Background: Efforts to improve maternal health have focused on measuring health and nutrition service coverage. However, high maternal mortality rates, despite improved service coverage, suggests that coverage indicators alone that do not account for quality can overestimate the health benefits of a service. Effective coverage (EC) cascades have been proposed as an approach to capture service quality within population-based coverage measures, but the proposed maternal health EC cascades have not been operationalized. This study aims to operationalize the effective coverage cascades for antenatal care (ANC) and maternal nutrition services using existing data from low- and middle-income countries (LMICs). Methods: We used household surveys and health facility assessments from seven LMICs to estimate EC cascades for ANC and maternal nutrition services provided during ANC visits. We developed theoretical coverage cascades, defined health facility readiness and provision/experience of care scores and linked the facility-based scores to household survey data based on geographic domain and facility type. We then estimated the coverage cascade steps for each service by country. Findings: Service contact coverage for at least one ANC visit (ANC1) was high, ranging from 80% in Bangladesh to 99% in Sierra Leone. However, there was a substantial drop in coverage from service contact to readiness-adjusted coverage, and a further drop to quality-adjusted coverage for all countries. For ANC1, from service contact to quality-adjusted coverage, there was an average net decline of 52 percentage points. For ANC1 maternal nutrition services, there was an average net decline of 48 percentage points from service contact to quality-adjusted coverage. This pattern persisted across cascades. Further exploration revealed that gaps in service readiness including lack of provider training, and gaps in provision/experience of care such as limited nutrition counseling were core contributors to the drops in coverage observed. Conclusions: The cascade approach provided useful summary measures that identified major barriers to EC. However, detailed measures underlying the steps of the cascade are likely needed to support evidence-based decision-making with more actionable information. This analysis highlights the importance of understanding bottlenecks in achieving health outcomes and the inter-connectedness of service access and service quality to improve health in LMICs.

The authors all completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and all authors except Rebecca Heidkamp disclose no relevant interests. Rebecca Heidkamp reports the following activities: a leadership role with the Society for Implementation Science for Nutrition and membership in the WHO-UNICEF Technical Experts Group on Nutrition Measurement.

The authors wish to acknowledge the Bill & Melinda Gates Foundation for their support of this project.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

For HHS data, we utilized data from the DHS program. For the HFA data, we utilized data from the Service Provision Assessment (SPA) and the Service Availability and Readiness Assessment (SARA). The DHS and SPA are publicly available data (https://dhsprogram.com/data/available-datasets.cfm). We obtained permission from the Sierra Leone Ministry of Health to use the 2017 SARA data.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

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All data produced in the present study are available upon reasonable request to the authors. To assist others who would like to implement the methods and/or replicate these results, the statistical code written for these analyses is publicly available.

https://zenodo.org/doi/10.5281/zenodo.7671805