Results

largely consists of nurses, midwives, and community health workers providing care in primary health settings. At the health facilities, the surveys included health facility assessments measuring facility-level management, funding, and drug, equipment, and infrastructure availability; health provider interviews including vignettes on the provision of ANC; patient exit interviews; and direct observations of ANC consultations between patients and providers. These similarities in instruments and sampling methodology allow this study to use these baseline surveys to compare the three gaps in the five countries. Annex 4B describes the harmonization process, analytical decisions, and data limitations in detail.

The next section discusses the evidence from the five countries in the data set on the relative sizes of the three gaps. It links data from three sources: interviews and knowledge tests of health care providers, structural assessments of health facilities, and direct clinical observations of ANC consultations. Structural assessments of health facilities provide the data on the physical constraints faced by the facilities: what equipment, supplies, and drugs do they have relative to what they need? Health worker interviews provide information on what providers know to do when presented with a hypothetical scenario, and direct observations allow measuring what providers actually do in consultations with patients. Therefore, comparing what providers can do given equipment and drug availability with what they know how to do and comparing that with what they actually do allows measuring the relative sizes of the three gaps.

This section presents the findings on the quality of care of ANC consultations in Cameroon, the Central African Republic, the Democratic Republic of Congo, Nigeria, and the Republic of Congo.

Health worker knowledge, physical capacity, and practice This subsection describes the results on health worker knowledge, the availability of equipment and supplies, and what is in fact done, without linking the different elements.

Health worker knowledge The first gap in the three-gap model is the know gap, which estimates gaps in health worker knowledge—what is it that the health workers simply do not

know? Thus, the assessment turns to health worker knowledge of the WHO essential protocol for ANC. There are two key aspects of this analysis. First, these are health workers whose job description includes the provision of ANC. Second, a key methodological difference between the implementation of the knowledge test and the vignette in the Democratic Republic of Congo may result in different assessments of the levels of health worker knowledge. As is discussed below, health workers in the Democratic Republic of Congo were presented with several care options and had to select the relevant ones, while in the other countries, providers had to list from memory all relevant care to be provided. As such, the assessment does not compare knowledge levels between the other four countries with that in the Democratic Republic of Congo.

Table 4.2 presents the results of the knowledge tests. The highest levels of knowledge are related to physical examinations. The availability of equipment and high levels of performance on these exams—weighing the pregnant woman, taking her blood pressure, measuring the size of her uterus, and listening to the fetal heartbeat—suggest that they may be relatively salient in these contexts. However, apart from listening to the fetal heartbeat, none of these actions have clear links to maternal or neonatal health outcomes (Carroli, Rooney, and Villar 2001). The salience of knowledge of actions that are less well linked to end outcomes may in fact crowd out the performance of actions that may be less salient but in fact have a clearer link to mortality and morbidity.

However, beyond the basic physical examinations, there is significant variation within and across the five countries studied. Broadly, the results for health worker knowledge suggest a few patterns, particularly in the provision of preventive care. While some basic aspects of ANC are well known, knowledge of protocol is far from universal, with stark differences across countries, but also within countries, with particularly low levels of knowledge of preventive care and counseling.

Physical capacity The second gap discussed in the three-gap model is the know-can gap, which refers to deficiencies in physical infrastructure, drugs, and supplies that keep health workers from providing all the care they know to provide. Thus, this subsection examines the structural capacity of the health facilities in the data. Figure 4.2 and table 4A.1, in annex 4A, present the availability of equipment and consumables used for ANC at the health facilities where observations of first prenatal consultations were observed. The results highlight several striking patterns. Consistent with the high levels of knowledge of basic physical examinations in all the countries studied, permanent equipment—scales,