A cross-sectional study to evaluate antenatal care service provision in 3 hospitals in Nepal

Abi Merriel*, Nashna Maharjan, Gemma Clayton, Miriam Toolan, Mary Lynch, Katie Barnard, Tina Lavender, Michael Larkin, Nisha Rai, Meena Thapa, Deborah M. Caldwell, Christy Burden, Dharma S. Manandhar, Abigail Fraser

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


BACKGROUND: Globally, many mothers and their babies die during pregnancy and childbirth. A key element of optimizing outcomes is high-quality antenatal care. The Government of Nepal has significantly improved antenatal care and health outcomes through high-level commitment and investment; however, only 69% of patients attend the 4 recommended antenatal appointments. OBJECTIVE: This study aimed to evaluate the quality and perceptions of antenatal care in Nepal to understand compliance with the Nepalese standards. STUDY DESIGN: This cross-sectional study was conducted at a tertiary referral and private hospital in Kathmandu and a secondary hospital in Makwanpur, Nepal. The study recruited 538 female inpatients on postnatal wards during the 2-week data collection period from May 2019 to June 2019. A review of case notes and verbal survey of women to understand the pregnancy information they received and their satisfaction with antenatal care were performed. We created a summary score of the completeness of antenatal care services received ranging from 0 to 50 (50 indicating complete conformity with standards) and investigated the determinants of attending 4 antenatal care visits and patient satisfaction. RESULTS: The median antenatal care attendance was 4 visits at the secondary and referral hospitals and 8 visits at the private hospital. However, 24% of the patients attended <4 visits. Furthermore, 117 of 538 patients (22%) attended the first-trimester visit, and 65 of 538 patients (12%) attended visits at all points recommended in the standards. More than 90% of the women had blood pressure monitoring, hemoglobin estimation, blood grouping and Rhesus typing, and HIV and syphilis screening. Approximately 50% of the women had urinalysis at every visit (interquartile range, 20–100). Moreover, 509 of 538 patients (95%) reported receiving pregnancy information, but retention was variable: 509 of 538 patients (93%) received some information about danger signs, 290 of 502 patients (58%) remembered headaches, and 491 of 502 patients (98%) remembered fluid leaking. The antenatal care completeness score revealed that the private hospital offered the most complete clinical services (mean, 28.7; standard deviation, 7.1) with the secondary hospital performing worst (mean, 19.1; standard deviation, 7.1). The factors influencing attendance at 4 antenatal care visits in the multivariable model were beginning antenatal care in the first trimester of pregnancy (odds ratio, 2.74; 95% confidence interval, 1.36–5.52) and having a lower level of education (no school: odds ratio, 0.46 [95% confidence interval, 0.23–0.91]; grades 1–5: odds ratio, 0.49 [95% confidence interval, 0.26–0.92]). Overall, 303 of 538 women (56%) were satisfied with their antenatal care. The multivariable analysis revealed that satisfaction was more likely in women attending the private hospital than in women attending the referral hospital (odds ratio, 3.63; 95% confidence interval, 1.68–7.82) and lower in women who felt the antenatal care facilities were not adequate (odds ratio, 0.35; 95% confidence interval, 0.21–0.63) and who wanted longer antenatal appointments (odds ratio, 0.5; 95% confidence interval, 0.33–0.75). CONCLUSION: Few women achieved full compliance with the Nepali antenatal care standards; however, some services were delivered well. To improve, each antenatal contact needs to meet its clinical aims and be respectful. To achieve this communication and counseling training for staff, investment in health promotion and delivery of core services are needed. It is important that these interventions address key issues, such as attendance in the first trimester of pregnancy, improving privacy and optimizing communication around danger signs. However, they must be designed alongside staff and service users and their efficacy tested before widespread investment or implementation.

Original languageEnglish
Article number100015
JournalAJOG Global Reports
Issue number3
Early online date30 Jun 2021
Publication statusPublished - Aug 2021

Bibliographical note

© 2021 The Authors. Published by Elsevier Inc. This
is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/bync-nd/4.0/)


  • accessing care
  • antenatal care
  • developing countries
  • Nepal
  • pregnancy care
  • quality improvement
  • service evaluation


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