Beyond Attendance: Facility-level variations in the delivery of essential Antenatal Care interventions during routine Group Antenatal Care implementation in Tanzania: A Secondary Analysis

Technical Summary: Beyond Attendance – Facility-level Variations in G-ANC Delivery in Tanzania

Problem Statement
While Antenatal Care (ANC) coverage has improved in low- and middle-income countries (LMICs), evidence indicates that attendance alone does not guarantee the receipt of the full package of recommended maternal health interventions. In Tanzania, despite high rates of at least one ANC visit, only an estimated 40% of women receive "effective" ANC care. Group Antenatal Care (G-ANC) has emerged as a promising model to improve service utilization and quality. However, there is a significant knowledge gap regarding how implementation performance varies across different health facilities when G-ANC is integrated into routine government systems. Specifically, it remains unclear whether increased attendance translates into the consistent delivery of essential preventive and diagnostic interventions across diverse facility types (dispensaries, health centers, and district hospitals).

Methodology
This study is a secondary analysis of routinely collected implementation data from the "Mlinde Mama Project," a G-ANC initiative implemented in the Geita Region of Tanzania between January 2023 and August 2024.

• Study Design: A descriptive, cross-sectional analytical design conducted within an implementation science framework, adhering to Standards for Reporting Implementation Studies (StaRI) guidelines.
• Setting and Population: The analysis included 5,936 pregnant women enrolled in 149 G-ANC cohorts across six public health facilities: two dispensaries, two health centers, and two district hospitals. No sampling was performed; the study utilized data for all eligible participants.
• Intervention: The project integrated G-ANC into routine services, utilizing the Unified Community System (UCS) digital platform for cohort management, appointment tracking, and performance monitoring. Sessions combined clinical assessments with group education and peer support.
• Indicators: Twelve facility-level ANC indicators were assessed based on Tanzanian national guidelines and WHO recommendations. These included ANC4+ (completion of four visits), facility delivery, intermittent preventive treatment for malaria (IPTp3+), iron–folate supplementation, hemoglobin testing, malaria testing, HIV testing, syphilis testing, deworming, blood pressure monitoring, tetanus vaccination, and urine testing.
• Metrics: A composite facility performance score was calculated as the arithmetic mean of coverage across nine selected indicators. Three indicators (blood pressure, tetanus, and urine testing) were excluded from the composite score due to universal coverage, eligibility dependencies, or documentation inconsistencies, respectively.
• Analysis: Descriptive statistics were used to summarize coverage by facility and facility type. Data were analyzed using Microsoft Excel, with performance visualized through comparative tables and heatmaps.

Key Results

• High Attendance and Delivery: Coverage for ANC4+ visits was consistently high across all facilities (90.2%–95.0%), as was facility delivery (94.1%–97.7%). Blood pressure monitoring achieved 100% coverage across all sites.
• Substantial Variation in Preventive/Diagnostic Care: Significant disparities were observed in the delivery of essential interventions:
  • IPTp3+: Ranged from 60.1% (Nzera District Hospital) to 86.3% (Bwanga Health Centre).
  • Iron–Folate: Varied from 75.0% (Katoro Health Centre) to 92.7% (Bwanga Health Centre).
  • HIV and Syphilis Testing: Coverage ranged widely, from 59.9% to 95.0% for HIV and 59.9% to 95.0% for syphilis.
  • Urine Testing: Showed the lowest coverage overall, ranging from 30.1% to 62.7%.
• Composite Performance Scores: Facility-level composite scores ranged from 80.1% to 91.9%. Bwanga Health Centre ranked highest (91.9%), while Butengorumasa Dispensary ranked lowest (80.1%).
• Facility Type Differences: Health centers demonstrated the strongest overall implementation performance, particularly for preventive interventions like IPTp3+, HIV, and syphilis testing. District hospitals generally recorded the lowest coverage for these specific indicators, while dispensaries showed variable performance (e.g., highest deworming coverage but lower HIV/syphilis testing).

Key Contributions

1. Differentiation of Utilization vs. Content: The study provides empirical evidence that high ANC attendance under a G-ANC model does not automatically equate to the receipt of the full package of recommended interventions. It highlights a critical gap between service utilization and effective coverage.
2. Facility-Level Variation: It documents that implementation performance varies significantly even when facilities operate under the same intervention model, digital platform, and national guidelines. This suggests that local contextual factors (e.g., staffing, commodity availability, leadership) are more influential than the facility designation alone.
3. Performance Benchmarking: The study establishes a composite performance score methodology that allows for the ranking of facilities based on the breadth of essential care delivered, moving beyond simple attendance metrics.
4. Health Center Superiority: Contrary to assumptions that higher-level facilities (hospitals) might perform better due to resources, health centers demonstrated superior consistency in delivering the full ANC package, likely due to better staffing-to-patient ratios and workflow management.

Significance and Claims
The paper claims that successful integration of G-ANC into routine health systems depends not only on the intervention model itself but heavily on facility-level implementation capacity. The authors assert that:

• Monitoring Must Evolve: Routine maternal health monitoring systems must move beyond attendance indicators to include measures of ANC content and quality to assess "effective coverage."
• Targeted Quality Improvement: Quality improvement efforts should prioritize strengthening the delivery of lower-performing components (specifically IPTp3+, HIV/syphilis testing, and urine testing) and addressing operational barriers such as commodity stock-outs and laboratory constraints.
• Context Matters: Scaling up G-ANC requires assessing implementation readiness and organizational capacity at the facility level, as local factors determine whether increased attendance translates into improved health outcomes.
• Policy Implication: The study argues that the success of G-ANC should be judged by the proportion of women receiving the complete package of interventions, not merely by the number of women attending visits.

The authors maintain a modest tone, acknowledging that as a secondary analysis of routine data without a control group, the study identifies implementation patterns and variations rather than establishing causal relationships. They note limitations regarding data quality, the lack of a non-G-ANC comparison group, and the inability to measure specific implementation fidelity factors (e.g., provider competency, group dynamics) directly.