Prevalence and determinants of readiness of health facilities for quality antenatal care services in Bangladesh

The quality antenatal care (ANC) services can reduce the risk of the pregnancy complications, and 3 hence reduce the maternal and child morbidity and mortality. To ensure the quality ANC services 4 to the pregnant women, it is essential that healthcare providers should be fully prepared with six 5 tracer indicators recommended by World Health Organization. In this study, the prevalence of 6 readiness by selected covariates has been examined. Potential factors responsible for the readiness 7 have also been identified. Using data from nationally representative Bangladesh Health Facility Survey (BHFS), 2017, the 10 readiness indices of health facilities providing ANC services have been measured based on the six 11 tracer indicators of the service. The chi-square test has been applied to check the association of 12 selected covariates with the readiness index, and to obtain the adjusted associations of covariates, 13 we have carried out a multinomial logistic regression model. A huge gap has been found in the facilities of Bangladesh to prove quality ANC services. This is 23 a high time to reduce this gap in achieving sustainable development goals related with maternity 24 and neonatal mortality. The present study recommends that the government of Bangladesh should 25 take necessary initiatives to fully prepared healthcare providers so that quality ANC services can 26 be equally provided to each pregnant woman. 27 30 31


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A huge gap has been found in the facilities of Bangladesh to prove quality ANC services. This is 23 a high time to reduce this gap in achieving sustainable development goals related with maternity 24 and neonatal mortality. The present study recommends that the government of Bangladesh should 25 take necessary initiatives to fully prepared healthcare providers so that quality ANC services can 26 be equally provided to each pregnant woman. Antenatal care (ANC) is a widely accepted accessible and cost-efficient way to improve maternal 42 and perinatal health outcomes [1]. ANC links women with health system and helps them to get 43 proper information and advice regarding pregnancy complications, postnatal care including 44 newborn care, promotion of early and exclusive breastfeeding, and planned birth spacing [2][3][4]. 45 Therefore, negative pregnancy outcomes can be impeded by identifying and treating maternal 46 health compilations during pregnancy through ANC [2] . Better quality antenatal care can promote 47 a woman to choose skilled care for herself and her child at and after birth of the child [5][6][7][8]. 48 Furthermore, ANC could prevent maternal and neonatal deaths through prevention, treatment 49 during pregnancy and also skilled care at and after childbirth [9]. Reducing maternal mortality 50 ratio (MMR) as well as neonatal mortality rate (NMR) is considered as one of the global key 51 priorities. In order to ensure this, the international community has adopted the third sustainable 52 development goal (SDG 3) which aims to reduce MMR and NMR to 70 per 100000 live births and 53 12 per 1000 live births, respectively by 2030 [10]. Despite some achievements, around 295000 54 maternal deaths and 2.4 million neonatal deaths occur worldwide [10,11]. Low resource countries 55 account for majority of these deaths and most could be prevented if women had access to antenatal 56 care [11][12][13]. As the reason for most maternal deaths is pregnancy or childbirth related 57 complications, quality ANC could reduce such complications and hence results in lower maternal 58 mortality [12]. Again, the risk of morbidity and mortality of their children can also be reduced by 59 ensuring adequate maternity care during pregnancy [14]. 60 Although four ANC visits during pregnancy are required to ensure the safety of mothers and 61 their children, World Health Organization (WHO) recently revised ANC guidelines for most 62 efficacious pregnancy outcomes [4,15]. According to new guidelines, a minimum of eight ANC 63 5 visits in the absence of complications is recommended throughout pregnancy period, which will 64 be challenging for developing countries to achieve this target due to many barriers [15]. Moreover,65 in order to meet this challenge, health facilities need to be well prepared with trained staffs, 66 medicines, equipment, and infrastructure [8]. The availability and readiness to offer the services 67 are important determinants of health care service utilization [8]. Increasing ANC utilization is 68 essential to improve maternal and newborn health outcomes, but it fails to meet the targets of SDG 69 3 if quality ANC offered by health facilities is poor [16,17]. Availability of services is deemed 70 as a primary requirement for high-quality care delivery: and investigating readiness of healthcare 71 providers is critical for understanding quality of care [16]. Therefore, examining readiness to offer 72 ANC is required to improve quality of ANC.

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Although some progress has been made over the last two decades, Bangladesh  This study utilized data derived from nationally representative Bangladesh Health Facility Survey  In this study, in order to assess the readiness of antenatal care services, the facilities which offer 114 antenatal care services were selected. Among the interviewed facilities, 1505 facilities were 115 reported available to provide ANC services and those facilities were taken in this study. Again, 116 data have been weighted i.e., complex survey design has been used in the study in order to avoid 117 overestimation or underestimation problem.

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Outcome Variable 119 We used service availability and readiness assessment (SARA) reference manual of WHO to 120 identify the items or tracer indicators that a facility needs to offer quality ANC services [30]. To 121 define the readiness of facilities providing antenatal care, less restrictive as well as Bangladesh 122 context-oriented version of ANC service readiness measure has been applied in this study [2]. To 123 serve this purpose, six tracer indicators under five domains given in Table 1  In the study, outcome variable was readiness of health facilities to offer antenatal care services.

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The readiness index was created by WHO approach, where equal weights were given to each 129 8 domain of indicators/ items and also to each item at each weighted domain for providing antenatal 130 care services. The above six items are considered for each facility and summed up to generate 131 weighted mean readiness score [8,28,30,31]. Finally, mean score was multiplied by 100 to obtain 132 the results of readiness score in percentage. Mathematically, the readiness score for the ℎ facility  Based on the readiness scores, the health facilities were divided into three categories in this 141 study. The facilities with readiness score 75 or below are considered as having low readiness; 142 facilities with 75 to 99 score considered as having moderate readiness; and facilities with 100 score 143 considered to be highly ready (complete readiness) to offer antenatal care services. Thus, the 144 readiness score was categorized as low, medium and high readiness in this study.

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In the study, based on the previous studies on readiness of health facilities, the six covariates were To obtain the descriptive statistics for the selected variables, percentage frequency was computed.

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To check associations between several covariates and readiness of antenatal care services, the chi-171 square test was used in the study. Since readiness of antenatal care service is a polytomous outcome 172 variable, multinomial logistic regression model was used to determine adjusted associations of 173 covariates with readiness of facilities [34]. STATA 14 package has been used in the study for 174 analyzing the data.

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Results obtained from univariate and bivariate analyses have been reported in Table 2. Table 3 177 represents the results of regression model.

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The covariates found to be significantly associated with readiness on antenatal care services in 287 bivariate analysis are selected for multivariate analysis. In this study, multinomial logistic 288 regression analysis has been performed considering low readiness as baseline outcome category 289 for the comparison with medium readiness and high readiness.     (Table 3 is here) 355 This study also found some potential factors responsible for lower readiness of health facilities to 356 offer ANC services. In the study, the outcome variable "readiness index" have three categories, patients regarding the hemoglobin test, urine test, blood pressure apparatus and taking of iron or 367 folic acids tablets, the authorities of urban facilities try to provide these necessary ANC services 368 in the facilities. Again, the discrimination between urban and rural facilities was also observed in 369 bivariate analysis for the above services (