Quality of first antenatal care visits and perinatal outcomes: Evidence from a cohort study in Ethiopia, Kenya, South Africa, and India

Antenatal care (ANC) is crucial for maternal and newborn health. Although ANC coverage has improved globally, ANC quality remains suboptimal. This study assessed the quality of first ANC visits and their association with perinatal outcomes. We used data from the eCohort study that collected longitudinal data on ANC utilization and quality until the end of pregnancy in Ethiopia, Kenya, South Africa, and India. Perinatal outcomes of interest included fetal losses (miscarriages ≥13 weeks of gestation or stillbirths) and low birth weight (LBW) newborns. Good quality ANC at first visits was defined as receiving six essential care components: blood pressure measurement, blood and urine tests, ultrasound, iron and folic acid supplementation, and counseling on pregnancy danger signs. We conducted mixed-effect logistic regressions to assess associations between good quality ANC and perinatal outcomes, with sensitivity analyses where good quality ANC excluded ultrasound scans. Among 3,600 pregnant women followed until the end of pregnancy, 5.8% received all six components at their first visits (from 1.3% in India to 14.0% in Ethiopia), and 30.7% received five components (5.7% in India to 52.5% in Kenya). Between 3.7% of women in Ethiopia and 6.3% in India experienced a fetal loss. Between 8.5% of newborns in Ethiopia and 16.3% in India were born LBW. Good quality ANC at first visits was associated with a 32% to 59% lower risk of fetal loss (primary analysis: risk ratio (RR) 0.41, 95% confidence interval (CI) 0.10–0.72; sensitivity analysis: RR 0.68, 95% CI 0.44–0.92). No significant associations were observed between good quality ANC and LBW. This study identified important gaps in ANC quality and found that good quality ANC is associated with a lower fetal loss risk. Investments must be made to improve ANC quality and ensure the delivery of essential care in pregnancy.