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Background  Good quality antenatal care (ANC) helps reduce adverse maternal and newborn outcomes, especially in low and middle-income countries (LMICs). Most of the currently used ANC indicators only measure contact with services. We aimed to create and validate a new indicator measured as a score, considering both contact and content, that can be used for monitoring.    Methods  We used data from national surveys conducted in LMICs. Information on ANC was used to build an adequacy score (ANCq) that would be applicable to all women in need of ANC. Cronbach's alpha and factor analysis were used to assess the proposed indicator. We also used a convergent validation approach, exploring the association of our proposed indicator with neonatal mortality.    Results  The ANCq score was derived from seven variables related to contact with services and content of care ranging from zero to ten. Surveys from 63 countries with all variables were used. The validity assessment showed satisfactory results based on Cronbach's alpha (0.82) and factor analysis. The overall mean of ANCq was 6.7, ranging from 3.5 in Afghanistan to 9.3 in Cuba and the Dominican Republic. In most countries, the ANCq was inversely associated with neonatal mortality and the pooled for all surveys Odds Ratio was 0.90 (95% CI = 0.88-0.92).    Conclusions  ANCq allows the assessment of ANC in LMICs considering contact with services and content of care. It also presented good validity properties, being a useful tool for assessing ANC coverage and adequacy of care in monitoring and accountability exercises.

journal of global health

A new content-qualified antenatal care coverage indicator: Development and validation of a score using national health surveys in low- and middle-income countries