Maternal Healthcare Autonomy and Neonatal Mortality in Nigeria: A Survival Analysis Using the 2024 Nigeria Demographic and Health Survey

BACKGROUND: Neonatal mortality remains a major public health concern and contributes substantially to under-five mortality. Maternal healthcare autonomy is a dimension of women's empowerment that may be associated with healthcare utilization and improve neonatal survival. However, evidence on the role of maternal healthcare autonomy and its interaction with antenatal care (ANC) in reducing neonatal mortality remains limited. METHODS: This study used nationally representative data from the 2024 Nigeria Demographic and Health Survey, including the most recent births to women aged 15-49. Kaplan-Meier survival analysis and log-rank tests compared survival probabilities. Cox proportional hazards models estimated adjusted hazard ratios (HRs) and 95% confidence intervals (CIs), with the primary model adjusted for baseline maternal, socioeconomic and healthcare-related factors. Post-birth variables were examined in secondary analyses. Interaction effects between autonomy and ANC were assessed, and sensitivity analyses were used with Weibull proportional hazards and accelerated failure time models. RESULTS: Women aged 25-34 years had the highest proportion of high healthcare autonomy (22.10%), while women with no formal education were more concentrated in the low autonomy group (6.73%). Higher autonomy was associated with lower neonatal mortality hazards, although associations were not statistically significant in the primary model (substantial autonomy: aHR = 0.86; high autonomy: aHR = 0.76). Sensitivity analyses using Weibull models showed consistent estimates. Interaction analysis showed that ANC modified this relationship, with the lowest risk observed among women with high autonomy and ≥ 4 ANC visits. CONCLUSION: Higher maternal healthcare autonomy was associated with lower neonatal mortality hazards, although the association was attenuated and not statistically significant after adjustment for baseline factors. Strengthening women's healthcare decision-making alongside improving maternal healthcare access may contribute to better neonatal outcomes.