Effect of Enhanced Nutrition and Infection Management Intervention Packages on Antenatal Quality of Care Indicators in Rural Amhara, Ethiopia.

Background: High-quality antenatal care (ANC) can improve the detection, management, and monitoring of pregnancy-related complications. International guidelines recommend at least 8 antenatal care contacts during pregnancy. Interventions to improve the quality of antenatal care may promote positive pregnancy outcomes. Objectives: To assess the impact of enhanced nutrition and infection intervention packages on antenatal quality of care indicators among pregnant women in rural Amhara, Ethiopia Methods: Pregnant women presenting at 12 rural health centers at <24 weeks of gestation were enrolled in this pragmatic clinical effectiveness study. Using 2x2 factorial design, health facilities were allocated to provide an Enhanced Nutrition Package (ENP) or routine nutrition care (non-ENP), followed by individual-level randomization into Enhanced Infection Management Package (EIMP) or routine care (non-EIMP). The composite antenatal quality of care (QoC) score was calculated and compared between arms using cluster-level analyses, at the health center level (for ENP marginal effects), multivariate regression analyses (for EIMP marginal effects), and generalized estimating equations (for combined effects versus routine care). All models were adjusted for imbalanced individual and household factors. Results: From August 2020 to December 2021, a total of 2392 women were randomized (604 ENP+EIMP, 600 ENP alone, 593 EIMP alone, 595 neither package) and followed until June 2022. There was a significant difference in the number of ANC contacts in the ENP group (vs non-ENP: adjusted mean difference [aMD]=1.67, 95% CI: 1.18 to 2.16), EIMP (vs non-EIMP: aMD=0.38, 95% CI: 0.14 to 0.62), and ENP+EIMP (vs routine: aMD=1.92, 95% CI: 1.48 to 2.36). There was also a significant difference in ANC quality of care (ANC QoC) score in ENP (vs non-ENP: aMD=2.13, 95% CI: 0.54 to 3.72); EIMP (vs non-EIMP: aMD=0.89, 95% CI, 0.44 to 1.34), and ENP+EIMP (vs routine: aMD=2.77, 95% CI: 1.28 to 4.27). Conclusions: Combination of enhanced nutrition and infection management interventions had the largest effect on the number of ANC contacts and ANC QoC score. Bolstering nutrition and infection management services during pregnancy could encourage additional ANC contacts, providing an opportunity to provide targeted care.