IN A NUTSHELL Author's noteAntenatal care (ANC) is a foundation of maternal and new-born health, offering an opportunity to prevent, detect, and manage complications during pregnancy. Despite global progress toward Universal Health Coverage (UHC), inequities in ANC access and quality persist across low- and middle-income countries (LMICs). This paper examines the contributory factors to inequity in ANC quality using evidence from recent multi-country analyses and systematic reviews. Findings reveal that disparities are driven by interrelated demand-side, supply-side, and enabling factors, including education, socioeconomic status, health system capacity, and affordability barriers. Although ANC coverage has improved globally, quality remains uneven and inequitable. Addressing these inequities requires policy reforms emphasizing system readiness, financial protection, and equity-sensitive monitoring mechanisms. The paper highlights the need to reframe ANC as both a maternal health intervention and a measure of social justice and health system resilience
By Dr. Hadiza Magaji Mahmoud, MBBS
Masters in Reproductive Health, MSc Public Health (LSHTM), AMRSPH
Inequity in Antenatal Care Quality in Low- and Middle-Income Countries
Introduction
Antenatal care (ANC) serves as a fundamental public health strategy for improving maternal and neonatal outcomes. Through regular monitoring, health education, and timely interventions, ANC reduces the risk of complications, stillbirths, and maternal mortality. However, across low- and middle-income countries (LMICs), inequities persist not only in access but in the quality of care provided. Global attention has largely focused on expanding service coverage, yet this approach often overlooks disparities in the content, timeliness, and effectiveness of ANC (The Lancet Global Health, 2018).
Equity in ANC represents more than equal access; it reflects fairness in opportunity, resources, and outcomes. Despite widespread adoption of the WHO’s recommendation for eight ANC contacts, many LMICs continue to fall short in achieving equitable, high-quality services (WHO, 2016).
This paper synthesizes emerging evidence on the determinants of ANC inequity, with particular attention to demand, supply, and enabling factors influencing maternal health outcomes.
Methodological Approach
This paper synthesizes findings from peer-reviewed articles, global reports, and household surveys published between 2018 and 2025. Emphasis was placed on large-scale analyses such as Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS), and WHO Global Health Observatory datasets. Critical appraisal focused on how different social, economic, and systemic determinants interact to produce inequities in ANC quality.
Results and Discussion
1. Understanding Inequity Beyond Coverage
While ANC coverage has improved globally, quality gaps remain substantial. The WHO (2025) reports that between 45% and 90% of women in LMICs receive at least four ANC visits (ANC4+). However, only 18.1% achieve the recommended eight or more visits (Tegegne et al., 2024). This “coverage–quality gap” highlights a systemic challenge: presence at a facility does not guarantee adequate care.
A multi-country analysis by Jiwani et al. (2025) revealed readiness-adjusted ANC1+ coverage ranging from 64.0% in Haiti to 76.2% in Nepal, exposing significant variations in service preparedness. Similarly, a systematic review by Tamir et al. (2025) reported that non-utilization of ANC services averaged 10.6% but reached 40% in some LMICs, particularly where services were under-resourced or geographically inaccessible. These findings collectively indicate that inequity is rooted not only in access barriers but in system-level deficiencies.
- Demand-Side Determinants
Maternal education, age, employment status, and health literacy play significant roles in ANC utilization. Educated women are more likely to recognize the value of preventive care, seek early ANC, and demand higher-quality services. The disparity is evident when comparing Belarus where ANC quality indicators are high to Chad, where service uptake is low, largely due to differences in educational attainment and national GDP per capita (The Lancet Global Health, 2018). Poor health literacy and sociocultural norms often compound inequities by discouraging early engagement with formal care systems.
- Supply-Side Determinants
Health system capacity comprising infrastructure, human resources, and equipment forms the backbone of ANC quality. In many LMICs, particularly in rural or poor settings, care delivery is hindered by a shortage of trained providers, weak facility readiness, and inadequate diagnostic capacity. Countries such as Belarus and Kazakhstan, which maintain strong primary health systems, demonstrate narrow ANC inequalities. In contrast, South Sudan and Nigeria exhibit both low coverage and high inequality (DHS/MICS data), underscoring the link between system weakness and maternal health inequity.
- Enabling Factors and Structural Barriers
Financial protection mechanisms, such as health insurance and user fee exemptions, are critical enablers of equitable ANC. In settings without such measures, affordability remains a major barrier, particularly for women in informal employment or subsistence economies. Health insurance coverage has shown promise in mitigating inequities, promoting early attendance, and improving continuity of care (Okedo-Alex et al., 2019). Conversely, lack of coverage perpetuates cycles of underutilization and poor maternal outcomes.
Policy Implications
Tackling ANC inequity requires integrated policy approaches grounded in principles of Universal Health Coverage (UHC) and social protection. Governments and partners should prioritize the following actions:
- Equity-sensitive monitoring: Integrate disaggregated equity indicators (by wealth, geography, and education) into national maternal health surveillance systems.
- Investment in system readiness: Strengthen infrastructure, training, and logistics to ensure every contact delivers the full complement of evidence-based interventions.
- Financial protection mechanisms: Expand insurance coverage and remove user fees for essential maternal health services.
- Community engagement: Promote demand generation through education, women’s empowerment, and culturally responsive health promotion.
- Policy learning from success stories: Countries like Rwanda and Sri Lanka demonstrate that political commitment and equitable financing can significantly narrow ANC gaps.
These strategies must be supported by political will and accountability frameworks that promote equity from ambition to a measurable health system goal.
Conclusion
Inequities in antenatal care reflect deeper systemic injustices within health systems. The persistent gap between coverage and quality illustrates that the promise of universal maternal health remains unfulfilled for many women in LMICs. Addressing these inequities requires reframing ANC as both a clinical and social justice necessity. Governments must strengthen health systems to deliver equitable, high-quality, and respectful care ensuring that every pregnancy is supported by a system capable of protecting both mother and child.
References
The Lancet Global Health. (2018). Equity in antenatal care quality: An analysis of 91 national household surveys. The Lancet Global Health, 6(11), e1186–e1195. https://doi.org/10.1016/S2214-109X(18)30389-9
World Health Organization. (2016). WHO recommendations on antenatal care for a positive pregnancy experience. World Health Organization. https://www.who.int/publications/i/item/9789241549912
World Health Organization. (2025). Antenatal care coverage – at least four visits (ANC4+). WHO Global Health Observatory. https://www.who.int/data/gho/indicator-metadata-registry/imr-details/80
Tegegne BA, Alem AZ, Amare T, Aragaw FM, Teklu RE. Multilevel modelling of factors associated with eight or more antenatal care contacts in low and middle-income countries: findings from national representative data. Ann Med Surg (Lond). 2024 Apr 16;86(6):3315-3324. https://pubmed.ncbi.nlm.nih.gov/38846896/#:~:text=6)%3A3315%2D3324.-,doi%3A%2010.1097/MS9.0000000000002034,-. PMID: 38846896; PMCID: PMC11152864.
Jiwani SS, Rana S, Hazel EA, Maïga A, Wilson EB, Amouzou A. Building an effective coverage cascade for antenatal care: linking of household survey and health facility assessment data in eight low- and middle-income countries. J Glob Health. 2025; 15:04048 https://jogh.org/2025/jogh-15-04048/#:~:text=DOI%3A%2010.7189/jogh.15.04048
Tamir TT, Gebrehana DA, Zegeye AF, Terefe B, Tekeba B. Magnitude, distribution and determinants of non-utilization of antenatal care services among women in low- and middle-income countries: Insights for implementation of WHO recommendations. PLoS One. 2025 Aug 18;20(8):e0330596. https://pubmed.ncbi.nlm.nih.gov/40824956/#:~:text=18%3B20(8)%3Ae0330596.-,doi%3A%2010.1371/journal.pone.0330596,-. PMID: 40824956; PMCID: PMC12360577.
Okedo-Alex, I. N., Akamike, I. C., & Ezeanosike, O. B. (2019). Determinants of antenatal care utilization in sub-Saharan Africa: A systematic review. BMJ Open, 9(10), e031890. https://doi.org/10.1136/bmjopen-2019-031890
