higher than that of a study in the USA, which recorded 30% classified as ‘adequate-plus’ and 45% adequate utilization [25]. The recommended ANC schedule of the USA is higher than that of the Malaysian schedule; therefore applying the US standard may result in a lower proportion of ‘adequate-plus’. However, national standards are country-specific, according to availability of technical, human and financial resources, and affordability. Therefore, adequacy of care is specific to national standards, of which each operates within a substantially different resource envelope. Our study found that over half of the women had <80% of the recommended routine ANC content documented in their antenatal records (52% vs 48%). A previous study agrees with this finding (70% vs 30%) [26]. The results from this present study appear to indicate better adherence to recommended routine content compared with the other study, in terms of proportion of women with ≥80% of ANC content (48% vs 30%). However, there are differences in assessment criteria. For example, the assessment criteria for maternal weight in the American study required that maternal weight be measured at every visit, whereas the assessment criteria for maternal weight in this present study considered the recommended number of visits. If the total visits are less than the recommended schedule, evidence of weight taken at each visit is accepted as having met the scoring criteria (Supplementary Table S1). Another study that used the APNCU index and its variants, found that the odds for preterm births were higher among those who had intensive (adequate-plus) and inadequate utilization than adequate utilization [25]. Although it did not reach statistical significance, women who had adequate-plus utilization appeared to be associated with higher prevalence of preterm births in our study. A significantly larger proportion of high-risk women were shown to have intensive utilization and poorer pregnancy outcomes [18]. This explained the association between intensive utilization and preterm birth since high-risk women, in general, were scheduled for frequent monitoring visits. ANC content adequacy was significantly associated with preterm birth but did not appear to influence LBW. This is consistent with a study which reported that low adherence to routine ANC content (<80% of recommended routine practice) was associated with increased odds of preterm birth (adjusted odds ratios (aOR) = 1.8, 95% confidence interval (CI) = 1.0–3.4), but had no effect on LBW (aOR = 1.0, 95% CI = 0.5–1.9) [26]. As discussed elsewhere, women who deliver preterm would have lesser opportunities to receive routine care which might have contributed to improved outcomes [17]. However, in this study, the scoring criteria for the ANC content considered the gestational age of birth where relevant, except for health education. Furthermore, the mean gestational age of preterm births was 34 weeks, wherein health education topics assessed in this study could have already been provided prior. The limitations associated with the study design have been discussed elsewhere [17, 18]. Though facility-based routine data have high relevance to improving quality and outcomes of care, we recognize the challenges associated with data extraction in a paper-based medical record system. Nevertheless, in the face of stagnating progress in pregnancy outcomes, we believe initiation of such assessment is crucial. The effect between ANC adequacy and pregnancy outcomes would have reached statistical significance if a larger sample size was enroled. The effects of independent variables on pregnancy outcomes were not explored since this paper specifically deals with quality of ANC and pregnancy outcomes. Our study shows inadequate ANC content is associated with higher prevalence of preterm birth and provides suggestive evidence that inadequate utilization of ANC increases the risk of preterm birth. The study demonstrates relevance of using both utilization and content assessment in evaluating quality of ANC. The findings demonstrated logical consistency as compared with other studies. In summary, the methods could be reviewed and may allow for comprehensive evaluation of technical performance, thereby, facilitating improving quality and informing policy formulation. The initiation and continuous refinement of the evaluation methods will bring about an impetus to address gaps in ANC. Supplementary material Supplementary material is available at International Journal for Quality in Health Care online. Acknowledgements The authors wish to acknowledge the contribution of Dr Ophelia Mendoza, Adjunct Prof of the Department of Epidemiology and Biostatistics, College of Public Health, University of the Philippines, for the advice on sampling and sample size estimate; Prof Dr Karuthan Chinna and Prof Dr Sanjay Rampal of Department of Social and Preventive Medicine, University of Malaya, for the advice on data analysis; and the Department of Health of Selangor, for allowing the study to be conducted. Authors’ contribution Conceived or designed the work: all. Acquired, analysed or interpreted data for the work: all. Drafted the work or revised it critically for important intellectual content: all. Approved the final version to be published: all. Agreed to be accountable for the work: all. Funding This work was supported by Mediconsult Sdn. Bhd. to PLY for a PhD study. The funder had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. References 1 Alexander GR, Kotelchuck M. Quantifying the adequacy of prenatal care: a comparison of indices. Public Health Rep  1996; 111: 408– 18. discussion 419. Google Scholar PubMed  2 Alexander GR, Kotelchuck M. Assessing the role and effectiveness of prenatal care: history, challenges, and directions for future research. Public Health Rep  2001; 116: 306– 16. Google Scholar CrossRef Search ADS PubMed  3 Bloch JR, Dawley K, Suplee PD. Application of the Kessner and Kotelchuck prenatal care adequacy indices in a preterm birth population. Public Health Nurs  2009; 26: 449– 59. Google Scholar CrossRef Search ADS PubMed  4 Beeckman K, Fred Louckx F, Masuy-Stroobant G et al.  . The development and application of a new tool to assess the adequacy of the content and timing of antenatal care. BMC Health Serv Res  2011; 11: 213. 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Saving Lives, Improving Mothers’ Care—Surveillance of Maternal Deaths in the UK 2011–13 and Lessons Learned to Inform Maternity Care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–13 . Oxford: National Perinatal Epidemiology Unit, University of Oxford, 2015. 23 Carroli G, Villar J, Piaggio G et al.  . WHO systematic review of randomised controlled trials of routine antenatal care. Lancet  2001; 357: 1565– 70. Google Scholar CrossRef Search ADS PubMed  24 Enkin MW, Glouberman S, Groff P et al.  . Beyond evidence: the complexity of maternity care. Birth  2006; 33: 265– 9. Google Scholar CrossRef Search ADS PubMed  25 VanderWeele T, Lantos J, Siddique J et al.  . A comparison of four prenatal care indices in birth outcome models: comparable results for predicting small-for-gestational-age outcome but different results for preterm birth or infant mortality. J Clin Epidemiol  2009; 62: 438– 45. Google Scholar CrossRef Search ADS PubMed  26 Handler A, Rankin K, Rosenberg D et al.  . Extent of documented adherence to recommended prenatal care content: provider site differences and effect on outcomes among low-income women. Matern Child Health J  2012; 16: 393– 405. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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International Journal for Quality in Health CareOxford University Press

Published: Mar 24, 2018

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