PREPRINT: Beyond Attendance: Facility-level variations in the delivery of essential Antenatal Care interventions during routine Group Antenatal Care implementation in Tanzania: A Secondary Analysis
July 15, 2026
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Study Overview
This study examined how the delivery of essential antenatal care (ANC) interventions varied across six public health facilities implementing routine Group Antenatal Care (G-ANC) in Geita Region, Tanzania.
Researchers conducted a secondary analysis of routinely collected implementation data from the Mlinde Mama Project between January 2023 and August 2024. The study included 5,936 pregnant women enrolled in 149 G-ANC cohorts across two dispensaries, two health centres, and two district hospitals.
While Group Antenatal Care has been shown to improve maternal health service utilization, relatively little is known about how consistently essential ANC interventions are delivered when the model is integrated into routine government health systems.
The study sought to move beyond measuring attendance alone by assessing whether women actually received the recommended package of preventive, screening, and diagnostic services during pregnancy.
Key Findings
Coverage of ANC attendance and facility delivery was consistently high. Across all facilities, 90–95% of women completed four or more ANC visits, while 94–98% delivered in health facilities.
Blood pressure monitoring achieved 100% coverage across all six implementation sites, and malaria testing remained above 91% at every facility.
However, substantial variation was observed for several critical ANC interventions:
- IPTp3+: 60.1%–86.3%
- Iron–folate supplementation: 75.0%–92.7%
- Haemoglobin testing: 70.0%–87.3%
- HIV testing: 59.9%–95.0%
- Syphilis testing: 59.9%–95.0%
- Urine testing: 30.1%–62.7%
These findings demonstrate that women may attend ANC consistently while still failing to receive the complete package of recommended maternal health interventions.
Facility Performance Ranking
A composite facility performance score was calculated using nine essential ANC indicators.
- Bwanga Health Centre: 91.9% (Rank 1)
- Nkome Dispensary: 86.2% (Rank 2)
- Katoro Health Centre: 84.5% (Rank 3)
- Chato District Hospital: 82.7% (Rank 4)
- Nzera District Hospital: 80.8% (Rank 5)
- Butengorumasa Dispensary: 80.1% (Rank 6)
The difference between the highest- and lowest-performing facilities was more than 11 percentage points, despite all facilities implementing the same intervention model and using the same digital platform.
Effective Coverage and Quality of Care
The findings reinforce an important principle in maternal health: attendance does not necessarily equate to quality of care.
Although Group Antenatal Care was associated with high levels of continued engagement with maternal health services, gains in attendance did not always translate into comprehensive delivery of preventive and diagnostic interventions.
Health centres demonstrated the strongest overall implementation performance, particularly for IPTp3+, HIV testing, and syphilis testing. The results suggest that organizational effectiveness, leadership, provider engagement, supportive supervision, and commodity availability may be more important determinants of success than facility level alone.
The study also highlighted persistent health-system constraints, including laboratory limitations, stock-outs of diagnostic commodities, workforce shortages, and inconsistent documentation practices.
Policy and Programmatic Implications
The authors recommend that routine maternal health monitoring systems move beyond attendance indicators and incorporate measures of effective coverage and ANC content.
Programs should consider institutionalizing facility-level dashboards that monitor implementation performance and identify lower-performing sites requiring additional support.
Quality improvement efforts should prioritize:
- Improving IPTp3+ coverage
- Strengthening HIV and syphilis testing
- Addressing urine testing commodity shortages
- Enhancing supportive supervision
- Improving laboratory capacity
- Monitoring implementation quality during scale-up
Future implementation of Group Antenatal Care should incorporate continuous quality improvement mechanisms to ensure that increases in attendance are accompanied by improvements in the content and quality of care.
Conclusion
This study demonstrates that successful maternal health programs should be evaluated not only by the number of women attending antenatal care, but by the proportion receiving the complete package of recommended interventions.
Among women enrolled in routine Group Antenatal Care, attendance and facility delivery were consistently high. However, important variations persisted in preventive and diagnostic services across facilities.
The findings suggest that implementation success depends not only on the intervention itself but also on facility-level implementation capacity, organizational effectiveness, and health-system readiness.
As countries scale innovative maternal health interventions such as Group Antenatal Care, ensuring effective coverage will be essential for achieving equitable improvements in maternal and newborn health.
Publication Details
The preprint was published in 2026 and reports findings from the Mlinde Mama Project in Geita Region, Tanzania. It represents one of the largest evaluations of routine Group Antenatal Care implementation in Tanzania, involving nearly 6,000 pregnant women across six public health facilities.
The project was funded by the Gates Foundation through the Grand Challenges initiative (Investment ID: INV-046249) and was implemented by Prime Health Initiative Tanzania in collaboration with the Ministry of Health, PMO-RALG, regional authorities, and local government partners.
Suggested citation:
Hellar A, Mandali H, Kinyina A, et al. Beyond Attendance: Facility-Level Variations in the Delivery of Essential Antenatal Care Interventions During Routine Group Antenatal Care Implementation in Tanzania. Research Square. 2026. doi:10.21203/rs.3.rs-10228315/v1.