Clinical process quality of antenatal care in low and middle-income countries: Cross-sectional evidence from 13 countries

Increasing access to high-quality antenatal care is essential for reducing maternal and neonatal mortality in low- and middle-income countries (LMICs), yet systematic evidence on the quality of care remains limited. This study provides the broadest overview to date of the clinical process quality of antenatal care in LMICs, using nationally representative data from 13 countries (Afghanistan, Democratic Republic of Congo, Egypt, Ghana, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda) to document levels and variability in quality and to examine differences between public and private health facilities. We analyse cross-sectional data from 21,850 antenatal consultations directly observed across these settings. Clinical quality is measured as the proportion of essential actions completed by healthcare providers during consultations, including history taking, physical examinations, and the recommendation of appropriate tests and treatments. Overall, the clinical quality of antenatal care is alarmingly low, with providers completing on average only 39% of recommended actions (median 37.5, interquartile range 21.7-55.6). Quality varies substantially both within and between countries and is poorly predicted by commonly used proxies such as facility infrastructure, medication availability, or staffing levels. Although private for-profit facilities are generally better equipped and staffed and charge fees nearly five times higher than those in public facilities, there is no evidence that they provide higher-quality antenatal care. These findings indicate that the clinical quality of antenatal care remains low in resource-poor settings. It remains unclear to what extent increases in antenatal care utilization - long emphasised in international development targets - will translate into improved maternal and neonatal outcomes, given the low quality of care currently being delivered. The results also provide no evidence to suggest that greater reliance on private-sector provision would improve quality.