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Original Article
Association between early antenatal care and antenatal care contacts across low-and middle-income countries: effect modification by place of residence
Paschal Awingura Apanga, Maxwell Tii Kumbeni
Epidemiol Health. 2021;43:e2021092.   Published online November 2, 2021
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AbstractAbstract AbstractSummary PDFSupplementary Material
The relationship between receiving early antenatal care (ANC) and 8 or more antenatal contacts (ANC8+) has not been well characterised across low-and middle-income countries (LMICs). It is also unclear whether the association between early ANC and ANC8+ is modified by a woman’s place of residence. Our primary aim was to assess the relationship between early ANC and ANC8+ and to investigate whether this relationship was modified by place of residence. We also estimated the coverage of ANC8+ across LMICs.
We analysed data on 207,388 mothers with a recent live birth using multiple indicator cluster surveys conducted between 2017 and 2020 in 30 LMICS. Modified Poisson regression with robust variance was used to evaluate the relationship between early ANC and ANC8+, whilst adjusting for country, clustering, stratification, and sampling weights. Effect modification by place of residence was assessed on additive and multiplicative scales. A meta-analysis was conducted to pool prevalence estimates of ANC8+ across all countries.
The overall prevalence of ANC8+ was 35.6%, ranging from 1.7% in Madagascar to 99.4% in Belarus. Early ANC was positively associated with ANC8+ (adjusted prevalence ratio [aPR], 2.61; 95% confidence interval [CI], 1.82 to 3.74). There was evidence of positive effect modification on additive (relative excess risk due to interaction, 0.39; 95% CI, 0.35 to 0.44) and multiplicative (aPR, 1.78; 95% CI, 1.08 to 2.95) scales.
Many LMICs may not have adopted the 2016 World Health Organization guidelines on ANC8+. Receiving early ANC was associated with a higher likelihood of ANC8+, particularly for women in rural areas.
Key Message
Our findings suggest that early antenatal care (ANC) was associated with the likelihood of receiving eight or more ANC contacts (ANC8+) among all mothers across low-and middle-income countries. This association was modified by a woman’s place of residence such that mothers living in rural areas who received early ANC had a higher prevalence of ANC8+. Public health programs, which focus on increasing the coverage of ANC8+ should encourage all pregnant women to receive early ANC, particularly those living rural areas.


Citations to this article as recorded by  
  • Determinants of Focused Antenatal Care Utilization Among Women in Simiyu Region Tanzania
    Agatha F. Ngowi, Serafina Mkuwa, Laura Shirima, Frida Ngalesoni, Gasto Frumence
    SAGE Open Nursing.2023; 9: 237796082311707.     CrossRef
  • The moderating role of partners’ education on early antenatal care in northern Ghana
    Paschal Awingura Apanga, Maxwell Tii Kumbeni, James Kotuah Sakeah, Ayokunle A. Olagoke, Olufemi Ajumobi
    BMC Pregnancy and Childbirth.2022;[Epub]     CrossRef
Cohort Profile
Cohort profile: the Kisalaya cohort of mother-infant dyads in rural south India (2008-2012)
Smitha Chandrashekarappa, Krupa Modi, Karl Krupp, Kavitha Ravi, Anisa Khan, Vijaya Srinivas, Poornima Jaykrishna, Anjali Arun, Murali Krishna, Purnima Madhivanan
Epidemiol Health. 2020;42:e2020010.   Published online March 11, 2020
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  • 161 Download
AbstractAbstract PDF
The <i>Kisalaya</i> cohort was established in 2008, providing integrated antenatal care (ANC) and human immunodeficiency virus (HIV) testing in order to reduce adverse birth outcomes and pediatric HIV infections. The program used a mobile clinic model to deliver health education, ANC, and HIV/sexually transmitted infection testing and management to pregnant women in rural communities in southern India. This cohort includes pregnant women residing in 144 villages of the Mysuru <i>taluk (a rural region) who received ANC through the mobile clinic and delivered their infants between 2008 and 2011. Of the 1,940 women registered for ANC at primary healthcare centers during this time period, 1,675 (75.6%) were enrolled in the <i>Kisalaya</i> cohort. Once women enrolled in the <i>Kisalaya</i> cohort gave birth, the cohort expanded to include the mother-infant dyads with a retention rate of 100% at follow-up visits at 15 days and at 6 months post-delivery. The baseline data collected during the <i>Kisalaya</i> study included both questionnaire-based data and laboratory-based investigations. Presently, a study entitled “<i>Early life influences on adolescent mental health: a life course study of the Kisalaya birth cohort in south India</i>” is in the process of data collection (2019-2020).

Epidemiol Health : Epidemiology and Health