Antenatal care service readiness and associated factors in health facilities across Afghanistan, Bangladesh, and Nepal: a comparative analysis.

backgroundAlthough antenatal care (ANC) is one of the key interventions for maternal and newborn health, simply providing ANC does not mean that facilities will be ready to provide quality care. Afghanistan, Bangladesh and Nepal made progress in maternal health services but with much variation across the three countries as they have differing degrees of fragility of their health systems, governance and geography and service-delivery arrangements. However, comparative evidence using standardized facility-readiness indicators is scarce. This study assessed and compared ANC service readiness and its associated facility-level factors in health facilities across these three countries.

methodsThis was a secondary analysis of nationally representative cross-sectional health facility survey data on ANC readiness indicators: Afghanistan Service Provision Assessment (2018-2019), Bangladesh Health Facility Survey (2017) and Nepal Health Facility Survey (2021). In the analytical sample, 95 facilities in Afghanistan, 1,495 in Bangladesh and 1,494 in Nepal provided ANC. The primary outcome was an equally weighted composite ANC readiness score ranging from 0 to 20, where higher scores indicate greater readiness to provide ANC. Negative binomial regression models including adjustments for complex survey design were fitted in each country. Findings are interpreted as country-specific survey-period estimates rather than pooled causal country effects, because surveys were carried out in different years and situations vary across health-systems.

resultsThe mean ANC readiness scores were Afghanistan (11.90 ± 3.81), Nepal (11.46 ± 2.50), and Bangladesh (9.87 ± 2.97). All these countries consistently showed that availability of ANC- providers and better basic amenities predict an increase in readiness. Facilities charging fixed user fees also showed higher readiness in Bangladesh (Incidence rate ratio [IRR] = 1.07) and Nepal (IRR = 1.07). In Afghanistan, public facilities had lower readiness (IRR = 0.56) than private, while government funding improved it (IRR = 1.35). Readiness also varied significantly by province. In Bangladesh, external supervision (IRR = 1.12) and client opinion review (IRR = 1.05) enhanced readiness, but compared with non-government organization clinics/hospitals, all other facility type demonstrated significantly lower readiness. In Nepal, primary health care centers were more ready than federal hospitals (IRR = 1.12), and routine quality assurance (IRR = 1.04) and management meetings (IRR = 1.05) positively influenced readiness.

conclusionANC-trained providers and basic amenities were common determinants of readiness in all three countries: however, context-determined the influence of managing authority, funding, supervision and facility type. Findings should be interpreted in context of the differing survey years and health-system settings. Context-specific interventions are needed to strengthen ANC readiness for better maternal health service delivery outcomes in South Asia.