Input, process, and output factors contributing to quality of antenatal care services: a scoping review of evidence

Background High-quality antenatal care (ANC) provides a lifesaving opportunity for women and their newborns through providing health promotion, disease prevention, and early diagnosis and treatment of pregnancy-related health issues. However, systematically synthesised evidence on factors influencing the quality of ANC services is lacking. This scoping review aims to systematically synthesize the factors influencing in provision and utilisation of quality ANC services. Methods We conducted a scoping review of published evidence on the quality of ANC services. We searched records on four databases (PubMed, Scopus, Embase, and Google scholar) and grey literature from 1 to 2011 to 30 August 2021. We analysed data using Braun and Clarke’s thematic analysis approach. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guideline for the review. We explained themes using the Donabedian healthcare quality assessment model (input-process-output). Results Several inputs- and process-related factors contributed to suboptimal quality of ANC in many low and lower- or middle-income countries. Input factors included facility readiness (e.g., lack of infrastructure, provision of commodities and supplies, health workforce, structural and intermediary characteristics of pregnant women, and service delivery approaches). Processes-related factors included technical quality of care (e.g., lack of skilled adequate and timely care, and poor adherence to the guidelines) and social quality (lack of effective communication and poor client satisfaction). These input and process factors have also contributed to equity gaps in utilisation of quality ANC services. Conclusion Several input and process factors influenced the provision and utilization of optimum quality ANC services. Better health system inputs (e.g., availability of trained workforces, commodities, guidelines, context-specific programs) are essential to creating enabling facility environment for quality ANC services. Care processes can be improved by ensuring capacity-building activities for workforces (training, technical support visits), and mentoring staff working at peripheral facilities. Identifying coverage of quality ANC services among disadvantaged groups could be the initial step in designing and implementing targeted program approaches. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-05331-5.


Rationale
3 Describe the rationale for the review in the context of what is already known. Explain why the review questions/objectives lend themselves to a scoping review approach.

97-103
Objectives 4 Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g., population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.

1-4=105
METHODS Protocol and registration 5 Indicate whether a review protocol exists; state if and where it can be accessed (e.g., a Web address); and if available, provide registration information, including the registration number. NA Eligibility criteria 6 Specify characteristics of the sources of evidence used as eligibility criteria (e.g., years considered, language, and publication status), and provide a rationale.

121-132
Information sources* 7 Describe all information sources in the search (e.g., databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed.

113-119
Search 8 Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated.

113-119
Selection of sources of evidence † 9 State the process for selecting sources of evidence (i.e., screening and eligibility) included in the scoping review.

133-148
Data charting process ‡ 10 Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators.

133-156
Data items 11 List and define all variables for which data were sought and any assumptions and simplifications made. 149-154 Critical appraisal of individual sources of evidence § 12 If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate).

126-132
Synthesis of results 13 Describe the methods of handling and summarizing the data that were charted.

SECTION
ITEM PRISMA-ScR CHECKLIST ITEM Page, line # Selection of sources of evidence 14 Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram. 157-177 Characteristics of sources of evidence 15 For each source of evidence, present characteristics for which data were charted and provide the citations.

157-172
Critical appraisal within sources of evidence 16 If done, present data on critical appraisal of included sources of evidence (see item 12). NA

Results of individual sources of evidence 17
For each included source of evidence, present the relevant data that were charted that relate to the review questions and objectives. Appendix Synthesis of results 18 Summarize and/or present the charting results as they relate to the review questions and objectives. Page 10 1-249 DISCUSSION Summary of evidence 19 Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups.  A: ("Quality of care" OR quality OR accessibil* OR acceptabilit* OR "skilled care" OR affordab* OR effective* OR efficien* OR frequen* OR continu* OR adequa* OR time* OR "antenatal care intervention*" OR coverage OR utiliz* OR "respect* care" OR "dignified care" OR satisf* OR safe* OR "womencentered" OR "patient-centered" OR equit* OR cost* ) B: ("Antenatal care" OR "antenatal service*" OR "prenatal care" OR "prenatal service*" OR "pregnancy care" OR "perinatal care" OR "perinatal service*" OR "antenatal check-up*" OR "antenatal visit*" OR "antenatal follow-up" OR "antenatal follow up"  High gaps -iron-folate supplementation (72%) and malaria prevention (86%). Low uptake of (referring population EC) than among only those who had received ANC 4+ visits. Countries had lower average coverage for care content than ANC 4+. Half the women had 4+ANC visits and 85% had at least one visit. Health education, iron supplementation, blood pressure measurement and tetanus toxoid were ANCs more commonly received components. Joshi et al 2014 [15] Nepal Quanti tative To identify factors associated with 1) attendance at four or more ANC visits and 2) receipt of good quality ANC.
Factors of predictor of good quality Older age, higher parity, and higher levels of education and household economic status of the women were predictors of both attendances at 4+ visits and receipt of good quality ANC. Women who did not smoke, had a say in decision-making, whose husbands had higher levels of education and were involved in occupations other than agriculture, receiving their ANC from a skilled provider, in a hospital, living in an urban area and being exposed to general media. Majrooh et al 2014 [16].

Punjab
Mixed metho ds To assess the coverage and quality antenatal care in the primary health care facilities in 'Punjab' province of 'Pakistan'.

High discontinuation in the subsequent visits
Enrolment for ANC was 55.9% and dropout was 32.9% in subsequent visits. The quality of services regarding assessment, treatment and counselling was extremely poor. The reasons for low coverage and quality were the distant location of facilities, deficiency of facility resources, indifferent attitude, and non-availability of the staff. Lack of client awareness about importance of ANC and self-empowerment for decision-making to seek care were also responsible for low coverage. (Saizonou et al. 2014 [17] Benin Qualita tive To assess the performance of antenatal services Satisfactory health system inputs The health system inputs for ANC service the inputs, procedures, and satisfaction of the pregnant women, was satisfactory. The services organization, health care environment, patient reception and interpersonal communication were the elements which showed deficiencies. Achia et al 2015 [18] Kenya Quanti tative To examine individual and community level factors associated with adequate use of maternal antenatal health services.

Factors of adequacy of care
The individual-level factors associated with adequate use of MHC-the greater educational attainment by the woman or her partner, higher socioeconomic status, access to medical insurance coverage, and greater media exposure. Greater community ethnic diversity, higher community-level socioeconomic status, and greater community-level health facility deliveries were the contextual-level factors associated with adequate use of MHC.

Study Country Study Aim Quality of ANC Key findings
Fagbamigb e et al 2015 [19] Nigeria Quanti tative To assess the quality of ANC services in Nigeria Low uptake of interventions in routine visits IPD and IPT were given to only 20.7 % and 37.6 % respectively in Nigeria. 41.7 % had HIV test and obtained results. Only 4.6 % of women received good quality of ANC while nearly 1.0 % did not receive any of the components. About 11.3 % of the attendees had minimum acceptable quality of ANC. Quality was higher among users who initiated ANC early, with 4 ANC visits, attended to by skilled health workers, attended government and private hospitals and clinics, who lives in urban areas, having higher educational attainment, upper wealth quintiles and attended to by skilled ANC provider. Kambala et al 2015 [20] Malawi Quanti tative To measure women's perceived quality of maternal and newborn care using a composite scale Perceived quality A high perceived quality of care -interpersonal relations, conditions of the examination rooms and nursing care services. Self-introduction by the health worker, explanation of examination procedures, consent seeking, encouragement to ask questions, confidentiality protection and being offered to have a guardian during delivery were associated with a high-quality rating of interpersonal relations for antenatal and delivery care services, literate, never experienced a still birth and, first ANC visit were associated with a high-quality rating of room conditions for ANC service. Villadsen et al 2015 [21] Ethiopia Qualita tive To design a participatory ANC strengthening intervention and assess effectiveness on quality of ANC.

Individual and organisation factors of quality
The continued attention to the ANC provision during implementation stimulated increased priority of ANC among health care providers. The organizational structure of the facilities and lack of continuity in care provision turned out to be a major challenge for implementation. positive effect of the intervention on health education on danger signs during pregnancy, laboratory testing for blood tests other than HIV, health problem identification, and satisfaction with the service. Maternal education impacts outcomes significantly. Bayou et al 2016 [22] Ethiopia Quanti tative

Midwife provided services
Midwives did somewhat better than nurses in reporting these conditions. midwives informed pregnant women about pregnancy-related issues.

Quanti tative
To assess the adequacy of ANC and its association with pregnancy outcomes Good quality ANC reduce preterm birth Sixty-three percent of women showed higher than recommended ANC utilization; 52% had <80% of recommended routine care content. Preterm births were lower among women with adequate level of utilization compared with inadequate and intensive levels. women who received inadequate care content were associated with a higher prevalence of preterm birth. Afulani et al 2019 [43] Kenya Quanti tative To assess the quality of ANC women received in Migori county,

Gaps in communication with poor satisfaction
Key gaps demonstrated in communication. About half of women were not educated on pregnancy complications. about one-third did not often understand the purposes of tests and medicines received and did not feel able to ask the health care provider questions. women who were literate, employed, and who received all their ANC in a health center had higher experiences scores.

Study Country Study Aim Quality of ANC Key findings
Alyahya et al 2019 [44] Jordan Qualita tive To explore the quality of ANC in Jordan Better communication improved quality Reasons for this included longer consultation time, a higher quality of services, better interpersonal and communication skills of healthcare providers, better treatment, more advanced equipment and devices, availability of female obstetricians, and more flexible appointment times. These women only perceived public hospital services as necessary in pregnancy-related complications and labour, as the costs of private sector services in such cases are too high. Jo et al [45] Banglad esh Qualita tive To determine service subcomponents and provider and patient costs of ANC services

Low services complaints in physical exam and test
High compliance (> 50%) of service subcomponents were observed in blood pressure monitoring, weight measurement, iron and folate supplementation given, and tetanus vaccine, while lower compliance of service subcomponents (< 50%) were observed in some physical examinations such as oedema and ultrasonogram and routine tests such as blood test and urine test. Mario  The percentage of crude adequate contact was 60.9% for ANC. The percentage of quality-adjusted contact was 14.6% for ANC, Adequate contact was associated with receiving high-quality care at ANC, Being a teenager, low educational level, multiparity and low level in the household wealth index were negatively associated with adequate contact with healthcare providers for ANC. Receiving a maternal and child health handbook was positively associated with adequate contact for ANC and receiving high-quality ANC. Owili et al 2019 [49] SSA Quanti tative To explore the determinants of quality of ANC

General readiness improves quality
Those with ANC guideline and central electricity supply were more likely to provide optimal information. Provider's qualification and experience were also important in information provision and clinical care independently. A considerable proportion of women do not receive adequate ANC in India. Stark socio-economic and regional disparity was evident about the availability and provision of the quality of ANC among women. Women belonging to the poorest wealth quintile or the adolescent age group, illiterate women and those residing in the central and eastern regions of the country did not receive adequate ANC. About 70% of pregnant women received appropriate ANC, which was timely, delivered by skilled professionals, and sufficient in the number of visits made. Thida et al [54] Myanma r

Quanti tative
To identify the types of HWs for ANC Low perceived quality Low perceived good quality ANC and delivery care for HDP and PPH.
More than 85% of the participants rated quality of care for managing complications as good. Yakob et al [55] Ethiopia Quanti tative To assess the quality and effective coverage of ANC services.

Poor effective coverage of ANC visit
The crude coverage 62% for ANC in Ethiopia in 2016. ANC quality was 34% and 81% received <50% of the recommended ANC clinical actions. When adjusting the crude coverage by the service quality, the mean EC of ANC services was 22%. Adhikari et al 2020 [56] Nepal Quanti tative To analyse the sociodemographic correlates of the frequency and quality of ANC.
Poor quality care, with advantaged women received good quality While 70% of the Nepalese women surveyed had at least four ANC visits, only 21% of these women received good-quality ANC. educated women and the women of rich wealth index were more likely to receive more antenatal visits. women living in rural areas, and those who had more than two children were less likely to receive a higher number of Women started to come earlier for their first ANC visit; more women attended their first ANC visit in the second trimester of pregnancy in 2019 than in the previous years, including age, educational level, gravidity, parity, infectious diseases, and level of anaemia.
Berehe et al 2020 [60] Ethiopia Quanti tative To determine the quality of ANC Suboptimal quality of care The magnitude of good quality of ANC service was low. The frequently identified problems were inability to take full history, lack of proper counselling, poor healthcare provider and client interaction, improper registration, and a variation in providing quality of care in each visit. Quality of ANC was associated with residence, educational status gravidity, parity, and visit. Dadras et al 2020 [61] Iran Quanti tative To explore the sociodemographic factors and potential barriers associated with adequate ANC Only one third of Afghan women received adequate quality Almost a third of Afghan women in this study had adequate ANC (≥ 8 visits). The women in older age group, those with higher education and family income, women with longer length of stay, those of legal status had adequate ANC. the poor knowledge and attitude toward ANC, the poor quality of services; and the difficulties in access were the main obstacles toward adequate ANC. Defar et al 2020 [62] Ethiopia Quanti tative To the structural quality of ANC service provision in Ethiopian health facilities Poor availability of tracer ANC items The availability of specific services was very low. Tetanus toxoid. The mean availability among the ten tracer items (vaccination, folic acid, iron supplementation, and monitoring of HTP) for quality ANC services was 50%. Health canters, health posts and clinics scored lower ANC service readiness. The overall readiness index score was lower for private health facilities. Regional inequity was also observed.

Study Country Study Aim Quality of ANC Key findings
Fauziah et al 2020 [63] Indonesi a

Quanti tative
To assess the quality of ANC in rural and urban PHC

Poor optimal quality
The results indicate that 52.6% of ANC quality is categorized bad. Furthermore, there is different ANC quality based on body weight, the height of fundus uteri, and administration of iron tablet.

Harsha
Bangura et al 2020 [64] Nepal Mixed metho ds To improve utilization, quality of care, and the patient experience.
Group ANC approach was effective Group ANC approach-85.7% of visits completing all process elements, and high content fidelity, with all village clusters meeting the minimum target frequency for 80% of topics. Group gestational matched and stable group intervention feasible through training, documentation, feedback, and logistics. group ANC provided in collaboration with local government clinics has the potential to provide accessible and highquality ANC. Hategeka et al 2020 [65] Rwanda Quanti tative

Poor recommended visits
One third (33%) of the participants attended less than half of the recommended ANC visits. significant association between; physical abuse; not being allowed to assume position of choice during examination; not having privacy during examination and antenatal care service utilization. The difference in the logs of expected count on the number of ANC visits is lower for women who experienced lack of privacy during examinations, who discriminated based on specific attributes and who were left unattended. The proportions of women who had ≥8 ANC visits and first ANC visit at ≤3 months gestation was 6.3% and 35.6% respectively. Women aged 35-39 at childbirth, middle wealth quintile women, women whose husbands had higher education were more likely to have ≥8 ANC visits. Early timing of first ANC visit was low among women with birth order 3-4. The likelihood of having early ANC visits was high among women whose pregnancies were intended, the richest women and women whose husbands had higher education. Anik et al [73] South Asian (SA) region

Quanti tative
To explain the measurement of adequacy of ANC Inadequate ANC visits. Empowerments improve quality Only 30% women received adequate ANC in SA, ranging from 8.4% in Afghanistan to 39.8% in Nepal. The poor utilisation of adequate ANC services was most prevalent among the women residing in rural areas and that of poor families as well as low empowerment status in SA countries. Conversely, highly empowered but poor was positive association with adequate ANC services. Anindya et al 2021. [74] 39 LMICs

Quanti tative
To assess socioeconomic inequalities in effective coverage ANC services Low quality adjusted coverage The quality-adjusted coverage of RMNCH services in 39 countries was substantially lower than service contact, and ANC outcomes. UMICs had higher effective coverage levels compared with LMICs. Socioeconomic inequalities tend to be wider when using effective coverage measurement compared with crude and service contact measurements. UMICs had a lower magnitude of inequality compared with LMICs.

Study Country Study Aim Quality of ANC Key findings
Arroyave et al 2021 [75] (LMICs) Quanti tative To create and validate a new indicator for ANC.

ANCq
The overall mean of ANCq was 6.7, ranging from 3.5 in Afghanistan to 9.3 in Cuba and the Dominican Republic. the ANCq was inversely associated with neonatal mortality. Ayalew et al 2021 [76] Ethiopia Quanti tative To assess women's satisfaction and its associated factors with ANC services.
Factors associate d satisfaction of care 53.8% of women were satisfied with the ANC services. Age of mothers, advice on danger signs in pregnancy, previous ANC visits, respectful maternity care, and planned pregnancy were significantly associated with women's satisfaction with ANC services. Bobo et al [77].

East Africa
Quanti tative To assesses inequalities in the use of quality ANC in nine East African countries using Low 4ANCvisits and interventions About 54.4% had 4+ ANC contacts, but only 21% reported receiving all six services. The coverage of 4+ ANC and receipt of all six services was pro-rich within and across all countries. The highest inequality in 4+ANC contacts was in Ethiopia, while women in Burundi had the highest inequality in coverage of all six services. Higher education levels and media exposure were predictors of service uptake, while women who had unintended pregnancies were less likely to make four or more ANC contacts and receive six services. Most women received low-quality ANC across all countries and socioeconomic levels, even when they managed to have adequate contact with providers. Those women who received quality care had primary or higher education, reside in urban areas or had plans to have a child. Kedir et al [78] Ethiopia Quanti tative To examine associated factors with the quality of ANC.

Inadequate ANC visits
Less than one-fourth of women received high-quality ANC including poor uptake of counselling on malaria prophylaxis and testing for HIV, living in a poor community was associated with reduced odds of receiving highquality ANC. Tadele  Low maternal age, low educational level, non-marital status, ethnic minority, planned pattern of prenatal care, hospital type, unplanned place of delivery, uninsured status, high parity, no previous premature birth, and late recognition of pregnancy were identified as individual determinants of inadequate use. Contextual determinants -living in neighbourhoods with higher rates of unemployment, single parent families, medium-average family incomes, low-educated residents, and indigenous were associated with inadequate use or late visit, and inadequate use was more likely among women who smoked during pregnancy. Lassi et al [86] Many countrie s

Revie w
To review the effectiveness of care delivered through community level inputs for improving MNH outcomes.
Task shifting reduce ANC hospitalisation. home visitation improved ANC Task shifting to midwives and CHWs, home visitation significantly improved ANC, tetanus immunization coverage, referral and early initiation of breast feeding with reductions in antenatal hospital admission. Training of TBAs as a part of community-based intervention package significantly impacts referrals. Home visitation, community mobilization and training of CHWs and TBA have the maximum potential to improve a range of maternal and newborn health outcomes. Perception of poor maternal care managers' and providers' perspectives provided poor quality of maternal healthcare. Factors contributing to the perception of poor maternal healthcare included: late reimbursement of funds, heavy workload of providers, lack of essential drugs and stock-out of medical supplies, lack of policy definition, OOP payment, and inequitable distribution of staff. Arroyave et al [90] Many LMICs

Syste matic review
To conduct a global analysis of socioeconomic inequalities in ANC using national surveys from LMICs Inequalities in quality care between and within countries Higher ANCq scores were observed among women living in urban areas, with secondary or more level of education, belonging to wealthier families and with higher empowerment in nearly all countries. In addition, countries with higher ANCq mean presented lower inequalities; while countries with average ANCq scores presented wide range of inequality, with some managing to achieve very low inequality. Strategies used to (a) increase access to timely prenatal care, (b) improve the content of prenatal care, and (c) enhance the organization and delivery of prenatal care. (a) increase consumer awareness about the importance of preconception and early prenatal care, facilitate spatial mapping of access gaps, and improve continuity of patient records; (b) support collaborative quality improvement, facilitate performance