Survival analysis of the association between antenatal care attendance and neonatal mortality in 57 low- and middle-income countries

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 = 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.

Keywords: Survival analysis; antenatal care; low- and middle-income countries; neonatal mortality.

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.

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.