https://orcid.org/0009-0001-1818-1749
Figures
Abstract
Background
Pakistan has the third highest under-five mortality rate globally and minimal progress in reducing it, obstructing its achievement of Sustainable Development Goals (SDGs) 3.2 targets. Despite a decline, Pakistan remains one of the top ten contributors to worldwide under-five mortality. Proper antenatal care (ANC) is vital for improving maternal and child health outcomes. This study aims to assess the association between ANC visits and under-five mortality. Moreover, this study also measures the association between the timing of ANC visits and under-five mortality.
Methods
A difference-in-difference (DID) study design with propensity score matching (PSM) was employed to investigate the contributing impact of ANC on the estimation of under-five mortality rates. Statistics from two datasets, 2012 and 2018, of Pakistan demographic and health surveys (PDHS) have been utilized for analyses. This research sample consists of 15698 women aged 15–49 who attended ANC visits at varying times before childbirth.
Results
This study has reported 730 cases of under-five mortality. 98% involved Women who had less than eight or more ANC visits, whereas 2% of under-five mortality cases occurred among those women who had eight or more ANC visits. Overall, our results showed that women who had 1–3 ANC visits reduced the likelihood of under-five mortality in Pakistan by 36% (CI=0.459–0.909, P-value 0.012), the women who had 4–7 ANC visits decreased the likelihood of under-five mortality by 45% (CI=0.364–0.843, P-value 0.006). Moreover, the females with eight or more ANC visits also reduced the likelihood of under-five mortality by 98% (CI=0.512–1.896, P-value 0.966).
Conclusions
Policies and programs focusing more on ANC visits should be implemented to reduce under-five mortality rates significantly. By emphasizing timely and frequent ANC visits, these insights support the development of targeted interventions that can significantly improve child survival rates and support the achievement of SDG targets. Moreover, based on our DID analysis, the implementation of the free maternal and child healthcare (MCH) policy in Pakistan has led to a significant increase in ANC utilization and a consistent reduction in the under-five mortality rates.
Citation: Nawaz R, Gong S, Zhao Y, Khalid N, Zhou Z, Waseem M (2025) Association between antenatal care visits and under-five mortality: An Analysis of the Pakistan demographic and health surveys. PLoS ONE 20(4): e0318668. https://doi.org/10.1371/journal.pone.0318668
Editor: Muhammad Farooq Umer, King Faisal University, SAUDI ARABIA
Received: March 1, 2024; Accepted: January 20, 2025; Published: April 11, 2025
Copyright: © 2025 Nawaz et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: This study was funded by the National Natural Science Foundation of China (72374169 to S.G). However, the foundation was not involved in the research design or activities related to data collection, analysis, or manuscript writing.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: ANC, Antenatal care; DID, Difference-in-Differences; IRB, Institutional Review Board; MCH, Maternal and Child Healthcare; MDGs, Millennium Development Goals; PDHS, Pakistan Demographic and Health Survey; POD, Place of delivery; PSM, Propensity score matching; SDGs, Sustainable development goals
Introduction
Child mortality is a critical global public health indicator, often reflecting the quality of ANC, childbirth, early postnatal care (PNC), and child healthcare outcomes, all of which contribute to a nation’s development status [1–4]. The World Health Organization (WHO) has implemented various strategies to minimize child mortality and improve child health outcomes. Globally, the first six days of a newborn’s life present the highest risk of child mortality, accounting for 15% of under-five mortality. This highlights the importance of proper ANC, safe delivery, and quality PNC. In 2015, approximately 2.6 million neonatal deaths were reported, a 42% reduction since 1990 [5]. Implementing comprehensive health initiatives like the Millennium Development Goals (MDGs), which focus on key aspects of reducing child mortality and improving healthcare outcomes, is vital in reducing child-related illnesses and their effect on mortality rates [4–7]. Despite all these developments, child mortality remains an alarming concern in resource-constraint regions like Africa and Southeast Asia nations, including Pakistan [4].
Pakistan has been progressively dropping behind its South Asian neighbors in reducing maternal and under-five deaths [8,9]. Since the 1990s, neonatal and under-five mortality rates in Pakistan have increased, while progress in reducing maternal mortality has been exceptionally slow [4,10]. Previous studies have identified financial and social barriers [11–13] and poor service quality as key factors obstructing Pakistan’s development in improving maternal and child healthcare outcomes [14–17]. According to the estimate, one in every 20 children goes to death before reaching his fifth birthday in Pakistan [18]. This poses a significant challenge for the government in achieving the SDGs. The SDGs (3.2) aim to reduce neonatal mortality to fewer than 15 deaths per 1,000 births and under-five mortality to at least 25 deaths per 1,000 births by 2030 [11]. The government of Pakistan has committed to reducing neonatal mortality to 12 deaths per 1000 births and under-five mortality to 25 deaths per 1000 live births. ANC is a parental well-being program delivered by qualified healthcare providers and to pregnant women, primarily aimed at identifying and monitoring those high-risk [19–21].
Interactions with professional healthcare providers during ANC visits help to identify and address early health issues, including infectious diseases regarding pregnancy [22]. Studies have shown that none of the countries have successfully reduced maternal mortality rates to fewer than 100 per 100,000 live births without ensuring that every woman receives care from a qualified healthcare provider during the pregnancy and immediately after the delivery [23].
In 2016, the WHO recommended a minimum of eight ANC visits: the first ANC visit should occur within the first three months of pregnancy, two more visits in the second trimester, and the final five visits during the third trimester [24,25]. This research extends these guidelines, emphasizing the number of ANC visits, the timing of the first ANC visit, and the quality of care provided by the healthcare providers.
Pakistan has made some progress in utilizing ANC services, but it remains far from achieving its MGD-5 targets. Many women still give birth without accessing these essential services [26]. In 2013–2014, only 44% of women in Pakistan utilized ANC services, particularly in rural areas [27]. To improve ANC services utilization, reduce maternal mortality, and enhance child health, the government of Pakistan introduced a new cadre in 2006 to provide timely maternal healthcare [28,29]. However, previous studies suggest that community health workers (CMWs) have yet to become significant contributors to ANC service delivery [30].
Numerous researchers have demonstrated that ANC services positively impact the reduction of child mortality [31–33]. Moreover, ANC’s influence on under-five mortality is carefully connected to socio-economic and environmental factors [34]. The importance of ANC visits for maternal and child healthcare cannot be overstated. Nevertheless, prior studies have often been limited to exploring the association between ANC and child mortality. Therefore, this study is designed to fill this gap by investigating the effect of ANC visits on Pakistan healthcare outcomes from 2012 to 2018, concentrating its impact on under-five mortality. The study aims to determine whether the number of ANC visits and the timing of the first visit influence child health outcomes, using a matching approach combined with a DID research design to address confounding variables related to under-five mortality and ANC visits. The outcomes of this study will help policymakers, healthcare providers, and public health organizations upgrade and implement health strategies and interventions to strengthen MCH and achieve SDGs.
Methods
Research setting and data
This research utilized the data from the PDHS conducted in 2012 and 2018. The PDHS are national surveys carried out every five years, designed to provide representative data on various health, socio-economic, and demographic factors across all regions of Pakistan, aiming to enhance maternal and child health outcomes. The fourth and fifth wave were utilized in this study have been launched by the National Institute of Population Studies (NIPS) in collaboration with the United States Agency for International Development (USAID) funding [9]. The 2012 and 2018 surveys employed a stratified, two-stage cluster sampling method to select the respondents. Additional details regarding the survey and collection of methods can be found in the final reports of PDHS 2012 and 2018 [35,36]. The data was gathered through interviews with females aged between 15–49 years. The PDHS includes three main questionnaires: household, women, and men. Our research gathered data on child mortality and related covariates from the women’s questionnaire [35,36]. To minimize recall bias, this study utilizes PDHS data, which follow standardized data collection protocols, including pre-tested, structured questionnaires. The recall period for key variables, such as antenatal care visits and the timing of the first visit, is limited to five years or less. Additionally, the PDHS dataset undergoes rigorous data cleaning and validation procedures to identify and correct inconsistencies in self-reported information. These measures help to ensure the reliability and accuracy of the data. The analysis focused on a combined sample of 7461 children from the 2012 survey and 8281 children from the 2018 survey.
Sample selection
The sample selection specifically focused on children for whom complete information regarding their survival status was available. Children of mothers who were separated, widowed, not cohabitating, or not in a marital union were excluded from the analysis. This exclusion was made because the father’s involvement in childcare might be limited or absent, particularly in cases where the mother was widowed or single. Additionally, mothers who had been married more than once were excluded to avoid potential residual effects from previous unions on the current one. Three main selection criteria were employed to conduct the analysis. Firstly, it includes births within the five years preceding the survey date. Secondly, during the survey, antenatal and post-natal care information critical to assessing MCH was recorded for last-born children only. Therefore, the sample was further restricted to the last-born children. Lastly, only children with their current age or age at the time of death (recorded in months/years) were included to generate the survival variable. As a result, the sample size was reduced to 15698 out of 100,120 across both surveys. The analysis of under-five mortality included all 15698 children (2012=7461; 2018= 8281). The sample size for the analysis varied slightly across models, depending on the number of missing values among covariates, with variations up to 5.4%. Before executing the analysis, a multicollinearity analysis was conducted to recognize the probable concerns. No concern about the multicollinearity was highlighted, and the variance inflation factors (VIF) have also been less than 5, with an average score of 1.89. Fig 1 depicts the flowchart of the sample selection of the current research.
Treatment and the outcome variable
In our study, the health outcome is under-five child mortality, meaning the death of a child before the age of five. This information was obtained from the complete birth histories recalled by the interviewed women and recorded in the surveys. We define “treatment” as the use of ANC. Women with 1–3 ANC visits are named treatment 1; they are compared to women who had less than three and no ANC visits (Control 1) during their complete gestation period. The women who had 4–7 ANC visits are considered treatment 2, compared with those who had less than seven or no ANC visits (Control 2). Treatment 3 is for those women who have eight or more ANC visits throughout their entire pregnancy compared with those who have less than eight or no ANC visits (Control 3). The timing of the first ANC visit was analyzed by comparing women who had their first visit during the third trimester (Treatment 4) and those who did not have any ANC visits (Control 4). Treatment 5 consisted of women who had their first ANC visit during the second trimester, compared to women who had their first visit either in the third trimester or no ANC visit (Control 5). Lastly, Treatment 6 included women who had their first ANC visit in the first trimester, compared to those who had their first visit in the second, third, and no ANC visit. The mortality rates for the control groups under five years from 2012 to 2018 may differ due to various unknown factors. The same factors and differences will influence the variation in these rates for the treatment groups in the timing and frequency of ANC visits.
The treatment (ANC) is associated with numerous factors that contribute to under-five mortality. Fig 2 demonstrates the association between ANC and the outcome of interest. Socio-economic factors like education level, employment status, and wealth index are all connected with ANC. Furthermore, health-related factors such as place of delivery (POD) also interact with ANC in influencing under-five mortality. These health factors are additionally linked to maternal factors like the mother’s age and age at first birth, which also play a role in the outcome. Child-related factors, including birthweight, birth order, and the preceding interval between births, are connected with socioeconomic and maternal factors. The community-level covariate includes rural/urban residency, all linked to ANC and under-five mortality.
Ethical considerations
This study involves human participants and procedures and questionnaires for standard DHS surveys have been reviewed and approved by the ICF Institutional Review Board (IRB). Additionally, country-specific DHS survey protocols are reviewed by the ICF, IRB and typically by an IRB in the host country. ICF and IRB ensures that the survey complies with the US Department of Health and Human Services regulations for protecting human subjects (45 CFR 46), while the host country IRB ensures that the survey complies with the laws and norms of the nation. Participants gave informed consent to participate in the study before taking part. Patients and/or the public were not involved in this research’s design, conduct, reporting, or dissemination plans. The DHS also employs culturally sensitive methodologies to ensure that survey instruments are appropriately adapted to local contexts. This includes translating questionnaires into local languages, training interviewers to be culturally aware, and using locally trusted community members to conduct interviews. These measures help overcome cultural barriers and ensure that participants feel comfortable and willing to provide accurate information.
Statistical analysis
We employed the Cox proportional hazards regression model to determine the direct associations between the independent and dependent variables. This model allows for a focused analysis of the direct effects of ANC visits on the mortality of those under five while accounting for potential confounding factors. Cox proportional hazards regression also enables the insertion of censored data and effectively models time-to-event data with censoring as a dependent variable [37,38].
The analysis involves three models. Model 1 included the outcome variable without including the covariates, while Model 2 introduced additional covariates along with the outcome variable. Moreover, Model 3 enlightened the interaction between the dependent variable and household wealth. This approach is rooted in the Andersen behavioral model of health service utilization [39], which suggests that family wealth can influence factors like access to quality healthcare and nutrition, which are key determinants of childhood mortality [40,41].
We employed a two-stage research design to enhance the comparison among the treated and control groups. Our analysis started by matching individuals with identical household features to ensure equal probability of ANC utilization across both groups. We utilized PSM for this purpose. PSM is a statistical method designed to address the primary drawback of causal inferences in observational studies, where standardized control groups are not established [42]. This technique creates matched pairs of control and treatment individuals with similar propensity scores [43]. Once the matched sample is created, the treatment effect can be directly assessed by comparing outcomes between the treated and control groups [44].
The PSM method was employed to compare under-five mortality between women who utilize ANC and those who do not [45]. PSM was selected because ANC utilization is not random and is significantly influenced by observable and unobservable factors. The variables for PSM were selected based on demographic and socioeconomic covariates from the PDHS that showed a significant association with ANC utilization and child mortality. Using a logistic regression model, women who utilized ANC were matched to those who did not. To assess the balance of covariates before and after PSM, we applied a Chi-Square test, considering a 5% level of significance or higher indicative of imbalance.
We also applied the DID technique to examine the impact of ANC services on under-five child mortality. DID is a quasi-experimental method that compares changes in outcomes over time between an intervention (treatment group) and a non-intervention group (control group) [46]. Although DID is primarily used with panel data to estimate the effects of policies or programs, it has also been employed with repeated cross-sectional data from the same areas, as seen in previous studies [47–49]. We conducted the multivariate normal (MVN) imputation procedure to report the missing values, assuming that the missing data was randomly scattered. We have run the number of imputations to 20. MVN imputation was selected because of its capability to handle the complex interdependencies among the variables. We ensured that the imputed values accurately predicted the missing data, and there was no significant difference in the results before and after imputation [50]. All the analyses were performed in STATA software 16.0 (Stata Corp, College Station, TX, USA) at a 95% confidence interval.
The covariates included were the child’s gender, birth order, preceding birth interval, and perceived birthweight. Maternal factors include the mother’s age (in years), education level (measured continuously), number of living children (constantly measured), Caesarean section history (No=0, Yes=1), multiple births (singleton=0, multiple=1), father’s education (measured continuously), and employment status in the year before the survey. Socioeconomic factors include delivery in a health facility (non-medical=0, medical=1) and family wealth. Community-level factors include residence status (Urban=0, Rural=1). Detailed information is provided in Table 1.
Results
Socio-demographic characteristics of the sample
Table 2 presents the socio-demographic characteristics of the pooled sample. This study included 13,458 children from PDHS 2012 and 13,504 children from PDHS 2018, all born within five years before each survey. Of these, 7,461 children (2012) and 8,287 (2018) met the selection criteria. Among the sample, 382 (5.12%) children in 2012 and 348 (4.20%) in 2018 died within five years. The gender distribution was nearly equal in both surveys, with 51.41% male in 2012 and 52.02% male in 2018. The average age of the mothers was 29.6 years, with a standard deviation of 6.34 years in both surveys. Approximately 56% (2012) and 54% (2018) of households were rural, with average family wealth indices of -0.13 (SD = 0.95) and -0.09 (SD = 0.98), indicating prevalent poverty. The ANC composite scores were 1.25 (SD = 0.97) and 1.46 (SD = 0.89) in 2012 and 2018 respectively.
Table 3 illustrates the mortality rates of those under five based on the timing of the first ANC visit. For women who had no ANC visit, the under-five mortality rate was 4.44% and 12.50% in 2012 and 2018, respectively. Similarly, for the women who had their first ANC visit in the first trimester, the mortality rate reduced from 4.08% in 2012 to 3.63% in 2018. Furthermore, the Women who had their first ANC visit in the second trimester experienced a decline in under-five mortality to 4.27% in 2012 and 3.79% in 2018. Finally, for those women who had their first ANC visit in the third trimester, the mortality rate increased to 5.36% in 2012, and in 2018, the mortality rate decreased to 5.78%.
Multivariate analysis
The key supposition of Cox regression is proportional hazards, which we verified using the scaled Schoenfeld residuals test [37]. The test outcomes disclosed no violation of this assumption, as the proportionality for the overall model, as well as for each predictor and covariate, was not significant (p-values > 0.05).
The association between the number of ANC visits and child mortality
The results of the unadjusted model are presented in Table 4. They highlight insignificant relationships between the number of ANC visits and child mortality between the three models across the 2012 and 2018 PDHS surveys, except for the number of ANC visits 1–3 in model 2 for PDHS 2012, which showed a reduction in child mortality by (HR=0.86; CI=0.47–0.97; p > 0.05). Socio-demographic factors linked to an increased risk of child mortality include higher multiple births, older maternal age, mother education, and mother employment. Conversely, factors like female gender, birth intervals, higher birthweight, place of delivery, and higher parity are associated with a protective effect.
Propensity score matching results
The PSM generated a matched sample of 4,817 birth cases. Table 5 compares the statistics for individual demographic and socioeconomic characteristics of women who had ANC visits with those who did not before and after matching. Before PSM, no baseline characteristics showed a significant difference (P-value < 0.05) in under-five mortality between the treatment and control groups. After the PSM, all characteristics showed a significant difference (P-value > 0.05) in under-five mortality between the treatment and control groups. This indicates that the PSM approach effectively minimized the differences in observed characteristics between the groups. Fig S1 explains ANC 1–3 visits for match and unmatched observations. Additionally, Fig S2 demonstrates number of ANC 4–7 visits before and after matching and finally, Fig S3 illustrates the number of ANC visits eight or more for match and unmatched observations.
The estimation of DID outcomes
Table 6 presents the primary outcome of the DID analysis for the matched sample with all covariates added to the model. The estimates for Treatment 1 ANC visit 1–3 recommended that compared to women who had no ANC visit, the women who had 1–3 ANC visit decreased the likelihood of under-five mortality by 36% (CI = 0.45–0.90%, P-value = 0.012). This estimate is statistically significant, with a P-value of 0.05, indicating a significant difference in under-five mortality between women who had 1–3 ANC visits and those who did not attend ANC at all. Correspondingly, under-five mortality was 45% lower for women with 4–7 ANC visits. This difference was also statistically significant (CI = 0.36–0.8%, P-value = 0.006) compared to women who had 1–3 ANC visits or no ANC visits. Finally, Table 6 demonstrates that women with eight or more ANC visits compared with women who had 4–7 ANC visits, women who had 1–3 ANC visits, and those who did not attend ANC at all also reduced the likelihood of under-five mortality by (OR= 0.98 CI = 0.51–1.89%, P-value < 0.966).
Table 7 describes the impact of the timing of the first antenatal care (ANC) visit on under-five mortality. The analysis found no statistically significant effect of a first ANC visit in the third trimester on under-five mortality (P-value = 0.242) compared to women without ANC visits. In contrast, for the women who had their first ANC visit in the second trimester, there was also no statistically significant effect of a first ANC visit in the second trimester on under-five mortality (P-value = 0.106) compared to those women who had their first ANC visit in the third trimester and did not have any ANC visits. Furthermore, the Women who had their first ANC visit in the first trimester experienced a 45% reduction in under-five mortality (CI = 0.332–0.629, P-value < 0.000) compared to those with later visits.
Discussion
Our study utilized the data from widespread nationwide representative Pakistan DHS (2012 and 2018) to analyze the association between the number of ANC visits and the time for the first ANC visit on child health outcomes, specifically, under-five mortality in Pakistan. Firstly, we used Cox proportional hazard regression to measure the association between the number of ANC visits and under-five mortality. Though the results are insignificant, the overall results indicated a reduction in under-five mortality and an increase in ANC visits. The ratio of under-five mortality decreased from 5.12% in 2012 to 4.20% in 2018. These patterns of results were consistent across both PDHS waves. Several socio-demographic factors were also connected with an increased risk of child mortality, including higher multiple births, older maternal age, mother education, and mother employment. Conversely, factors like female gender, longer birth intervals, higher birthweight, place of delivery, and higher parity are associated with a protective effect. Our study’s finding is consistent with the finding of [51].
Furthermore, constructed on the DID model estimation, our research outcomes provided proof of a 45% decrease in under-five mortality for the women who had 4–7 ANC visits compared to the women who had 1–3 ANC visits as compared to the women who had no visit at all. The results also highlighted that only 2% of the under-five mortality occurs for the women who had eight or more ANC visits as compared to the women who had 4–7 ANC visits, women who had 1–3 ANC visits as compared to the women who had no visit at all.
To the best of our knowledge, this study is one of the first to specifically examine the impact of the number of ANC visits and the timing of the first ANC visit on under-five child mortality in Pakistan. Studies have shown that increasing ANC visits reduces under-five mortality [52–54]. For instance, Jana Kuhnt and Sebastian Vollmer [55] analyzed data from 193 DHS surveys (1990–2013) and found that a single ANC visit reduced neonatal mortality by 1.04% and infant mortality by 1.07%. Similarly, a study from Bangladesh employing multivariate logistic regression across three DHS surveys found that ANC visits with professional healthcare providers are linked to a decreased likelihood of under-five mortality among females [56]. Another study in Kenya by Malachi et al. [57] also examined the effectiveness of ANC services in reducing neonatal mortality. Using the binary logistics regression, the study found that mothers with ANC visits have lower rates of neonatal mortality. The Government of Pakistan has made significant efforts to improve MCH, offering free services, particularly in remote areas. Drawing on this well-acknowledged evidence, the Pakistani Government announced an innovative squad of skilled birth attendants [58]. Previous studies from Pakistan have highlighted that factors such as place of delivery, education, wealth, and funding for demand-side interventions are linked with the utilization of ANC services [59]. Our research findings will assist policymakers in shaping policies that reflect the impact of ANC visits with professional healthcare providers on reducing under-five mortality. This will also promote the increased utilization of ANC services.
Strengths and limitations
The main strength of the current study lies in its use of nationwide demographic data. Even though there has been no randomized control experiment, a repetitive cross-sectional examination from the identical sample frame can be utilized to acquire causal interpretation [60]. The double methodology we have engaged in the present research has confirmed that bias has been reduced by comparing the treatment and control groups, which should be identical before applying the quasi-experimental research design for causal inference.
The DID methodology assumes that persons’ unmeasured serious features can affect the result based on the variances amongst the treatment and control groups [61]. It was highlighted earlier in the current research that the utilization of the double approach has minimized possible biases. Still, we cannot omit the unmeasured features. Nevertheless, we have selected our covariates with the help of a cautious understanding of the prior works. The limitation connected with this research is the utilization of cross-sectional data, which prevents establishing a causal relationship. Additionally, cultural factors that discourage discussing the deceased or the emotional distress of recalling a lost child may have led to underreporting of mortality. Another limitation of the current study is the quality of DHS statistics. As irregular to most nationwide investigations, there have been missing values in the statistics. The concern regarding the missing values has been lectured by using multiple imputations. The procedure of the multiple imputations was effective for the statistics missing at random; in addition, the present research safeguarded that the imputed statistics were projections of the missing statistics. The current research also highlighted that no constructive dissimilarities were found before or after the multiple imputations.
Policy implications
Improving access to ANC should be a priority to reduce under-five mortality. Policymakers should implement programs that promote early and regular ANC visits, particularly in rural areas. This could involve expanding the healthcare structure, training skilled healthcare specialists, providing community-based health services, offering transportation support, and increasing awareness about the importance of early pregnancy check-ups through community awareness campaigns. Our results are helpful for policymakers, healthcare providers, and public health organizations. Aligning national health policies with WHO guidelines, including recommending at least eight ANC visits with the first visit in the first trimester, will improve maternal and child health outcomes. Additionally, investing in quality ANC services and training healthcare providers will be crucial for achieving the SDGs of reducing child mortality by 2030.
Conclusions
This study employed PSM and DID logistic regression analysis to discover the association between ANC visits and under-five mortality. Our findings suggest that the number of ANC visits and the timing of the first visit significantly reduce under-five mortality. We recommend at least eight ANC visits, with the first visit occurring during the first trimester, by the 2016 WHO guidelines. To make meaningful progress in lowering under-five mortality rates and achieving the SDGs by 2030, it is vital to implement programs that promote free MCH services early and regular ANC visits, especially in remote and rural regions where access to healthcare services is limited. These programs could include community outreach, transportation support, and education about the importance of early prenatal care. Additionally, we recommend future research that explores the causal relationship between ANC and under-five mortality in greater detail and assesses the quality and accessibility of ANC services, as these factors may also play a key role in improving child health outcomes. Addressing barriers to accessing quality care, especially for vulnerable populations, will be crucial to achieving sustainable reductions in under-five mortality.
Supporting information
S1 Fig. ANC visits 1–3 for match and unmatched observations.
https://doi.org/10.1371/journal.pone.0318668.s001
(TIF)
S2 Fig. ANC visits 4–7 for match and unmatched observations.
https://doi.org/10.1371/journal.pone.0318668.s002
(TIF)
S3 Fig. ANC visits eight or more for match and unmatched observations.
https://doi.org/10.1371/journal.pone.0318668.s003
(TIF)
References
- 1. Mackenbach JP. Re-thinking health inequalities. Eur J Public Health. 2020;30(4):615. pmid:32558893
- 2. Houweling TA, Kunst AE, Mackenbach JP. Measuring health inequality among children in developing countries: does the choice of the indicator of economic status matter?. Int J Equity Health. 2003;2(1):1–12.
- 3. Jalloh MB, Bah AJ, James PB, Sevalie S, Hann K, Shmueli A. Impact of the free healthcare initiative on wealth-related inequity in the utilization of maternal & child health services in Sierra Leone. BMC Health Services Research. 2019;19(1):1–15.
- 4. Li Z, Karlsson O, Kim R, Subramanian SV. Distribution of under-5 deaths in the neonatal, postneonatal, and childhood periods: a multicountry analysis in 64 low- and middle-income countries. Int J Equity Health. 2021;20(1):109. pmid:33902593
- 5. Nove A, Friberg IK, de Bernis L, McConville F, Moran AC, Najjemba M, et al. Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling study. Lancet Glob Health. 2021;9(1):e24–32. pmid:33275948
- 6. Dhir SK, Dewan P, Gupta P. Maternal and neonatal tetanus elimination: Where are we now?. Research and Reports in Tropical Medicine. n.d.;2021:247–61.
- 7. Shaeen SK, Tharwani ZH, Bilal W, Islam Z, Essar MY. Maternal mortality in Pakistan: Challenges, efforts, and recommendations. Ann Med Surg (Lond). 2022;81:104380. pmid:36042926
- 8. Ashraf N, Sarwar S, Bibi N. Determinants of maternal mortality in Pakistan. Age. 2021;40(30):9–2.
- 9.
National Institute of Population Studies (Pakistan), Macro International, Institute for Resource Development. Pakistan demographic and health survey. National Institute of Population Studies. 2012.
- 10. Agha S, Williams E. Quality of antenatal care and household wealth as determinants of institutional delivery in Pakistan: Results of a cross-sectional household survey. Reprod Health. 2016;13(1):84. pmid:27430518
- 11. Khowaja BMH, Feroz AS, Saleem S. Facilitators and barriers influencing utilization of services provided by community midwives in district Thatta, Pakistan: a qualitative exploratory study. BMC Pregnancy Childbirth. 2022;22(1):506. pmid:35733093
- 12. Kumar R, Mehraj V, Ahmed J, Khan SA, Ali TM, Batool S, et al. Barriers experienced by community midwives to provide basic emergency obstetric and newborn care in rural Pakistan. BMC Health Serv Res. 2023;23(1):1305. pmid:38012758
- 13. Midhet F, Becker S. Impact of community-based interventions on maternal and neonatal health indicators: Results from a community randomized trial in rural Balochistan, Pakistan. Reprod Health. 2010;7:30. pmid:21054870
- 14. Memon ZA, Khan GN, Soofi SB, Baig IY, Bhutta ZA. Impact of a community-based perinatal and newborn preventive care package on perinatal and neonatal mortality in a remote mountainous district in Northern Pakistan. BMC Pregnancy Childbirth. 2015;15:106. pmid:25925407
- 15. Utz B, Zafar S, Arshad N, Kana T, Gopalakrishnan S, Nynke van den Broek. Status of emergency obstetric care in four districts of Punjab, Pakistan - results of a baseline assessment. J Pak Med Assoc. 2015;65(5):480–5. pmid:26028380
- 16. Fikree FF, Mir AM, Haq I. She may reach a facility but will still die! An analysis of quality of public sector maternal health services, District Multan, Pakistan. J Pak Med Assoc. 2006;56(4):156–63. pmid:16711335
- 17. Bhutta ZA, Hafeez A, Rizvi A, Ali N, Khan A, Ahmad F, et al. Reproductive, maternal, newborn, and child health in Pakistan: challenges and opportunities. Lancet. 2013;381(9884):2207–18. pmid:23684261
- 18. Bhutta ZA, Hafeez A. What can Pakistan do to address maternal and child health over the next decade?. Health Res Policy Syst. 2015;13 Suppl 1(Suppl 1):49. pmid:26792061
- 19. Jha V. Current status of end-stage renal disease care in India and Pakistan. Kidney International Supplements. 2013;3(2):157–60.
- 20. Clarke S. The number one challenge facing the nursing profession-A need for a fresh look. Nurs Outlook. 2023;71(3):102005. pmid:37423686
- 21. Noh J-W, Kim Y-M, Lee LJ, Akram N, Shahid F, Kwon YD, et al. Factors associated with the use of antenatal care in Sindh province, Pakistan: A population-based study. PLoS One. 2019;14(4):e0213987. pmid:30943243
- 22. Tegegne TK, Chojenta C, Getachew T, Smith R, Loxton D. Antenatal care use in Ethiopia: a spatial and multilevel analysis. BMC Pregnancy Childbirth. 2019;19(1):399. pmid:31675918
- 23. Amungulu ME, Nghitanwa EM, Mbapaha C. An investigation of factors affecting the utilization of antenatal care services among women in post-natal wards in two Namibian hospitals in the Khomas region. J Public Health Afr. 2023;14(3):2154. pmid:37197265
- 24.
World Health Organization. Standards for improving quality of maternal and newborn care in health facilities. 2016.
- 25.
W. H. Organization. WHO recommendations on antenatal care for a positive pregnancy experience. World Health Organization, 2016.
- 26. Farah Rashid, Sara Makhdoom. Maternal Health in Pakistan: Where do we stand?. JIMDC. 2019;8(3):99–100.
- 27. Zakar R, Zakar MZ, Aqil N, Chaudhry A, Nasrullah M. Determinants of maternal health care services utilization in Pakistan: evidence from Pakistan demographic and health survey, 2012–13. J Obstet Gynaecol. 2017;37(3):330–7.
- 28. Khowaja BMH, Shahil Feroz A, Saleem S. Factors influencing utilisation of services provided by community midwives and their non-retention in district Thatta, Pakistan: a qualitative study protocol. BMJ Open. 2022;12(7):e052323. pmid:35863826
- 29. Khowaja BMH, Feroz AS, Rani M, Khowaja Q, Khowaja MAA, Abrejo F, et al. Acceptability of community midwives in rural communities of Pakistan: A qualitative exploratory study. medRxiv. 2023;2023–02.
- 30. Sarfraz M, Hamid S. Challenges in delivery of skilled maternal care - experiences of community midwives in Pakistan. BMC Pregnancy Childbirth. 2014;14:59. pmid:24499344
- 31. Roy S, Haque MA. Effect of antenatal care and social well-being on early neonatal mortality in Bangladesh. BMC Pregnancy Childbirth. 2018;18(1):485. pmid:30526513
- 32. Tekelab T, Chojenta C, Smith R, Loxton D. Factors affecting utilization of antenatal care in Ethiopia: A systematic review and meta-analysis. PLoS One. 2019;14(4):e0214848. pmid:30973889
- 33. Rosário EVN, Gomes MC, Brito M, Costa D. Determinants of maternal health care and birth outcome in the Dande Health and Demographic Surveillance System area, Angola. PLoS One. 2019;14(8):e0221280. pmid:31437180
- 34. Deribew A, Ojal J, Karia B, Bauni E, Oteinde M. Under-five mortality rate variation between the Health and Demographic Surveillance System (HDSS) and Demographic and Health Survey (DHS) approaches. BMC Public Health. 2016;16(1):1–7.
- 35.
DHS, M. Demographic and health surveys. Calverton: Measure DHS. 2013
- 36.
Demographic NP. Health survey. Demographic and health survey. 2017-18.
- 37.
Cleves MA. An introduction to survival analysis using Stata. Stata Press; 2008.
- 38. Dickman PW, Coviello E. Estimating and Modeling Relative Survival. The Stata Journal: Promoting communications on statistics and Stata. 2015;15(1):186–215.
- 39. Andersen RM. National health surveys and the behavioral model of health services use. Med Care. 2008;46(7):647–53. pmid:18580382
- 40. Tharwani ZH, Bilal W, Khan HA, Kumar P, Butt MS, Hamdana AH, et al. Infant & Child Mortality in Pakistan and its Determinants: A Review. Inquiry. 2023;60:469580231167024. pmid:37085986
- 41. Memon Z, Fridman D, Soofi S, Ahmed W, Muhammad S, Rizvi A, et al. Predictors and disparities in neonatal and under 5 mortality in rural Pakistan: cross sectional analysis. Lancet Reg Health Southeast Asia. 2023;15:100231. pmid:37614356
- 42. Dhadda A, Greene G. “The Healthy Migrant Effect” for Mental Health in England: Propensity-score Matched Analysis Using the EMPIRIC Survey. J Immigr Minor Health. 2018;20(4):799–808. pmid:28389831
- 43. Rosenbaum PR, Rubin DB. Propensity scores in the design of observational studies for causal effects. Biometrika. 2022;110(1):1–13.
- 44. Austin PC. An Introduction to Propensity Score Methods for Reducing the Effects of Confounding in Observational Studies. Multivariate Behav Res. 2011;46(3):399–424. pmid:21818162
- 45. Dixit P, Dwivedi LK, Ram F. Strategies to Improve Child Immunization via Antenatal Care Visits in India: A Propensity Score Matching Analysis. PLoS One. 2013;8(6):e66175. pmid:23824555
- 46. Ryckman T, Robinson M, Pedersen C, Bhattacharya J, Bendavid E. Impact of Feed the Future initiative on nutrition in children aged less than 5 years in sub-Saharan Africa: difference-in-differences analysis. bmj. 2019;367.
- 47. Pedraja-Chaparro F, Santín D, Simancas R. The impact of immigrant concentration in schools on grade retention in Spain: a difference-in-differences approach. Applied Economics. 2015;48(21):1978–90.
- 48. Dunn G. The impact of the Boko Haram insurgency in Northeast Nigeria on childhood wasting: a double-difference study. Confl Health. 2018;12:6. pmid:29410702
- 49. Tatah L, Delbiso TD, Rodriguez-Llanes JM, Gil Cuesta J, Guha-Sapir D. Impact of Refugees on Local Health Systems: A Difference-in-Differences Analysis in Cameroon. PLoS One. 2016;11(12):e0168820. pmid:27992563
- 50. Rubin DB. Multiple imputation. Flexible Imputation of Missing Data. 2018:29–62.
- 51. Hastono SP, Lusida N, Arinda YD, Arsyi M, . Antenatal care services in decreasing under-five mortality. Revista Brasileira de Saúde Materno Infantil. 2023;23:e20220438.
- 52. Singh A, Pallikadavath S, Ram F, Alagarajan M. Do antenatal care interventions improve neonatal survival in India?. Health Policy Plan. 2014;29(7):842–8. pmid:24038077
- 53. Wahl B, Nama N, Pandey RR, Garg T, Mishra AM, Srivastava S, et al. Neonatal, Infant, and Child Mortality in India: Progress and Future Directions. Indian J Pediatr. 2023;90(Suppl 1):1–9. pmid:37695418
- 54. Nannan NN, Groenewald P, Pillay-van Wyk V, Nicol E, Msemburi W, Dorrington RE, et al. Child mortality trends and causes of death in South Africa, 1997 - 2012, and the importance of a national burden of disease study. S Afr Med J. 2019;109(7):480–5. pmid:31266573
- 55. Kuhnt J, Vollmer S. Antenatal care services and its implications for vital and health outcomes of children: evidence from 193 surveys in 69 low-income and middle-income countries. BMJ Open. 2017;7(11):e017122. pmid:29146636
- 56. Abir T, Ogbo FA, Stevens GJ, Page AN, Milton AH, Agho KE. The impact of antenatal care, iron-folic acid supplementation and tetanus toxoid vaccination during pregnancy on child mortality in Bangladesh. PLoS One. 2017;12(11):e0187090. pmid:29091923
- 57. Tekelab T, Chojenta C, Smith R, Loxton D. The impact of antenatal care on neonatal mortality in sub-Saharan Africa: A systematic review and meta-analysis. PLoS One. 2019;14(9):e0222566. pmid:31518365
- 58.
Ministry of Planning, Development and Reform, Government of Pakistan. Pakistan Millennium Development Goals Report 2013. Islamabad, Pakistan: Government of Pakistan & the United Nations Development Programme; 2013.(accessed May 08 2023).
- 59. Agha S, Carton TW. Determinants of institutional delivery in rural Jhang, Pakistan. Int J Equity Health. 2011;10:31. pmid:21801437 .
- 60. McGovern ME, Herbst K, Tanser F, Mutevedzi T, Canning D, Gareta D, et al. Do gifts increase consent to home-based HIV testing? A difference-in-differences study in rural KwaZulu-Natal, South Africa. Int J Epidemiol. 2016;45(6):2100–9. pmid:27940483
- 61. Jakubowski A, Stearns SC, Kruk ME, Angeles G, Thirumurthy H. The US President’s Malaria Initiative and under-5 child mortality in sub-Saharan Africa: A difference-in-differences analysis. PLoS Med. 2017;14(6):e1002319. pmid:28609442