A cross sectional study to evaluate antenatal care service provision in three hospitals in Nepal

Background Globally too many mothers and their babies die during pregnancy and childbirth, a key element of optimizing outcomes is high-quality antenatal care (ANC). The Government of Nepal have significantly improved ANC and health outcomes through high-level commitment and investment, but still only 69% attend four recommended antenatal appointments. Objective To evaluate the quality and perceptions of ANC in Nepal to understand the compliance with Nepalese standards. Study Design This cross-sectional study took place at a tertiary referral and private hospital in Kathmandu, and a secondary hospital in Makwanpur. It recruited 538 female inpatients on postnatal wards during the two-week data collection period in May/June 2019. A case note review and verbal survey of women to understand the pregnancy information they received and their satisfaction with ANC was performed. We created a summary score of the completeness of ANC services received ranging 0-50 (50 indicating complete accordance with standards) and investigated the determinants of attending 4 ANC visits and patient satisfaction. Results The median ANC attendance was 4 visits at the secondary and referral hospitals and 8 at the private hospital. 24% attended less than 4 visits. 22% (117/538) attended a first trimester visit and 12% (65/538) attended visits at all points recommended in the standards. Over 90% of women had blood pressure monitoring, hemoglobin estimation, blood grouping and Rhesus typing, HIV and syphilis screening. 50% of women had urinalysis at every visit (IQR 20 to 100). 95% (509/538) reported receiving pregnancy information, but retention was variable: 93% (509/538) received some information about danger signs, 58% (290/502) remembered headaches whereas 98% (491/502) remembered fluid leaking. The ANC completeness score revealed the private hospital offered the most complete clinical services (mean 28.7, SD=7.1) with the secondary hospital performing worst (mean 19.1, SD=7.1). The factors influencing attendance at 4 ANC visits in the multivariable model were beginning ANC in the first trimester (OR 2.74 (95% CI 1.36, 5.52) and having a lower level of education (no-school OR 0.46 (95% CI 0.23, 0.91), Grades 1-5 OR 0.49 (95%CI 0.26, 0.92)). Overall 56% (303/538) of women were satisfied with ANC. The multivariable analysis revealed satisfaction was more likely in women attending the private hospital compared to the referral hospital (OR 3.63 95% CI 1.68 to 7.82) and lower in women who felt the ANC facilities were not adequate (OR 0.35 95% CI 0.21 to 0.63) and who wanted longer antenatal appointments (OR 0.5 95% CI 0.33 to 0.75). Conclusions Few women achieved full compliance with the Nepali ANC standards, however, some services were delivered well. To improve, each antenatal contact needs to meet its clinical aims and be respectful. To achieve this communication and counselling training for staff, investment in health promotion and delivery of core services is needed. It is important that these interventions address key issues, such as attendance in the first trimester, improving privacy and optimizing communication around danger signs. However, they must be designed alongside staff and service users and their efficacy tested prior to widespread investment or implementation