The development and application of a new tool to assess the adequacy of the content and timing of antenatal care

Abstract

Abstract
Background: Current measures of antenatal care use are limited to initiation of care and number of visits. This
study aimed to describe the development and application of a tool to assess the adequacy of the content and
timing of antenatal care.
Methods: The Content and Timing of care in Pregnancy (CTP) tool was developed based on clinical relevance for
ongoing antenatal care and recommendations in national and international guidelines. The tool reflects minimal
care recommended in every pregnancy, regardless of parity or risk status. CTP measures timing of initiation of care,
content of care (number of blood pressure readings, blood tests and ultrasound scans) and whether the
interventions were received at an appropriate time. Antenatal care trajectories for 333 pregnant women were then
described using a standard tool (the APNCU index), that measures the quantity of care only, and the new CTP tool.
Both tools categorise care into 4 categories, from ‘Inadequate’ (both tools) to ‘Adequate plus’ (APNCU) or
‘Appropriate’ (CTP). Participants recorded the timing and content of their antenatal care prospectively using diaries.
Analysis included an examination of similarities and differences in categorisation of care episodes between the
tools.
Results: According to the CTP tool, the care trajectory of 10,2% of the women was classified as inadequate, 8,4%
as intermediate, 36% as sufficient and 45,3% as appropriate. The assessment of quality of care differed significantly
between the two tools. Seventeen care trajectories classified as ‘Adequate’ or ‘Adequate plus’ by the APNCU were
deemed ‘Inadequate’ by the CTP. This suggests that, despite a high number of visits, these women did not receive
the minimal recommended content and timing of care.
Conclusions: The CTP tool provides a more detailed assessment of the adequacy of antenatal care than the
current standard index. However, guidelines for the content of antenatal care vary, and the tool does not at the
moment grade over-use of interventions as ‘Inappropriate’. Further work needs to be done to refine the content
items prior to larger scale testing of the impact of the new measure.