Antenatal care processes in rural Southern Nepal: gaps in and quality of service provision—a cohort study

OBJECTIVES: This study aimed to compare a standard quality of care definition to one that reflected focused antenatal care (FANC) guidelines and examine associations with receipt of good quality of care. DESIGN: This study was a longitudinal cohort study. SETTINGS: Five government health posts in the Sarlahi district of Southern Nepal PARTICIPANTS: Pregnant women between the ages of 15 and 49 who presented for their first antenatal care (ANC) visit at the study health posts. MAIN OUTCOMES: There were two quality of care definitions: (1) provision of seven services at least once during pregnancy (QOC1) and (2) provision of services to reflect the FANC guidelines by incorporating a frequency of care dimension for certain services (QOC4+). RESULTS: There was variation in service provision both in terms of frequency of provision and by gestational age at the visit. There were 213 women (49.1%) that received good quality care by the first definition, but when the frequency of service provision was included for the second definition the percentage dropped to 6.2%. There were significant differences in provision of quality care by health post for both definitions. The number of visits (QOC1 adjusted risk ratio (aRR) 1.18, 95% CI 1.13 to 1.23; QOC4+ aRR 1.46, 95% CI 1.11 to 2.80) and care during the first trimester (QOC1 aRR 1.22, 95% CI 1.01 to 1.49) and maternal age (QOC1 aRR 1.27, 95% CI 1.03 to 1.58) were associated with greater likelihood of good quality ANC. CONCLUSION: This analysis demonstrated that measuring quality of care by receipt of services at least once during pregnancy may overestimate the true coverage of quality of ANC. Future efforts should improve feasibility of including frequency of care in quality of care definitions.