Antenatal care – at least four visits
The number of women of reproductive age (15-49 years) with a live birth in a specified reference period who received antenatal care (ANC) four or more times from any provider is expressed as a percentage of women in the same age range with a live birth in the same period.
Routinely collected administrative data; population-based household surveys
Routinely collected administrative data:
Data from routinely collected and compiled administrative data sources will provide information as recorded in medical charts/records or registers and are entered into national and/or subnational health information systems:
- Health information management system (HMIS) and/or
- District Health Information Management System (DHIS2).
Routinely collected administrative data and health facility statistics are the preferred data source in settings with a high utilization of health facility services and data are recorded in a manner that ensures good data quality for both the public and private health sectors.
Key source of data: Administrative data sources include health facility and health services data abstracted from obstetric and neonatal medical records. Relevant information is recorded about the number and timing of ANC visits among all women who attended ANC during pregnancy within health facilities on paper forms completed by health personnel and/or through an electronic medical record. Data from paper or electronic sources are entered or abstracted into a database or registry and are compiled and analyzed within the national and/or subnational HMIS. The Ministry of Health (MoH) and/or National Statistical Offices (NSO) are usually responsible for the reporting of this indicator.
Indicator definition and calculation: The indicator is calculated as the percentage of women who received ANC four or more times by any provider among women with an ANC visit in a health facility during a specified reference period.
(Number of antenatal clients with a fourth ANC visit in a specified time period / Number of antenatal clients with a first ANC visit in a specified time period) x 100
Unless specified, the statistic may include any woman regardless of age and includes both live births and stillbirths, as defined by the health facility and/or national or subnational vital statistics offices.
The numerator and denominator definition of ANC is based on individual health facility report or is in accordance with the country-specific definition by the MoH and/or NSO.
Frequency of measurement: The indicator can be calculated on an annual basis or may be tracked on a more frequent and ongoing basis (e.g. monthly, quarterly), depending on facility, subnational and national processes for data entry, compilation and analysis. As a guide, the recommended frequency of measurement based on reporting level is outlined below:
- Facility level: Monthly, quarterly, or as needed based on the country and/or facility need
- Subnational (first and second administrative) level: Monthly or quarterly
- National level: Annually (data can be aggregated to provide national-level data).
Disaggregation: By level of facility, location of facility (e.g. urban, rural), type of health personnel, and timing of ANC visit.
Missing values: Missing values are usually not known, or not reported.
Population-based household surveys:
The main source of data for this indicator has been through population-based household surveys collected through nationally or subnationally representative and statistically sound questionnaires, such as:
- Demographic Health Surveys (DHS) (1)
- Multiple Indicator Cluster Surveys (MICS) (2)
- Reproductive Health Surveys (RHS)
- Other household surveys with a similar methodological design
Population-based household survey data are the preferred data source in settings with a low utilization of health facility services, or where private health sector data are excluded from routinely collected administrative data sources.
Key source of data: Eligible women of reproductive age (15–49 years) are identified in the household survey for inclusion and interviewed using an individual women’s questionnaire. Women are considered eligible for survey interview if they are either usual residents or visitors of the household who stayed there the night before the interview.
All eligible and interviewed women between 15 and 49 years of age who had a live birth during a specified reference period, typically 2–5 years prior to the time of interview, are asked “Did you see anyone for antenatal care for this pregnancy?”, in reference to the last live birth the individual woman had during the same reference period. If women saw anyone for ANC, they are then asked to identify “How many times did you receive antenatal care during this pregnancy?”
MoH and NSO typically conduct household surveys and compile, analyze and report the results for this indicator in collaboration with the survey program (e.g., DHS, MICS, RHS) and funding agency.
Indicator definition and calculation: Individual women of reproductive age are asked about ANC visits for their most recent live birth. Questions about ANC visits are asked, irrespective of the child’s current living status (dead or alive), and are for live births that they have had during a specified reference period, which is typically 2–5 years before the time of the survey completion.
The definition is as follows:
The percentage of interviewed women (aged 15 to 49 years) with a live birth in the 2–5 years prior to survey completion who received ANC four or more times from any provider.
The indicator is calculated as follows:
(Number of women [aged 15–49 years] with a live birth who received ANC four or more times from any provider / Total number of women [aged 15–49 years] with a live birth) x 100
Frequency of measurement: Household surveys are typically conducted every 3–5 years.
Disaggregation at population level: Type of health personnel, place of delivery, mode of delivery, place of residence (e.g. urban, rural), sex of live birth, birth order, socioeconomic status (e.g. education level, wealth quintile), age of woman at the time of delivery, and births attended by skilled health personnel.
Missing values: Included in the distribution as “don’t know” and/or “missing”
The antenatal period presents opportunities for reaching pregnant women with interventions that may be vital to both maternal, fetal and newborn health and well-being. ANC is a critical component for improving maternal and newborn health and provides a platform for important healthcare functions, including: health promotion, screening and diagnosis, injury and disease prevention, as well as birth preparedness and preparation for the postnatal period. By implementing timely and appropriate evidence-based practices, ANC can reduce morbidity and mortality and optimize overall health and well-being. ANC also provides the opportunity to communicate with and support women, families and communities at a critical time in the course of a woman’s life. ANC comprises effective communication about physiological, biomedical, behavioural, sociocultural issues, as well as emotional and psychological support, to pregnant women in a respectful way (3-5)
This indicator helps program management at global, national and subnational levels by monitoring and evaluating perinatal outcomes and using data to make informed decisions about the planning, development and evaluation of health services delivery and initiatives. The World Health Organization (WHO) previously recommended that pregnant women complete at least four ANC visits. However, new guidelines from the WHO ANC Model (2018) increase the recommended number of contacts a pregnant woman has with health providers throughout her pregnancy from four to eight visits, and future programs should consider measuring based on these guidelines (1).
This indicator should be interpreted with caution as it is a measure of contact with the health system and does not take account the content and quality of care received. Receiving ANC during pregnancy does not guarantee the receipt of evidenced-based interventions that are effective in improving maternal and newborn health and survival. It should not be assumed that women received ANC in accordance with WHO, other international organizations, and/or country-specific recommendations or guidelines. Therefore, this indicator should be complemented with information on the content and quality of interventions received during each ANC contact in order to more effectively monitor and evaluate the effectiveness and impact of maternal and newborn health interventions.
Data collected from administrative and other routine data systems:
Administrative data may suffer from poor quality such as irregularities in report generation, data duplication and inconsistencies (6). Reporting challenges exist at the facility level given data quality issues, including; incomplete, inaccurate and lack of timely data due to insufficient capacity in the health system or inadequate system design.
Many HMIS databases or registries are event-based and only include ANC information for women who delivered a birth at a health facility. In some instances, the denominator may include births delivered by women of an unspecified age range and include both live births and stillbirths. In addition, the definition of a stillbirth varies by country and context, such as differences in inclusion for gestational age (e.g. 20–28 weeks) and birthweight (e.g. ≥ 500 grams). As this often only represents those women who present to health facilities for ANC, it does not capture the number of pregnancies and demand for ANC within the total population. These differences in definitions compromise the ability to compare data between countries.
Administrative data should be interpreted with caution in settings where data quality is poor and the percentage of births at public and private sector health facilities is low, or where data from the private health sector are not compiled within the HMIS reporting.
In settings where routine HMIS data lack information on pregnancies and/or births that occur outside the public sector – for example, in homes or private sector facilities – the total number of births in the HMIS should not serve to estimate the denominator for this indicator. Where data on the total numbers of live births for the entire population for the denominator are unavailable, evaluators can calculate total estimated live births using census data for the total population and crude birth rates in a specified area (total expected live births = estimated population x the total crude birth rate).
Data collected through household surveys:
Women may not be able to accurately recall details around childbirth when data are collected through household surveys (7). There is also a time lag as the recall period is from two to five years before the survey data are collected.
The most commonly used denominator is the number of live births, which acts as a proxy for the number of pregnant women. However, inclusion of only live births underestimates the total number of pregnancies by excluding those that end in stillbirth or spontaneous or induced abortion, as well as ectopic and molar pregnancies. It also causes survivor bias in that only those women who are alive at the time of interview would be included and underestimates the total number of women requiring care during pregnancy.
The indicator usually measures visits with any provider because national-level household surveys do not collect provider data for each visit. In addition, standardization of the definition of health personnel is sometimes difficult because of differences in naming conventions, competencies and training of health personnel between and within countries (8)
For more information on this indicator, see the MoNITOR indicator reference sheet developed by the WHO: Who-indicators (srhr.org)
access, newborn (NB), safe motherhood (SM)
- The DHS Program [website]. Rockville: ICF International; 2020 (http://www.dhsprogram.com/, accessed 21 October 2020).
- Multiple Indicator Cluster Surveys (MICS) [website]. New York: UNICEF; 2020 (http://mics.unicef.org, accessed 21 October 2020).
- WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: World Health Organization; 2016.
- Every Woman Every Child. Indicator and monitoring framework for the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030). Geneva: World Health Organization; 2016.
- Lattof SR, Moran AC, Kidula N, Moller AB, Chayathilaka CA, Diaz T, Tunçalp Ö. Implementation of the new WHO antenatal care model for a positive pregnancy experience: a monitoring framework. BMJ Glob Health. 2020;5(6):e002605 (https://gh.bmj.com/content/5/6/e002605.long, accessed 9 November 2020).
- Abouzahr C, Boerma T. Health information systems: the foundations of public health. Bull World Health Organ. 2005;83(8): 578–83.
- Blanc AK, Diaz C, McCarthy KJ, Berdichevsky K. Measuring progress in maternal and newborn health care in Mexico: validating indicators of health system contact and quality of care. BMC Pregnancy Childbirth. 2016;16(1):255 (https://doi.org/10.1186/s12884-016-1047-0, accessed 21 October).
- Definition of skilled health personnel providing care during childbirth: the 2018 joint statement by WHO, UNFPA, UNICEF, ICM, ICN, FIGO and IPA. Geneva: World Health Organization; 2018