Building an effective coverage cascade for antenatal care: linking of household survey and health facility assessment data in eight low- and middle-income countries.

Background: Substantial gaps exist between pregnant women's contact with health facilities and the quality of care they receive (effective coverage) in low- and middle-income countries (LMICs). An effective coverage cascade is a useful analytical approach to uncover gaps due to poor facility service readiness and quality of care. We estimated readiness-adjusted antenatal care (ANC) coverage and built an effective coverage cascade in countries with available data. Methods: We used data from latest household and health facility surveys in eight countries accounting for 28 925 women and 8621 facilities. Service readiness was assessed based on the availability of core items needed to provide quality ANC. We linked the household surveys with health facility data by subnational region and facility type to estimate readiness-adjusted ANC coverage for at least one, four, and eight or more ANC contacts and ANC content. We built a four-step ANC effective coverage cascade and calculated loss of coverage in terms of ANC readiness coverage gaps and missed opportunities. Results: The majority of women sought ANC services in lower-level facilities, except in Bangladesh, Nepal and Senegal. While at least one antenatal care contact (ANC1+) service coverage was high, ranging from 89.2% (95% confidence interval (CI) = 87.2-90.9) in Haiti to 98.1% (95% CI = 97.5-98.6) in Malawi, readiness-adjusted ANC1+ coverage was lower, ranging from 64% (95% CI = 62.4-65.5) in Haiti to 76.2% (95% CI = 75.1-77.2) in Nepal. We obtained readiness gaps as high as 33.7 percentage points in Malawi and missed opportunities of 21 percentage points in Tanzania. Poor diagnostic capacity and insufficient trained human resources drove the low ANC facility readiness. We found large inequalities in readiness-adjusted ANC1+ by socioeconomic status favouring wealthier and urban resident women. Conclusions: The effective coverage cascade for ANC services helped uncover large readiness gaps, missed opportunities, and socioeconomic inequalities. Improvements in facilities' diagnostic capacity and availability of trained human resources will enhance their ability to provide high quality health services and ensure health gains.