Quality of Antenatal Care and Maternal Mortality in Madagascar: Analysis of Regional Disparities and Non-Linear Modeling
,
Abstract
Objective: Maternal mortality remains a major public health challenge in Madagascar, with notable regional disparities. Antenatal care (ANC) plays a critical role in preventing maternal deaths, yet its coverage and quality vary significantly across regions. This study aims to assess the association between ANC quality and maternal mortality rate (MMR), focusing on regional disparities and exploring potential non-linear relationships.
Materials and methods: We conducted a retrospective ecological study using publicly available data from Madagascar’s 22 regions. ANC indicators included blood pressure monitoring, blood and urine tests, iron supplementation, and antiparasitic treatment. Linear regression and Generalised Additive Models (GAM) were used to examine associations and non-linear patterns. Statistical analyses were performed using R version 4.2.2, with a significance threshold of 5%.
Results: Considerable disparities were observed in ANC coverage across regions. Linear models revealed no significant association between ANC indicators and MMR (p > 0.05). However, GAM identified significant non-linear relationships for blood pressure monitoring (p < 0.0045) and blood testing (p < 0.0055), suggesting potential threshold effects.
Conclusion: Addressing maternal mortality in Madagascar requires enhancing both access to and the quality of ANC. Accounting for regional disparities and non-linear trends is essential in developing effective public health interventions.
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12. Hosmer Jr DW, Lemeshow S, Sturdivant RX. Applied logistic regression. 3nd ed. United States of America: Wiley, 2013.
13. Ronsmans C, Graham WJ. Maternal mortality: who, when, where, and why. Lancet. 2006;368(9542):
1189-200.
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15. Lincetto O, Mothebesoane-Anoh S, Gomez P, Munjanja S. Antenatal care. Opportunities for Africa's newborns: Practical data, policy programmatic support for newborn care in Africa. Cape Town: Partnership for
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16. Tura G, Fantahun M, Worku A. The effect of health facility delivery on neonatal mortality: systematic review and meta-analysis. BMC Pregnancy Childbirth. 2013;13:18.
17. Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res. 1974;9(3):208-20.
18. Gage AJ, Guirlène Calixte M. Effects of the physical accessibility of maternal health services on their use in rural Haiti. Popul Stud (Camb). 2006;60(3):271-88.
19. Say L, Raine R. A systematic review of inequalities
in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context. Bull World Health Organ. 2007;85(10):812-9.
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22. Filippi V, Chou D, Ronsmans C, Graham W, Say L. Levels and Causes of Maternal Mortality and Morbidity. 3nd ed. Washington (DC): The International Bank for Reconstruction and Development/The World Bank, 2016.
23. Hounton S, Menten J, Ouédraogo M, Dubourg D, Meda N, Ronsmans C, al. Effects of a Skilled Care Initiative on pregnancy-related mortality in rural Burkina Faso. Trop Med Int Health. 2008;13 Suppl 1:53-60.
24. World Health Organization. Strategies towards ending preventable maternal mortality (EPMM). World Health Organization, 2015.
25. World Health Organization. Trends in maternal
mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division: executive summary. https://iris.who.int/handle/10665/327596. (accessed 2019).
26. Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: when? Where? Why? Lancet. 2005;365(9462):891-900.
27. Rutstein SO, Johnson K. The DHS Wealth Index. DHS Comparative Reports No. 6. United States of America: ORC Macro, 2004.
28. Victora CG, Barros AJD, França GVA, da Silva ICM, Carvajal-Velez L, Amouzou A. The contribution of poor and rural populations to national trends in reproductive, maternal, newborn, and child health coverage: analyses of cross-sectional surveys from 64 countries. Lancet Glob Health. 2017;5(4):e402-e407.
29. Freedman LP, Kruk ME. Disrespect and abuse of women in childbirth: challenging the global quality and accountability agendas. Lancet. 2014;384(9948):e42-4.
2. World Health Organization. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World bank group and UNDESA/population division. https://www.who.int/publications/i/item/9789240068759 (accessed 2023).
3. Bemanana HS, Rafamantanantsoa S. Maternal mortality in hospital settings in Madagascar: A 43-case study. Médecine d'Afrique Noire. 2023;70(6):349-56. Available at: https://www.santetropicale.com/kiosque/une_uk.asp?id_revue=man&numero=7006&mois_numero=June&libe
lle_annee=2023&id_article=3655#openModal_3655 .
4. Bemanana HS, Rafamantanantsoa S, Razanabao TE, Razafindraibe AF, Rakotondrafarasata RS, Fenomanana SM. Determinants of maternal mortality in hospital settings in Madagascar. J Sante Publique. 2024;36(5):131-8. Available at: file:///C:/Users/mi.jafarabadi/Downloads/sylvestre-bemanana-2024-les-determinants-de-deces-maternel-en-milieu-hospitalier-a-madagascar.pdf .
5. Lancet Newborn Interventions Review Group; Lancet Every Newborn Study Group. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost?. Lancet. 2014;384(9940):347-70.
6. Samuel O, Zewotir T, North D. Decomposing the urban-rural inequalities in the utilisation of maternal health care services: evidence from 27 selected countries in Sub-Saharan Africa. Reproductive health. 2021;18(1):216.
7. Apanga PA, Awoonor-Williams JK. Maternal Death in Rural Ghana: A Case Study in the Upper East Region of Ghana. Front Public Health. 2018;6:101.
8. Institut National de la Statistique (INSTAT). RGPH3_Niveaux tendances et caracteristiques de la mortalite à Madagascar. Antananarivo, Madagascar: INSTAT; 2021.
9. Institut National de la Statistique (INSTAT), ICF. Enquête démographique et de santé à Madagascar (EDSMD-V) 2021. Antananarivo, Madagascar; Rockville, Maryland, USA: INSTAT et ICF; 2022.
10. Carroli G, Rooney C, Villar J. How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence. Paediatr Perinat Epidemiol. 2001;15 Suppl 1:1-42.
11. Freedman LP, Waldman RJ, de Pinho H, Wirth ME, Chowdhury AM, Rosenfield A. Transforming health systems to improve the lives of women and children. Lancet. 2005;365(9463):997-1000.
12. Hosmer Jr DW, Lemeshow S, Sturdivant RX. Applied logistic regression. 3nd ed. United States of America: Wiley, 2013.
13. Ronsmans C, Graham WJ. Maternal mortality: who, when, where, and why. Lancet. 2006;368(9542):
1189-200.
14. Campbell OM, Graham WJ. Strategies for reducing maternal mortality: getting on with what works. Lancet. 2006;368(9543):1284-99.
15. Lincetto O, Mothebesoane-Anoh S, Gomez P, Munjanja S. Antenatal care. Opportunities for Africa's newborns: Practical data, policy programmatic support for newborn care in Africa. Cape Town: Partnership for
Maternal, Newborn and Child Health. 2006:55-62.
16. Tura G, Fantahun M, Worku A. The effect of health facility delivery on neonatal mortality: systematic review and meta-analysis. BMC Pregnancy Childbirth. 2013;13:18.
17. Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res. 1974;9(3):208-20.
18. Gage AJ, Guirlène Calixte M. Effects of the physical accessibility of maternal health services on their use in rural Haiti. Popul Stud (Camb). 2006;60(3):271-88.
19. Say L, Raine R. A systematic review of inequalities
in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context. Bull World Health Organ. 2007;85(10):812-9.
20. Benova L, Cumming O, Campbell OM. Systematic review and meta-analysis: association between water and sanitation environment and maternal mortality. Trop Med Int Health. 2014;19(4):368-87.
21. Van Lerberghe W, De Brouwere V. Of blind alleys and things that have worked: history's lessons on reducing maternal mortality. Safe motherhood strategies: a review of the evidence. 2001.
22. Filippi V, Chou D, Ronsmans C, Graham W, Say L. Levels and Causes of Maternal Mortality and Morbidity. 3nd ed. Washington (DC): The International Bank for Reconstruction and Development/The World Bank, 2016.
23. Hounton S, Menten J, Ouédraogo M, Dubourg D, Meda N, Ronsmans C, al. Effects of a Skilled Care Initiative on pregnancy-related mortality in rural Burkina Faso. Trop Med Int Health. 2008;13 Suppl 1:53-60.
24. World Health Organization. Strategies towards ending preventable maternal mortality (EPMM). World Health Organization, 2015.
25. World Health Organization. Trends in maternal
mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division: executive summary. https://iris.who.int/handle/10665/327596. (accessed 2019).
26. Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: when? Where? Why? Lancet. 2005;365(9462):891-900.
27. Rutstein SO, Johnson K. The DHS Wealth Index. DHS Comparative Reports No. 6. United States of America: ORC Macro, 2004.
28. Victora CG, Barros AJD, França GVA, da Silva ICM, Carvajal-Velez L, Amouzou A. The contribution of poor and rural populations to national trends in reproductive, maternal, newborn, and child health coverage: analyses of cross-sectional surveys from 64 countries. Lancet Glob Health. 2017;5(4):e402-e407.
29. Freedman LP, Kruk ME. Disrespect and abuse of women in childbirth: challenging the global quality and accountability agendas. Lancet. 2014;384(9948):e42-4.
| Files | ||
| Issue | Vol 19, No 3 (September 2025) | |
| Section | Original Articles | |
| DOI | https://doi.org/10.18502/jfrh.v19i3.20055 | |
| Keywords | ||
| Antenatal Care Health Services Accessibility Maternal Mortality Madagascar Public Health Regression Analysis | ||
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How to Cite
1.
Bemanana H, Razafaindraibe A, Rafamantanantsoa S. Quality of Antenatal Care and Maternal Mortality in Madagascar: Analysis of Regional Disparities and Non-Linear Modeling. J Family Reprod Health. 2025;19(3):174-183.
