Identification of gaps in the continuum of maternal and neonatal care in a high-mortality setting: An observational study in rural Guinea-Bissau.

Objectives: Coverage of the continuum of maternal and neonatal care, including antenatal care (ANC), childbirth and early postnatal care (PNC), is critically low across sub-Saharan Africa. Meanwhile, related monitoring remains neglected. We quantified coverage gaps along the continuum of maternal and neonatal care in rural Guinea-Bissau and assessed background factors associated with continuum-of-care completion.

Methods: In a cross-sectional study using data from the Bandim Health Project's nationally representative rural health and demographic surveillance system (HDSS), we assessed individual-level obtainment of ≥1, ≥4 and ≥8 ANC contacts (ANC1/4/8), facility-based childbirth and PNC within 24 h postpartum for HDSS-registered births between 1 February 2023 and 31 January 2024. Among facility births, we also assessed postpartum admission ≥24 h. We defined continuum-of-care completion as the obtainment of ANC4, facility-based childbirth and PNC within 24 h and investigated associations between background factors (household assets, maternal age, education, parity, region, ethnicity, health facility distance and recall time) and continuum-of-care completion in regression models.

Results: Among 2258 births, 35% (n = 798) completed the continuum of care; 22% (n = 494) obtained none of the contributing services. Individual service coverage ranged from 6% (ANC8, n = 128) to 99% (ANC1, n = 2236). Individual coverage of the services included in the continuum-of-care assessment was 62% (n = 1403) for ANC4, 56% (n = 1268) for facility-based childbirth and 52% (n = 1167) for PNC. Continuum-of-care completion differed by region and ethnicity. Living near a health facility, higher maternal education, more household assets, low parity and longer recall time were associated with higher continuum-of-care completion.

Conclusions: Continuum-of-care completion is low in rural Guinea-Bissau and not fully reflected by individual coverage indicators. This calls for a higher focus on continuum-of-care coverage and related gaps, both locally and globally. Meanwhile, the identified higher reporting of continuum-of-care completion with longer maternal recall questions the use of survey data and beckons for monitoring based on timely routine data.