Nepal’s New Antenatal Care Model: More Visits, but Not Yet Better Care

When the World Health Organization overhauled its antenatal care guidelines in 2016, the headline change was arithmetic: the minimum number of recommended check-ups during pregnancy jumped from four to eight. But the revision was never meant to be a counting exercise. Alongside the expanded schedule, WHO prescribed specific evidence-based practices for each contact, from nutritional counseling and maternal and fetal assessments to health-system interventions such as tetanus immunization and iron supplementation. The intent was to shift pregnancy care worldwide from a fragmented, risk-detection model toward a comprehensive, quality-focused one. Nepal formally adopted the new model in 2022, becoming one of the countries attempting to translate the global guidance into the daily routines of primary health facilities. Yet a new qualitative study from Kavre district suggests that, in the critical early phase of implementation, the reform has largely been absorbed as a paperwork change rather than a transformation in how pregnant women are cared for.

The study, published in PLOS Global Public Health, was led by Samita K C and colleagues, who set out to capture how the new antenatal care model was actually landing on the ground in one of Nepal’s districts near the capital. The researchers designed an exploratory qualitative investigation built around three perspectives that rarely get equal weight in implementation research: the pregnant women using the services, the health workers delivering them, and the local policymakers responsible for steering the rollout. Six government health facilities at the primary care level were purposively selected from three municipalities across Kavre district, ensuring that the sample reflected the settings where most Nepali women actually encounter the health system rather than the better-resourced hospitals of major cities.

The data collection combined in-depth interviews with direct observation. The team conducted eight interviews with pregnant women, seven with antenatal care providers, and three with local policymakers, and supplemented these conversations with field notes from observations carried out in all six facilities. Interview transcripts and observation notes were coded manually and analyzed thematically, an approach that allows patterns to emerge from the material rather than testing predetermined hypotheses. This methodological choice matters for the study’s central finding: the researchers were not measuring whether women attended eight visits, but probing what the new model meant to the people living and working inside it, and what they understood its purpose to be.

The first major theme to emerge was perhaps the most sobering. Providers and policymakers alike tended to view the new antenatal care model primarily as an increase in visit frequency and in the documentation that accompanies each visit, rather than as a vehicle for enhanced quality of care. In other words, the reform was being interpreted through its most visible, most easily counted feature. Although orientation sessions on the increased number of visits had been delivered to providers, most of the health workers interviewed lacked a clear understanding of the content and purpose of each individual contact in the eight-visit schedule. The distinction is not academic. WHO’s 2016 guidelines assign different assessments, counseling topics, and interventions to specific visits, so a provider who does not grasp what each contact is meant to accomplish cannot deliver the model as designed, no matter how many appointments are recorded.

This gap between the letter of the guidelines and the understanding of frontline workers has a well-documented history in global health implementation. When a new model arrives as a directive about numbers rather than a training program about substance, health facilities often respond by extending existing routines: the same brief check-up, repeated more times, with additional forms to complete. The Kavre findings suggest that the orientation provided to Nepali providers conveyed the schedule change but not the clinical logic behind it, leaving the deeper ambitions of the WHO revision, continuity of care, comprehensive assessment, and person-centered counseling, largely unrealized in daily practice.

The second theme shifted the lens from providers to the women themselves. Pregnant women, particularly those living in rural areas of the district, reported substantial logistical, financial, and physiological challenges in completing all eight recommended visits and in reaching referral sites when complications or higher-level care required it. For a woman in a remote village, each additional visit means another journey, another transport cost, another day away from work and household responsibilities, and another physical effort made while carrying a pregnancy. The study’s findings indicate that the burden of the expanded schedule falls unevenly, with rural women facing compounding barriers that their urban counterparts do not. What global guidelines frame as a minimum standard of care can, in resource-constrained settings, become a demand that the health system and the women it serves are not yet equipped to meet.

The financial dimension deserves particular attention. Nepal has made significant strides in encouraging institutional delivery and routine pregnancy care, but out-of-pocket costs for transport, food, and lost wages remain a real deterrent for many families. When the recommended number of visits doubles, these costs effectively double with it. The physiological challenges women described, including the strain of frequent travel during later pregnancy, add a further layer of difficulty that clinical guidelines drafted in Geneva do not always anticipate. The study does not argue that the eight-visit model is wrong; rather, it documents that the conditions needed to make the model workable for rural Nepali women were not yet in place during the early implementation period.

Observations in the six facilities reinforced what the interviews revealed. Field notes collected alongside the conversations showed the practical texture of implementation: the availability of guidelines on site, the flow of clients through visits, and the ways providers structured each appointment. Taken together with the interview data, the observations supported the study’s overarching conclusion that implementation in Kavre district remained focused on visit quantity rather than quality. The researchers found that the machinery of the new model, its schedules and its documentation, had been installed, while its clinical heart, the specific content and purpose of each contact and the principle of person-centered care, had not yet taken hold.

The authors are clear about what would need to change. Strengthening providers’ capacity through training that goes beyond visit counts, ensuring that the actual guidelines are available in facilities, enhancing understanding of the model’s purpose and intended implementation, and fostering genuinely person-centered care are, in their assessment, essential if the new antenatal care model is to deliver its intended benefits. Each of these recommendations addresses a specific failure point documented in the study: the knowledge gap among providers, the absence of reference materials, the shallow interpretation of the reform, and the disconnect between what women experience and what the model promises. The findings carry weight beyond Nepal. Dozens of low- and middle-income countries are in various stages of adopting the WHO 2016 guidelines, and the Kavre experience offers a cautionary lesson about the distance between policy adoption and practice change.

What makes this study valuable is precisely its refusal to treat implementation as a binary of success or failure. By listening to women, providers, and policymakers in equal measure, and by pairing interviews with direct observation, the researchers captured a system in transition, one that has absorbed the arithmetic of reform but not yet its philosophy. The eight-visit schedule represents a genuine opportunity to improve maternal outcomes, but only if each visit delivers the assessments, counseling, and interventions that justify its existence. In Kavre district, the early evidence suggests that the opportunity remains largely untapped, and that the next phase of Nepal’s antenatal care reform must invest as much in understanding and capacity as it has in schedules and forms.

Subject of Research: Early implementation of the WHO eight-visit antenatal care model in Kavre district, Nepal

Article Title: From visit counts to quality care: A qualitative study on early implementation of a new model for antenatal care in Kavre district, Nepal

Article References: K C, S., Shakya, R., Shrestha, A., Shrestha, A., & Radovich, E. (2026). From visit counts to quality care: A qualitative study on early implementation of a new model for antenatal care in Kavre district, Nepal. PLOS Global Public Health, 6(10), e0005076. https://doi.org/10.1371/journal.pgph.0005076

Image Credits: AI Generated

DOI: 10.1371/journal.pgph.0005076

Keywords: antenatal care, WHO guidelines, Nepal, maternal health, qualitative research, primary health care, implementation science, pregnancy, global public health, Kavre district, health policy, person-centered care