QUALITY OF ANTENATAL CARE SERVICES IN LOW-INCOME COUNTRIES: INVESTIGATING ITS MEANING AND MEASUREMENT

Background: Measuring quality of maternal health services is a fundamental step toward enhancing our understanding of how to improve maternal health outcomes; yet comprehensive quality of care measures are limited. This research aimed to inform our understanding of antenatal care service quality, investigate and develop methods for the analysis of health facility assessment data in LMIC settings, and improve available measures of service quality. Methods: We conducted simulation studies using theTanzania 2015 DHS and SPA surveys to assess benefits and costs of using sampling weights in rate estimation and the best method for calculating standard errors. Using SPA data from three countries (Haiti, Malawi, and Tanzania), we developed, characterized, and compared a set of facility readiness and provision of care indices for ANC and assessed the association between facility readiness and provision of care for ANC. Separately, we conducted qualitative data collection in Tanzania to investigate client and provider perspectives of ANC service quality. Results: We found that in the Tanzania DHS and SPA, weighted estimates have a lower mean squared error (MSE) than unweighted estimates, indicating that the effect of the bias tradeoff was greater than the effect of the variance tradeoff for most indicators assessed. Within a country, ANC quality of care indices constructed using different methodologies were quite similar. We found small, but significant associations between facility readiness to provide ANC and provision of care across countries and index constructions. Finally, we found that both clients and providers perceived quality of ANC as comprised of items related to experience of care, provision of care, and cross- cutting essential physical and human resources. Conclusion: The findings from this study have had practical implications for the evaluation conducted in Tanzania. In addition, this research provides practical guidance on methodological approaches for measuring quality of antenatal care that can be applied to LMIC countries with similar quality of care data while highlighting gaps in quality of care measurement, particularly related to the experience of care