Maternal-Child Healthcare Continuity and Zero-Dose Status Among Children in Nigeria: A Pooled DHS Analysis, 2013–2024

Abstract Background Routine immunization inequities remain a major public health challenge in many low- and middle-income countries despite substantial global progress in vaccine coverage [1–3]. Increasing global attention has focused on “zero-dose” children, defined as children who have not received the first dose of a diphtheria-tetanus-pertussis-containing vaccine (DTP1/Penta1) [2]. While previous studies have examined socioeconomic and geographic determinants of immunization exclusion, less attention has been paid to the role of maternal-child healthcare continuity in shaping childhood immunization uptake. Objective To examine the relationship between maternal-child healthcare continuity, measured primarily through antenatal care (ANC) attendance, and zero-dose status among children aged 12–23 months in Nigeria using pooled Nigeria Demographic and Health Survey (NDHS) data from 2013, 2018, and 2024. Methods This study conducted a secondary analysis of pooled nationally representative NDHS datasets from 2013, 2018, and 2024 [4–6]. The analysis included 17,572 children aged 12–23 months. Zero-dose status was defined as non-receipt of the first dose of a DTP-containing vaccine. The primary exposure variable was ANC attendance categorized as 0 visits, 1–3 visits, 4–7 visits, and 8 + visits. Survey-weighted descriptive statistics, Rao-Scott chi-square tests, and survey-adjusted logistic regression models were used to estimate associations between maternal healthcare continuity and zero-dose status while accounting for clustering, stratification, and sampling weights. Results The pooled weighted prevalence of zero-dose status was 40.5% (95% CI: 39.0%–42.0%). Zero-dose prevalence declined from 49.4% in 2013 to 35.0% in 2018 but slightly increased to 37.0% in 2024. A strong dose-response relationship was observed between ANC attendance and zero-dose prevalence. Children whose mothers had no ANC attendance had an 80.2% zero-dose prevalence compared with 12.6% among children whose mothers attended at least eight ANC visits. In adjusted models, compared with no ANC attendance, mothers with 1–3 ANC visits had 74% lower odds of having a zero-dose child (AOR: 0.26; 95% CI: 0.22–0.30), mothers with 4–7 visits had 83% lower odds (AOR: 0.17; 95% CI: 0.15–0.19), and mothers with 8 + visits had 88% lower odds (AOR: 0.12; 95% CI: 0.10–0.14). Wealth and maternal education were also independently associated with lower odds of zero-dose status. Conclusion Zero-dose status in Nigeria appears strongly associated with maternal-child healthcare discontinuity rather than solely an immunization service failure. Integrated maternal and child healthcare strategies that strengthen continuity of care may contribute substantially to reducing immunization exclusion and improving equitable vaccine coverage.