Enhanced quality of nutrition services during antenatal care through interventions to improve maternal nutrition in Bangladesh, Burkina Faso, Ethiopia, and India.

Background: Quality antenatal care (ANC) services are critical for maternal health and nutrition. Information on the quality of nutrition interventions during ANC is scarce in low- and middle-income countries. We examined the effects of intensified maternal nutrition interventions during ANC on service readiness, provision of care, and experience of care and assessed the inter-relationships between the dimensions of quality. Methods: We used data from impact evaluations of maternal nutrition interventions in Bangladesh, Burkina Faso, Ethiopia, and India. We calculated the quality of nutrition services during ANC using information from health facility assessments, health care provider interviews, ANC observations, and client exit interviews. We used structural equation models to examine relationships between the dimensions of quality. Results: Health facilities in all four countries had a high service readiness component in terms of basic amenities, equipment and supplies, medicines and commodities, and guidelines (mean (x̄) = 8-10 in Bangladesh and Burkina Faso, x̄ = 7-9 in Ethiopia, and x̄ = 6-8 in India). Scores for provision of care were low across the countries but higher in intervention compared to control areas in Bangladesh (5.2 vs. 2.9) and Burkina Faso (5.6 vs. 4.8), but not significantly different in Ethiopia (range = 4.7-5.0) and India (range = 2.6-3.5). For experience of care, client satisfaction scores were high and similar between intervention and control areas in all countries (range = 8.3-9.7), but client experience scores were lower with statistically significant differences observed only in Bangladesh (x̄ = 8.2 in intervention vs. x̄ = 7.1 in control areas). The interventions had significant direct effects on service readiness in Bangladesh (β = 0.07), Burkina Faso (β = 1.20), and Ethiopia (β = 1.0), on the provision of care in Bangladesh (β = 2.27), Burkina Faso (β = 1.27), and India (β = 0.96), and experience of care in Bangladesh (β = 0.21). Conclusions: In this study, we provided evidence on various dimensions of service quality that may be improved by interventions to strengthen nutrition services during ANC in diverse low- and middle-income countries.