Background
In 2020, an estimated 287 000 women died globally from pregnancy‐related causes and 2 million babies were stillborn, half occurring during the third trimester [To improve maternal health and outcomes, the WHO released its comprehensive recommendations on ANC for positive pregnancy experience in 2016 [Since February 2018, the governments of Burkina Faso, Rwanda and Zambia, as well as Assam and Tamil Nadu states in India, have prioritized the adaptation and adoption of the WHO ANC recommendations. Initial efforts lead to the development of the WHO ANC recommendations adaptation toolkit [In collaboration with Ministries of Health (MoHs) and country research partners, the study uses implementation science to systematically introduce and test the applicability of the adapted ANC package in selected sites across four countries. It aims to generate key evidence on the implementation of the adapted ANC packages and inform future national adaptation and scale up. Study objectives are outlined in Table Study objectives1. Does the adherence to the country/state package of ANC interventions by health workers improve with the country/state-specific ANC package?  a. Does the implementation of country/state-specific ANC package (including targeted community mobilization) increase early initiation of ANC among pregnant women?2. Is the country/state-specific ANC package acceptable to and does it create value for women and health workers?1. What are the human resources training and supervision needs of implementing the country/state-specific ANC package?2. What is the cost of implementing the country/state-specific ANC packages compared with standard of care?3. What are the effects of the ANC package on retaining women in ANC services? (Burkina Faso only)1. Does the adherence to the country/state package of ANC interventions improve among health workers using the adapted WHO digital ANC module compared with standard care?  a. Does the implementation of the country-specific ANC package (including targeted community mobilization) increase early initiation of ANC among pregnant women?2. Is the use of the country-adapted WHO digital ANC module acceptable to, and does it create value for, women and health workers?1. What are the human resources training and supervision needs to ensure fidelity of deployment of the adapted WHO digital ANC module?2. What are the financial resources needed to implement the adapted WHO digital ANC module for the study, and what resources would be needed to achieve scale?