How much time do health services spend on antenatal care? Implications for the introduction of the focused antenatal care model in Tanzania

The World Health Report 2005 calls for "Realizing the Potential of Antenatal Care" [1]. While antenatal care interventions, in and of themselves, cannot be expected to have a major impact on maternal mortality, their purpose is to improve maternal and perinatal health, 'this being an end in itself and necessary for improving the health and survival of infants' [2]. In addition, the potential of ANC as a line of action to increase the rate of births attended by skilled health staff, and its value as entry point for other health programmes such as malaria, TB, nutrition and HIV/AIDS is now better understood and applied [1–4].

The concept of the new ANC model, as promoted by WHO, reflects this new understanding of the role of ANC [5]. The number of visits for those, identified not to be at high risk, is reduced to four. Each of these visits consists of a well defined set of activities related to three equally important general areas, namely (1) 'screening for conditions likely to increase adverse outcomes', (2) 'providing therapeutic interventions known to be beneficial', and (3) 'educating pregnant women about planning for a safe birth, emergencies during pregnancy and how to deal with these [5]. It has been highlighted that since the number of visits is reduced to four in the basic component, 'sufficient time must be made during each visit for discussion of the pregnancy and related issues with the patient' [5]. The emphasis on communication in the new antenatal care model was appreciated by women and health care providers alike [6].

It is estimated that 21,000 mothers died in Tanzania due to complications in pregnancy and delivery in the year 2000 [7] despite a high coverage of ANC of 98% [8]. The median number of antenatal consultations is 3.9 [9]. ANC is provided by health workers with 2 to 4 years of professional training. Quality assessments showed that less than half of all women get information about pregnancy complications, receive iron tablets, and have access to anti-malarial medicine. About 44 % of all women in Tanzania deliver at a health facility [8]. These data suggests that the potential benefits of ANC are not yet exploited.

This paper describes the current performance of ANC in dispensaries in South Tanzania with special emphasis on an assessment of the time health care providers spend on the different activities of ANC. The current practice is compared with standard times of the new focused ANC model.

The main findings of the study are: (1) Time requirements per consultation for the new model are substantially higher than current practise (2) The average time a health worker currently spends on an ANC first visit client is about 15 minutes, for a revisit client 9 minutes. (3) The major gap between current practise and the new model lies in health education and counselling.

Our finding of the 46 minutes time period for a first consultation of focused ANC corresponds well with the 40 minutes approximation made for the new WHO ANC model [5]. However, the estimate for the revisit differs: according to the WHO manual, a revisit should take 20 minutes, while this study suggests the need for 36 minutes. As there is no breakdown in the WHO manual for the time estimated for the different steps in the service provision, it is difficult to assess what components are responsible for the difference.

The impact, the required changes and the needed resources for the implementation of the new ANC model have been identified in the WHO randomised controlled trial. The trial was conducted in settings where 'resources available were sufficient for the implementation of adequate, basic, routine, western type antenatal care' [13]. The analysis compared the old ANC performance with the new model and it was concluded that the new model with reduced visits is as good as the old one, and even saves time and cost [5, 13, 14].

It is unlikely that such statements are also applicable for less developed countries like Tanzania, where current performance of ANC probably did not meet the definition of 'adequate, basic, routine western type ANC' and where – despite the official policy in the old model of recommended monthly visits, – the median number of ANC visits was already low (3,9 visits) [9]. Thus, the reduction of visits in ANC guidelines will not produce substantial savings in Tanzania. The implementation of the national adaptations of the new WHO ANC model can be expected to raise the standard of currently provided care: the identification of those in need of additional care will most probably increase. Focus on health education and counselling and the development of an individualized birth plan has the potential to increase the number of births attended by health professionals and antenatal referrals, recognized as one of the key factors to reduce maternal mortality [2].

Nevertheless, this study suggests that more than twice as much time as currently spent on ANC service provision is needed for implementing a good practise of the new model. It is thus questionable, if the new Focused ANC can be implemented without an increase of resources and in particular human resources.

The need for additional resources might become even more evident when ANC is used as an entry point for additional preventive interventions [2, 4]. The new Focused ANC model in Tanzania already gives consideration to programmes such as nutrition and malaria, STIs and HIV/AIDS. However, if voluntary counselling and testing for HIV is to become part of ANC, additional 20 minutes per client will be required, as shown in a recent study at the Muhimbili University Hospital in Daressalaam, Tanzania [15]. The difference between current performance and Focused ANC including HIV voluntary testing and counselling would increase to 45 minutes. As literature confirms [16, 17], the workload differs between dispensaries and between working days. Therefore, no general call for additional human resources for the implementation of the Focused ANC model seems adequate. While some dispensaries will be able to implement the new model with only some organisational improvements and adjustments, other settings will need additional staff. The challenge for health care managers will be to identify those in need of more resources.

We are aware that the current practise does not fully comply with the guidelines of the previous model. However, we want to highlight the change in resource requirements when changing from current practise to a meaningful implementation of the new model.

Health education and counselling has been identified as the major gap between the current performance and the proper performance of focused ANC. Information and communication are essential elements of health care provision. Reviews of women's experiences of maternity care highlight their importance [18]. Women participating in the new WHO model expressed their satisfaction with the nurses taking enough 'time to make them fully understand the message' [19, 13]. The emphasis on ensuring that 'all women understand why they need to have a skilled attendant for their delivery, and how they are able to access obstetric care for emergencies' [3] is one of the most promising but at the same time most challenging components of the new ANC model.

Several issues need to be taken into account when interpreting our data on health education and counselling. Firstly, the general daily health talks were not included in our time analysis. Secondly, information given to the client during examination was not classified as counselling. Reassuring information on the current health status of the women and her pregnancy is valuable and important, but it is different from individual counselling, which refers to the specific conditions and preferences of the women and should lead to an individual birth plan, including contingencies for unforeseen events. The quality of counselling appears to be low. While the danger and prevention of anaemia and malaria as well as issues of hygiene and breastfeeding were the key topic of the information given, danger signs, the individual birth plan and birth preparedness were hardly mentioned. According to 1999 data, 6 in 10 women attending ANC in Tanzania had not received any information regarding pregnancy complications [8].

These findings highlight that so far no culture of counselling, in particular of individual counselling, has been developed. Bearing in mind that counselling, especially the development of an individual birth plan, and birth preparedness, is one of the major components of the new Focused ANC model, these findings suggest that much attention needs to be given to train on the concept of counselling, its importance and its requirements. This will require a learning process in providers and clients alike, as most women observed were rather passive and reluctant to ask questions. A close partnership between service provider and client is essential to take advantage of ANC as an entry point for behavioural change and awareness raising on danger signs.

Fifteen minutes of counselling for each visit is quite a long time, and the results of the simulation might suggest reconsidering the list of counselling items. While some health education issues such as diet and nutrition, exercise and rest during pregnancy, personal hygiene etc. can probably be addressed in group counselling, as practised in many African countries [20], the value of individual counselling in particular with regard to the development of an individualized birth plan and emergency preparedness needs to be highlighted.

While the introduction of Focused ANC in Tanzania appears to have the potential to significantly improve the health of pregnant women and to increase the number of births with skilled attendants, such a change neither comes easily nor quickly. The programme is not just a small change in what was previously practised over many years, not just a reduction in the number of recommended visits, a focus on interventions proven to be effective and an appeal to abolish those practices that have been shown to be ineffective or harmful. In particular, with the focus on education and counselling as well as on individual counselling, the programme calls for a fundamental change in the attitudes, the skills and qualities required from ANC personnel.

Training that goes beyond the assimilation of knowledge of the pure facts of the content of each visit, but a training that fosters a deep understanding of the concept of focused ANC and thus tapping the roots of motivation, is essential to change old practices and to implement the new model.

Focused ANC is a great step forward. However, it will not come for free. This study suggests that the new model does not generally save cost and time on the provider side. Investment in additional human resources is necessary in some local settings to ensure its proper implementation. Given the expected benefits for maternal and perinatal health, it will be a very worthwhile investment.