Antenatal care use at age less than 20 years

 

Definition:

 

The percent of pregnant young women aged less than 20 years with a live birth within a given time period who attended antenatal care (ANC) with a skilled attendant at least once for reasons related to the most recent pregnancy.

WHO guidelines on the content of ANC visits include the following components: clinical examination, blood testing to detect syphilis and severe anemia (and HIV, malaria, etc. according to the epidemiological context), gestational age estimation, uterine height, blood pressure, maternal weight and height, test for sexually transmitted infections (STIs), urine test, request blood type and Rh, tetanus toxoid, iron/folic acid supplementation, and recommendations for emergencies (WHO, 2002). For more detail on this and related indicators, see WHO (2010); WHO (2006).

A skilled attendant is defined as an accredited health professional who has 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.  This includes midwives, doctors and nurses but excludes traditional birth attendants (WHO, 2006).

A live birth is the birth of a fetus after 22 weeks' gestation or weighing 500g or more that shows signs of life - breathing, cord pulsation or with audible heartbeat.  This cut-off point refers to when the perinatal period begins (WHO, 2006).

This indicator is calculated as:

(Number of women aged 20 years and under with a live birth who attended ANC at least once during most recent pregnancy / Total number of women with live births within the reference period) x 100

Data Requirements:

 

This indicator can be calculated from the survey questions in Demographic Health Survey (DHS), the Reproductive Health Survey (RHS), UNICEF Multiple Indicator Cluster Survey (MICS), and other national surveys that ask about the number of ANC visits women had with their most recent births. Specialized survey data and health facility records can also be used for more localized studies. Data must be disaggregated by age to determine the percentage of adolescents being served and can also be disaggregated by the type of facility (public, private, non-governmental, community-based), by district and urban rural location, and by women’s education, wealth quintile, and parity. 

WHO and UNICEF compile empirical data from household surveys and produce regional and global estimates based on population-weighted averages weighted by the total number of births. These estimates are used only if available data cover at least 50 percent of total births in the regional or global groupings (WHO, 2010).

Data Sources:

 

Population-based surveys, such as DHS, RHS, and MICS; facility records and health services data

Purpose:

 

The main purpose of an ANC indicator is to provide information on young women’s use of ANC services. It is important to give special attention to adolescents (those 10-19 years old) seeking obstetric care because they are at high risk of complications and death. Pregnancy in adolescence contributes to the cycle of maternal deaths and indicates limited access to reproductive health services.

The association between one antenatal visit (with care provision of unknown quality) and maternal mortality is weak (Bergsjø, 2001). This indicator measures a service delivery contact or opportunity which, in itself, does not save lives. Impact is achieved when these contacts are used to deliver high quality effective interventions.  Thus, the finding that women who attend ANC are more likely to use skilled health personnel for care during birth and that ANC may facilitate better use of emergency obstetric services supports the use of this indicator in combination with the indicator percent of deliveries attended by skilled personnel. Therefore, women's use of ANC is more strongly associated with improved perinatal survival (McDonagh, 1996) and measures of ANC coverage may have a greater role in the monitoring and evaluation of programs addressing newborn health and survival (WHO, 2006).

Although epidemiological studies show an association between improved maternal health outcome and ANC, most fail to control for selection biases that would positively influence the outcome (Villar, 2000).

Issue(s):

 

ANC coverage provides a crude measure of ANC utilization (Rooney, 1992), but it does not capture the number and timing of visits, the reasons for seeking care, the skills of the provider, or the quality of care received. Therefore, evaluators should not infer that similar rates of ANC coverage mean similar levels of care.

Receiving ANC care during pregnancy does not guarantee that adolescent women received all of the recommended and necessary interventions. In fact, it is unlikely. However, at least four ANC visits – the WHO recommended minimum - increases the likelihood of receiving the full range of interventions (WHO, 2010).

For data compiled at the health facility level, discrepancies are possible in recording and reporting numbers of visits and these data would differ from global figures based on survey data collected at the household level. In addition, data on women’s use of ANC from routine health records may lack information on pregnancies occurring outside the public health sector, including home and private facility deliveries. 

Collecting this data through vital registration sometimes means the data may not be collected in a format appropriate for constructing this indicator.  Frequently the data are episode- rather than woman-based (i.e. the number of consultations performed by the provider is recorded but not the number of times a specific woman is seen). Since women may be seen several times, and may also present at different facilities, this creates the potential for double counting and therefore overestimating ANC coverage. Health service data may also be poor quality and records may be incomplete or missing.

Gender Implications:

 

Adolescent girls tend to recognize their pregnancies later in gestation, often due to lack of knowledge of fertile periods and/or irregular menstrual cycles. In many places it is culturally taboo for a young girl to get pregnant out of wedlock, and even if she suspects her own pregnancy, she may not seek ANC services for fear of discrimination or being found out.

Because some countries deem it culturally inappropriate for women to discuss issues related to their bodies with men, women may not be able to communicate pregnancy related problems to male providers. In addition, where young women lack access to household resources or where they lack the autonomy to seek health care on their own, family members may not be willing to invest resources in ANC, particularly if a given pregnancy is progressing "normally."

References:

 

Bergsjø, P. (2001). What is the evidence for the role of antenatal care strategies in the reduction of maternal mortality and morbidity? In Vincent De Brouwere, Wim Van Lerberghe (Eds.), Safe Motherhood Strategies: A review of the evidence. Studies in Health Services Organisation and Policy no 17. Antwerp: ITG Press.

McDonagh, M. 1996. Is antenatal care effective in reducing maternal morbidity and mortality? Health Policy Plan. 11(1): 1-15.

UNFPA, 2010. How Universal is Access to Reproductive Health? A review of the evidence. http://www.unfpa.org/public/home/publications/pid/6526

Villar J, Carroli G, Khan-Neelofur D, Piaggio G, Gülmezoglu M. Patterns of routine antenatal care for low-risk pregnancy. Cochrane Database of Systematic Reviews 2001, Issue 4. Art. No.: CD000934.

WHO, 2011. Global Health Observatory (GHO), Antenatal care Situation and trends, Geneva: WHO. http://www.who.int/gho/maternal_health/reproductive_health/antenatal_care_text/en/index.html

WHO, 2010. Indicator Code Book: World Health Statistics - World Health Statistics indicators, Geneva: WHO http://www.who.int/gho/publications/world_health_statistics/WHS2010_IndicatorCompendium.pdf?ua=1 

WHO, 2006. Reproductive Health Indicators: Guidelines for their generation, interpretation and analysis for global monitoring, Geneva: WHO http://apps.who.int/iris/bitstream/10665/43185/1/924156315X_eng.pdf

WHO, 2002. Antenatal Care Randomized Trial: Manual for the Implementation of the New Model, Geneva: WHO. http://apps.who.int/iris/bitstream/10665/42513/1/WHO_RHR_01.30.pdf