From visit counts to quality care: A qualitative study on early implementation of a new model for antenatal care in Kavre district, Nepal

In 2016, WHO updated its antenatal care (ANC) guidelines, increasing the minimum number of ANC visits from four to eight and recommending practices for those visits. Nepal adopted this new ANC model in 2022, but limited research has examined how the model has been implemented. This study explored the perspectives of pregnant women, ANC providers and local policymakers on the rollout of the new ANC model in Kavre district of Nepal. We conducted an exploratory qualitative study involving interviews with pregnant women, ANC providers and local policymakers along with semi-structured facility observations. Six primary care level government health facilities offering ANC services were purposively selected from three municipalities of Kavre district, Nepal. Data included eight interviews with pregnant women, seven with providers and three with local policymakers along with field notes from observations in six facilities. Interview transcripts and observation field notes were coded manually and analyzed thematically. Three major themes emerged from the analysis of the interviews and observations. Providers and policymakers viewed the new ANC model mainly as increase in visit frequency for documentation rather than enhanced quality care. Although orientation on the increased number of visits was presented to providers, most providers lacked understanding on the content and purpose of each visit. Pregnant women, particularly those in rural areas, reported logistical, financial and physiological challenges in completing all recommended visits and accessing care at referral sites. Implementation of new ANC model in Kavre district largely remained focused on visit quantity rather than quality. Strengthening provider’s capacity, ensuring availability of guidelines, enhancing understanding of its purpose and implementation, and fostering person centered care are essential to achieve the intended benefits of the model.