{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T17:56:21Z","timestamp":1791222981504,"version":"4.1.0"},"reference-count":30,"publisher":"Public Library of Science (PLoS)","issue":"10","license":[{"start":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T00:00:00Z","timestamp":1791158400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100009660","name":"London School of Hygiene and Tropical Medicine","doi-asserted-by":"publisher","award":["DONAT16116"],"award-info":[{"award-number":["DONAT16116"]}],"id":[{"id":"10.13039\/100009660","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosglobalpublichealth.org"],"crossmark-restriction":false},"short-container-title":["PLOS Glob Public Health"],"abstract":"<jats:p>In 2016, WHO updated its antenatal care (ANC) guidelines, increasing the minimum number of ANC visits from four to eight and recommending practices for those visits. Nepal adopted this new ANC model in 2022, but limited research has examined how the model has been implemented. This study explored the perspectives of pregnant women, ANC providers and local policymakers on the rollout of the new ANC model in Kavre district of Nepal. We conducted an exploratory qualitative study involving interviews with pregnant women, ANC providers and local policymakers along with semi-structured facility observations. Six primary care level government health facilities offering ANC services were purposively selected from three municipalities of Kavre district, Nepal. Data included eight interviews with pregnant women, seven with providers and three with local policymakers along with field notes from observations in six facilities. Interview transcripts and observation field notes were coded manually and analyzed thematically. Three major themes emerged from the analysis of the interviews and observations. Providers and policymakers viewed the new ANC model mainly as increase in visit frequency for documentation rather than enhanced quality care. Although orientation on the increased number of visits was presented to providers, most providers lacked understanding on the content and purpose of each visit. Pregnant women, particularly those in rural areas, reported logistical, financial and physiological challenges in completing all recommended visits and accessing care at referral sites. Implementation of new ANC model in Kavre district largely remained focused on visit quantity rather than quality. Strengthening provider\u2019s capacity, ensuring availability of guidelines, enhancing understanding of its purpose and implementation, and fostering person centered care are essential to achieve the intended benefits of the model.<\/jats:p>","DOI":"10.1371\/journal.pgph.0005076","type":"journal-article","created":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T17:29:25Z","timestamp":1791221365000},"page":"e0005076","update-policy":"https:\/\/doi.org\/10.1371\/journal.pgph.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["From visit counts to quality care: A qualitative study on early implementation of a new model for antenatal care in Kavre district, Nepal"],"prefix":"10.1371","volume":"6","author":[{"ORCID":"https:\/\/orcid.org\/0009-0006-7182-9985","authenticated-orcid":true,"given":"Samita","family":"K C","sequence":"first","affiliation":[{"name":"Dhulikhel Hospital, Kathmandu University Hospital","place":["Dhulikhel, Nepal"],"department":["Research and Development Division"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rajani","family":"Shakya","sequence":"additional","affiliation":[{"name":"Dhulikhel Hospital, Kathmandu University Hospital","place":["Dhulikhel, Nepal"],"department":["Research and Development Division"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abha","family":"Shrestha","sequence":"additional","affiliation":[{"name":"Kathmandu University School of Medical Sciences","place":["Dhulikhel, Nepal"],"department":["Department of Community Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abha","family":"Shrestha","sequence":"additional","affiliation":[{"name":"Dhulikhel Hospital, Kathmandu University Hospital","place":["Dhulikhel, Nepal"],"department":["Department of Gynecology and Obstetrics"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emma","family":"Radovich","sequence":"additional","affiliation":[{"name":"London School of Hygiene and Tropical Medicine","place":["London, United Kingdom"],"department":["Faculty of Epidemiology and Population Health"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,10,5]]},"reference":[{"issue":"9268","key":"pgph.0005076.ref001","doi-asserted-by":"crossref","first-page":"1551","DOI":"10.1016\/S0140-6736(00)04722-X","article-title":"WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care","volume":"357","author":"J Villar","year":"2001","journal-title":"Lancet"},{"key":"pgph.0005076.ref002","volume-title":"WHO Recommendation on Antenatal care for positive pregnancy experience","author":"World Health Organization","year":"2016"},{"issue":"4","key":"pgph.0005076.ref003","doi-asserted-by":"crossref","first-page":"529","DOI":"10.1111\/1471-0528.13819","article-title":"What matters to women: a systematic scoping review to identify the processes and outcomes of antenatal care provision that are important to healthy pregnant women","volume":"123","author":"S Downe","year":"2016","journal-title":"BJOG"},{"key":"pgph.0005076.ref004","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1016\/j.bpobgyn.2016.05.005","article-title":"Preventing deaths due to the hypertensive disorders of pregnancy","volume":"36","author":"P von Dadelszen","year":"2016","journal-title":"Best Pract Res: Clin Obstet Gynaecol"},{"key":"pgph.0005076.ref005","unstructured":"Ministry of Health and Population. National Medical Standard for Maternal and Newborn Care. 2020."},{"key":"pgph.0005076.ref006","unstructured":"DOHS\/Family Welfare Division. ANC to PNC Continuum of Care Guideline. 2080."},{"key":"pgph.0005076.ref007","unstructured":"Ministry of Health and Population G of N. Nepal Safe Motherhood and Newborn Health Road Map 2030. 2019."},{"key":"pgph.0005076.ref008","volume-title":"Nepal Demographic and Health Survey 2022","author":"Ministry of Health and Population [Nepal], NE and ICF","year":"2023"},{"key":"pgph.0005076.ref009","doi-asserted-by":"crossref","first-page":"200","DOI":"10.1186\/s12884-015-0625-x","article-title":"Challenges and opportunities for implementing evidence-based antenatal care in Mozambique: a qualitative study","volume":"15","author":"A Biza","year":"2015","journal-title":"BMC Pregnancy Childbirth"},{"issue":"8","key":"pgph.0005076.ref010","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0255297","article-title":"Provider-perceived benefits and constraints of complete adherence to antenatal care guideline among public health facilities, Ethiopia: a qualitative study","volume":"16","author":"T Seyoum","year":"2021","journal-title":"PLoS One"},{"issue":"11","key":"pgph.0005076.ref011","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0241185","article-title":"Status of the WHO recommended timing and frequency of antenatal care visits in Northern Bangladesh","volume":"15","author":"BK Sarker","year":"2020","journal-title":"PLoS One"},{"issue":"1","key":"pgph.0005076.ref012","doi-asserted-by":"crossref","first-page":"1208","DOI":"10.1186\/s12913-022-08594-y","article-title":"Status of the latest 2016 World Health Organization recommended frequency of antenatal care contacts in Sierra Leone: a nationally representative survey","volume":"22","author":"Q Sserwanja","year":"2022","journal-title":"BMC Health Serv Res"},{"key":"pgph.0005076.ref013","doi-asserted-by":"crossref","first-page":"6696829","DOI":"10.1155\/2021\/6696829","article-title":"Noncompliance with the WHO\u2019s recommended eight antenatal care visits among pregnant women in Sub-Saharan Africa: a multilevel analysis","volume":"2021","author":"EK Odusina","year":"2021","journal-title":"Biomed Res Int"},{"issue":"1","key":"pgph.0005076.ref014","doi-asserted-by":"crossref","first-page":"166","DOI":"10.1186\/s12884-023-05497-6","article-title":"Perceptions on acceptability of the 2016 WHO ANC model among the pregnant women in Phalombe District, Malawi - a qualitative study using Theoretical Framework of Acceptability","volume":"23","author":"P Nyumwa","year":"2023","journal-title":"BMC Pregnancy Childbirth"},{"issue":"1","key":"pgph.0005076.ref015","doi-asserted-by":"crossref","first-page":"82","DOI":"10.1186\/s12961-023-01014-5","article-title":"New Antenatal Model in Africa and India (NAMAI) study: implementation research to improve antenatal care using WHO recommendations","volume":"21","author":"NAMAI Research Group","year":"2023","journal-title":"Health Res Policy Syst"},{"key":"pgph.0005076.ref016","article-title":"Reproductive Health Matters An international journal on sexual and reproductive health and rights Improving Maternal Health: Getting What Works To Happen","author":"L Penn-Kekana","year":"2007"},{"key":"pgph.0005076.ref017","doi-asserted-by":"crossref","first-page":"535","DOI":"10.1177\/0038038509103208","article-title":"Implementing, embedding, and integrating practices: An outline of normalization process theory","volume":"43","author":"C May","year":"2009","journal-title":"Sociology"},{"key":"pgph.0005076.ref018","unstructured":"Department of Health Services. Annual Health Report 2079\/80. 2024."},{"issue":"4","key":"pgph.0005076.ref019","doi-asserted-by":"crossref","first-page":"1893","DOI":"10.1007\/s11135-017-0574-8","article-title":"Saturation in qualitative research: exploring its conceptualization and operationalization","volume":"52","author":"B Saunders","year":"2018","journal-title":"Qual Quant"},{"key":"pgph.0005076.ref020","doi-asserted-by":"crossref","first-page":"328","DOI":"10.1080\/14780887.2020.1769238","article-title":"One size fits all? What counts as quality practice in (reflexive) thematic analysis?","volume":"18","author":"V Braun","year":"2021","journal-title":"Qual Res Psychol"},{"issue":"1","key":"pgph.0005076.ref021","doi-asserted-by":"crossref","first-page":"279","DOI":"10.1186\/s12913-022-07577-3","article-title":"Development of a theory-informed questionnaire to assess the acceptability of healthcare interventions","volume":"22","author":"M Sekhon","year":"2022","journal-title":"BMC Health Serv Res"},{"issue":"3","key":"pgph.0005076.ref022","doi-asserted-by":"crossref","first-page":"258","DOI":"10.1177\/15586898241257546","article-title":"Qualitative thematic analysis in a mixed methods study: guidelines and considerations for integration","volume":"18","author":"M DeJonckheere","year":"2024","journal-title":"J Mixed Methods Res"},{"issue":"4","key":"pgph.0005076.ref023","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pdig.0001340","article-title":"The implementation realities of a digital antenatal care improvement intervention: Insights from ethnographic work in primary health facilities in Nepal","volume":"5","author":"S Karki","year":"2026","journal-title":"PLOS Digit Health"},{"issue":"12","key":"pgph.0005076.ref024","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2020-002965","article-title":"The impact of implementing the 2016 WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience on perinatal deaths: an interrupted time-series analysis in Mpumalanga province, South Africa","volume":"5","author":"T Lavin","year":"2020","journal-title":"BMJ Glob Health"},{"issue":"2","key":"pgph.0005076.ref025","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2018-000779","article-title":"Not just a number: examining coverage and content of antenatal care in low-income and middle-income countries","volume":"3","author":"L Benova","year":"2018","journal-title":"BMJ Glob Health"},{"issue":"6","key":"pgph.0005076.ref026","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pgph.0001991","article-title":"More is not enough: High quantity and high quality antenatal care are both needed to prevent low birthweight in South Asia","volume":"3","author":"S Neupane","year":"2023","journal-title":"PLOS Glob Public Health"},{"issue":"2","key":"pgph.0005076.ref027","doi-asserted-by":"crossref","first-page":"173","DOI":"10.9745\/GHSP-D-13-00176","article-title":"The quality-coverage gap in antenatal care: toward better measurement of effective coverage","volume":"2","author":"S Hodgins","year":"2014","journal-title":"Glob Health Sci Pract"},{"key":"pgph.0005076.ref028","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1186\/s13012-015-0242-0","article-title":"Making sense of implementation theories, models and frameworks","volume":"10","author":"P Nilsen","year":"2015","journal-title":"Implement Sci"},{"key":"pgph.0005076.ref029","doi-asserted-by":"crossref","first-page":"40","DOI":"10.1186\/1748-5908-2-40","article-title":"A conceptual framework for implementation fidelity","volume":"2","author":"C Carroll","year":"2007","journal-title":"Implement Sci"},{"issue":"1","key":"pgph.0005076.ref030","doi-asserted-by":"crossref","first-page":"876","DOI":"10.1186\/s12884-022-05200-1","article-title":"Measuring the quality of antenatal care in a context of high utilisation: evidence from Telangana, India","volume":"22","author":"E Radovich","year":"2022","journal-title":"BMC Pregnancy Childbirth"}],"container-title":["PLOS Global Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0005076","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T17:29:31Z","timestamp":1791221371000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0005076"}},"subtitle":[],"editor":[{"given":"Massy","family":"Mutumba","sequence":"first","affiliation":[{"name":"Washington University in St. Louis","place":["UNITED STATES OF AMERICA"]}],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,10,5]]},"references-count":30,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2026,10,5]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pgph.0005076","relation":{},"ISSN":["2767-3375"],"issn-type":[{"value":"2767-3375","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,5]]}}}