
The 8th Global Symposium on Health Systems Research (HSR2024) held in Nagasaki, Japan, brought together global experts to address pressing health systems challenges. Among the research showcased was a study by the Countdown to 2030 Data & Analysis Center for Effective Coverage, presented by Safia Jiwani, a Countdown researcher from Johns Hopkins University, highlighting critical gaps in antenatal care (ANC) services in low- and middle-income countries (LMICs).
Download the poster here.
Why Antenatal Care Matters
Pregnancy should be a time of health and hope, but in many LMICs, quality gaps in ANC services hinder efforts to prevent and manage pregnancy-related complications. While a high percentage of pregnant women access ANC services, the quality and readiness of these services often fall short, leaving significant health gains unrealized.
A Four-Step Coverage Cascade: Bridging Gaps Between Use and Quality
The research team presented a comprehensive effective coverage cascade, linking household survey data from 28,925 women with health facility assessments of 8,621 facilities across eight countries. Key findings revealed:
- Service Coverage vs. Quality Gaps: While most women accessed ANC services, readiness-adjusted coverage—a measure of whether facilities met key readiness criteria—was significantly lower. For example, in Malawi, ANC1+ service coverage was 98.1%, but readiness-adjusted coverage dropped to 64%.
- Barriers to Readiness: Diagnostic capacity and availability of trained human resources were consistently inadequate, particularly in lower-level public facilities, where most women seek care.
- Inequities in Care: Wealthier women and urban residents were more likely to access readiness-adjusted ANC services, leaving women in rural areas and lower socioeconomic groups disproportionately underserved.

Figure. Antenatal care effective coverage cascade
The study underscored two key issues:
- Readiness Gaps: The absolute difference between ANC service coverage and readiness-adjusted coverage.
- Missed Opportunities: The gap between readiness-adjusted service coverage and the quality content of ANC services delivered.
For instance, in Tanzania, missed opportunities amounted to 21 percentage points, highlighting areas where facilities failed to deliver essential services even when women accessed care.
Transforming Findings into Action
Addressing these gaps requires targeted interventions:
- Investing in Facility Readiness: Enhancing diagnostic tools and training healthcare providers can significantly improve the quality of care.
- Equity-Driven Approaches: Strategies that prioritize rural and underserved populations are essential to ensure no woman is left behind.
The findings provide actionable insights to policymakers, health system leaders, and development partners. Improving health outcomes in LMICs requires more than just access—it demands quality care that meets the needs of all women, regardless of where they live or their socioeconomic status. These results underscore the urgent need for targeted improvements to reduce maternal and neonatal mortality and achieve universal health coverage goals.
Other recent publications from the effective coverage data & analysis center:
- Antenatal readiness country profiles (2022)
- Effective Coverage of Modern Contraceptive Use in Ethiopia: An Ecological Linking Analysis of Service Provision Assessment and National Health Equity Surveys (2024)
- Quality adjusted coverage of family planning services in low- and middle-income countries: Analysis of 33 countries using Demographic and Health Survey data (2024)