Pregnancy Health Financing and Maternal–Newborn Survival: Financial Hardship, ANC Coverage and Neonatal Mortality

Background: Financial protection and maternal–newborn survival are central to universal health coverage, yet global evidence rarely links household financial hardship with antenatal care (ANC), delivery-care pathways and neonatal mortality over a long historical horizon. Objective: This study examined whether pregnancy-related financial hardship and catastrophic health spending are associated with neonatal mortality and whether ANC coverage, facility delivery and care-sector structure explain or modify this relationship. Methods: A balanced global country-year panel covering 198 countries/territories from 1950 to 2025 was analysed. A Pregnancy Financial Hardship Index (PFHI) was constructed through principal component analysis using financial hardship, catastrophic spending and impoverishment indicators. The study applied two-way fixed effects, dynamic panel modelling, mediation and moderation models, quantile regression, threshold/spline analysis, machine learning prediction, SHAP explainability, double machine learning and sequence forecasting. Results: Neonatal mortality declined from approximately 33.3 to 23.3 deaths per 1,000 live births across decades, while ANC, delivery care, sanitation and clean fuels improved. In fixed-effects models, PFHI was not a robust average predictor, but ANC 4+ coverage was strongly associated with lower neonatal mortality (coefficient = -0.153, p < 0.001). Full pathway models identified sanitation and DTP3 vaccination as significant protective factors. Random Forest achieved the best prediction performance (test RMSE = 3.809; R-squared = 0.448), while SHAP highlighted early ANC timing, DTP3, hygiene, caesarean delivery and sanitation as leading predictors. Conclusion: Newborn survival is shaped by integrated financing–care–environment pathways rather than a single direct hardship coefficient. Policy should combine financial protection with early, repeated and quality ANC, facility delivery, sanitation and targeted high-risk surveillance. Originality: The paper offers a global longitudinal framework combining econometrics, pathway analysis and explainable AI for pregnancy health financing and neonatal survival.