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Semin Perinatol. 2019 Aug;43(5):297-307. doi: 10.1053/j.semperi.2019.03.020. Epub 2019 Mar 16.

Trends of antenatal care during pregnancy in low- and middle-income countries: Findings from the global network maternal and newborn health registry.

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Aga Khan University, Karachi, Pakistan.
RTI International, Durham, NC, United States.
University of Zambia, Lusaka, Zambia.
University of Alabama at Birmingham, Birmingham, AL, United States.
INCAP, Guatemala City, Guatemala.
University of Colorado School of Medicine, Aurora, CO, United States.
Lata Medical Research Foundation, Nagpur, India.
Boston University, Boston, MA, United States.
KLE Academy of Higher Education and Research's JN Medical College, Belagavi, India.
Thomas Jefferson University, Philadelphia, PA, United States.
Columbia University, New York, NY, United States.
Moi University, Eldoret, Kenya.
Indiana University, Indianapolis, IN, United States.
RTI International, Durham, NC, United States. Electronic address:



Antenatal care (ANC) is an important opportunity to diagnose and treat pregnancy-related complications and to deliver interventions aimed at improving health and survival of both mother and the infant. Multiple individual studies and national surveys have assessed antenatal care utilization at a single point in time across different countries, but ANC trends have not often been studied in rural areas of low-middle income countries (LMICs). The objective of this analysis was to study the trends of antenatal care use in LMICs over a seven-year period.


Using a prospective maternal and newborn health registry study, we analyzed data collected from 2011 to 2017 across five countries (Guatemala, India [2 sites], Kenya, Pakistan, and Zambia). Utilization of any ANC along with use of select services, including vitamins/iron, tetanus toxoid vaccine and HIV testing, were assessed. We used a generalized linear regression model to examine the trends of women receiving at least one and at least four antenatal care visits by site and year, controlling for maternal age, education and parity.


Between January 2011 and December 2017, 313,663 women were enrolled and included in the analysis. For all six sites, a high proportion of women received at least one ANC visit across this period. Over the years, there was a trend for an increasing proportion of women receiving at least one and at least four ANC visits in all sites, except for Guatemala where a decline in ANC was observed. Regarding utilization of specific services, in India almost 100% of women reported receiving tetanus toxoid vaccine, vitamins/iron supplementation and HIV testing services for all study years. In Kenya, a small increase in the proportion of women receiving tetanus toxoid vaccine was observed, while for Zambia, tetanus toxoid use declined from 97% in 2011 to 89% in 2017. No trends for tetanus toxoid use were observed for Pakistan and Guatemala. Across all countries an increasing trend was observed for use of vitamins/iron and HIV testing. However, HIV testing remained very low (<0.1%) for Pakistan.


In a range of LMICs, from 2011 to 2017 nearly all women received at least one ANC visit, and a significant increase in the proportion of women who received at least four ANC visits was observed across all sites except Guatemala. Moreover, there were variations regarding the utilization of preventive care services across all sites except for India where rates were generally high. More research is required to understand the quality and influences of ANC.


Antenatal care; Low-middle income countries; Maternal health

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