title: The timing of antenatal care initiation and the content of care in Sindh, Pakistan.
abstract: Policymakers and program planners consider antenatal care (ANC) coverage to be a primary measure of improvements in maternal health. Yet, evidence from multiple countries indicates that ANC coverage has no necessary relationship with the content of services provided. This study examines the relationship between the timing of the first ANC check-up, a potential predictor of the content of services, and the provision of WHO recommended services to women during their pregnancy.
  
  
  
  The study uses data from a representative household survey of Sindh with a sample comprising of 4,000 women aged 15-49 who had had a live birth in the two years before the survey. The survey obtained information about the elements of care provided during pregnancy, the timing of the first ANC check-up, the number of ANC visits made during the last pregnancy and women's socio-economic and demographic characteristics. Bivariate analysis was conducted to examine the relationship between the proportion of women who receive six WHO recommended services and the timing of their first ANC check-up. Multivariate analysis was conducted to identify predictors of the number of elements of care provided.
  
  
  
  While most women in Sindh (87 %) receive an ANC check-up, its timing varies by parity, education and household wealth. The median time to the first ANC check-up was 3 months for women in the richest and 7 months for women in the poorest wealth quintiles. In multivariate analysis, wealth, education, parity and age at marriage were significant predictors of the number of elements of care provided. Women who received an early ANC check-up were much more likely to receive WHO recommended services than other women, independent of a range of socio-economic and demographic variables and independent of the number of ANC visits made during pregnancy.
  
  
  
  In Sindh, the timing of the first ANC check-up has an independent effect on the content of care provided to pregnant women. While it is extremely important that providers are adequately trained and motivated to provide the WHO recommended standards of care, these findings suggest that motivating women to make an early first ANC check-up may be another mechanism through which the quality of care provided may be improved. Such a focus is most likely to benefit the poorest, least educated and highest parity women. Based on these findings, we recommend that routine data collected at health facilities in Pakistan should include the month of pregnancy at the time of the first ANC check-up.
authors.affiliation: The Bill and Melinda Gates Foundation, P.O. Box 23350, WA 98102, Seattle, Washington, USA. sohailagha@gmail.com.
authors.forename: Sohail
authors.initials: S
authors.lastname: Agha
authors.affiliation: Jhpiego - an affiliate of Johns Hopkins University, Baltimore, Maryland, USA.
authors.forename: Hannah
authors.initials: H
authors.lastname: Tappis
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D006268:Health Facilities / Q000706:statistics & numerical data*; D006801:Humans; D008875:Middle Aged; D015999:Multivariate Analysis; D010154:Pakistan; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011247:Pregnancy; D011295:Prenatal Care / Q000379:methods / Q000592:standards / Q000706:statistics & numerical data*; D011787:Quality of Health Care; D012959:Socioeconomic Factors; D013997:Time Factors; D061665:Time-to-Treatment / Q000706:statistics & numerical data*; D055815:Young Adult
keywords: Antenatal care; Maternal health services; Pakistan; Pregnancy; Pregnant women; Prenatal care; Utilization