Support Tool for Improving Quality of Antenatal Care

The tool outlines evidence-based, high-impact antenatal care (ANC) interventions and quality of care measures for use by policymakers and program managers working to improve quality of ANC for pregnant women in low-resource settings. The WHO 2016 ANC recommendations promote respectful, individualized, woman-centered care at every contact between ANC client and provider. These recommendations include universal and context-specific interventions within five categories: routine antenatal nutrition, maternal and fetal assessment, preventive measures, interventions for the management of common physiologic symptoms in pregnancy, and health system interventions to improve the utilization and quality of ANC. The tool focuses on high-impact, evidence-based ANC interventions for routine antenatal care and for early detection and management of complications in pregnant women. It also includes a flexible menu of ANC quality of care measures (input, process, and outcome) that managers and ANC providers can monitor as part of program interventions to improve quality of ANC. The tool consists of five tables listing high-impact ANC interventions and quality of care measures categorized by ANC contact and gestational age. The majority of indicators in this document are quality of care "process" measures, such as the proportion of pregnant women with blood pressure check, since much of pregnancy care involves routine interventions. A smaller number of quality health "outcome" measures are included for women being treated for a complication, such as the proportion of women being treated for chronic or gestational hypertension with blood pressure controlled below 140/90 mm Hg. The tool is organized into four "buckets" based on the typical flow of a high-quality ANC contact: assessment, prevention and treatment clinical interventions, counseling for behavioral and other woman-led interventions tailored to gestational age, and detection, stabilization, and referral for complications (if present). Some WHO 2016 ANC recommendations may or may not be relevant for individual countries, depending on the country context and local burden of disease. Table 1 provides a high-level overview of ANC interventions and indicators, categorized by relevance for each pregnancy trimester. Tables 2-4 provide more detail on high-impact ANC interventions and associated quality of care process and outcome measures, organized by ANC contact and stage of pregnancy. Table 5 summarizes essential inputs (e.g., commodities, medicines, laboratory testing) for the provision of high-quality ANC, from which ANC input measures can be derived for monitoring by QI teams. The intervention and measures tables are based on the following global references, primarily derived from WHO's Integrated Management of Pregnancy and Childbirth (IMPAC) series: WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience (WHO 2016), Managing Complications in Pregnancy and Childbirth (MCPC), Second edition (WHO 2017), Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice (WHO 2015), Global Reference List of 100 Core Health Indicators (WHO 2018), and The National Institute for Health and Care Excellence (NICE) guidelines. The tool is designed to be adaptable to different country contexts and areas of focus, and users are encouraged to develop additional measures as needed. The quality of care measures in blue font and marked with a diamond () are considered most important and/or feasible to monitor as part of quality improvement programs in low-resource settings.