Antenatal Care and Neonatal Outcome
Survival analysis of the association between
antenatal care attendance and neonatal
mortality in 57 low- and middle-income
countries
David T Doku1,2* and Subas Neupane1
1School of Health Sciences, University of Tampere, Tampere Finland and 2Department of Population
and Health, University of Cape Coast, Cape Coast, Ghana
*Corresponding author. School of Health Sciences, FI-33014, University of Tampere, Tampere, Finland. E-mail:
[email protected]
Editorial decision 13 June 2017; Accepted 16 June 2017
Abstract
Background: Neonatal mortality is unacceptably high in most low- and middle-income
countries (LMICs). In these countries, where access to emergency obstetric services is
limited, antenatal care (ANC) utilization offers improved maternal health and birth outcomes. However, evidence for this is scanty and mixed. We explored the association between attendance for ANC and survival of neonates in 57 LMICs.
Methods: Employing standardized protocols to ensure comparison across countries, we
used nationally representative cross-sectional data from 57 LMICs (N ¼ 464 728) to investigate the association between ANC visits and neonatal mortality. Cox proportional hazards multivariable regression models and meta-regression analysis were used to analyse
pooled data from the countries. Kaplan-Meier survival curves were used to describe the
patterns of neonatal survival in each region.
Results: After adjusting for potential confounding factors, we found 55% lower risk of
neonatal mortality [hazard ratio (HR) 0.45, 95% confidence interval (CI) 0.42–0.48] among
women who met both WHO recommendations for ANC (first visit within the first trimester and at least four visits during pregnancy) in pooled analysis. Furthermore, metaanalysis of country-level risk shows 32% lower risk of neonatal mortality (HR 0.68, 95% CI
0.61–0.75) among those who met at least one WHO recommendation. In addition, ANC
attendance was associated with lower neonatal mortality in all the regions except in the
Middle East and North Africa.
Conclusions: ANC attendance is protective against neonatal mortality in the LMICs studied,
although differences exist across countries and regions. Increasing ANC visits, along with
other known effective interventions, can improve neonatal survival in these countries.
Key words: Survival analysis, neonatal mortality, antenatal care, low- and middle-income countries
VC The Author 2017; Published by Oxford University Press on behalf of the International Epidemiological Association 1668
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact
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International Journal of Epidemiology, 2017, 1668–1677
doi: 10.1093/ije/dyx125
Advance Access Publication Date: 13 July 2017
Original article
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Introduction
Goal 4 of the world’s just-ended developmental agenda,
the millennium development goals (MDGs), focused on reduction in child mortality.1 As a target, goal 4 aimed at
reducing under-5 mortality by two-thirds between 1990
and 2015. The MDGs agenda has contributed to a remarkable reduction in under-5 mortality globally.2 As a result,
the global number of deaths of under-5 children has
declined from 12.7 million in 1990 to 6 million in 2015, although the number of births has increased over the period.
This decline is not only in terms of absolute numbers but
also in mortality rates for children in this age group. These
have declined, over the 25-year period by more than 50%,
from 90 per 1000 live births to 43 per 1000 live births.2
Although significant achievements were seen in under-5
mortality, neonatal mortality, which is a main component
of the under-5 mortality, has not seen a significant reduction over the same period. This has resulted in an increase
in the proportion of neonatal mortality within the under-5
deaths over the two and a half decades. In 1990, neonatal
mortality was 37% of under-5 mortality, and by 2012, the
figure rose to 44%: thus a deficit of 2.9 million neonatal
deaths globally.3,4 Concerted effort is needed to reverse
these trends in order to improve overall child survival, particularly, in low- and middle-income countries (LMICs)
where the burden of neonatal mortality is highest.2–4
Neonatal mortality also contributes to the inequalities
in health between high-income and low-income countries.5,6 Neonatal mortality remains unacceptably high in
most LMICs and the highest is in sub-Saharan Africa.7,8
According to a study by Lawn et al.,4 there is a lag of about
100 years in neonatal survival between African countries
on the one hand, and Europe and North America on the
other. Overall, the slow progress made towards addressing
neonatal mortality has led to renewed commitments to
tackling the challenge. The sustainable development goals
(SDGs) are one of such commitments which open a new
era to tackle the unfinished agenda of the MDGs as well as
other emerging social, developmental and global health
challenges. The SDG 3 target 3.2 aims at reducing neonatal
mortality to 12 per 1000 live births by the year 2030.9
Other important renewed commitments include the Every
Newborn Action Plan (ENAP) which seeks to end preventable stillbirth and newborn death.3 Data from LMICs are
critical in forming intervention and tracking progress towards achieving these goals.
Antenatal care (ANC) offers pregnant women an opportunity to access preventive care. In LMICs where access to
emergency obstetric services is limited, ANC presents a viable option for pregnant women to be screened for potential risks during pregnancy or delivery. It also provides an
opportunity for treatment and health education including
nutritional advice and interventions about risky behaviour
such as smoking and alcohol cessation programmes. A few
studies have investigated the effect of ANC utilization on
birth outcomes, particularly on neonatal mortality.10–13
Their evidence is inconclusive; whereas some found ANC
utilization, including the number of visits, to be associated
with reduced risk of neonatal mortality,10,13 others found
adverse or no relations between ANC utilization and birth
outcomes. Hollowell et al.,11 conducting a systematic review of the association between ANC and infant and neonatal mortality in high-income countries, concluded that
there was insufficient evidence that ANC interventions
reduced neonatal or infant mortality in vulnerable populations. Dowswell et al.14 on the other hand, in a recent systematic review of alternative ANC packages for low-risk
pregnant women, found that in LMICs in particular, a
reduced number of ANC visits was associated with higher
perinatal mortality. However, no such evidence was found
for those in high-income countries nor for other child
health outcomes. For women in LMICs, the World Health
Organization (WHO) recommends at least four ANC visits
for normal pregnancy, and the first visit is recommended
to be within the first 3 months of conception.15 Despite
these recommendations, studies have reported low ANC
Key Messages
• This paper is the first to investigate, using comparable data, the association between antenatal care visits and neonatal mortality in low- and middle-income countries.
• In pooled analysis, 55% reduced risk of neonatal mortality was found among women who met both WHO recommendations (first visit within the first trimester and at least four visits during pregnancy).
• Meta-analysis of country-level risk shows that meeting at least one antenatal care recommendation reduced the risk
of neonatal mortality by 32%.
• Increased ANC visits, along with other known effective interventions, will improve neonatal survival in low- and middle-income countries.
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coverage among women in LMICs.13,16 There is a need for
evidence regarding the benefits of ANC utilization on important health outcomes, to support interventions which
are geared towards increasing ANC utilization in particular and improving maternal, neonatal and child health in
general. Comparable national representative data from
LMICs, investigating this relationship, would shed light on
this. A systematic search of the literature revealed that no
study using comparable data has investigated the association between ANC utilization and neonatal mortality in
many LMICs. Our study aimed to investigate whether
ANC attendance improves neonatal survival in LMICs.
We were also interested in looking at the regional differences in neonatal survival.
Methods
Ethical approval for the study was granted from the relevant institutions in the various countries and respondents
gave written consent in all the countries. Participants gave
consent for the data to be used for publication.
Data source
We used nationally representative cross-sectional data
from 57 LMICs, collected from 2005 to 2015, in the most
recent Demographic and Health Survey (DHS). The DHS
uses a standardized questionnaire and methodology for
data collection in order to facilitate international comparison. Details of the DHS are published elsewhere [http://
www.dhsprogram.com/data/data-collection.cfm]. In our
analysis we used ‘Birth record’ files published by the DHS.
Permission to use the data was granted by Measure DHS.
The data were publicly available and no further permission
from the respective countries was required for their use.
Study population
Data were collected on the outcome of the most recent live
birth within 3 years preceding the survey for each woman
of reproductive age 15–49 years (N ¼ 464 728). In
Bangladesh, Egypt, Jordan, Maldives and Pakistan, the
sample was collected among ever-married women as
opposed to all women (both ever-married and other
women) in the other countries included.
The 57 countries were grouped into six regions modelled on the WHO classification of regions. Out of 57
countries, 33 (63%) were in Africa, four were in East Asia
& Pacific (6.9%), six were in Europe & Central Asia
(2.0%), seven were in Latin America & Caribbean (9.5%),
two were in Middle East & North Africa (4.6%) and five
were in South Asia (13.5%). The full list of countries and
surveys is shown in Table 1.
Variables
The outcome variable for this study was neonatal death,
defined as death of a live-born during the first 28 complete
days of life. The information on month and year of each
birth, child’s survival status and current age or age at
death, as applicable, was available in the data. Age at
death was recorded in days if the child died within 1 month
of birth.
The primary independent variables were the number of
ANC visits and timing of first ANC visit. In this study,
ANC refers to health care service provided to mother and
fetus during pregnancy to ensure best outcome for both.
The responses to the number of ANC visits were categorized into four: no visits, one visit, two to three visits and
four or more visits. The timing of first ANC visit was categorized as: no visit, <4 months, 4–5 months, 6–7 months
and 8þ months. WHO recommended at least four visits,
with the first ANC visit as soon as possible in pregnancy,
preferably in the first trimester for healthy women with no
underlying medical problem.15 We therefore created a new
variable based on the number and timing of first ANC visits: ‘those who did not meet the WHO recommendation’,
‘those who had the first ANC visit within the first trimester’, ‘those who had at least four ANC visits’ and ‘those
who met both recommendations’.
The data on background characteristics of the mother
[age, place of residence, body mass index (BMI), wealth
quintile, children ever born, sex of child and education]
were also available and included in the analysis as covariates in order to investigate the independent association between ANC attendance and neonatal mortality. The
wealth quintile is the composite measure of the household’s cumulative living standard based on ownership of
specified assets split into quintiles: poorest, poorer, middle,
richer and richest.17
Statistical analysis
We applied sample weight to estimate the distribution of
independent and dependent variables, to account for the
cluster sampling structure. The weighted distribution of
the independent variables and covariates was also presented, with the number of neonatal deaths in each category in the total sample. The DHS conducted editing and
imputation of missing procedures before the data were
released. We used Cox proportional hazard regression to
estimate the hazard ratios (HRs) with their 95% confidence intervals (CIs) for neonatal mortality.
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Table 1. Distribution of the number of antenatal care (ANC) visits and the timing of the start of the first ANC visits by country
and region
Country Na Number of ANC visits Timing of first ANC visits (months)
No care 1 visit 2–3 visits 4þ visits < 4 4–5 6–7 8þ Median
months
Africa
Benin (2011–12) 6640 11.6 2.4 23.1 58.3 48.3 27.5 6.7 4.7 3.8
Burkina Faso (2010) 8320 4.3 4.2 58.4 33.1 40.6 39.9 14.0 1.1 4.3
Burundi (2010) 4251 0.9 3.5 61.8 33.6 20.4 44.2 31.9 2.3 5.3
Cameroon (2011) 6145 15.0 2.3 21.1 60.7 33.1 35.4 14.8 1.2 4.5
Chad (2014–15) 8984 34.3 3.4 28.8 31.3 28.9 26.7 8.0 0.8 4.2
Comoros (2012) 1428 6.6 3.7 26.5 49.2 57.2 23.5 7.9 2.9 3.6
Congo (2011–12) 4560 7.2 0.8 14.2 77.2 43.6 39.5 9.4 0.3 4.1
Congo DR (2013–14) 9349 9.9 3.8 38.5 47.2 16.7 40.4 29.7 2.8 5.4
Cote d’Ivoire (2011–12) 4055 7.2 9.8 38.9 43.3 29.0 34.4 25.6 3.2 5.0
Ethiopia (2011) 5991 57.8 5.1 19.1 17.8 10.2 16.2 12.2 3.3 5.3
Gabon (2012) 2751 4.9 0.6 15.9 77.2 61.2 26.6 6.6 0.4 3.6
Ghana (2014) 3108 2.9 1.3 9.0 86.2 62.1 28.1 6.2 0.6 3.6
Guinea (2012) 3868 12.8 4.4 26.2 56.3 40.1 30.5 14.8 1.8 4.2
Kenya (2014) 10350 4.1 3.6 36.4 55.9 19.7 41.1 32.1 2.9 5.4
Lesotho (2014) 1900 4.7 1.6 20.1 73.3 40.6 33.7 18.2 2.6 4.4
Liberia (2013) 3429 2.5 1.8 14.7 77.6 66.7 23.4 6.0 0.8 3.3
Madagascar (2008–09) 6484 9.6 4.0 38.3 47.2 25.5 42.4 19.7 1.8 4.8
Malawi (2010) 10668 1.6 2.8 51.3 44.2 12.4 48.0 35.8 2.0 5.6
Mali (2012–13) 5340 24.8 5.3 28.2 40.9 34.0 26.5 11.5 2.6 4.2
Mozambique (2011) 6381 9.1 4.8 35.7 49.5 12.7 46.3 29.0 2.5 5.5
Namibia (2013) 2127 3.3 1.1 10.6 62.4 41.5 38.8 14.3 1.5 4.3
Niger (2012) 6781 13.2 6.2 46.9 33.2 22.0 40.4 22.1 1.9 5.0
Nigeria (2013) 16178 33.7 1.9 10.7 51.0 17.6 29.8 16.7 1.5 5.0
Rwanda (2014–15) 4512 0.7 3.2 51.7 44.3 56.0 30.9 10.8 1.4 3.9
Sao Tome (2008–09) 965 0.7 4.6 15.7 71.8 49.7 30.9 12.7 1.4 3.9
Senegal (2014) 6635 2.8 5.9 43.4 47.1 57.8 27.8 9.4 1.3 3.6
Sierra Leone (2013) 5689 1.6 0.5 9.0 75.8 44.7 41.9 9.8 0.7 4.1
Swaziland (2006–07) 1535 2.8 1.0 15.3 78.6 23.8 48.1 23.5 1.4 5.1
Tanzania (2010) 4316 1.9 3.9 54.0 39.8 18.6 49.0 28.0 2.0 5.2
Togo (2013–14) 3699 7.1 3.3 32.9 56.4 27.0 41.9 21.4 2.5 4.9
Uganda (2011) 3981 4.2 4.1 43.0 47.2 20.7 42.7 29.1 3.1 5.2
Zambia (2013–14) 7044 1.4 2.0 41.6 54.1 24.4 54.3 18.4 1.1 4.8
Zimbabwe (2010–11) 3300 11.3 3.0 22.7 61.9 17.5 38.8 27.0 5.3 5.4
Africa pooled 180759 12.4 3.4 32.8 51.4 36.4 34.9 16.8 1.9 4.5
East Asia & Pacific
Cambodia (2014) 4107 3.9 2.9 16.7 75.6 79.2 12.7 3.7 0.4 2.5
Indonesia (2012) 9699 3.0 1.6 7.3 87.4 79.8 12.0 3.8 0.9 2.4
Philippines (2013) 3667 4.0 1.8 10.0 84.3 60.4 28.5 6.0 1.0 3.6
Timor-Leste (2009–10) 4835 12.7 3.5 28.5 54.7 43.8 32.0 10.1 0.9 4.0
East Asia pooled 22308 5.5 2.3 14.2 78.0 65.8 21.3 5.9 0.8 3.1
Europe & Central Asia
Albania (2008–09) 792 1.9 3.9 24.9 69.0 79.9 14.4 2.2 1.5 3.0
Armenia (2010) 826 0.7 0.2 3.4 93.8 81.3 17.1 0.9 0.0 3.3
Azerbaijan (2006) 1195 19.4 7.5 20.7 49.2 56.6 13.4 6.8 2.8 3.4
Kyrgyz Republic (2012) 2195 2.7 0.6 9.9 83.9 79.1 15.2 2.7 0.2 3.1
Moldova (2005) 909 1.6 0.4 4.5 89.3 69.3 21.2 6.0 1.1 3.3
Ukraine (2007) 524 0.5 0.2 1.3 78.8 83.7 11.8 2.0 0.4 2.9
Europe pooled 6443 5.3 2.3 11.8 80.7 75.0 15.5 3.4 1.2 3.2
(continued)
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We created survival time in days: the time elapsed since
birth in the case of children who were still alive, and between birth and death in the case of children who had
died. To calculate the survival time in days, we imputed
15th day of the month for those whose days of birth were
missing.
Adjusted hazard ratios for neonatal death were first calculated for the total sample, adjusting for each of the main
independent variables (number of ANC visits, timing of
first ANC visit and recommended ANC visits), the sociodemographic variables (maternal age, place of residence,
BMI, wealth quintile, children ever born, sex of child and
maternal education), year of survey and country. We also
estimated the country- and regional-level hazard ratios
with their 95% CIs to investigate the association of neonatal death with ANC attendance, adjusted for all studied
soci-demographic variables. These estimates were plotted
using the meta-analysis (metan) command in Stata.
Indonesia, the Philippines, Ukraine and Armenia were
excluded from the country-level analysis due to few or no
cases of neonatal mortality per the categories of the independent variable (recommended ANC visits) used. To
examine the timing of death, we calculated the daily hazard rates for neonatal death during the first 28 completed
days of life, stratified by WHO recommended ANC compliance. Survival curves for the infant during the first
month of life, stratified by the regions to investigate the regional differences in neonatal survival rates, were also plotted. All statistical analyses were conducted using STATA/
SE 14.0.
Results
The distribution of main independent variables, ANC attendance (number of ANC visits and timing of first ANC
visits) for each studied country and pooled values for the
regions are presented in Table 1. Adjusted hazard ratios of
the associations between neonatal mortality, ANC attendance and other maternal and demographic variables are
shown in Table 2. The multivariable model shows that
those who had two to three ANC visits (HR 0.70, 95%
CI 0.64–0.77) and four or more visits (HR 0.54, 95%
CI 0.50–0.59) had lower risk of neonatal death than those
who had no care. The risk of neonatal death among those
who had first ANC visits before 4 months was 41% lower
(HR 0.59, 95% CI 0.54–0.65) than those who had no visit.
When we combined the two recommendations into one
variable, we found that the risk of neonatal death was
Table 1. Continued
Country Na Number of ANC visits Timing of first ANC visits (months)
No care 1 visit 2–3 visits 4þ visits < 4 4–5 6–7 8þ Median
months
Latin America & Caribbean
Bolivia (2008) 4651 9.6 3.4 15.2 71.5 60.4 19.2 9.1 1.4 3.3
Colombia (2010) 8639 3.3 1.0 7.0 87.7 74.9 16.2 4.7 0.7 2.7
Dominican Republic (2013) 1945 0.5 0.3 2.4 95.4 81.1 14.6 3.3 0.3 2.6
Guyana (2009) 918 2.1 1.0 5.5 77.4 47.3 32.3 13.2 2.1 4.0
Haiti (2012) 3848 9.8 4.1 20.2 65.3 57.2 22.3 9.4 1.2 3.6
Honduras (2011–12) 5825 3.3 1.7 6.1 88.9 76.3 15.3 4.2 0.9 2.8
Peru (2012) 4923 1.5 0.7 3.5 94.2 73.6 17.6 6.3 0.9 2.9
Latin America pooled 30750 4.6 1.8 9.0 84.6 67.3 19.6 7.2 1.1 3.1
Middle East
Egypt (2014) 12579 8.7 0.6 6.6 82.8 76.3 11.1 2.8 0.9 2.6
Jordan (2012) 4841 0.9 0.6 4.0 94.5 90.7 6.3 1.8 0.3 2.3
Middle East pooled 17420 6.9 0.7 6.2 86.2 83.5 8.7 2.3 0.6 2.5
South Asia
Bangladesh (2014) 4621 21.4 17.9 29.4 31.2 24.3 19.3 13.3 5.8 5.1
India (2005–06) 28655 23.0 6.0 33.5 37.0 43.0 22.7 8.3 2.3 3.8
Maldives (2009) 1977 0.1 0.3 1.7 85.6 91.4 6.3 1.3 0.3 1.8
Nepal (2011) 2847 14.4 6.2 27.8 51.6 50.3 26.5 7.1 1.8 3.7
Pakistan (2012–13) 5765 22.6 13.3 26.8 37.1 42.6 15.4 13.1 6.2 3.7
South Asia pooled 43866 21.3 8.2 31.0 39.4 50.3 18.0 8.6 3.3 3.6
All countries
Pooled 301546 8.6 3.3 22.9 62.4 58.0 17.4 8.0 2.9 3.4
aNumber of respondents in each country and region.
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Table 2. Association of neonatal death with antenatal care (ANC) visits and other demographic characteristics at the most recent birth
Na Weighted
percentage
Number of
neonatal deaths
Adjusted HRb
(95% CI)
P-value
Number of ANC visits
No visits 40939 13.4 1262 (3.1) 1.0
1 visit 11029 3.6 318 (2.9) 0.97 (0.83–1.12) 0.700
2–3 visits 79927 26.2 1745 (2.2) 0.70 (0.64–0.77) <0.001
4þ visits 172892 56.7 2764 (1.6) 0.54 (0.50–0.59) <0.001
Timing of first ANC visits (months)
No visits 36637 12.3 1176 (3.2) 1.0
< 4 months 125865 42.4 2165 (1.7) 0.59 (0.54–0.65) <0.001
4–5 months 87275 29.4 1714 (2.0) 0.62 (0.56–0.68) <0.001
6–7 months 41662 14.0 721 (1.7) 0.58 (0.52–0.65) <0.001
8þ months 5399 1.8 118 (2.2) 0.55 (0.42–0.71) <0.001
WHO recommendations for ANC visits
Had not met any recommendations 110257 36.3 2694 (2.4) 1.0
Had first ANC visit within first trimester 20918 6.9 573 (2.7) 0.74 (0.67–0.83) <0.001
Had at least 4 ANC visits 67945 22.3 1172 (1.7) 0.49 (0.46–0.53) <0.001
Has met both recommendations 104946 34.5 1592 (1.5) 0.45 (0.42–0.48) <0.001
Maternal age group
15–19 32226 7.0 1233 (3.8) 1.0
20–24 120172 26.1 3770 (3.1) 0.68 (0.62–0.74) <0.001
25–29 134372 29.2 3480 (2.6) 0.46 (0.42–0.50) <0.001
30–34 91130 19.8 2403 (2.6) 0.39 (0.35–0.43) <0.001
35–39 55857 12.1 1675 (3.0) 0.40 (0.35–0.45) <0.001
40þ 26877 5.8 956 (3.6) 0.45 (0.40–0.52) <0.001
Area of residence
Urban 143975 31.3 3705 (2.6) 1.0
Rural 316659 68.7 9812 (3.1) 1.02 (0.96–1.07) 0.463
BMI (kg/m2)
<18.5 42835 13.5 1521 (3.6) 1.11 (1.04–1.18) <0.001
18.5–24.9 198767 62.6 5780 (2.9) 1.0
25.0–28.9 53460 16.8 1496 (2.8) 1.10 (1.04–1.17) 0.001
30.0 22543 7.1 605 (2.7) 1.20 (1.09–1.31) <0.001
Wealth quintile
Poorest 109491 23.8 3435 (3.1) 1.0
Poorer 101460 22.0 3108 (3.1) 1.07 (1.01–1.14) 0.017
Middle 94152 20.4 2751 (2.9) 1.15 (1.08–1.23) <0.001
Richer 85573 18.6 2442 (2.9) 1.17 (1.09–1.25) <0.001
Richest 69960 15.2 1780 (2.5) 1.25 (1.15–1.36) <0.001
Children ever born
1 child 76051 16.5 1690 (2.2) 1.0
2–3 190792 41.4 5372 (2.8) 1.30 (1.20–1.40) <0.001
4–5 103245 22.4 2977 (2.9) 1.58 (1.44–1.74) <0.001
6 90546 19.7 3476 (3.8) 2.21 (1.99–2.46) <0.001
Sex of child
Male 234331 50.9 7778 (3.3) 1.0
Female 226304 49.1 5739 (2.5) 0.75 (0.72–0.78) <0.001
Maternal education
No education 165692 36.0 5683 (3.4) 1.0
Primary 142532 30.9 4165 (2.9) 0.90 (0.85–0.95) <0.001
Secondary or more 152412 33.1 3668 (2.4) 0.94 (0.89–1.00) 0.058
aFrequency distribution of each of the independent variables in the total sample. The total for each of the variables may not be same because of the missing information in ANC visits variables.
bAdjusted for all other factors in table and for the country and year of survey variables.
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26% lower (HR 0.74, 95% CI 0.67–0.83) among women
who had first ANC visit within the first trimester of gestation, 51% lower (HR 0.49, 95% CI 0.46–0.53) among
those who had at least four ANC visits and 55% lower
(HR 0.45, 95% CI 0.42–0.48) among those who met both
recommendations compared with those who did not meet
any of the recommendations.
The risk of neonatal mortality among those who had at
least one of the two WHO recommended ANC visit compared with those who did not meet any of the two recommendations, stratified by country and regions and sorted
from lowest to highest risk, are presented in Figure 1.
Country-level analysis shows that, in most countries, ANC
attendance is associated with lower risk of neonatal
Figure 1. Adjusted hazard ratios (HRs) and their 95% CI for the risk of neonatal mortality among those who met at least one ANC recommendation.
The model was adjusted for maternal age, area of residence, BMI, wealth quintile, children ever born, sex of child and maternal education.
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mortality among those who met at least one WHO recommendation compared with those who did not. Similarly,
per regions, a lower risk of neonatal mortality was found
in all the regions among those who met at least one ANC
recommendation compared with those who did not. The
exception was in the Middle East & North Africa region
(HR 0.97, 95% CI 0.65–1.45) where no difference was
found between these groups. The meta-analysis of the
country-level risk shows 32% lower risk of neonatal death
among those who met at least one recommendation (HR
0.68, 95% CI 0.61–0.75) than those who did not.
The hazard was highest in the first week of life. It
decreased sharply after the first week (Figure 2). Infants
born to mothers who did not meet the WHO recommendations had greater excess hazard of dying during the first
month of life than those born to mothers who fulfilled
both or at least one recommendation. The risk was lowest
among those who met both recommendations. The Europe
and Central Asia region experienced better survival,
whereas the South Asia region had the worst survival
(Figure 3). The regional differences in the neonatal survival
were statistically significant (P < 0.001).
Discussion
Using a unique and comparable data set (N ¼ 464 728) collected from 2005 to 2015, we conducted survival analysis
on the influence of ANC attendance on neonatal death in
57 LMICs. ANC attendance is protective against neonatal
mortality in most of the countries studied. After adjusting
for potential confounding factors in pooled analysis, we
found 55% lower risk of neonatal mortality among
women who met both WHO recommendations for ANC.
Furthermore, ANC attendance was found to be protective
against neonatal mortality in all the regions except in the
Middle East and North African region where no difference
was found. Additionally, meta-analysis shows a 32%
reduced risk of neonatal mortality among women who met
at least one WHO recommendation in the LMICs studied.
As expected, we found a greater hazard during the early
neonatal period, similar to that found by an earlier study
which explored other risk factors of neonatal mortality in
some LMICs.18 Nonetheless, children born to mothers
who did not meet any of the WHO recommendations, or
met just one of them, had excess risk throughout the neonatal period compared with those who met both
recommendations.
ANC visits are potentially beneficial for both the baby
and the mother. ANC is an opportunity for promoting
healthy behaviour among mothers as well as promotion of
parenting skills, which are particularly important for new
mothers.
In 2016, the WHO introduced new guidelines for ANC,
which recommend a minimum of eight ANC contacts during pregnancy and the first contact is recommended to be
within the first 12 weeks of gestation.19 The goal of this
new guideline is to fully use the opportunity of providing
ANC to save lives. Our findings suggest that this new recommendation is important, timely and can contribute to
ending some preventable neonatal deaths in LMICs.
Furthermore, in LMICs where HIV infection is high, the
ANC visit offers mothers the opportunity to be screened
for the virus, and those who test positive can be treated to
prevent mother to child transmission. This might also contribute to neonatal survival. Women who attend ANC
might be advised to seek out skilled delivery care or institutional delivery, as well as postnatal care (PNC). It has been
shown that women who attend ANC are more likely to
have institutional care during labour.20 An association between ANC attendance and skilled delivery care has also
been reported,21 although with some exceptions.22 Both
Figure 2. Daily hazard of neonatal mortality for infants during the first
month of life, stratified by recommended ANC visit of mother.
Figure 3. Daily survival curves from neonatal mortality for infant during
the first month of life stratified by the region.
International Journal of Epidemiology, 2017, Vol. 46, No. 5 1675
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institutional delivery and skilled delivery care can contribute to improving neonatal outcome. This could explain our
finding of an association between ANC attendance and
neonatal survival. In addition, our finding of higher child
mortality in the first few days of life emphasizes the importance of PNC alongside ANC. In this respect, the quality of ANC is essential. It is unknown whether women who
met the recommended ANC visits also received these recommended services or whether the service providers have
the adequate knowledge, skills, supplies and equipment to
deliver high quality care.
This study underscores the crucial importance of ANC
to child survival in LMICs. Apart from the role of ANC attendance in predicting neonatal mortality, we also
explored the role of other sociodemographic factors,
including maternal education and BMI, in the risk of neonatal death in LMICs. These findings are similar to those
reported in earlier studies.18,23 A number of studies have
also reported some of these sociodemographic factors as
predictors of ANC.13,16
Our findings, of independent association between ANC
attendance and neonatal mortality in relation to these earlier studies, emphasize the complexity of the risk for neonatal death, which should inform interventions in LMICs.
Earlier studies have identified a number of barriers to
ANC utilizations, including cost and provider barriers, in
developing countries.24,25 Although barriers might be
country-specific, the evidence of substantial reduction in
neonatal mortality risk by ANC attendance, found in the
present study, means that conscious efforts at addressing
these barriers at local, national and regional levels are necessary to improve neonatal health in LMICs. We found
regional differences: ANC attendance was found to be protective against neonatal mortality in all the regions except
in the Middle East and North African region. Given that
data from only two countries in this region were available
and included in this study, the interpretation of the regional differences should be done with caution.
In the DHS, antenatal health care utilization was selfreported and may be biased by social desirability within
the society where the women lived. Also, ANC attendance
was measured for births within the past years preceding
the study; hence it may be affected by recall bias. What
constitutes ANC in each country may vary–ANC might
not necessarily mean care by skilled health personnel, and
thus the result should be interpreted within this context.
Causal inference is limited due to the cross-sectional nature
of the data.
Furthermore, data on births and deaths from which the
neonatal mortality was estimated were reported retrospectively by mothers and could be subject to recall bias.
However previous studies, which validated such measures
in retrospective and longitudinal surveys, found them to be
accurate.26 Initial assessment of the health data in the
DHS-I suggests that they are accurate estimates.27 We did
not investigate the quality of antenatal care in this study,
as the focus was mainly on the association between ANC
attendance and neonatal mortality. Future studies, which
will explore the quality of ANC delivery in LMICs and
how it relates to neonatal mortality as well as the aspects
of ANC that are beneficial to neonatal survival, will contribute further to the present findings. Such studies should
also explore the link between ANC and PNC and their effects on neonatal survival in these countries.
Conclusions
We conclude that ANC is protective against neonatal mortality in the LMICs studied, although differences exist
across the countries and by region. Our study provides a
comprehensive overview on the association between ANC
visits and neonatal mortality in nearly half of the world’s
LMICs. This study contributes to the literature on the subject and clarifies the importance of ANC visits on a health
outcome of global importance. To address the huge burden
of neonatal mortality in these countries, it is important to
increase ANC coverage and attendance.
The data are publicly available at [http://dhsprogram.
com/Data/]. Permission to use the data is required from
Measure DHS.
Acknowledgements
We would like to thank Mr Jani Raitanen of the School of Health
Sciences, University of Tampere, Finland, and Mr George Adjei of
the Kintampo Health Research Centre, Ghana, for their involvement
in the validation of the data.
Authors contributions
S.N. and D.T.D. conceptualized the study and developed the analytical strategy. D.T.D. and S.N. conducted the statistical analysis and
drafted the manuscript. Both authors did the critical revision of the
manuscript and approved the final version.
Conflict of interest: None declared.
References
1. United Nations. Official List of MDG Indicators. 2008. http://
mdgs.un.org/unsd/mdg/Host.aspx?Content¼indicators/officiallist.htm (29 July 2016, date last accessed).
2. United Nations. Millennium Development Goals Report 2015.
http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/
MDG%202015%20rev%20%28July%201%29.pdf (28 July
2016, date last accessed).
1676 International Journal of Epidemiology, 2017, Vol. 46, No. 5
Downloaded from https://academic.oup.com/ije/article/46/5/1668/3960260 by guest on 08 September 2023
3. World Health Organization. Every Newborn: An Action Plan to
End Preventable Deaths. http://apps.who.int/iris/bitstream/
10665/127938/1/9789241507448_eng.pdf?ua¼1 (28 July 2016
date last accessed).
4. Lawn JE, Blencowe H, Oza S et al. Every newborn: progress, priorities, and potential beyond survival. Lancet 2014;18:189–205.
5. Houweling TA, Kunst AE, Looman CW, Mackenbach JP.
Determinants of under-5 mortality among the poor and the rich:
a cross-national analysis of 43 developing countries. Int J
Epidemiol 2005;34:1257–65.
6. Houweling TA, Kunst AE. Socio-economic inequalities in childhood mortality in low- and middle-income countries: a review of
the international evidence. Br Med Bull 2010;93:7–26.
7. Lawn JE, Cousens S, Zupan J; Lancet Neonatal Survival Steering
Team. Four million neonatal deaths: when? where? why? Lancet
2005;365:891–900.
8. Lawn JE, Kerber K, Enweronu-Laryea C, Cousens S. 3.6 million
neonatal deaths—what is progressing and what is not? Semin
Perinatol 2010;34:371–86.
9. United Nations. Sustainable Development Goals. 2015. http://
www.un.org/sustainabledevelopment/sustainable-developmentgoals/ (2 November 2016, date last accessed).
10. Raatikainen K, Heiskanen N, Heinonen S. Under-attending free
antenatal care is associated with adverse pregnancy outcomes.
BMC Public Health 2007;7:1.
11. Hollowell J, Oakley L, Kurinczuk JJ, Brocklehurst P, Gray R.
The effectiveness of antenatal care programs to reduce infant
mortality and preterm birth in socially disadvantaged and vulnerable women in high-income countries: a systematic review.
BMC Pregnancy Childbirth 2011;11:13.
12. Ibrahim J, Yorifuji T, Tsuda T, Kashima S, Doi H. Frequency of
antenatal care visits and neonatal mortality in Indonesia. J Trop
Pediatr 2012;58:184–88.
13. Singh A, Pallikadavath S, Ram F, Alagarajan M. Do antenatal
care interventions improve neonatal survival in India? Health
Policy Plan 2014;29:842–48.
14. Dowswell T, Carroli G, Duley L et al. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane
Database Syst Rev. 2010;10:CD000934.
15. World Health Organization. WHO Recommended
Interventions for Improving Maternal and Newborn Health.
2nd edn. Geneva: WHO Department of Making Pregnancy
Safer, 2009.
16. Neupane S, Doku DT. Determinants of time of start of prenatal
care and number of prenatal care visits during pregnancy among
Nepalese women. J Community Health 2012;37:865–73.
17. Demographic and Health Survey Measure. Standard Recode
Manual for DHS 6. Calverton, MD: MEASURE DHS, USAID,
2013.
18. Cresswell JA, Campbell OM, De Silva MJ, Filippi V. Effect of
maternal obesity on neonatal death in sub-Saharan Africa: multivariable analysis of 27 national datasets. Lancet 2012;380:
1325–30.
19. World Health Organization. WHO Recommendations on
Antenatal Care for a Positive Pregnancy Experience. Geneva:
WHO, 2016.
20. Mengistu TA, Tafere TE. Effect of antenatal care on institutional
delivery in developing countries: a systematic review. JBI
Database Syst Rev Implement Rep 2011;9:1447–70.
21. Guliani H, Sepehri A, Serieux J. What impact does contact with
the prenatal care system have on women’s use of facility delivery? Evidence from low-income countries. Soc Sci Med
2012;74:1882–90.
22. Stanton C, Blanc AK, Croft T et al. Skilled care at birth in the developing world: progress to date and strategies for expanding
coverage. J Biosoc Sci 2007;39:109–20.
23. Fink G, Ross R, Hill K. Institutional deliveries weakly associated
with improved neonatal survival in developing countries: evidence from 192 Demographic and Health Surveys. Int J
Epidemiol 2015;44:1879–88.
24. Finlayson K, Downe S. Why do women not use antenatal services in low- and middle-income countries? A meta-synthesis of
qualitative studies. PLoS Med 2013;22:e1001373.
25. Matsuoka S, Aiga H, Rasmey LC, Rathavy T, Okitsu A.
Perceived barriers to utilization of maternal health services in
rural Cambodia. Health Policy 2010;95:255–63.
26. Garenne M, van Ginneken J. Comparison of retrospective surveys with a longitudinal follow-up in Senegal: SFS, DHS and
Niakhar. Eur J Popul 1994;10:203–21.
27. Macro International Inc. 1993. An Assessment of the Quality of
Health Data in DHS-I Surveys. DHS Methodological reports
No.2. Calverton, MD: Macro International Inc., 1993.
International Journal of Epidemiology, 2017, Vol. 46, No. 5 1677
Downloaded from https://academic.oup.com/ije/article/46/5/1668/3960260 by guest on 08 September 2023