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GOAL AND TARGET ADDRESSED

Goal 5. Improve maternal health
Target 5.B: Achieve, by 2015, universal access to reproductive health

DEFINITION AND METHOD OF COMPUTATION

Definition
Antenatal care coverage (at least one visit) is the percentage of women aged 15–49 with a live birth in a given time period that received antenatal care provided by skilled health personnel at least once during their pregnancy.

Antenatal care coverage (at least four visits) is the percentage of women aged 15–49 with a live birth in a given time period that received antenatal care by any provider four or more times during their pregnancy.

Concepts
A live birth is the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy, which, after such separation, breathes or shows any other evidence of life—such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles—whether or not the umbilical cord has been cut or the placenta is attached.

Antenatal care constitutes screening for health and socioeconomic conditions likely to increase the possibility of specific adverse pregnancy outcomes; providing therapeutic interventions known to be effective; and educating pregnant women about planning for safe birth and emergencies during pregnancy and how to deal with them.

Skilled health personnel are accredited health professionals—such as a midwifes, doctors or nurses—who have been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies; childbirth and the immediate postnatal period; and in the identification, management and referral of complications in women and newborns. Both trained and untrained traditional birth attendants are excluded.

Traditional birth attendants are traditional, independent (of the health system), non-formally trained and community-based providers of care during pregnancy, childbirth and the postnatal period.

Method of computation
The percentage of women aged 15–49 with a live birth in a given time period that received antenatal care provided by skilled health personnel at least once during their pregnancy (ANC 1+) is calculated by dividing the number of women attended at least once during pregnancy by skilled health personnel for reasons related to the pregnancy by the total number of women with a live birth and multiplying by 100.

The percentage of women aged 15–49 with a live birth in a given time period that received antenatal care four or more times during pregnancy (ANC 4+) is calculated by dividing the number of women attended at least four times during pregnancy by any care provider for reasons related to the pregnancy by the total number of women with a live birth and multiplying by 100.

Unlike ANC 1+, ANC 4+ includes care given by any provider, not just skilled health personnel. This is because key national level household surveys do not collect information on type of provider for each visit.

RATIONALE AND INTERPRETATION

The antenatal period presents opportunities for reaching pregnant women with interventions that may be vital to their health and wellbeing and to that of their infants. The World Health Organization (WHO) recommends a standard model of four antenatal visits based on a review of the effectiveness of different models of antenatal care. WHO guidelines are specific on the content of antenatal care visits, which should include:
  • a clinical examination;
  • blood testing to detect syphilis and severe anaemia (and others such as Human Immunodeficiency Virus and malaria as necessary according to epidemiological context);
  • estimations of gestational age and uterine height;
  • taking blood pressure;
  • recording maternal weight/height;
  • performing a detection of symptomatic Sexually Transmitted Infections Urine test (multiple dipstick);
  • requesting blood type and Rh;
  • giving tetanus toxoid;
  • providing iron/folic acid supplementation; and
  • providing recommendations for emergencies/hotlines for emergencies.

It is important to note that the indicators of antenatal care (at least one visit and at least four visits) do not capture these components of care. These indicators are based on a standard question that simply asks if the health of the woman was checked during pregnancy. Thus, it should not be assumed that women received all of the components listed above. The indicator values range from 0 to 100, with 100 being the ideal situation in which all pregnant women between 15 and 49 years have seen a doctor at least once—or four times—during their pregnancy. For ANC 1+, indicator values generally fall between 50 and 100 per cent. For ANC 4+, values tend to be lower, often substantially. Antenatal care coverage figures should be closely followed together with a set of other related indicators, such as proportion of deliveries attended by a skilled health worker or deliveries occurring in health facilities, and disaggregated by background characteristics, to identify target populations and plan policy actions accordingly.

SOURCES AND DATA COLLECTION

Household surveys should be used as the main data sources for the antenatal care indicator. Possible surveys include Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS), Fertility and Family Surveys (FFS), Reproductive Health Surveys (RHS) and other surveys based on similar methodologies. Surveys are normally conducted at 3 to 5 year intervals.

In order to facilitate interpretation of trends and differentials based on survey data, it is useful to report confidence intervals together with estimates.

DISAGGREGATION

The disaggregation of this indicator by geographical area and population groups provides an indication of the wide differences in access to reproductive health care in different areas and by different socio-economic groups. Further analyses are needed to understand the reasons of such differences in order to plan actions to overcome them.

COMMENTS AND LIMITATIONS

Receiving antenatal care during pregnancy does not guarantee the receipt of interventions that are effective in improving maternal health. Receiving antenatal care at least four times, which is recommended by WHO, increases the likelihood of receiving effective maternal health interventions during antenatal visits. Importantly, although the indicator for at least one visit refers to visits with skilled health providers, four or more visits usually measures visits with any provider because national-level household surveys do not collect provider data for each visit. In addition, standardization of the definition of skilled health personnel is sometimes difficult because of differences in training of health personnel in different countries.

Recall error is a potential source of bias in the data. In household surveys, the respondent is asked about each live birth for a period up to five years before the interview. The respondent may or may not know or remember the qualifications of the person providing antenatal care.

GENDER EQUALITY ISSUES

The low social status of women in some countries limits their access to economic resources and basic education and thus their ability to make decisions related to health and nutrition. Some women are denied access to care when it is needed either because of cultural practices of seclusion or because decision-making is the responsibility of other family members.

DATA FOR GLOBAL AND REGIONAL MONITORING

Data for this indicator at the global level are produced by the United Nations Children’s Fund (UNICEF), for ANC +1 and ANC +4, and WHO, for ANC +4. are The main data sources for global antenatal care indicators are national-level household surveys including: DHS, MICS, FFS, RHS and national surveys based on similar methodologies. For industrialized countries (where the coverage is high), data sources include routine service statistics.

Before data are included in the global databases, UNICEF and WHO undertake a process of data verification that includes correspondence with field offices to clarify any questions regarding estimates.

Discrepancies between global and national level data are possible if national figures are compiled at the health facility level. These figures would differ from global figures which are based on survey data collected at the household level.

Some survey reports may present a total percentage of pregnant women with antenatal care from a skilled health professional that does not conform to the definition provided above (for example, includes a provider that is not considered skilled such as a community health worker). In that case, the percentages with antenatal care from a doctor, a nurse or a midwife are totalled and entered into the global database.

UNICEF and WHO also produce regional and global estimates. These are based on population-weighted averages weighted by the total number of births. These estimates are presented only if available data cover at least 50 per cent of total births in the regional or global groupings.

SUPPLEMENTARY INFORMATION



EXAMPLES



REFERENCES

United Nations Children’s Fund. Childinfo – Monitoring the Situation of Children and Women. New York. Internet site http://www.childinfo.org/.

World Health Organization. Sexual and Reproductive Health. Geneva. Internet site http://www.who.int/reproductive-health/global_monitoring/index.html.

World Health Organization (2002). Antenatal Care Randomized Trial: Manual for the Implementation of the New Model. Geneva. Available from http://whqlibdoc.who.int/hq/2001/WHO_RHR_01.30.pdf.

World Health Organization (2003). Antenatal Care in Developing Countries: Promises, Achievements and Missed Opportunities: An Analysis of Trends, Levels and Differentials, 1990-2001. Geneva. Available from http://whqlibdoc.who.int/publications/2003/9241590947.pdf.

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