Temporal and regional variations in use, equity and quality of antenatal care in Egypt: a repeat cross-sectional analysis using Demographic and Health Surveys

Access to good quality antenatal and skilled delivery care can prevent the majority of maternal and perinatal deaths [1‐5]. Specifically, the role of antenatal care (ANC) in monitoring pregnancy is three-fold: prevention of conditions that may have unfavourable effects on the health of the mother and child, treatment of health problems, and provision of information about pregnancy, childbirth and the postnatal period to the mother [6‐8]. The World Health Organization (WHO) released new recommendations on routine ANC for pregnant women in November 2016 [9]. In addition to increasing the recommended number of ANC contacts from a minimum of four to eight, this recommendation highlighted the importance of quality of care received by women during pregnancy. Following this recommendation, global attention has been shifting from predominantly measuring utilisation (coverage) of ANC to additional considerations of equity and quality of this care in order to tackle remaining preventable morbidity and mortality among women and their babies [10‐13].

In the last three decades, Egypt has seen substantial improvements in maternal survival: a decrease in maternal mortality from 174 per 100,000 live births in 1992–3 [14] to a level of around 33–42 per 100,000 live births by 2015 [15, 16]. This progress was achieved through various strategies to increase utilisation of care, such as provider training, introduction of standards of care, facility upgrades and public awareness campaigns. Some of these interventions were specifically targeted to maternal services, and some were wider programmes aimed at the health system as a whole. Female education levels and modern contraceptive prevalence rate, both of which are linked to better reproductive and maternal health outcomes, also increased during this time period [17]. Yet, substandard care by obstetricians, absent or poor quality antenatal care, and delays in recognising problems and seeking care were identified as the most important avoidable causes of maternal death [17]. ANC is particularly important as a vehicle for communicating information about complications of pregnancy and delivery, and discussing birth preparedness in general.

Egypt has reached near universal coverage with 1+ ANC visits (> 90% in the 2010–2014 period) [18]. With high levels of care utilisation, it is imperative that the focus turns to identifying and closing remaining differences in the provision of good quality care (including both under- and over-medicalisation) [12, 19] and in equitable access to care [20]. Egypt is also a regionally and globally important middle-income country (e.g. in terms of economy, population, culture, and exporting doctors) with a growing population and pressures on public healthcare, evidenced by a growing proportion of care provided by the private sector [18, 21, 22]. Thus, Egypt’s health system and socioeconomic and political context provide an excellent opportunity to formulate targeted policy interventions to ensure equity and quality of care to further improve maternal and newborn health and inform other countries with similar circumstances.

The objective of this paper is to describe the changes over time in the use of ANC in Egypt, focusing on the sector of provision (public versus private), and the content and equity of ANC, nationally and by region, in order to inform future policies.

In this paper, we presented a comprehensive analysis of ANC service use in Egypt over the past three decades using nationally representative data. We showed that Egypt’s improvements in ANC coverage were characterized by women’s decreasing reliance on public-sector services, an increasing number of visits during pregnancy and narrowing regional differences in coverage. Despite improvements in ANC coverage, the percentage of women who received all measured components of care in the latest survey remained very low in both sectors. In addition, we identified differences across wealth groups and regions.

The private sector provided about two-thirds of ANC at the beginning of the period under consideration, increasing to nine out of 10 women using private ANC by the most recent survey. In Egypt, a private ANC visit is estimated to cost 10 times more than a public visit [25] and public ANC services are supposed to be provided free of charge in the morning and for a low fee during the afternoon. Considering that most women have access to public health facilities [14, 26], the large private-sector market share suggests that most women consider the care delivered by public services inadequate [27] and are willing to pay additionally for services. A lack of essential medications and tests [28, 29], an unresponsive system with long waiting times, difficulties booking appointments and lack of provider choice [30] have been previously described at national level [31, 32]. These likely contribute to the increase in use of private providers [32]. In this context, private ANC use is likely to have contributed to the burden of out-of-pocket payments in the country. According to World Bank, out-of-pocket payments amounted to 62% of current health expenditure in Egypt in 2015 [33].

Meanwhile, a tenth of women did not receive any ANC in 2010–2014, particularly in Frontier Governorates and in Upper Egypt, where a large share of Egypt’s low-income households live [34]. Women in the poorest regions report distance, transportation and service fees as persistent barriers to ANC access [35]. Eligible beneficiaries may not be aware of the existence of payment exemptions to poorer families [29], while subsidies aimed at the poorest households appear to have failed to be targeted at such households [25, 36]. To support these women, it is necessary to address the existing bias in the health system towards urban areas [32], focusing the scale-up of services to the areas with the lowest coverage [31]. To ensure women’s access to services, it is fundamental to expand financial protection through social health insurance coverage for the poor and those in the informal sector [31], and ensure that mechanisms of financial support are known to users. Community health workers have been previously successful in informing communities, raising awareness of the importance of services and improving demand for them [37]. This successful experience could be replicated to inform other women of the benefits to which they are entitled.

On the other hand, women from wealthier households and women using private ANC received ever-increasing numbers of ANC visits. This phenomenon is likely driven by factors including profit-making incentives such as selling packaged ANC services with large numbers of visits and the use of unnecessary technologies [12]. Another possibility is that women prefer a higher number of visits, considering this a sign of better, more attentive care. These hypotheses would be consistent with the over-medicalization process observed in the Egyptian system, for example in the form of increased percentages of caesarean sections, [38], which reached 52% of deliveries nationally in 2014 [18].

Despite the increase in the average number of visits, less than a third of women attending public or private ANC reported receiving all assessed components of care. The percentage of women with eight or more visits receiving all such care components was also remarkably low in both the public and private sectors. This is particularly serious considering that all the components assessed should be provided during the first visit, and many of the care components should be performed multiple times over the course of pregnancy according to national guidelines [9, 39]. Thus, providers in both sectors seem to fail to deliver ANC according to national and international guidelines. The lack of some drugs and equipment in the public sector [28, 29, 32] might prevent some women from accessing blood and urine tests and more complex services, while women in the private sector might forego tests and care costed separately. However, four out of the seven measured components do not require sophisticated equipment. Moreover, information on danger signs was the least reported component, despite only requiring providers’ time with women. The reported gap in their provision of these four components suggests that providers’ lack of incentives or knowledge to meet patients’ needs may be partially responsible for inadequate ANC quality. Poor compliance with guidelines, including poor providers’ communication, has been previously reported in Menoufia and Alexandria [30]. A possible solution may be found in an incentive scheme that increased public providers’ likelihood of administering ANC components in Lower and Upper Egypt [40]. However, we observed that provision in private ANC, where salaries were higher, was also poor. Therefore, a combination of strategies targeting quality of care within both public and private sectors should be used to address this issue. Approaches might include the use of performance-based incentives in the public system, or further training and licensing systems focused on quality [31]. Moreover, structural observations of compliance with guidelines should be part of the quality supervision of health facilities [29].

In addition to suboptimal content of care, women from the wealthiest 40% of households and urban regions generally received more components in both public and private sectors compared to the poorest 40% and those in rural regions. Tetanus protection was an exception; vaccinations are provided in the public but not in private sector, with private users referred to the public system to get vaccinated. Reasons for these women getting more components might include women paying to receive more services, or better private care, but also represent differences between less and more educated women, the latter being more aware of the care they should receive. As a result, poorer, less educated and less empowered women might be receiving worse quality of care [25, 41]. To address the existing inequities in care content, interventions will have to focus attention on those reporting the fewest components of care. For instance, performance-based incentives in the public system might be targeted at services provided to less well-off women. Defining the content and price of service packages might also be used to ensure quality [31]. This could be combined with outreach initiatives in target communities [37], to educate women to be aware of the care they should receive. Moreover, improving the participation of informed women could contribute to improve services’ quality [31], for example measuring and placing importance on women’s satisfaction with the health services.

To track future improvements in ANC, there is a need to move away from simply measuring coverage to introduce indicators that support the monitoring and evaluation of quality in ANC [12]. Egypt has already taken steps in the right direction, implementing a antenatal surveillance program to monitor the quality and frequency of antenatal care visits [32]. However, this system also needs to have a focus on disadvantaged groups and regions in order to achieve equity [31]. Equity-focused models, disaggregated by key data, can contribute to identifying barriers and assessing progress in facilities’ capacity to provide services [42]. Future research should inform such equity-focused efforts to improve ANC quality. Questions may include assessing if poor-quality ANC is linked to specific types of providers, identifying the determinants behind poor compliance with guidelines in public and private ANC, and evaluating how the interventions’ described can improve quality and equity.

The limitations of this study are connected to our use of the DHS data and the type of analyses we conducted. Surveys only included women that had live births, thus information on women with poor outcomes (e.g., stillbirth, miscarriage, maternal death) is not captured in the study sample. Although no studies have been conducted that examine mothers’ recall of ANC in Egypt, results from different countries suggest the quality of the information collected by the DHS surveys in other areas and countries is acceptable [43‐45]. Additionally, the long recall period (5 yrs) might have affected the ability of some women to accurately recall whether they received specific interventions. The analysis of components of care only represented an aspect of quality, but others such as timing of the care, or the patient-provider relation are not collected by the DHS. Information on whether the components of care were provided with the required frequency, or whether these components were performed correctly was not available.

Egypt’s improvements in ANC coverage were characterized by women’s decreasing reliance on public services and a rise in the number of ANC visits. These changes suggest inadequate public ANC and an increase in out-of-pocket payments among women moving to the private sector hoping for better care. Despite improvements in ANC coverage, changes failed to translate into adequate ANC. Less than a third of women received, at least once during pregnancy, the seven essential ANC components measured by DHS. Furthermore, women from poorer households reported receiving fewer components than their wealthier counterparts. Policymakers need now to move rapidly to ensure that improvements in ANC coverage were not made in vain, and that they target differences in coverage and quality across groups in the country, and in both public and private sectors. It is only through the introduction of equity-focused interventions targeting ANC quality that the health of all Egyptian women can be improved. Further research needs to support this effort by assessing the determinants behind poor quality of ANC and evaluating potential interventions.