Background: Antenatal iron-folic acid (IFA) supplementation improves maternal anemia and poor pregnancy outcomes. Antenatal use of IFA supplements also has an effect on child survival.

Objective: The current study investigated the effect of antenatal IFA supplements on the risk of childhood mortality in Nepal over a 15-y period from 1996 to 2011.

Methods: Survival information of 12,891 singleton most recent live-born infants from pooled 2001, 2006, and 2011 Nepal Demographic and Health Surveys was used. Primary outcomes were mortality indicators in children <5 y of age and the main exposure variable was use of IFA supplements. Data were analyzed by using STATA 13.1 (StataCorp) and were adjusted for the cluster sampling design. Analyses used multivariate Cox proportional hazards regression adjusted for potential confounders.

Results: Antenatal use of IFA supplements significantly reduced the risk of early neonatal deaths by 45% [adjusted HR (aHR): 0.55; 95% CI: 0.38, 0.79] and total neonatal deaths by 42% (aHR: 0.58; 95% CI: 0.39, 0.85). Similarly, the risk of infant and under-5 mortality was significantly reduced by 32% and 48%, respectively. For mothers who started IFA at 1–4 mo of pregnancy and used 150–240 supplements, neonatal and under-5 mortality were significantly reduced by 55% (aHR: 0.45; 95% CI: 0.24, 0.85) and 57% (aHR: 0.43; 95% CI: 0.23, 0.78), respectively. Population attributable risk estimates found 15% of under-5 deaths were attributed to nonuse of IFA, and 29,000 under-5 deaths could be prevented in the next 5 y with universal IFA coverage.

Conclusions: Antenatal IFA supplementation significantly reduces the risk of neonatal and under-5 deaths in Nepal. The greatest effect on child survival was found in women who started IFA early in pregnancy and took 150–240 supplements. Universal IFA coverage could improve neonatal and child survival.