Discussion
Adverse health outcomes can be prevented by quality healthcare during pregnancy and childbirth [Indian, Burkinabe, Rwandan and Zambian national governments have prioritized ANC and are committed to improving its quality. Since 2018, the four MoHs, supported by WHO, have led the adaptation of the 2016 ANC recommendations to country/state settings, aligning their ANC policies. These efforts represent a novel approach led by national governments, which after adapting their ANC policies on the basis of the WHO recommendations, identified the need to better understand how to implement their updated ANC service packages. This led to the development of the New antenatal care model in Africa and India (NAMAI) study, employing implementation science to design and test the packages’ implementation. The COM-B model and theoretical framework for acceptability will be employed to learn how best to design co-interventions and implement the updated national/state ANC policies. For Burkina Faso and India, a vision of success is, ultimately, understanding how to sustainably deliver and support the scale up of an updated, quality, costed, and adapted ANC package. In Rwanda and Zambia, a vision of success is, ultimately, understanding how to employ a digital intervention to sustainably deliver and support the scale up of an updated, quality, costed, and adapted ANC package and which would be integrated within the digital ecosystem [Results from this study aim to build the global evidence base on how to implement quality ANC across different settings and inform pathways to scale, which ultimately will lead to stronger health systems with better maternal and perinatal outcomes. The study also seeks to contribute to the field of implementation science; to our knowledge, it is the first large-scale implementation research trial to understand the implementation of WHO ANC recommendations in LMICs. It presents an opportunity to explore the application of this framework in a different context and identify potential areas for theoretical and methodological refinement.Moreover, we seek to strengthen links with newly released WHO recommendations on maternal and newborn care for a positive postnatal experience to improve learnings and implementation [