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Appropriate antenatal care is a key ele-ment of programs to improve the health ofmothers and newborns. Recently thePopulation Council and partners studiedantenatal care in Ghana, Kenya, andSouth Africa. These investigations showedthat a focused approach, emphasizingquality of care over quantity, is acceptable,but can be difficult to implement becauseof scarce resources and staff turnover.

Approaches to antenatal careOn the whole, antenatal care programs in developingcountries have been modeled on those in developedcountries. These programs, however, have been poorlyimplemented and largely ineffective. In response, theWorld Health Organization (WHO) designed and testeda focused antenatal care package that includes only coun-seling, examinations, and tests that serve an immediatepurpose and have a proven health benefit. For example,many antenatal care programs screen for suspected riskfactors for pregnancy complications. However, thisapproach has been challenged, and WHO’s focusedapproach does not use it. The WHO recommends reduc-ing the number of antenatal care visits to four, and thishas not been found to pose a risk to the health of moth-er or baby.

South AfricaThe Maternal, Child and Women’s Health Unit of theKwaZulu-Natal Department of Health wanted toimprove the quality of antenatal care provided in its clin-ics. To this end, it collaborated with the PopulationCouncil’s USAID-funded Frontiers in ReproductiveHealth program, the Reproductive Health Research Unit

of the University of Witwatersrand, and the Departmentof Medical Microbiology and Infectious Diseases of theNelson Mandela School of Medicine at the University ofNatal. These groups developed and pilot-tested a versionof the WHO-recommended package of care, involvingfive (rather than four) antenatal care visits and two post-natal care visits. The focused package also includedcounseling on the prevention of sexually transmittedinfections, onsite syphilis screening with same-dayresults, and HIV prevention information and referral.

The teams used a pre- and post-test comparisongroup design, comparing the current standard of care insix clinics with focused care in another six clinics. Theyfound that the introduction of the programs was feasible.However, patient care did not improve as much ashoped. Not as many women as planned received coun-seling on nutrition in pregnancy, breastfeeding, and post-partum family planning. Nor were women adequatelyeducated about pregnancy danger signs. Such disappoint-ing results might be attributable to high staff turnover.By the time of the endline survey, only two of the sixintervention clinics had at least one staff member whohad covered all the training modules. Thus, interventionssuch as this, which rely heavily on teaching staff newways of organizing and providing services, must developstrategies that allow for relatively rapid rates of staffturnover.

Frontiers has been working with the Department ofHealth in KwaZulu-Natal province to develop a compre-hensive package of policies, tools, and job aides tostrengthen antenatal care services; the nationalDepartment of Health is also interested in adapting theseproducts.

Ghana and KenyaIn Ghana, Frontiers collaborated with the NoguchiMemorial Institute for Medical Research and the GhanaHealth Service to examine the extent to which adapta-

FOCUSED ANTENATAL CAREACCEPTABLE, TRICKY TO IMPLEMENT

tion of the package influenced the quality of carereceived by pregnant women and its acceptability toboth providers and clients. The study took place at tenintervention clinics and four comparison clinics.

The researchers found that the new model is wellaccepted by clients and providers because of its com-prehensiveness and individualized care. But some com-ponents of the package were lacking in several clinics,in particular procedures for disease detection, includ-ing syphilis and HIV/AIDS. Existing opportunities forreferral were not fully used. Client privacy was some-times compromised, as many clinics partition theirconsulting rooms. And essential drugs and supplieswere not always available. Nevertheless, the focusedantenatal care model did result in improved qualityand continuity of care in Ghana. Clients visiting theintervention clinics obtained more comprehensive carethan those visiting comparison clinics.

In Kenya, the Frontiers program collaborated withthe Ministry of Health to determine whether focusedantenatal care has increased the coverage and quality ofservices. The study compared clinics in two interven-tion districts with clinics in a control district. Theresearchers found support for the focused servicesamong policymakers. But, as in the other countriesstudied, inadequate staff training and shortages ofequipment and supplies inhibit the full provision ofservices. Despite these challenges, the new model didincrease the quality of specific components of care,such as detection of diseases and counseling on familyplanning use postpartum. Further, clients report satis-faction with most aspects of the new model of antena-tal care provision.

“Focused antenatal care is acceptable to bothclients and providers and can improve care,” saidCouncil researcher Harriet Birungi. “However, to opti-mize the introduction of the new model, programmanagers and other key stakeholders need to developstrategies to deal with high staff turnover and a scarcityof needed supplies.”

Sources

Birungi, Harriet and W. Onyango-Ouma. 2006.“Acceptability and sustainability of the WHO focused ante-natal care package in Kenya,” FRONTIERS Final Report.Washington, DC: Population Council.(www.popcouncil.org/pdfs/frontiers/FR_FinalReports/Kenya_ANC.pdf )

Chege, Jane N., Ian Askew, Nzwakie Mosery, Mbali Ndube-Nxumalo, Busi Kunene, Mags Beksinska, Janet Dalton,Ester Snyman, Wilem Sturm, and Preshny Moodley. 2005.“Feasibility of introducing a comprehensive integrated pack-age of antenatal care services in rural public clinics in SouthAfrica,” FRONTIERS Final Report. Washington, DC:Population Council. (www.popcouncil.org/pdfs/frontiers/FR_FinalReports/SA_ANC.pdf )

Nyarko, Philomena, Harriet Birungi, Margaret Armar-Klemesu, Daniel Arhinful, Sylvia Deganus, Henrietta Odoi-Agyarko, and Gladys Brew. 2006. “Acceptability and feasibil-ity of introducing the WHO focused antenatal care packagein Ghana,” FRONTIERS Final Report. Washington, DC:Population Council. (www.popcouncil.org/pdfs/frontiers/FR_FinalReports/ghana_who_anc.pdf )

Outside fundingUnited States Agency for International Development

© 2007 The Population Council, Inc. www.popcouncil.org

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Reprinted from Population Briefs, May 2007www.popcouncil.org/publications/popbriefs/

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This work was funded by the generous support of the American peoplethrough the United States Agency for International Development (USAID).The opinions expressed herein are those of the authors and do not necessarilyreflect the views of USAID.