Potential antenatal care-mediated benefits of delivering maternal immunization in five low- and middle-income countries: a modeling analysis

BACKGROUND: Maternal immunization (MI) can prevent major infectious diseases in mothers and children by boosting the immunity of pregnant women. Antenatal care (ANC) delivery platforms could be leveraged to effectively provide MI. Adding MIs into ANC could potentially enhance ANC services, positively influencing both maternal and infant health outcomes and yielding broader benefits. We model these potential ANC-mediated health benefits in five low- and middle-income countries: Ethiopia, Ghana, Kenya, Pakistan, and South Africa. METHODS: We first developed a conceptual framework delineating pathways through which MI-ANC could enhance ANC utilization and quality, leading to improved care-seeking for facility delivery, postnatal care, and major childhood vaccinations (e.g., measles, diphtheria-pertussis-tetanus [DPT] third dose), as well as decreased infant mortality. Using a decision-analytic model informed by Demographic and Health Survey data, we simulated the potential benefits of MI-ANC delivery across socioeconomic groups at varying hypothetical MI coverage levels. RESULTS: MI-ANC integration would be associated with improvements in maternal and child health outcomes across all countries studied, mediated through enhanced engagement with ANC services. Under a scenario of full MI-ANC coverage, for example, infant mortality in Ethiopia's poorest quintile was projected to decline from approximately 60 to 50 deaths per 1000 live births. In-facility delivery rates were estimated to increase from 11% to 35%, postnatal care utilization from 4% to 11%, measles-containing vaccine coverage from 43% to 71%, and DPT3 immunization from 36% to 63%. These improvements would vary substantially by country and socioeconomic group, with the largest gains observed in populations with lower baseline ANC utilization. CONCLUSIONS: Integrating MIs into ANC services has the potential to yield ANC-mediated health benefits, particularly in settings with low baseline ANC utilization. These findings can help inform priority-setting, support the design of targeted pilot programs, and guide future empirical implementation research on the possible broader impacts of MI-ANC delivery.