Barriers and enablers to integrating maternal and child health services to antenatal care in low and middle income countries
For most women in low and middle income countries (LMIC), antenatal care (ANC) plays a highly important dual role: not only does ANC provide effective interventions to reduce the risks associated with pregnancy and childbirth, it can also serve as a delivery platform for other health services. Particularly in settings where the prevalence of HIV/AIDS, sexually transmitted infections (STIs), tuberculosis (TB) and malaria is high, integrating services for these conditions with ANC can significantly expand their reach. In fact, the World Health Organization (WHO) identified integration of ANC with other health programmes as a key strategy for reducing missed opportunities for patient contact and improving maternal and child health (MCH). Evidence from the countries studied, however, suggests that in practice integrated delivery of ANC with other health services is not systematic or adequate and that opportunities for providing care for women are lost.
Several factors enable or hinder the integration of other health services with ANC. There may be barriers in the specific health system context where services are delivered: for example, lack of trained health workers may prevent delivery of a full range of services, even if these are prescribed by national health policies. Factors related to broader political and social context can present significant hurdles for effective integration. Hence, delivery of integrated care that combines ANC with other health services to expand coverage and improve health outcomes requires an understanding of the main barriers and enablers to be successful.
We present a comprehensive review of drivers for integration of health programmes with ANC. The review combines published peer reviewed literature with grey literature sources. We provide a synthesis of the key barriers and enablers to integration in different contexts, bringing together randomised controlled trials and other published studies on how integrated delivery of ANC with other health services affects MCH outcomes, user experience, service access and coverage, and programme efficiency when compared with ‘routine’ models of care in which the same services were delivered separately.