A review of the literature found few studies that quantified the association between ANC and SBA use or institutional delivery [5,6,7]. The majority of studies were largely observational and used traditional regression approaches to examine correlates of maternal healthcare utilization [5,6,7]. To our knowledge, this is the first study in Bangladesh to use propensity score matching to examine the impact of ANC on maternal healthcare utilization.
The present study revealed a significant and positive impact of appropriate ANC on SBA use and on institutional delivery after matching treated and untreated mothers on all included observable characteristics. It should be noted that some variables which would have been appropriate to include in the propensity matching such as timing of ANC visits, location of ANC, quality of ANC, and the particular order of ANC visits were not available in the 2014 BDHS dataset. The results align with previous literature, which highlighted a positive impact of appropriate ANC on SBA use and institutional delivery in Bangladesh [5,6,7]. Our results agreed with another study linking ANC with institutional delivery in India that used propensity score matching . It is likely that ANC serves as a critical juncture to educate and refer mothers to health facilities [23, 24]. Overall, the findings from this study support the assertion that the provision of ANC is a tangible means to elicit uptake of SBA use and institutional delivery in Bangladesh. However, the results of this study do not conclusively establish causal relationships between appropriate ANC and SBA and institutional delivery given the cross-sectional nature of the BDHS dataset. As well, while propensity matching removes bias on observable characteristics, hidden bias may still persist due to unaccounted confounders which may overestimate the beneficial effects of ANC on SBA use and institutional delivery, albeit the sensitivity analyses conducted herein suggests that the positive effects of ANC are still largely robust.
Data from the BDHS suggests that 32% of women received four or more ANC visits; there are still 21% of women who received no ANC, 47% received 1 to 3 ANC visits. Given the relationship of ANC to SBA and delivery (both of which are associated with improved maternal and child outcomes), there is an urgent need for Bangladesh to increase the number of women who receive appropriate ANC.
Bangladesh has implemented a number of successful strategies nationally and regionally that could be scaled to reach more women [7, 25,26,27]. For example, to reduce financial barriers, Bangladesh has implemented maternal health voucher scheme [25, 27]. The voucher scheme targets socioeconomically disadvantaged mothers and provides them with three ANC visits, a SBA for home- or facility-based delivery, one post-natal care visit, and cash remunerations for travel expenses . Past evaluations found the voucher scheme to reduce out-of-pocket expenditures, decrease the equity gap and increase ANC uptake, SBA use, and institutional delivery within select voucher areas [28, 29].
Additionally, in 2007, a regional Maternal Neonatal and Child Health program in Bangladesh was implemented as an extension to an ongoing initiative in rural Matlab [7, 26]. The program enhanced networks between community and facility services. Through this program, existing ANC delivery was also strengthened to include additional evidence-based interventions. The program appears promising as an effective intervention in promoting ANC uptake (see Pervin et al. 2012, Fig. 1), increasing institutional delivery, and reducing perinatal mortality [7, 26].
From a ‘grass roots’ perspective, Bangladesh has also implemented a community health worker program that trains local women as community health workers to educate mothers and deliver important maternity care services including ANC . Importantly, workers help to address the various socio-cultural barriers other community members may face when accessing health services . Given the usefulness of Bangladesh’s community health workforce, the provision of ANC by community health workers may serve as a pragmatic means to bridge cultural differences and further elicit uptake of skilled birth assistance and institutional delivery within the country. Overall, these programs have shown success regionally but it is possible that if they were to be scaled nationally, they may positively impact mothers who are not receiving appropriate ANC.; however, for these programs to be sustainable, they must also be supported with ongoing efforts to strengthen the availability and quality of services as well as reductions in out-of-pocket costs.
The present study provides evidence that four or more visits is sufficient to make a positive impact on two very important pregnancy health care outcomes, SBA and institutional delivery. In September 2015, the WHO advocated for the receipt of eight or more ANC visits, a substantial increase from the previous guideline of a minimum of four visits . Data from the BDHS suggest that the incremental gain in SBA and institutional delivery is highest within the first four ANC visits and then declines (Fig. 1). Given that that 68% of women in Bangladesh receive either zero or fewer than four ANC visits, efforts and resources might be better employed increasing the number of women who receive four visits rather than attempting to provide all women eight or more visits. Future cost-effective analyses are needed to determine the number of ANC visits that will optimize maternal outcomes.