Research Report Submitted To the Faculty of Humanities,
University of the Witwatersrand
Johannesburg, In Fulfilment of the Requirements for the Award of
Degree of Masters of Arts in Demography and Population Studies
Academic Year, 2014The World Health Organization has recommended focused antenatal care as a strategy
for reducing the burden of perinatal mortality and for the overall improvement of maternal and
child health. Fragmentary studies in Nigeria indicate that lack of ANC or inadequate ANC is a
predictor of perinatal death. However, most of these studies are hospital-based and suffer
heavily from selection bias and therefore do not adequately represent the general population.
This study examined the association between focused antenatal care and perinatal mortality in
Nigeria.
Data Source and Methods
The data for this study comes from the 2013 Nigeria Demographic and Health Survey
(DHS). The 2013 Nigeria DHS is the fifth round of nation-wide organized data collection
system supported by USAID and implemented by the National Population Commission (NPC
2014). The 2013 survey consists of nationally representative sample of 38,945 women aged 15-
49years and 17,359 men aged 15-59 years living in 38,904 households. The unique feature of
the 2013 survey is the collection of information that allows the estimation of perinatal mortality
possible.
The main outcome variables are stillbirth (death of fetus after 7months of pregnancy or
22weeks of gestation), early neonatal death (death within 6days of delivery) and perinatal
mortality (sum of stillbirths and early neonatal death). The main exposure variable is having at
least four antenatal care visits in the most recent pregnancy within the five year period
preceding the survey as recommended by WHO. Cox proportional hazard models were fitted to
answer the research question.
Results
There were 396 stillbirths and 925 early neonatal deaths and use of focused ANC is
61%; perinatal mortality rate as a whole is 41 per 1000 births. About 29% of all the early
neonatal deaths occurred on the day they were born while 61% within 48 hours of delivery. Use
of ANC varies significantly with maternal age, geopolitical zone (North/South), place of
residence (rural/urban), maternal education, wealth index, religion, and parity, sex of household
head, marital status and type of marriage (polygyny/monogamy). Further, perinatal mortality
rate vary according to some previously established trends: more at the extremes of maternal
ages, higher in northern than in the southern geopolitical zone, highest among those with
primary level of education and among lowest wealth quintile; among parity one and five or
more, male child, very small babies and small babies (<2.5Kg) and those delivered in health
facility.
In the final model, factors significantly reducing the risk of perinatal mortality are use of
focused ANC (HR=0.69, 95%CI: 0.65-0.73); being in the middle or rich wealth quintile
(HR=0.87, 95%CI: 0.83-0.92); living in southern zone of the country (HR=0.87, 95%CI: 0.84-
0.89); being of parity between two and four (HR=0.91, 95%CI: 0.83-0.99); having had a urine
test (HR=0.86, 95%CI: 0.81-0.91) and receiving all the six components of antenatal care
(HR=0.18, 95%CI: 0.13-0.25). Those factors found to increase the risk perinatal death include
living in rural area of the country (HR=1.32, 95%CI: 1.27-1.38); having between one and three
cowives (HR=1.21, 95%CI: 1.17-1.26) having had a complication during the pregnancy (HR=
1.20, 95%CI: 1.16-1.25); having a female as the head of the household (HR=1.05, 95%CI: 1.02-
1.09) and taking iron tablets for more than six months (HR=1.24, 95%CI: 1.15-1.34).
Conclusion
The results of the analysis show that use of focused ANC significantly reduces the risk
of perinatal mortality by about 31%; varying between 26% (risk reduction for early neonatal
death) and 28% (risk reduction for stillbirths). Other factors that are significantly associated
with reduction of perinatal mortality are residing in Southern part of the country, being of parity
of between two and four, being in the middle and/or rich wealth quintile, having had a urine test
during ANC visits and receiving all the six elements of antenatal care.
Policy implication
This results calls for the more investment in maternal and child health services
particularly antenatal care to make it more easily accessible in the overall framework of
improving maternal and child health. It specifically implies that socioeconomic development
programs should target basic schooling (especially female education), economic
welfare/poverty eradication, women empowerment as well as allocating more health resources
in the disadvantaged rural areas and Northern part of Nigeria.
Research implication
While this research has corroborated the recommendations of WHO it has also opened
up new areas of future research. There is the need to test the validity of World Health
Organization’s recommendations on the role of focused ANC on perinatal mortality using more
advanced statistical methods and designs such multi-level modelling, instrumental variable and
propensity score matching. To have a smooth transition from research to practice, operations
research have to be conducted in specific cultural and health systems contexts to deal with
issues specific to these contexts. Such operations research will involve assessing the capacity of
the health system on how to implement the new model of ANC in terms infrastructure, staffing,
training and re-training of staff and supplies. Attitudes and perception of providers and clients
about the new model needs to be determined also. It is also important to conduct a multicountry
analysis to assess the claim of WHO knowing fully that WHO conducted the trial of
this model in only four countries none of which is from sub-Saharan Africa
