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. 2026 Feb 19;10(2):100697. doi: 10.1016/j.mayocpiqo.2026.100697

Antenatal Care and Perinatal Mortality in Low- and Middle-Income Countries: Insights for Maternal and Newborn Health System

Belayneh Jejaw Abate a,∗, Sileshi Ayele Abebe b, Helen Brhan Alemaw h, Amare Teshome Tefera c, Yeshambel Andargie Tarekegn d, Bikis Liyew e, Kassaw Chekole Adane g, Martha Solomon Tadesse f, Muluken Chanie Agimas i
PMCID: PMC12934229  PMID: 41757131

Abstract

Objective

To examine differences in perinatal mortality among women with and without antenatal care (ANC) in low- and middle-income countries (LMICs) and identify associated factors.

Patients and Methods

This study analyzed demographic and health survey data collected between June 15, 2015, and May 31, 2024, from 41 LMICs, comprising 494,259 weighted observations. Mixed-effects logistic regression was used to account for the hierarchical data structure and identify factors associated with perinatal mortality among women with and without ANC, with P < .05 considered statistically significant.

Results

The prevalence of perinatal mortality among ANC users and non-ANC users was found to be 40.1 per 1000 total births (95% CI, 39.58-40.72) and 51.9 per 1000 total births (95% CI, 49.73-53.99), respectively. Among ANC users, women with 8 or more ANC contacts had a markedly lower prevalence (26.4 per 1000 births; 95% CI, 25.29–27.52). Preceding birth interval, a history of terminated pregnancy, mode of delivery, tetanus vaccine, wealth index, twin birth, type of cooking fuel, and subregions of world countries were significantly associated with perinatal mortality in both groups. Besides the type of toilet facility, women’s access to decision making, mothers’ education, and place of delivery were factors significantly associated with perinatal mortality in ANC user women.

Conclusion

Perinatal mortality was substantially higher among women without ANC, whereas women with 8 or more ANC contacts had approximately half the risk, emphasizing the urgent need to expand access to World Health Organization–recommended ANC and address key factors associated with perinatal mortality in LMICs.

Perinatal mortality, as defined by the World Health Organization (WHO), refers to the number of fetal deaths after 28 weeks of gestation and deaths within the first week of life per 1000 total births.1,2 It is one of the most critical indicators of maternal and neonatal health. Each year, an estimated 8 million perinatal deaths occur globally, with over 98% reported in low- and middle-income countries (LMICs), particularly in South Asia and sub-Saharan Africa.3,4 Most deaths result from preventable causes during pregnancy and childbirth, highlighting the importance of timely and quality maternal care.3,5,6

Antenatal care (ANC) is a cornerstone of maternal and newborn health, providing interventions such as tetanus vaccination, blood pressure monitoring, and fetal growth assessment that significantly reduce perinatal mortality.7, 8, 9 The WHO recommends a minimum of 8 ANC contacts to reduce perinatal mortality and enhance the quality of care.9 Global initiatives, including the Every Newborn Action Plan and United Nations Fund for Population Activities programs, emphasize universal access to quality maternal and newborn care as a strategy to prevent perinatal deaths, estimating that up to 3 million deaths could be averted annually if essential interventions are delivered effectively.10,11 Evidence from systematic reviews and meta-analysis indicates that adequate ANC attendance significantly reduces the risk of perinatal death8,12; however, coverage remains insufficient in many LMICs owing to weak health systems, financial barriers, and sociocultural constraints.13

Most existing studies are country specific and rarely compare perinatal mortality between women with and without ANC.5,7,14, 15, 16, 17 Comparative multicountry analyses are therefore essential to examine mortality rates across diverse populations, identify barriers to ANC access, and assess the quality of care delivered.8,18,19 Investigating the interaction of socioeconomic, maternal, and contextual factors can further highlight priority areas for intervention.8 This study aims to determine the prevalence and determinants of perinatal mortality among women with and without ANC in LMICs using a multilevel mixed-effects model. This approach accounts for the hierarchical structure of the data (ie, individual women nested within clusters, which are further nested within countries) and addresses challenges from multistage sampling and intragroup correlations.20, 21, 22, 23, 24 By comparing ANC users and nonusers, the study provides robust, policy-relevant evidence to inform strategies for reducing preventable perinatal deaths and achieving WHO and Sustainable Development Goal targets for maternal and newborn health.

Patients and Methods

Study Design, Period, and Setting

This study analyzed demographic and health survey (DHS) data collected between June 15, 2015, and May 31, 2024, from 41 LMICs. The DHS provides nationally representative data on a wide range of health and demographic indicators. The countries were identified on the basis of recent updated date sets and categorized into 7 subregions—South Asia (Afghanistan, Bangladesh, India, Nepal, and Pakistan); East Asia and Pacific (Cambodia, Myanmar, Timor-Leste, Indonesia, Papua-Guinea, and Philippines); Europe and Central Asia (Albania and Tajikistan); Middle East and North Africa (Jordan); Latin America and Caribbean (Colombia); West and Central Africa (Burkina Faso, Benin, Côte d’Ivoire, Mauritania, Gabon, Ghana, Gambia, Guinea, Liberia, Mali, Nigeria, Serra Leone, Senegal, and Angola); and East and Southern Africa (Burundi, Ethiopia, Madagascar, Malawi, Mozambique, Rwanda, South Africa, Tanzania, Uganda, Zambia, Zimbabwe, and Kenya).

Sampling Procedure, Sample Size, and Data Source

The DHS data set used a 2-stage stratified sampling method. In the first stage, 126,356 enumeration areas (clusters) were selected with probability proportional to their size. In the second stage, a fixed number of households per cluster were chosen using systematic random sampling. A total of 1,454,125 women aged 15 to 49 years, including permanent residents and overnight visitors, were eligible for interview. To ensure representativeness, DHS sampling weights (v005/1,000,000) were applied, resulting in a weighted sample of 494,259 women (452,549 ANC users and 41,710 non-ANC users) with births at 28 weeks’ gestation or more, including stillbirths and early neonatal deaths (0-6 days) within 5 years preceding the survey (Figure). Data were obtained from the DHS program following submission of a study proposal (https://dhsprogram.com/data/available-datasets.cfm).

Figure 1.

Figure 1

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Sample size determination for identifying prevalence and determinants of perinatal mortality among antenatal care (ANC) users and non-ANC users of reproductive-age women in low- and middle-income countries: Demographic and Health Surveys (DHSs), 2015-2024.

Dependent Variables

Perinatal mortality was defined as either stillbirth (fetal death ≥28 weeks’ gestation) or early neonatal death (death within 7 days of live birth), based on the procedures outlined in the DHS guidelines. The details of the calculation method for perinatal mortality rate, stillbirth, and early neonatal death can be found in the DHS Contraceptive Calendar tutor.2

Comparator

Antenatal care utilization was operationalized in 2 stages: first as a binary measure (ANC user vs nonuser), and second, to align with WHO recommendations on service adequacy, ANC users were further categorized by contact frequency into less than 8 ANC contacts and 8 or more ANC contacts.

Independent Variables

The independent variables included in the study are maternal age, sex of the household head, maternal and paternal education, place of residence, number of household children, maternal occupation, household wealth index, tetanus toxoid (TT) vaccine, women’s access to decision making, age at first birth, a history of pregnancy ever terminated, place of delivery, delivery assistance, birth interval, mode of delivery, drinking water source, toilet facility, media exposure, type of cooking fuel, distance from health facility, place of residence, and subregions of world countries. Details on the measurement of each predictor were reported in Appendix 1 (available online at https://www.mcpdigitalhealth.org/).

Data Management and Analyses

After the data had been obtained from the MEASURE DHS program, STATA software (version 17) was used to extract, recode, and perform both descriptive and inferential statistical analyses. The descriptive statistics were reported through various formats, including frequencies, percentages, figures, and tables. To ensure the study’s representativeness, sample weighting was applied during the analysis. Variables were categorized according to previously published methods. Missing data were observed for 8 predictors, ranging from 0.25% (a history of terminated pregnancy) to 6.5% (tetanus vaccination). These missing values were assumed to be missing at random and handled following DHS guidelines (Appendix 2, Supplemental Tables 1 and 2, available online at https://www.mcpdigitalhealth.org/).

To examine the determinants of perinatal mortality, mixed-effects binary logistic regression was used to account for the hierarchical structure of the DHS data. Variables with a P value if ≤.2 in bivariate analysis were considered for inclusion in multivariable models. Four models were developed: a null model with no predictors to estimate baseline variance, model I including individual-level factors, model II including community-level factors, and model III combining both individual- and community-level predictors. Analyzing models separately allows for a clearer understanding of the unique contributions of each level of predictors for both population groups of the study.

Clustering of perinatal mortality within communities was evaluated using the intraclass correlation coefficient, and the median odds ratio was calculated to determine the odds ratio between regions with the highest and lowest perinatal mortality risk. The proportion change in variance was used to evaluate the contribution of explanatory variables to the observed variation.25 Multicollinearity was assessed using the variance inflation factor (<5). Model fit was compared using the Akaike information criterion (AIC) and log-likelihood tests, with the best-fitting model selected on the basis of the lowest AIC and highest log-likelihood. Adjusted odds ratios (AORs) with 95% CIs were reported, with predictors considered statistically significant at P<.05 and highly significant at P<.01. The study was conducted in accordance with the STROBE guidelines for cross-sectional studies.

Results

Characteristics of the Study Participants

The study included a weighted sample of 494,259 (452,549 ANC users and 41,710 non-ANC users) childbearing-age women in LMICs. More than three-fourths of both ANC users (76.2%) and non-ANC users (70.2%) were aged 20 to 34 years. Over half of ANC users (52.8%) had completed secondary or higher education, whereas most non-ANC users (61.6%) had no formal education. Facility delivery was common among ANC users (76.7%), whereas home delivery predominated among non-ANC users (65.5%). Further descriptive characteristics of study participants are presented in Appendix 3 (available online at https://www.mcpdigitalhealth.org/).

Prevalence of Perinatal Mortality Among ANC Users and Non-ANC Users of Childbearing Women in LMICs

The prevalence of perinatal mortality among women who attended ANC was 40.1 per 1000 total births (95% CI, 39.58-40.72), showing considerable variation across countries, with rates ranging from 4.5 per 1000 total births in Albania to 82 per 1000 births in Pakistan. For non-ANC users, the prevalence was 51.9 per 1000 total births (95% CI, 49.73-53.99), varying from 1.8 per 1000 total births in Albania to 141 per 1000 births in Ghana. Stratifying ANC users by WHO-recommended contact frequency showed a clear dose-response pattern: women with fewer than 8 ANC contacts had a prevalence of 43.1 per 1000 births (95% CI, 42.44-43.75), whereas those with 8 or more contacts had a markedly lower prevalence of 26.41 per 1000 births (95% CI, 25.29-27.52) (Table 1). These findings highlight the protective association of ANC attendance and frequent contact with perinatal survival.

Table 1.

Prevalence of Perinatal Mortality Among ANC Users and Non-ANC Reproductive-Age Women in Low- and Middle-Income Countries: DHS 2015-2024.

Country Survey year Total non-ANC user (n) ANC user (n)
 Prevalence of Perinatal mortality
Total ANC user (n) ANC user <8 contacts (n) ANC user ≥8 contacts (n) Total non-ANC user (/1000) Total ANC user (/1000) ANC user <8 contacts (/1000) ANC user ≥8 contacts (/1000)
South Asia
 Afghanistan 2015 7492 12,349 11,539 810 64.1 50.1 51.29 33.48
 Bangladesh 2022 413 11,253 10,998 255 67.3 33.0 33.11 29.10
 India 2019-2021 10,658 164,375 128,674 35,701 44.2 39.7 44.19 23.46
 Nepal 2022 68 4192 4026 166 83.6 31.3 30.71 44.82
 Pakistan 2017-2018 816 5949 4984 965 78.8 82 83.99 71.85
East Asia and Pacific
 Cambodia 2021-2022 58 6691 5487 1204 31.7 13.7 13.46 14.80
 Myanmar 2015-2016 460 3155 2516 639 30.1 32.4 35.76 19.34
 Timor-Leste 2016 694 4296 3052 1244 37.1 25.3 26.05 23.36
 Indonesia 2017 398 14,713 5002 9711 78.2 21.8 36.89 14.03
 Papua New Guinea 2016-2018 1490 5265 4334 931 27.6 23.3 25.36 13.43
 Philippines 2022 137 6397 5080 1317 22.8 27.2 28.98 20.43
Europe and Central Asia
 Albania 2017-2018 252 1932 1245 687 1.8 4.5 6.14 1.58
 Tajikistan 2017 335 4052 3398 654 16.8 25.5 25.11 27.43
Middle East and North Africa
 Jordan 2023 121 5631 3334 2297 35.8 12.2 10.21 15.00
Latin America and Caribbean
 Colombia 2015 228 9121 5048 4079 38.9 14.6 19.02 9.03
West and Central Africa
 Burkina Faso 2021 74 9248 9154 94 98.8 34.2 33.73 78.52
 Benin 2017-2018 984 8071 7032 1039 51 45.9 45.92 45.62
 Côte d’Ivoire 2021 239 7060 6811 249 72.4 58.4 57.98 70.46
 Mauritania 2019-2021 872 6884 6084 800 40.3 44.8 45.84 36.72
 Gabon 2019-2021 117 4278 3506 772 57.5 31.7 35.65 13.83
 Ghana 2022 92 6434 4616 1818 141 34.2 34.82 32.60
 Gambia 2019-2020 25 5400 5141 259 131 53.9 55.35 25.70
 Guinea 2018 767 4747 4425 322 44.6 50.4 50.57 48.63
 Liberia 2019-2020 67 3968 2847 1121 80.6 47.9 53.29 34.14
 Mali 2018 1274 5383 5004 379 64.1 52.6 53.74 37.67
 Nigeria 2018 5331 16,716 12,007 4709 61.7 71.6 74.90 63.24
 Serra Leone 2019 112 7261 4778 2483 74.2 42.0 44.38 37.50
 Senegal 2019 105 7139 6283 856 31.4 41.3 40.34 48.34
 Angola 2015/2016 1534 6975 6243 732 49.1 42.5 42.84 39.55
East and Southern Africa
 Burundi 2023 62 8952 8708 244 33.7 54.1 53.37 80.20
 Ethiopia 2016 2811 4824 46,523 171 42.5 48.7 49.98 13.28
 Madagascar 2021 950 8335 8089 246 39.6 47.6 47.98 35.32
 Malawi 2016 244 13,312 13,071 241 80.1 41.3 41.16 51.38
 Mozambique 2022 724 6480 6069 411 39.5 41.5 42.24 30.46
 Rwanda 2019/2020 142 6163 6147 16 29.7 33.4 33.36 48.55
 South Africa 2016 172 2867 2248 619 74.3 27.9 31.99 13.07
 Tanzania 2022 610 7285 7084 201 49.1 47.0 46.26 72.92
 Uganda 2016 194 10,022 9781 241 93.1 51.9 52.19 40.92
 Zambia 2018 80 7265 7113 152 25.8 40.8 40.44 55.82
 Zimbabwe 2015 322 4682 4070 612 64.8 38.3 40.14 25.85
 Kenya 2022 186 13,425 13,017 408 68.8 28.6 28.47 34.34
Overall 41,710 452,549 372,693 79,856 51.9 (95% CI, 49.73-53.99) 40.1 (95% CI, 39.58-40.72) 43.10 (95% CI, 42.44-43.75) 26.41 (95% CI, 25.29-27.52)
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ANC, antenatal care; DHS, demographic and health survey.

Predictors of Perinatal Mortality Among ANC Users and Non-ANC Users of Reproductive-Age Women

Bivariable logistic regression (P<.2) was used to identify potential predictors of perinatal mortality separately for ANC users and nonusers, supplemented by clinical and conceptual relevance. Variables with variance inflation factor of >5 were excluded to avoid multicollinearity (Appendix 4, Supplemental Tables 3 and 4, available online at https://www.mcpdigitalhealth.org/). The mixed-effect logistic regression model (model III) was selected for both groups on the basis of on the highest log likelihood and lowest AIC. The intraclass correlation coefficient showed that 13.0% of the variance among ANC users and 24.8% among non-ANC users was attributable to cluster-level factors. The median odds ratios indicated 1.45 and 1.73 times higher odds of perinatal mortality for ANC and non-ANC users, respectively, when moving to higher-risk communities. Overall, the model explained 42.3% of the variance for ANC users and 36.5% for non-ANC users (Appendix 5, available online at https://www.mcpdigitalhealth.org/).

In the multivariable multilevel binary logistic regression analysis preceding birth interval, a history of terminated pregnancy, mode of delivery, tetanus vaccine, wealth index, twin birth, type of cooking fuel, and subregions of world countries were significantly associated with perinatal mortality in both ANC users and non-ANC users of reproductive-age women (P<.01). Type of toilet facility, women’s access to decision making, mother’s education, and place of delivery were factors significantly associated with perinatal mortality in ANC user women (Table 2). By holding other predictors constant, we interpreted the significant covariates as described further.

Table 2.

Determinants of Perinatal Mortality Among ANC Users and Non-ANC Users of Childbearing Women in Low- and Middle-Income Countries: DHS 2015-2024.

Variables Category ANC user
 Non-ANC user
AOR (95% CI) AOR (95% CI)
Mother education No education 1.07 (1.02-1.12)∗ 1.04 (0.87-1.24)
Primary 1.01 (0.96-1.06) 0.96 (0.79-1.18)
Secondary and above 1 1
Father education No education 0.95 (0.90-1.01) 1.07 (0.92-1.26)
Primary 0.97 (0.92-1.03) 1.09 (0.89-1.34)
Secondary and above 1 1
Wealth index Poor 1.19 (1.13-1.25)∗∗ 1.30 (1.08-1.57)∗∗
Middle 1.12 (1.07-1.18)∗∗ 1.22 (1.01-1.49)∗∗
Rich 1 1
Tetanus vaccine Not at all 1.82 (1.74-1.90)∗∗ 1.34 (1.15-1.57)∗∗
One times 1.12 (1.06-1.17)∗∗ 0.97 (0.77-1.23)
Two and above 1 1
Place of delivery Home 1.24 (1.19-1.29)∗∗ 1.00 (0.87-1.15)
Health facility 1 1
Preceding birth interval ≤33 mo 2.14 (2.07-2.22)∗∗ 1.79 (1.61-1.99)∗∗
>33 mo 1 1
History of terminated pregnancy Yes 6.34 (6.13-6.57)∗∗ 5.19 (4.62-5.85)∗∗
No 1 1
Cesarean section delivery Yes 1.29 (1.22-1.35)∗∗ 2.42 (1.89-3.08)∗∗
No 1 1
Drinking water source Unimproved 0.97 (0.93-1.02) 1.07 (0.94-1.21)
Improved 1 1
Type of toilet Unimproved 1.06 (1.02-1.11)∗∗ 1.00 (0.88-1.14)
Improved 1 1
Distance to health facility Big problem 1.03 (0.99-1.07) 0.92 (0.82-1.03)
Not big problem 1 1
Twin birth Yes 11.1 (10.4-11.9)∗∗ 11.6 (8.77-15.2)∗∗
No 1 1
Type of cooking fuel Clean fuel 1 1
Solid fuel 1.21 (1.16-1.28)∗∗ 1.36 (1.1-1.67)∗∗
Women access to decision Yes 1 —
No 1.11 (1.06-1.16)∗∗ —
Residence Urban 1 1
Rural 1.14 (1.08-1.20)∗∗ 0.94 (0.78-1.14)
Subregions of world countries South Asia 0.90 (0.85-0.95)∗∗ 0.86 (0.72-1.03)
East Asia and Pacific 0.51 (0.47-0.56)∗∗ 0.78 (0.59-1.04)
Europe and Central Asia 0.24 (0.19-0.31)∗∗ 0.15 (0.06-0.37)∗∗
Middle East and North America 0.13 (0.10-0.18)∗∗ 0.53 (0.16-1.76)
East and Southern Africa 0.88 (0.82-0.93)∗∗ 0.93 (0.76-1.14)
West and Central Africa 1 1
Latin America and Caribbean 0.36 (0.29-0.44)∗∗ 0.56 (0.23-1.33)
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Primary threshold for significance:

ANC, antenatal care; AOR, adjusted odds ratio; —, variable was not significant in bivariable analysis for non-ANC users; 1, reference category.

∗

P<.05; for stronger associations.

∗∗

P<.01.

Preceding birth intervals of less than 33 months had 2.14 (95% CI, 2.07-2.22) and 1.79 (95% CI, 1.61-1.99) times higher odds of perinatal mortality than birth intervals of 33 or more months among ANC users and non-ANC users of reproductive-age women, respectively.

The AORs of perinatal mortality were 6.34 (95% CI, 6.13-6.57) and 5.19 (95% CI, 4.62-5.85) times higher in women who had a history of terminated pregnancy than their counterparts among ANC users and non-ANC users childbearing women, respectively.

Women undergoing cesarean section (CS) delivery had 1.29 (95% CI, 1.22-1.35) and 2.42 (95% CI, 1.89-3.08) times higher odds of perinatal mortality than counterparts among ANC users and non-ANC users childbearing women, respectively.

The AORs of perinatal mortality were 1.82 (1.82; 95% CI, 1.74-1.90) and 1.34 (1.34; 95% CI, 1.15-1.57) times higher in women not taking the TT vaccine at all than those in women taking the TT vaccine 2 or more times among ANC users and non-ANC users of childbearing women, respectively.

The AORs of perinatal mortality were 1.19 (95% CI, 1.13-1.25) times higher for women with a poor wealth index than the odds for those with a rich wealth index among ANC users. Similarly, among non-ANC users, the AORs were 1.30 times (95% CI, 1.08-1.57) higher for women with a poor wealth index than those for their richer counterparts.

Being a twin or above birth had 11.1 (95% CI, 10.4-11.9) and 11.6 (95% CI, 8.77-15.2) times higher odds of perinatal mortality than single births among ANC users and non-ANC users of childbearing women, respectively.

The AORs of perinatal mortality were 1.21 (95% CI, 1.16-1.28) and 1.36 (95% CI, 1.10-1.67) times higher in participants who used solid fuel than those in participants who used clean fuel among ANC users and non-ANC users of childbearing women, respectively.

Approximately 38% (AOR, 0.62; 95% CI, 0.46-0.85) and 75% (AOR, 0.25; 95% CI, 0.07-0.87) lower odds of perinatal mortality were found in Europe and Central Asia than among counterparts of ANC users and non-ANC users of childbearing-age women, respectively.

Furthermore, women who lack formal education (AOR, 1.07; 95% CI, 1.02-1.12), who had unimproved toilet facilities (AOR, 1.06; 95% CI, 1.02-1.11), who do not have access to the decision-making process (AOR, 1.11; 95% CI, 1.06-1.16), and who gave birth at home (AOR, 1.24; 95% CI, 1.19-1.29) were identified as having higher odds of perinatal mortality than their counterparts among ANC users of reproductive-age women.

To further explore the WHO recommendation of 8 or more ANC contacts, we performed a stratified analysis to identify determinants of perinatal mortality among women with less than 8 ANC contacts and those with 8 or more ANC contacts. Several predictors remained consistently significant across both groups, demonstrating persistent risk regardless of ANC frequency. Short birth intervals (≤33 months), a history of terminated pregnancy, cesarean delivery, lack of tetanus vaccination, twin births, poor household wealth, use of solid cooking fuel, and rural residence were independently associated with higher odds of perinatal mortality in both strata, confirming their robust effect (Appendix 6, available online at https://www.mcpdigitalhealth.org/).

Discussion

The perinatal mortality rate serves as a vital indicator of a country’s health status owing to its correlation with the quality of health care services provided during pregnancy.26 In this study, an attempt has been made to assess the prevalence and determinants of perinatal mortality among ANC users and non-ANC users of childbearing women in LMICs.

Our findings indicate that women using ANC experienced a perinatal mortality rate of 40.1 per 1000 total births (95% CI, 39.58-40.72), significantly lower than the 51.9 per 1000 total births observed among non-ANC users (95% CI, 49.86-54.0). Among ANC users, those with 8 or more contacts had an even lower prevalence of 26.4 per 1000 births (95% CI, 25.29-27.52). These results are consistent with WHO evidence27 and previous studies indicating that ANC is associated with improved maternal and neonatal outcomes.7,28 The lower perinatal mortality observed among ANC users is associated with factors such as early detection of complications, higher likelihood of skilled birth attendance, and access to postnatal care.8

Although the perinatal mortality rate among ANC users is lower than that of non-ANC users, it remains alarmingly high, exceeding the Every Newborn Action Plan target of less than 12 per 1000 total births by 2030.11 This association may reflect inconsistent implementation of the WHO 8-contact ANC model in LMICs, where many women attend only 1 to 3 visits and may not receive essential interventions such as fetal growth monitoring and preeclampsia screening.27 Persistent gaps in health care access, socioeconomic disparities, geographic barriers, and cultural factors further limit ANC utilization and are associated with higher perinatal mortality.8,29 These findings underscore ANC as a critical factor in reducing perinatal mortality and suggest the need for policies and programs that improve coverage, quality, and equity of maternal care.

Our study found that preceding birth intervals of less than 33 months had higher odds of perinatal mortality in both ANC users and non-ANC users. This aligned with a systematic review30,31 and studies conducted across 46 LMICs32 and Ethiopia.33 This might be because mothers with short birth intervals often experience nutritional depletion because they may not have fully recovered from the previous pregnancy.34 This can lead to complications such as cervical insufficiency and uterine distension, inadequate breastfeeding for the previous child, as well as increased sibling competition for resources, potentially affecting the health and survival of newborns.32,35 Additionally, short birth intervals are linked to higher risks of complications such as anemia, gestational diabetes, and maternal hemorrhage, potentially compromising maternal health and increasing perinatal mortality.34 The finding highlights the importance of monitoring and supporting women with closely spaced pregnancies to mitigate associated health risks.

Women with a history of terminated pregnancies had higher odds of perinatal mortality than their counterparts, regardless of ANC use. The finding is consistent with a systematic review36 and studies conducted in Ethiopia6,37 and Dutch tertiary health care settings.38 A possible reason for this might be termination of pregnancy, especially if performed under unsafe conditions or if complications arise, which can lead to uterine damage, which may lead to complications in future pregnancies, such as uterine rupture or placenta accrete.39 In addition, infections following termination can lead to chronic inflammation or scarring within the uterus, potentially affecting future pregnancies.40 Furthermore, women who have undergone terminations may also experience psychological stress, which can worsen existing health issues or lead to behaviors detrimental to fetal health.6,41 The finding underscores a need to consider a woman’s history of terminated pregnancies when assessing her risk factors during prenatal care.

Women undergoing CS had higher odds of perinatal mortality than those delivering vaginally, in both ANC users and non-ANC users. This contrasts with global evidence showing that CS reduces maternal and perinatal morbidity and mortality when performed for appropriate medical indications.42,43 The discrepancy is likely due to confounding by indication: women with pregnancy complications such as fetal distress or severe pre-eclampsia are more likely to require emergency CS, and these underlying conditions independently elevate perinatal risk.44,45 Additionally, population-level factors, nonmedically indicated CS, and variations in health care quality may contribute because rates above 10% do not necessarily reduce mortality.42,46 The finding emphasizes the need for a balanced approach to childbirth methods that prioritizes the health and safety of both mothers and newborns.

Women who did not receive the TT vaccine had higher odds of perinatal mortality than those receiving at least 1 dose, in both ANC users and non-ANC users. This finding is consistent with studies from Bangladesh47 and Pakistan48 and likely reflects the risk of neonatal tetanus, which can be transmitted during delivery if mothers are not immunized, leading to severe complications and death.49 These results underscore the importance of ensuring TT vaccination coverage, particularly among underserved populations, in line with WHO recommendations as part of routine ANC.50 Strengthening such initiatives could substantially reduce perinatal mortality.

In line with earlier findings,51,52 our study confirms that twins are at a higher risk of perinatal mortality than singletons, regardless of ANC utilization. This might be because twin pregnancies are associated with a higher risk of complications, including postpartum hemorrhage and preterm birth,52 with the second twin facing greater morbidity and mortality due to potential obstetric complications such as placental separation and uterine atony after the birth of the first twin.51

Perinatal mortality rates were substantially lower in Europe and Central Asia than those in West Africa, regardless of ANC use. These regional differences likely reflect variations in health system capacity, socioeconomic development, and access to quality maternal and newborn services.5,53, 54, 55 Countries with stronger health infrastructure, higher ANC coverage, and effective maternal health policies, such as those in Europe, consistently report lower perinatal mortality rates.54 In contrast, limited health care resources, high poverty levels, and weak health service delivery systems in parts of Africa and South Asia contribute to persistently high perinatal mortality.53,54 Strengthening maternal health programs, improving ANC accessibility, and addressing systemic inequities remain critical to reducing perinatal deaths globally.

Among ANC users, the use of unimproved sanitation, reliance on solid cooking fuels, and lack of maternal education were significant predictors of perinatal mortality, likely owing to increased pathogen exposure, indoor air pollution, and lower health literacy, respectively.26,56,57 These findings highlight the importance of integrated public health strategies addressing sanitation, clean energy, and female education to improve perinatal outcomes.

Strengths and Limitations of the Study

This study’s main strength is the use of nationally representative, population-based DHS data with a large sample size, which improves the generalizability of the findings. However, several limitations should be noted. First, the cross-sectional design precludes any inference of causal relationships; therefore, all findings should be interpreted strictly as associations between ANC utilization, related factors, and perinatal mortality. Second, DHS data are based on self-reports, introducing potential recall bias, particularly for pregnancy outcomes up to 5 years before the survey. Finally, the DHS Contraceptive Calendar tool records twins and triplets under a single code (B), which may lead to underestimation of stillbirths.2

Conclusion and Recommendations

Perinatal mortality rates were higher among women who did not receive ANC than those who did. Among ANC users, those with ≥8 contacts had approximately half the perinatal mortality compared with women who had fewer than 8 contacts. Preceding birth interval, a history of terminated pregnancy, mode of delivery, tetanus vaccine, wealth index, twin birth, type of cooking fuel, and subregions of world countries were identified as significant predictors in both groups. These findings suggest that ANC utilization and the identified factors are associated with perinatal outcomes. Efforts to improve ANC coverage and contact frequency, particularly among populations with lower utilization, may be important, and attention to factors such as birth spacing, vaccination, and delivery practices may help inform public health strategies aimed at reducing perinatal mortality.

Potential Competing Interests

The authors report no competing interests.

Ethics Statement

This study was based on secondary data obtained from the Demographic and Health Surveys (DHS) Program. The DHS data are publicly available, fully anonymized, and de-identified prior to release to ensure the privacy and confidentiality of respondents. The DHS Program obtains written informed consent from all participants before data collection and conducts surveys in accordance with strict ethical guidelines, including approval by relevant institutional review boards (IRBs) in each participating country as well as by ICF International. Because the present analysis used anonymized secondary data and involved no direct contact with human participants, additional ethical approval and informed consent were not required, and the need for further ethical review was waived.

Acknowledgments

B.J.A.: conceived and designed the study, analyzed and interpreted the data, wrote the original draft of the manuscript, revised it, and approved the final manuscript. S.A.A., H.B.A., A.T., Y.A.T., B.L., K.C.A., M.S.T., and M.C.A.: involved in the data management, analysis, and interpretation of the findings. S.A.A. and M.C.A.: substantially contributed to the methodology of the article, and involved in the analysis and interpretation of the data. All authors reviewed and edited the manuscript for intellectual content. All authors read and approved the final version of the manuscript.

Footnotes

Grant Support: This study did not receive any specific funding from public, commercial, or not-for-profit funding agencies. No external financial support was utilized in the design of the study; collection, analysis, or interpretation of data; writing of the manuscript; or the decision to submit the article for publication.

Supplemental material can be found online at https://www.mcpdigitalhealth.org/. Supplemental material attached to journal articles has not been edited, and the authors take responsibility for the accuracy of all data.

Supplemental Online Material

Appendixes
mmc1.docx (64.8KB, docx)

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Supplementary Materials

Appendixes
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