Antenatal care MDG 5, Target 5b, Indicator 5.5 Workshop on MDG monitoring to 2015 and beyond Bangkok 9-13 July 2012 Liliana Carvajal UNICEF

MDG 5 – Improve maternal health Target 5.b – Achieve by 2015, universal access to reproductive health Indicator 5.5 – Antenatal care coverage At least 1 antenatal care visit At least 4 antenatal care visits

Antenatal care Background, definitions, relevance Regional perspective Measuring the standard indicator Measurement challenges

Antenatal care Background, definitions, relevance Regional perspective Measuring the standard indicator Measurement challenges

What is antenatal care ANC For pregnant women, regular contact with skilled health personnel (doctor, nurse or midwife) allows for a better management of their pregnancy including a variety of services, such as: treatment of hypertension to prevent eclampsia; tetanus immunization; micronutrient supplementation; and birth preparedness, including information about danger signs during pregnancy and childbirth.

Why is antenatal care important? Health care during pregnancy is vitally important in detecting and managing conditions that may complicate pregnancy and childbirth. The antenatal period presents important opportunities for reaching pregnant women with a number of interventions that may be vital to their health and well-being and that of their infants. The antenatal period is also an ideal opportunity to supply information on future birth spacing, which is recognized as an important factor in improving infant survival.

Why is antenatal care important? Moreover, in countries where malaria is endemic, ANC visits provide pregnant women with intermittent preventive treatment for malaria as well as insecticide- treated mosquito nets; Women who are HIV-positive receive help in avoiding transmission of the virus to their babies. Basic antenatal care provides women with a package of preventive interventions, including nutritional advice. Women are also alerted to danger signs that may threaten their pregnancy and given support in planning a safe delivery.

ANC4 The World Health Organization (WHO) recommends a minimum of four antenatal visits. WHO guidelines recommend that antenatal care includes, at a minimum: the measurement of blood pressure, testing of urine for bacteriuria and proteinuria, and blood tests to detect syphilis and severe anaemia.

Antenatal care Background, definitions, relevance Regional perspective Measuring the standard indicator Measurement challenges

Antenatal care – at least one visit Proportion of women (15-49 years old) attended at least once by skilled health personnel during pregnancy, 1990 and 2009 (Percentage) Across all regions, more pregnant women are offered at least minimal care Since 1990, the proportion of women receiving antenatal care has increased substantially in all regions. Important progress since 1990 in developing regions : 64 % in 1990 to 81% in 2009 Southern Asia and SSA are the regions with lowest coverage Source: MDG report 2011

ANC4 – at least four visits with any provider Proportion of women (15-49 years old) attended four or more times by any provider during pregnancy, 1990 and 2009 (Percentage) Not enough women receive the recommended frequency of care during pregnancy. The proportion of women receiving the recommended number of visits in developing regions remains low, though progress is being made, increasing from 35 per cent in 1990 to 51 per cent in 2009. A minimum of four antenatal care visits is recommended to ensure that pregnant women receive the interventions they need to prevent and manage complications. Source: MDG report 2011

Antenatal care Background, definitions, relevance Regional perspective Measuring the standard indicator Measurement challenges

Standard Indicators – ANC1 Antenatal care coverage (at least one visit) Proportion of women age 15-49 years that were attended at least once by skilled health personnel during pregnancy in the last 2 years Note: Skilled health personnel comprises: Doctor Nurse Midwife/auxiliary midwife Services = Blood pressure Urine sample Blood sample IPTp (if relevant)

Standard Indicators – ANC4 Antenatal care coverage (at least four visits) Proportion of women age 15-49 years that were attended at least four or more times by any provider during pregnancy in the last 2 years Note: This indicator refers to 4 or more checks from any provider

Sources The antenatal care coverage is typically calculated from data collected through national household surveys including: Multiple Indicator Cluster Surveys (MICS) Demographic Health Surveys (DHS), Reproductive Health Surveys and sometimes from data collected from administrative registrations.

Eligibility Women of reproductive age (15-49 years) Live birth in the two or five years preceding interview

Household survey – women’s questionnaire Includes about 20 questions related to the antenatal period – but the standard ANC1 indicator is based on 2 questions: Health providers

Reporting of ANC1 - Surveys Cambodia example – skilled providers doctor, nurse and midwife

Reporting of ANC1 - Surveys Bhutan example – skilled providers: doctor, nurse/ midwife, health assistant/basic health worker HA/BHW, Associate clinical officer ACO For global reporting, additional confirmation is needed for other categories

Household survey – women’s questionnaire ANC4 indicator For this indicator the provider is not included Additional questions on quality of care Services = Blood pressure Urine sample Blood sample IPTp (if relevant)

Reporting of ANC4-Surveys

Antenatal care Background, definitions, relevance Regional perspective Measuring the standard indicator Methodological challenges

Summary of methodological challenges Type of provider for antenatal care Questionnaires - coding categories need to be adapted in country MDG indicators – maintain broad coding categories for comparability Direct communication with country office to ensure correct interpretation for global reporting Maintain the broad categories shown in the model Q. Doctors, nurses midwives and auxiliary midwives are skilled health personnel who have midwifery skills to manage normal deliveries and diagnose or refer obstetric complications. For ANC1 the specific provider needs to be specified – needs to be adapted properly within countries to ensure that the categories that are included –usually MOH capture the main service providers and are recognized by respondents

Prepared by: Liliana Carvajal Statistics and Monitoring Section UNICEF/New York lcarvajal@unicef.org www.childinfo.org