Although the majority of pregnant women in many developing countries receive at least four antenatal care visits, they do not receive all of the services that they should, according to an analysis of Demographic and Health Survey (DHS) data.1 For example, even though about nine in 10 women in the Dominican Republic and Colombia who had had a birth in the past two years had had four or more antenatal care visits, only one in three had received the full set of antenatal services (e.g, blood pressure measurement, HIV testing) assessed in their country’s survey. In most other countries, the proportions were far smaller. Even among women in the study countries who had had at least four antenatal visits, only 60%, on average, had received any particular antenatal service.

Although the conventional regimen of antenatal care in developed regions often involves a dozen visits, an abbreviated schedule consisting of four or more visits has become the benchmark of adequate care for health systems in developing regions. Those four visits, however, may not provide all of the services that pregnant women should receive. To explore this issue, researchers analyzed DHS data from 41 developing countries. Countries were included if a DHS survey conducted between 2005 and 2011 had collected data on women’s receipt of at least five of the following antenatal services: blood pressure measurement, tetanus vaccination, urine testing (for bacteriuria and other abnormalities), counseling about danger signs, HIV counseling and testing, iron and folate supplementation, early antenatal care (prior to four months’ gestation) and provision of at least two doses of medication to prevent malaria. The researchers examined, among women who had had a birth in the past two years and had had at least four antenatal visits, the proportion who reported having received each antenatal service; they then averaged the proportions to create an indicator of the degree to which these women had received adequate care. Calculations of these averages were limited to the particular ser- vices assessed by the country’s DHS survey; for example, provision of treatment for malaria prevention was assessed only in Sub-Saharan Africa, where the disease is endemic. Women who said they did not know whether they had received a particular service were classified as having not received it. In addition to examining receipt of services among women who had at least four antenatal care visits, the researchers conducted similar analyses for all women who had had a birth in the past two years.

On average, 57% of women in the 41 countries had had four or more prenatal visits. Among these women, service coverage—the proportion who had received any particular service—averaged only 60%. While most women had had their blood pressure measured (91%) or received protection against tetanus (79%), fewer than a third had received at least 90 days of supplementation for iron and folate (30%) or, if applicable, received preventive treatment for malaria (25%). Only about half (55%) had had a visit before their fourth month of pregnancy.

Average coverage of services was highest in Colombia, the Dominican Republic, Nepal and the Maldives (81–85%); it was lowest in the Democratic Republic of Congo, Burundi, Niger and Madagascar (32–39%). The proportion of women who had had four antenatal visits was not necessarily related to the average level of coverage; for example, only about half of women in Sierra Leone (56%) and Nepal (53%) had had at least four visits, but among those who had, the average level of service coverage was much higher in the latter than in the former (83% vs. 44%). Similarly, the proportion of women in Indonesia who had had at least four visits was 81%, among the highest levels in the study, but average service coverage in the country (58%) was slightly below the mean.

To further illustrate that having four antenatal visits was not an indicator of adequate antenatal coverage, the researchers examined receipt of services among all women. In four countries—the Dominican Republic, Colombia, Peru and the Maldives—at least 87% of women had had at least four antenatal visits. However, only 34% of women in the first two countries had received all of the measured services, and the proportion was even lower in the Maldives (28%) and Peru (7%). In fact, in only nine countries had as many as 5% of women received the full slate of antenatal services measured by the country’s DHS, and in more than a third the proportion was essentially 0%.

The authors conclude that although the number of antenatal care visits that a woman receives matters—“in the sense that each visit provides an opportunity for provision of needed care”—the four-visit threshold typically used as an indicator of program performance is not a sufficient indicator of quality. Moreover, “continued use of this indicator reinforces the impression that an abbreviated schedule of antenatal care is adequate.” They suggest that the four-visit measure be replaced by an alternative indicator, such as the measure they used (the average of the proportions of women who received a set of specific services). Such a shift, they argue, would help ensure that the quantity of antenatal visits does not take precedence over their quality, and “would reflect much better how well the needs of the population are actually being met.”—P. Doskoch


1. Hodgins S and D’Agostino A, The quality-coverage gap in antenatal care: toward better measurement of effective coverage, Global Health: Science and Practice, 2014, 2(2)173–181.