Factors influencing the provision of antenatal urine testing in Kavrepalanchowk, Nepal: a mixed-method study

Routine urine testing during pregnancy is important for diagnosing complications like pre-eclampsia and gestational diabetes, but it is among the least frequently performed antenatal care (ANC) components in settings like Nepal. This study explores the infrastructure, supply, training, and other obstacles to routine urine testing in ANC in Nepal. Our mixed-method study analyzed the nationally representative Nepal Health Facility Survey (NHFS) 2021 and primary qualitative data from Kavrepalanchok district, Nepal: in-depth interviews (n=18) with local policymakers, ANC providers, and pregnant women and semi-structured observations in six health facilities. Facility observation notes and interview transcripts were coded using a template analysis approach, and the NHFS 2021 was descriptively analyzed. Findings were mapped to the WHO framework for the quality of ANC. Among health facilities offering ANC services in the NHFS 2021, only 32.5% performed urine dipstick testing on-site. Physical infrastructure and supplies enable pregnant women to provide urine samples and was adequate at health facilities. However, ANC providers rarely performed point-of-care dipstick tests in lower-level facilities. Limited laboratory capacity in lower-level facilities resulted in pregnant women making repeated visits or being referred to higher-level facilities to obtain urine tests. Healthcare providers were aware of the significance of urine testing but not of the recommended frequency. Urine tests were regularly performed during the first ANC visit and repeated only if there were other symptoms of pregnancy complications. Despite the availability of adequate physical resources for urine testing, routine urine tests were not conducted in every ANC visit, as recommended in Nepal guidelines. Training and supportive supervision are necessary to modify urine testing practices in ANC, including performing dipstick tests by ANC providers, at the point of care, in rural health facilities lacking lab services.