Percent women attended at least four times for antenatal care during pregnancy

 

The percent of women ages 15 to 49 with a live birth within a given time period who attended antenatal care (ANC) four or more times during their most recent pregnancy. Whether at a facility or community-based, optimally the ANC should be provided by skilled personnel including doctors, midwives, or nurses with midwifery skills. The number of live births is used as proxy for the numbers of women who need ANC care.

Based on a review of the effectiveness of different ANC models, WHO has recommended a standard model of four antenatal visits (WHO 2002). 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 (STI)s, 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).

This indicator is calculated as:

(Number of women ages 15 to 49 with live births who attended ANC four or more times during most recent pregnancy / Total number of women with live births within the reference period) x 100


 

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 can 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, age, 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).

If targeting and/or linking to inequity, classify facilities by location (poor/not poor) and disaggregate ANC visits by location.


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


 

This indicator provides information on women’s use of ANC services at the recommended level and can be used to track trends in utilization. Many health problems experienced by pregnant women can be prevented, detected and treated during ANC visits with trained health workers. Based on global data from 2000 to 2010, about 53 percent of pregnant women attended the recommended minimum of four ANC visits compared with only 39 percent of pregnant women in low-income countries.  Trend data on the percentage of women attending at least four ANC visits are not available for all countries, but available data show that there has been little improvement in this indicator in the past decade (WHO, 2011). The importance of ANC and the need for women’s increased access to and use of these services cannot be understated. Studies have found that women who attend ANC are more likely to use skilled health personnel during delivery, ANC may facilitate better use of emergency obstetric services, and ANC is also associated with improved perinatal survival (WHO, 2006). Overall, women’s use of ANC is central to achieving the Millennium Development Goals #5. improve maternal health and #4. reduce child mortality.

ANC utilization and coverage figures should be followed together with 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 facilitate health system planning.


 

Receiving ANC care during pregnancy does not guarantee that women received all of the recommended and necessary interventions. However, at least four ANC visits increases the likelihood of receiving the full range of interventions (WHO, 2010). Although the indicator for “at least one ANC visit” refers to visits with skilled health providers (doctor, nurse, midwife), “four or more ANC visits” usually measures visits with any provider because national-level household surveys do not collect provider data for each visit.

With population-based surveys, recall error is a potential source of bias given that the surveys ask the respondent about each live birth for a period up to five years before the interview. The respondent may or may not know or remember the number of visits, particularly as this number increases.  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. 


access, newborn (NB), safe motherhood (SM)

 

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

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://whqlibdoc.who.int/publications/2006/924156315X_eng.pdf  

WHO, 2002, Antenatal Care Randomized Trial: Manual for the Implementation of the New Model, Geneva: WHO. http://whqlibdoc.who.int/hq/2001/WHO_RHR_01.30.pdf

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