Trends and inequities in antenatal care use in South and Southeast Asia, 1987-2022: evidence from demographic and health surveys.

OBJECTIVES: To examine spatiotemporal trends, disparities and predictors of antenatal care (ANC) uptake in South and Southeast Asia from 1987 to 2022 using nationally representative demographic and health survey (DHS) data. DESIGN: Pooled analysis of cross-sectional nationally representative demographic and health survey (DHS) data. SETTING: Community-based and household-based surveys conducted across 12 countries in South and Southeast Asia (Afghanistan, Bangladesh, Cambodia, India, Indonesia, Maldives, Myanmar, Nepal, Pakistan, Philippines, Timor-Leste and Vietnam), spanning standard DHS rounds from 1987 to 2022. PARTICIPANTS: 776 005 births with available information on ANC visits, drawn from a pooled birth-history dataset of 5 277 239 unique births across the 12 countries. OUTCOME MEASURES: The main outcome measure was adequate ANC use, defined as ≥4 ANC visits versus <4 (including none). Predictors were assessed using survey-weighted univariable and multivariable logistic regression with least absolute shrinkage and selection operator (LASSO)-based variable selection, and geographic disparities were visualised using spatiotemporal maps by birth year. RESULTS: Overall, 50.1% of women received four or more ANC visits, increasing from 38.3% in 1985-1989 to 56.0% in 2020-2022. Over the same period, neonatal mortality declined from 50.6 to 19.1 per 1000 live births and maternal mortality from 770.9 to 187.2 per 100 000 live births. Adequate ANC use was higher among urban women (adjusted OR (aOR) 1.15, 95% CI 1.08 to 1.23), those with secondary or higher education (aOR 1.28, 95% CI 1.17 to 1.39) and those in the highest wealth quintile (aOR 1.87, 95% CI 1.70 to 2.05). Late ANC initiation was strongly associated with lower use (aOR 0.33, 95% CI 0.31 to 0.34). Higher odds were observed among women receiving ≥3 ANC components (aOR 1.89, 95% CI 1.77 to 2.02), daily television viewers (aOR 1.40, 95% CI 1.31 to 1.50) and women with decision-making autonomy (aOR 1.22, 95% CI 1.14 to 1.30). CONCLUSION: ANC use has improved over 30 years but remains insufficient and inequitable. Strengthening timely, high-quality ANC supported by women's empowerment and resilient primary care, outreach and referral will be crucial to achieve maternal and neonatal Sustainable Development Goals targets.