Prenatal care and child growth and schooling in four low- and medium-income countries

Abstract

Background: The effectiveness of prenatal care for improving birth and subsequent child outcomes in low-income countries remains controversial, with much of the evidence to date coming from high-income countries and focused on early-life outcomes. We examined associations between prenatal care visits and birth weight, height-for-age at 24 months and attained schooling in four low- and middle-income countries.

Methods: We pooled data from prospective birth-cohort studies from Brazil, Guatemala, Philippines and South Africa. We created a prenatal care utilization index based on the number and timing of prenatal visits. Associations were examined between this index and birth weight, height-for-age at 24 months, and highest attained schooling grade until adulthood.

Results: Among 7203 individuals in the analysis, 68.9% (Philippines) to 96.7% (South Africa) had at least one prenatal care visit, with most having at least four visits. Over 40% of Brazilians and Guatemalans had their first prenatal visit in the first trimester, but fewer Filipinos (13.9%) and South Africans (19.8%) did so. Prenatal care utilization was not significantly associated with birth weight (p>0.05 in pooled data). Each unit increase in the prenatal care utilization index was associated with 0.09 (95% CI 0.04 to 0.15) higher height-for-age z-score at 24 months and with 0.26 (95% CI 0.17 to 0.35) higher schooling grades attained. Although there was some heterogeneity and greater imprecision across sites, the results were qualitatively similar among the four different populations.

Conclusions: While not related to birth weight, prenatal care utilization was associated with important outcomes later in life, specifically higher height-for-age at 24 months and higher attained school grades. These results suggest the relevance of prenatal care visits for human capital outcomes important over the lifecycle.

Fig 1. Magnitude of associations and CIs (coefficients) of INDEX1 in non-mediation model.

The magnitudes of associations and CIs (coefficients) of INDEX1 with (a) birth weight (b) HAZ at 24m (c) highest attained schooling in non-mediation model. INDEX1 is the sum of three binary prenatal care variables: ever had prenatal care visits, number of prenatal care visits higher than local medium level and visit in the first trimester. The non-mediation (or unconditional) model did not control for earlier outcomes in estimates for later outcomes. The area of each square is proportional to the study's weight in the meta-analysis. The dashed vertical line is the overall meta-analyzed measure of association. The diamond is the meta-analyzed measure of association, the lateral points of which indicate confidence intervals for this estimate.