John: One of the major challenges facing the health systems of low and middle-income countries is to improve the antenatal care for pregnant women. In a new Cochrane Review from December 2015, Lawrence Mbuagbaw, from the Yaoundé Central Hospital in Cameroon and McMaster University in Canada, and colleagues have brought together the evidence on health system and community level interventions.

Lawrence: Many women die every day in developing countries because of complications of pregnancy and childbirth. This could be prevented by focusing on three main periods during the women’s maternity care: during pregnancy, by providing good antenatal care; during labour and delivery; and thirdly after delivery. The last two periods, labour and after delivery, are relatively short, and it is more challenging and resource intensive to provide care then because of the skills and equipment required. However, pregnancy, the antenatal period, is much longer and less resource intensive because care can be spread out. Antenatal care typically includes various components such as health promotion, disease prevention, early detection and treatment for complications and diseases, birth preparedness and readiness for potential complications. Even though it doesn’t address all the causes of maternal death, it is linked to professional assistance at delivery, and normal infant birth weight and the World Health Organisation recommends that pregnant women should have at least four visits while they are pregnant. We wanted to see what could be done to help achieve better antenatal care, and have found promising evidence of the benefits of some strategies.
We were most interested in the types of interventions that could improve attendance at antenatal care clinics and other outcomes; and found 34 eligible trials, with a total of approximately 400,000 women. Some trials tested community-based interventions such as media campaigns, education on self and infant care or financial incentives for pregnant women to attend antenatal care. Other trials looked at health systems interventions, including home visits for pregnant women or provision of equipment for clinics.
When one intervention was compared to no intervention, there was a small improvement in the number of women attending antenatal visits and the number of women delivering in a health facility; but there was no clear effect on deaths among the mothers or their babies or on birth weight. When two or more interventions were combined, women were more likely to have more antenatal care visits, there we’re fewer baby deaths and fewer low birthweight babies, compared to no interventions. But, in this comparison, there was no clear effect on the number of maternal deaths or the number of women who delivered in a health facility.
In summary, we’re able to conclude that single interventions may improve antenatal care coverage and encourage women to deliver in health facilities. Combined interventions may also increase the number of women who have at least one visit, reduce baby deaths and reduce the number of babies who are born with low weight.

John: If you would like to read more about the findings of Lawrence’s review, it is freely available to all from Cochrane Library dot com. Just visit the website and do a simple search for 'health system interventions and antenatal care'.