Content and quality – integrated, holistic, one‐stop antenatal care is needed for all

In the past few decades, efforts to reduce maternal and newborn mortality and morbidity globally have largely been directed at interventions that need to be in place around the time of birth. This has resulted in a significant increase in the number of women with skilled birth attendance (SBA): from 56% globally in 1990 to 74% estimated in 2015 (http://www.who.int/gho/publications/world_health_statistics/2015/en/). In the last few decades, less emphasis has been placed on ensuring the availability and quality of antenatal care (ANC). It is important to address this imbalance. Of the 50 essential interventions for reproductive, maternal, newborn and child health for which there is evidence of effectiveness, 16 are expected to be implemented during ANC (http://www.who.int/pmnch/knowledge/publications/201112_essential_interventions/en/). The interventions are inclusive of ‘routine’ ANC, as well as the recognition and management of malaria, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and tuberculosis. These interventions are most effectively and efficiently linked together in one integrated care package. This issue of BJOG includes a series of reviews in preparation for the development of new World Health Organisation (WHO) guidelines for ANC. Globally, just over 83% of all women attend for ANC on at least one occasion, and 64% attend four times or more (http://www.who.int/gho/publications/world_health_statistics/2015/en/). However, in many cases, this currently constitutes a series of missed opportunities. In this issue, Abalos et al. (BJOG 2016;123:519–528) make it clear that new guidelines will need to be developed, such that they can be contextualised and adapted to a country's health system and population's specific health needs. The systematic review by Downe et al. (BJOG 2016;123:529–539) in this issue reiterates that women overwhelmingly want and need care that results in a positive pregnancy experience. Both points seem to be self-evident, but it is important that this is explored in more detail by asking women themselves what they need, and by undertaking more robust assessments of what is the burden of disease during and after pregnancy. Studies from Pakistan and Malawi illustrate that maternal morbidity is high during and after pregnancy and, in low- and middle-income countries, over 50% of women report ill-health. In these same settings, however, there is very limited diagnostic capacity to identify which clinical conditions need to be treated. Psychological ill-health and domestic violence are not uncommon, but neglected, in existing care packages (Zafar et al. PLoS One 2015;10:e0138026). Kearns et al. (BJOG 2016;123:540–548) present and critique eight selected case studies in this issue, which illustrate how ANC can be provided at both health facility and community level. However, globally, there is still a striking lack of rigorous evaluation of how and in which context the provision of ANC care is effective in reducing adverse outcomes or improving maternal and newborn health. In this issue, de Jongh et al. (BJOG 2016;123:549–557) describe how ‘one stop’ integrated care requires healthcare providers to be knowledgeable and skilled, able to provide all components of ANC, working within a supportive healthcare system. Currently, in many settings, the quality of care provided does not meet the identified health needs of women, is not ‘women and baby friendly’, is not in line with current evidence-based practice and must be considered as ‘sub-standard’. A renewed focus on content, as well as quality, of antenatal and postnatal care is urgently needed. The International Committee of Medical Journal Editors (ICMJE) disclosure form is available as online supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.