Quality of antenatal and delivery care and postnatal care use: A multi-country observational study of 400,000 births

BACKGROUND: Postnatal care (PNC) plays a crucial role in averting newborn mortality, yet its use remains low, particularly in regions with the highest mortality. While demographic and social determinants of PNC use have been well studied and have informed current strategies focused on changing care-seeking behaviors, the stagnating decline in neonatal mortality highlights the need for upstream and system-wide approaches to increase PNC uptake. Limited evidence exists to guide system-level reforms; therefore, we investigated whether health systems that ensure high-quality perinatal care are associated with increased use of PNC. METHODS AND FINDINGS: We performed a cross-sectional observational study using Demographic and Health Survey data from 38 countries that had not met SDG neonatal mortality targets by 2020. The study population comprised women aged 15-49 years whose most recent live birth occurred within five years preceding the survey. We employed logistic regression models with country fixed effects to examine associations between: (1) perinatal service utilization, (2) service quality; and their relationship with postnatal checkups for newborns within 28 days. We analyzed utilization-quality interactions to determine how the effects of service coverage on PNC use varied by care quality and conducted wealth-stratified analyses to assess how quality effects on PNC use differed across socioeconomic groups. High-quality perinatal care was associated with a 2-fold increase in the probability of postnatal checkups within 28 days (0.406 in the highest quality tertile versus 0.221 in the lowest quality tertile). For mothers who received the lowest tertile of service quality, full utilization of perinatal services yielded negligible changes in postnatal checkup probability (0.217 to 0.216). Conversely, for mothers who received the highest quality of antenatal and perinatal care, full access to perinatal care improved the probability of postnatal check-ups (0.392 to 0.428). Notably, women in the lowest wealth quintile experienced a substantial increase in postnatal checkup probability from 0.224 to 0.481 between low and high-quality care cohorts, while this differential was less pronounced in the highest wealth quintile (0.236 to 0.450). Key limitations include restricted quality indicators, potential recall bias from self-reported measures, limited information on follow-up care, and the cross-sectional nature of the data, which limits causal interpretation. CONCLUSIONS: Our interaction analysis reveals a critical insight: high-quality care substantially enhanced the magnitude of the association between expanded perinatal service use and PNC use, whereas increased utilization alone was not linked to higher PNC uptake. Notably, the impact of improved care quality was most pronounced among the lowest wealth groups, highlighting its potential as a mechanism for promoting equity. By demonstrating the central role of care quality in promoting PNC utilization, particularly among disadvantaged populations, our findings suggest that improving health system quality could be a more effective strategy for achieving universal maternal healthcare coverage than traditional access-focused approaches.