|Survival analysis of the association between
antenatal care attendance and neonatal
mortality in 57 low- and middle-income
||David T. Doku, and Subas Neupane
||International Journal of Epidemiology, 0(0): 1-10; Doi: 10.1093/ije/dyx125B
More than one region
||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 (N¼464 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