Continuum of Maternal Healthcare and Neonatal Mortality in Sub-Saharan Africa
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Background
Neonatal mortality remains a significant public health challenge in Sub-Saharan Africa (SSA). The continuum of maternal care (COC), spanning antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC) represents an integrated pathway to improving neonatal survival. Multi-country evidence on how adherence to this full continuum affects neonatal outcomes across SSA is limited.
Objectives
This study aimed to: (1) construct a composite COC indicator and describe its sociodemographic distribution; (2) estimate its association with neonatal mortality; (3) conduct a counterfactual analysis; and (4) examine cross-country heterogeneity in the COC effect on neonatal mortality.
Methods
Pooled Demographic and Health Survey (DHS) data from 35 SSA countries (2010– 2026) were analyzed (N = 867,984 live births). A binary CoC indicator (coc1 = 1 if mother received ≥4 ANC visits, skilled birth attendance, and PNC within 48 hours) was constructed. Survey-weighted logistic regression adjusted for wealth, education, residence, parity, maternal age, child sex, child age, and country. Counterfactual predictive margins and a COC × country interaction model were estimated in Stata 18.
Results
Only 13.47% of mothers met the full COC threshold. COC completion was higher among wealthier, urban, more educated, and lower-parity women. After adjustment, CoC receipt was associated with significantly lower odds of neonatal death (aOR = 0.638, 95% CI: 0.577– 0.706, p < 0.001). Counterfactual analysis showed the predicted neonatal mortality probability would fall from 3.15% (no CoC) to 2.04% (full CoC), an absolute risk reduction of 1.11 percentage points. Cross-country interaction terms were largely non-significant; only Namibia reached significance (p = 0.036).
Conclusion
Completion of the full continuum of maternal care is independently associated with reduced neonatal mortality across SSA. Equity-focused policies should prioritize integrated service delivery for rural, poor, and less-educated women.
