In 2016, the World Health Organization (WHO) changed its Antenatal Care (ANC) guideline from a focused ANC model (1) to a standard ANC model, to reduce perinatal mortality and improve womens experience of care. The standard model contains 49 recommendations which are grouped into five types of interventions.The new recommendations include calcium supplementation throughout pregnancy to reduce the risk of pre eclampsia (nutritional intervention), systematic screening for active tuberculosis and early ultrasounding (maternal and fetal assessment intervention), up to six month dosing with sulfadoxine-pyrimethamine (SP) for preventing malaria, seven day antibiotic regimen for asymptomatic bacteriuria (preventive measures intervention) and a minimum of eight contacts with a skilled health personnel, to reduce perinatal mortality and improve womens experience of care (health systems intervention) (2, 3). Despite the expected benefits, there are financial concerns in developing countries, particularly in countries that failed to effectively implement the more simple focused model (4–6). Implementation of the standard model with anticipated increased resource requirements need to be considered in the light of resource scarcity and other competing priorities.
The basic version of a focused model recommends four visits for a normal pregnant woman, i.e. one visit in each first and second trimesters and two visits in the third trimester. In this model, recommendations fall within screening, providing therapeutic interventions and educating pregnant women. The implementation manual suggests that, all services should be provided at the ANC unit, where rapid and easy to perform test should be available. It also suggests that, the activity-time should be between 30 minutes and 40 minutes during the first visit, and 20 minutes for each of the subsequent three visits (1). Women requiring special care follows a different version but are eligible to the basic one afterwards.
Tanzania adapted the focused ANC model in 2002, and is still using it to screen, provide therapeutic interventions and educate pregnant women(7). Screening for malaria at the first ANC visit is an add on recommendation The majority of pregnant women receive care from nurses and midwives at primary health facilities (dispensaries and health centers), but are referred to higher levels when special care is needed (7, 8). On daily basis, a group health education session is followed up by indivualized assessment, screening, provision of medicine interventions and education. During screening, tests missing at ANC clinic are requested from a facility laboratory, which means activity-time may exceed that recommended by WHO.
Although Tanzania has documented improvement in focused ANC implementation such that 98% of pregnant women visit ANC at least once and 51% manage to complete four visits (9), there are remaining challenges. For example, only 24% of all pregnant women go for their first visit before the 4th month of pregnancy, and there are reports of underutilization, inadequate service provision, poor quality of care and scares resources (4, 7, 9–15).
Few studies have documented resources used for ANC in Tanzania and none have considered the costs of implementing a standard ANC model. Von Both (2008) estimated consultation costs from the health system perspective to be US$2.5 per visit (16), while Kowalewski (2002) estimated indirect user cost of US$9.9 per visit at primary health facilities (17). Another study in rural areas of southern Tanzania (2009) reported a cost of US$16.4 per visit from a health system perspective (18). In 2015, a study in the neighbouring country Rwanda estimated a cost of US$10.65 per visit (19) under the focused model and US$9.9 per visit after addition of some recommendations from the standard model (20), both from a health system perspective.
WHO's recommendations influences guideline updates in developing countries, yet country level economic evidence to support such decisions are scarce while resources for implementation are limited. Therefore, our objective was to estimate the cost of providing ANC services at primary health facilities in Tanzania under two scenarios: (1) the current practice, which reflects a suboptimal implementation of the focused ANC model, and (2) a hypothetical but full implementation of new recommendations from the standard ANC model on the same population.