Coverage and timing of antenatal care among poor women in 6 Mesoamerican countries

Substantial research has demonstrated the importance of antenatal care (ANC) for improving maternal, infant, and child health outcomes [1‐3]. ANC allows providers to prevent, detect, and manage obstetric complications, and is associated with a reduced risk of maternal mortality, premature birth, and low birth weight [4‐6]. ANC also links women to intra- and post-partum services such as skilled birth attendance and child vaccinations [7, 8].

ANC is particularly important for poor women, who frequently face obstetric risk factors such as inadequate nutrition, limited education, and low health literacy [9]. However, while poor women have the greatest need for ANC, they are also often the least likely to attend care. Such disparities are highlighted in Latin America and the Caribbean, which has the highest income inequality of any region in the world [10]. For instance, a 2014 study found that 97.8 % of Latin American women with a secondary education attended at least one ANC visit, compared to only 74.3 % of those without education [11]. Individual countries have recorded even wider disparities, including a 2006-07 study in Nicaragua which found that 92 % of women in the wealthiest quintile attended at least four ANC visits compared to only 61 % of women in the poorest quintile [12].

Studies of ANC in low and middle income countries frequently conclude that poverty is strongly associated with a lack of ANC [11]. However, despite being identified as a priority group, much less is known about the characteristics of these poor women and the specific barriers they face. This study aims to describe ANC coverage and timing among women living in the poorest areas of six Mesoamerican countries. We assess the variation in coverage among these poor populations, and identify demographic and household factors associated with ANC care that can be used to develop and target interventions to reduce health disparities.

We collected data from 8366 women giving birth in the past two years in El Salvador, Guatemala, Honduras, Mexico, Nicaragua, and Panama (Table 1). Approximately 15 % of women in our study were under 20 years old and the average number of total children ranged from 2.5 in Nicaragua to 3.5 in Panama. The majority were married (84 %) and homemakers (91 %). The percent of sampled women with no education ranged from 6 % in Honduras to 30 % in Guatemala. Women lived in a home with a female head of household 16 % of the time, ranging from 8 % in Mexico to 26 % in in Nicaragua and El Salvador. Most households (76 %) were located in a rural area. On average, households spent $33.13 per capita per month.

Insurance coverage was highest in Mexico (83 %), Guatemala (11 %), and El Salvador (8 %). Among those insured in Mexico, the vast majority (95 %) were insured by Seguro Popular. Approximately 9 % of women reported experiencing previous obstetric complications (a past stillbirth or miscarriage) and 13 % had heavy vaginal bleeding during the pregnancy of interest. Salvadoran women were most likely to have received CHW counseling in the past month (40 %), and Nicaraguans had the most media exposure in this period (90 % with any exposure to TV, radio, or newspaper). Nearly a third (32 %) of women lived within 15 min of their usual health facility, while over a fifth (21 %) were more than an hour away.

To our knowledge, this is the largest study of ANC coverage and timing conducted among poor women in Mesoamérica. The results reveal substantial variation in coverage across and within countries, and demonstrate that many women are not meeting ANC guidelines. While predictors of attending skilled ANC varied by country, low maternal education, adolescent pregnancies, unwanted pregnancies, speaking an indigenous language, high parity, lack of media exposure, and being unmarried were significant in multiple countries and consistent with the findings of a systematic review of ANC risk factors in developing countries [19].

Our study comes in the context of numerous efforts to reduce health disparities and achieve universal health coverage in Latin America and the Caribbean [20]. Some countries have been highly successful, such as Cuba, where 98 % of women attend four ANC visits [21]. Several countries in our study have implemented significant pro-poor programs in recent years. Nicaragua and El Salvador both underwent dramatic health reforms in the late 2000s to decrease out-of-pocket expenditures, introduce community outreach teams, and prioritize services for the poor [22, 23]. Honduras has been implementing its program for Accelerated Reduction of Maternal and Child Mortality (RAMNI) since 2008, which uses performance-based contracts for antenatal and other services in the poorest regions of the country [16]. Mexico has two well-known programs for the poor that encourage antenatal care: the Seguro Popular health insurance scheme, and the Prospera (formerly called Oportunidades) conditional cash transfer program, which directly support and incentivize ANC [24]. Despite all these efforts, universal ANC coverage has not been achieved, and a combination of demand and supply interventions are urgently needed in poor communities.

While barriers to ANC vary by country, several common findings emerge. First, countries should prioritize health services for, and seek to empower, the most vulnerable groups of women. This includes women who are unmarried, less-educated, adolescents, or indigenous. Qualitative research has identified social factors such as machismo and disempowerment as key barriers to women’s reproductive health autonomy, and many studies have established the important influence of women’s education on maternal and child health knowledge, behaviors, and outcomes [25, 26]. Women’s empowerment is also closely related to preventing unplanned pregnancies. Our study reinforces the finding that women who lack control over their fertility are less likely to know that they are pregnant, delaying their efforts to seek care [27]. This is a particular challenge in Nicaragua, where a third of women had not wanted to become pregnant, as well as in Panama, El Salvador, and Honduras. In addition to addressing the previously mentioned social factors, improving women’s access to family planning will require health system improvements. For instance, although Nicaragua’s National Health Plan prioritizes family planning, our baseline survey of health facilities for SMI found that many facilities still lacked contraceptive supplies [13]. Countries should strengthen family planning services to decrease unwanted pregnancies, and in particular should focus on programs targeting adolescents and culturally appropriate services for indigenous communities.

Another consistent finding is a strong association between media exposure and ANC attendance. This may reflect undetected differences in wealth status and living conditions, which could confound the relationship between media exposure and ANC attendance. While our finding does not draw a causal link between media messages and ANC, it does tell us that many of the women who are not attending ANC cannot be reached through mainstream media. Health programs should seek alternate forms of communication to reach these high-risk populations, such as sending health workers to communities or organizing women’s groups [28].

Additional context-specific challenges are also present in Guatemala and Panama, which had the lowest skilled ANC attendance. First, the SMI regions in these two countries, along with Mexico, contain largely indigenous populations. Guatemala’s extremely low skilled ANC rates are largely explained by women attending ANC visits with auxiliary nurses, who are not considered skilled providers. While our estimates for seeing any skilled or unskilled provider in Guatemala (84 %) were very similar to what was reported for a 2008-09 national survey (90 %), we found the proportion attending at least one visit with a skilled provider was less than one third [29]. A social network study in Guatemala also revealed that decision making about ANC is strongly influenced by women’s mothers, partners, and mothers-in-law [30]. In Panama, it is important to note that SMI is operating in two highly inaccessible regions. Therefore, it is unsurprising that our estimates of ANC coverage (87 % any ANC, 78 % at least one skilled ANC) are lower than the estimates reported for all rural women by a 2009 national survey (96 % any ANC) [31]. The geographic barriers facing women in these communities are especially influential, and will require creative solutions such as mobile teams to provide ANC. There are also supply barriers in both of these countries, and women are discouraged from attending ANC by a lack of laboratories and ultrasounds at nearby health facilities [30].

Our study has several limitations that should be considered when interpreting its findings. First, we relied on self-report by the women about their antenatal care. We minimized recall bias by restricting our analysis to births occurring in the past two years, but it will be important to compare our results with information about the timing and number of ANC visits from medical records. Additionally, the only way our study classifies “skilled” ANC is based on an international standard of provider type, and this can vary in practice by country. We did not analyze the quality of the ANC, which could imply additional efforts from countries that have already achieved high coverage of timely and continuous ANC with skilled providers. However, our study benefits from a large sample size, a current census that ensures representativeness, and a standard methodology allowing for comparison across countries.

Early and ongoing ANC is crucial for ensuring the health of both mothers and children. Our findings call for prioritizing resources to vulnerable groups and designing country-specific interventions to improve ANC coverage and timing in the poorest Mesoamerican communities. While our study found large gaps in ANC coverage, we also identified many municipalities within the poorest regions of each country where most women are meeting ANC standards. This is encouraging news for public health planners, as successful municipalities may offer effective practices to improve ANC in similarly impoverished communities across the region. Qualitative studies to identify best-practices from top performing areas and better understand the factors influencing women’s choices and health system bottlenecks can help guide the development of programs.

ANC, antenatal care; CAPI, computer-assisted personal interview; CHW, community health worker; CI, confidence interval; OR, odds ratio; SMI, Salud Mesoamérica Initiative; WHO, World Health Organization