Facility and healthcare worker characteristics.

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.

提高高质量产前保健的可及性，对于降低中低收入国家（low- and middle-income countries, LMICs）的孕产妇与新生儿死亡率至关重要，但目前有关保健质量的系统性证据仍较为匮乏。本研究利用覆盖13个国家（阿富汗、刚果民主共和国、埃及、加纳、海地、肯尼亚、马拉维、纳米比亚、尼泊尔、卢旺达、塞内加尔、坦桑尼亚及乌干达）的全国代表性数据，提供了迄今为止对中低收入国家产前保健临床过程质量最全面的概述，旨在记录保健质量的水平与变异程度，并对比公立与私立卫生机构间的质量差异。本研究分析了上述地区直接观测得到的21850例产前就诊横断面数据。临床质量以医护人员在就诊过程中完成的必要诊疗操作占比进行衡量，涵盖病史采集、体格检查以及推荐恰当的检查与治疗方案。整体而言，产前保健的临床质量低得令人堪忧，医护人员平均仅完成39%的推荐操作（中位数为37.5，四分位距为21.7~55.6）。保健质量在国家内部及国家间均存在显著差异，且常用的替代指标（如机构基础设施、药物可及性或人员配备水平）难以有效预测其质量水平。尽管营利性私立卫生机构通常配备更完善、人员更充足，且收费几乎是公立机构的五倍，但并无证据表明其提供的产前保健质量更高。上述研究结果表明，在资源匮乏的环境中，产前保健的临床质量仍处于较低水平。鉴于当前保健服务的质量低下，国际发展目标中长期强调的提高产前保健利用率，能在多大程度上转化为孕产妇与新生儿结局的改善，目前仍不明确。本研究结果也未提供证据表明，加大对私立卫生服务供给的依赖能够提升保健质量。