{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,20]],"date-time":"2026-07-20T17:27:25Z","timestamp":1784568445324,"version":"3.55.0"},"reference-count":31,"publisher":"BMJ","issue":"3","license":[{"start":{"date-parts":[[2026,3,10]],"date-time":"2026-03-10T00:00:00Z","timestamp":1773100800000},"content-version":"unspecified","delay-in-days":9,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000865","name":"Bill and Melinda Gates Foundation","doi-asserted-by":"publisher","award":["OPP1084399"],"award-info":[{"award-number":["OPP1084399"]}],"id":[{"id":"10.13039\/100000865","id-type":"DOI","asserted-by":"publisher"}]},{"name":"National Institute for Child Health 27 and Human Development","award":["(R01HD060712), (R01HD092411)"],"award-info":[{"award-number":["(R01HD060712), (R01HD092411)"]}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,2,24]]},"published-print":{"date-parts":[[2026,3]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>A significant number of women die from pregnancy and childbirth complications globally, particularly in low and middle-income countries. Receiving at least four antenatal care (ANC) visits is important in reducing maternal and perinatal deaths. However, few studies have investigated the factors linked to the completion of \u22654 ANC visits in Nepal.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To investigate factors associated with attending \u22654 ANC visits in Sarlahi district of southern Nepal.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design, setting and participants<\/jats:title>\n                    <jats:p>A secondary analysis was conducted on data from the Nepal Oil Massage Study (NOMS), a cluster-randomised, community-based longitudinal pregnancy trial including 34 village development committees. We investigated the associations between attendance of \u22654 ANC visits and socioeconomic, demographic, morbidity and pregnancy history factors using logistic regression; generalised estimating equations were used to account for multiple pregnancies per woman. All pregnancies resulting in a live birth (LB) (n=31\u2009867) were included.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Primary and secondary outcome measures<\/jats:title>\n                    <jats:p>Attendance of \u22654 ANC visits.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>31.4% of those pregnancies received 4+ ANC visits. Significant positive associations included socioeconomic factors such as participation in non-farming occupations for women (OR=1.52, 95%\u2009CI 1.19 to 1.93), higher education (OR=1.79, 95%\u2009CI 1.66 to 1.93) and wealth quintile (OR=1.44, 95%\u2009CI 1.31 to 1.59), nutritional status such as non-short stature (OR=1.17, 95%\u2009CI 1.07 to 1.27), obstetric history such as adequate interpregnancy interval (OR=1.31, 95%\u2009CI 1.19 to 1.45) and prior pregnancy but no LB (OR=2.14, 95%\u2009CI 1.57 to 2.92), symptoms such as vaginal bleeding (OR=1.35, 95%\u2009CI 1.11 to 1.65) and awareness of the government\u2019s conditional cash transfer ANC programme (OR=2.26, 95%\u2009CI 2.01 to 2.54). Conversely, identifying as the Shudra caste (OR=0.56, 95%\u2009CI 0.47 to 0.67), maternal age below 18 or above 35 (OR=0.81, 95%\u2009CI 0.74 to 0.88; OR=0.77, 95%\u2009CI 0.62 to 0.96), preterm birth (OR=0.41, 95%\u2009CI 0.35 to 0.49), parity \u22651 (OR=0.66, 95%\u2009CI 0.61 to 0.72) and the presence of hypertension during pregnancy (OR=0.79, 95%\u2009CI 0.69 to 0.90) were associated with decreased likelihood of attending \u22654 ANC visits.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>These findings demonstrate the importance of socioeconomic factors, including education, caste, wealth and occupation in completion of \u22654 ANC visits. In addition, biological factors including birth spacing, pregnancy complications and nutrition are important. The association with awareness of the government\u2019s conditional cash transfer programme is a motivation for a full evaluation of whether expanding that programme might improve prenatal care.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration number<\/jats:title>\n                    <jats:p>\n                      The clinicaltrial.gov trial registration number for NOMS was\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"clintrialgov\" xlink:href=\"NCT01177111\">NCT01177111<\/jats:ext-link>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2024-098478","type":"journal-article","created":{"date-parts":[[2026,3,10]],"date-time":"2026-03-10T14:55:19Z","timestamp":1773154519000},"page":"e098478","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Observational analysis of factors associated with completion of four or more antenatal care visits in Sarlahi district, Nepal"],"prefix":"10.1136","volume":"16","clinical-trial-number":[{"clinical-trial-number":"nct01177111","registry":"10.18810\/clinical-trials-gov"},{"clinical-trial-number":"nct01177111","registry":"10.18810\/clinical-trials-gov"}],"author":[{"ORCID":"https:\/\/orcid.org\/0009-0006-5144-5685","authenticated-orcid":false,"given":"Yiwei","family":"Yue","sequence":"first","affiliation":[{"name":"Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA"},{"name":"Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9176-3278","authenticated-orcid":false,"given":"Elizabeth A","family":"Hazel","sequence":"additional","affiliation":[{"name":"Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6360-3998","authenticated-orcid":false,"given":"Seema","family":"Subedi","sequence":"additional","affiliation":[{"name":"Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Scott","family":"Zeger","sequence":"additional","affiliation":[{"name":"Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Diwakar","family":"Mohan","sequence":"additional","affiliation":[{"name":"Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luke C","family":"Mullany","sequence":"additional","affiliation":[{"name":"Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James M","family":"Tielsch","sequence":"additional","affiliation":[{"name":"Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Subarna","family":"Khatry","sequence":"additional","affiliation":[{"name":"Nepal Nutrition Intervention Project, Lalitpur, Nepal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steven C","family":"LeClerq","sequence":"additional","affiliation":[{"name":"Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA"},{"name":"Nepal Nutrition Intervention Project, Lalitpur, Nepal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joanne","family":"Katz","sequence":"additional","affiliation":[{"name":"Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,3,10]]},"reference":[{"key":"2026062609355644000_16.3.e098478.1","unstructured":"World Health Organization . 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