Background Antenatal care (ANC) is crucial for ensuring the health of pregnant women and their newborns. Although ANC coverage has improved globally, ANC quality remains suboptimal in some settings. Evidence on the association between ANC quality and perinatal outcomes in low-resource countries is still limited. Hence, this study assessed ANC quality and its relationship with fetal loss and low birth weight (LBW) newborns.

Methods and findings We used data from the eCohort study that collected longitudinal data on ANC utilization and quality until the end of pregnancy across eight sites in Ethiopia, Kenya, South Africa, and India. Women were enrolled from public government-owned facilities only in India and South Africa and from both public and private facilities in Ethiopia and Kenya. Primary outcomes included fetal loss (≥13 weeks of gestation) and LBW. Good quality ANC was defined as receiving six essential care components during the first ANC visit: blood pressure measurement, blood and urine tests, ultrasound, iron and folic acid supplementation, and counseling on pregnancy danger signs. We conducted mixed-effect logistic regressions to assess the association between good quality ANC and perinatal outcomes, with a sensitivity analysis where good quality ANC excluded ultrasound scans. Among 3,597 pregnant women followed until the end of pregnancy, only 5.8% received all six essential care components during their first ANC visit (ranging from 1.4% in India to 14.0% in Ethiopia) and 30.7% received five care components (excluding ultrasounds) ranging from 5.7% in India to 52.5% in Kenya. Fetal loss prevalence was 3.7% in Ethiopia, 3.8% in Kenya, 4.0% in South Africa, and 6.0% in India. India and South Africa had higher rates of LBW newborns (among neonates who were alive at the time of the survey): 16.3% and 13.1%, respectively, compared to 8.6% in Ethiopia and 8.5% in Kenya. Multiple pregnancies were rarely detected at the first ANC visit. Good quality ANC was associated with a 22% to 58% lower risk of fetal loss (RR 0.78, 95% CI 0.61 – 0.95 to RR 0.42, 95% CI 0.10 – 0.73). No statistically significant associations were observed between good quality ANC and LBW.

Conclusions This study identified important gaps in ANC quality and found that receiving essential ANC services was associated with a lower risk of fetal loss. With increasing global ANC coverage, future research should continue assessing quality, and programs should prioritize quality improvement, ensuring the delivery of good clinical practice and proven evidence-based interventions in pregnancy.

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