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Survival analysis of the association between antenatal care attendance and neonatal mortality in 57 low- and middle-income countries
Open accessAbstract
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 = 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, meta-analysis 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.
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Reports relying on health sector data show that rates of receiving at least 4 ANC visits in Cox's Bazar are now around 77%.
“Reports relying on health sector data show that ANC coverage and facility-based births have gradually increased since 2017 and rates of receiving at least 4 ANC visits are now around 77%43”
From Predictors of antenatal care utilization among the Rohingya population in the refugee camps of Cox's Bazar, Bangladesh (2025) · cites this paper as [43]
The Methods (Data source; page unavailable) describe surveys from 2005–2015 across 57 countries, not health-sector reports tracking Cox’s Bazar since 2017. The Results (Table 2; page unavailable) give a pooled figure of 56.7% for four or more ANC visits. Searches for Cox’s Bazar, 77%, and post-2017 coverage or facility-birth trends found no passage addressing the attributed claim. (LLM, conf=0.78)
Experimental — accuracy not yet measuredANC coverage and facility-based births in Cox's Bazar have gradually increased since 2017.
“Reports relying on health sector data show that ANC coverage and facility-based births have gradually increased since 2017 and rates of receiving at least 4 ANC visits are now around 77%43”
From Predictors of antenatal care utilization among the Rohingya population in the refugee camps of Cox's Bazar, Bangladesh (2025) · cites this paper as [43]
The Methods (Data source; page not supplied) describe surveys from 2005–2015 across 57 countries, not health-sector reports tracking Cox’s Bazar since 2017. Searches for Cox’s Bazar, post-2017 increases in ANC coverage and facility-based births, and the 77% figure found no passage addressing those claims. (LLM, conf=0.78)
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Cites
Under-attending free antenatal care is associated with adverse pregnancy outcomes
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“An association between ANC attendance and skilled delivery care has also been reported,(21) although with some exceptions.(22) Both Figure 2.”
BackgroundGuliani, H., Sepehri, A., & Serieux, J. (2012) · Social Science & Medicine · doi:10.1016/j.socscimed.2012.02.008 · Cited by 70
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Simon, D., Michael, D., Rahman, M. S., Hiott, M. C., Rahim, A., Sanin, K. I., Tofail, F., & Wuermli, A. J. (2025) · Conflict and Health · doi:10.1186/s13031-025-00733-6 · Cited by 2
“This could reduce maternal, neonatal and under-5 mortality rates, and address developmental delays observed in the Rohingya community [43, 44].”
Metadata
- Authors
- Doku, D. T., & Neupane, S.
- Affiliations
- University of Cape Coast (GH)
- Tampere University (FI)
- Corresponding author
- Doku, David T
- Venue
- International Journal of Epidemiology
- Publisher
- Oxford University Press (OUP)
- Published
- 2017-07-13
- Volume
- 46
- Issue
- 5
- Pages
- 1668-1677
- ISSN
- 0300-5771 (ISSN-L)
- 1464-3685
- PMC
- PMC5837573
- OpenAlex
- W2771797805
- Cited by
- 117
- References
- 3
- Citations by year
- 2026: 9 · 2025: 7 · 2024: 10 · 2023: 17 · 2022: 20 · 2021: 12 · 2020: 26 · 2019: 12 · 2018: 4
- FWCI
- 12.55
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- International Journal of Epidemiology (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- Tampere University Institutional Repository (Tampere University) (submittedVersion, cc-by-nc)
- Funders
- Tampereen Yliopisto
- Topics
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Maternal and Neonatal Healthcare
- Health Sciences › Medicine › Obstetrics and Gynecology › Maternal and Perinatal Health Interventions
- Keywords
- prenatal care, neonatal mortality, low- and middle-income countries, maternal health, neonatal survival, emergency obstetric care
- MeSH terms
- Adolescent, Adult, Cross-Sectional Studies, Developing Countries, Female, Humans, Infant, Infant Mortality, Infant, Newborn, Male, Middle Aged, Patient Acceptance of Health Care, Pregnancy, Prenatal Care, Meta-Analysis as Topic, Multivariate Analysis, Survival Analysis, Young Adult
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