Utilisation of mobile phone interventions to improve the delivery of maternal health services in sub-Saharan Africa: A scoping review protocol.

INTRODUCTION: There has been significant progress in maternal health outcomes in the sub-Saharan African region since the early 1990s, in part due to digital and mobile health interventions. However, critical gaps and disparities remain. Mobile phones in particular have potential to reach underserved, hard-to-reach populations with underdeveloped infrastructure. In spite of the opportunities for mobile phones to address maternal mortality in the region, there is no extensive mapping of the available literature on mobile phone interventions that aim to improve access of maternal care in sub-Saharan Africa. The proposed scoping review aims to map literature on the nature and extent of mobile phones interventions designed to improve maternal care health services in the region. METHODS: Conduct of this scoping review will be guided by the Joanna Briggs Institute approach. Literature searches will be conducted in multiple electronic databases, including MEDLINE, Embase, CINAHL, APA PsycInfo, Cochrane Central Register of Controlled Trials, Global Health, African Index Medicus, Web of Science, and Applied Social Sciences Index & Abstracts. Grey literature will also be identified. Keyword searches will be used to identify articles. Two reviewers will independently screen eligible titles, abstracts and full articles with a third reviewer to help resolve any disputes. We will extract data on general study characteristics, population characteristics, concept, context, intervention details, study results, gaps and recommendations. DISCUSSION: Understanding use of mobile phones among underserved, hard-to-reach populations with underdeveloped infrastructure to address maternal mortality in developing countries is very critical to informing health systems on potential effective strategies. This review will complement the evidence base on utilisation of mobile phone interventions to improve the delivery of maternal health services in sub-Saharan Africa.

Trends and Inequalities in Maternal and Newborn Health Services for Unplanned Settlements of Lusaka City, Zambia.

Living conditions and other factors in urban unplanned settlements present unique challenges for improving maternal and newborn health (MNH), yet MNH inequalities associated with such challenges are not well understood. This study examined trends and inequalities in coverage of MNH services in the last 20 years in unplanned and planned settlements of Lusaka City, Zambia. Geospatial information was used to map Lusaka's settlements and health facilities. Zambia Demographic Health Surveys (ZDHS 2001, 2007, 2013/2014, and 2018) were used to compare antenatal care (ANC), institutional delivery, and Cesarean section (C-section) coverage, and neonatal mortality rates between the poorer 60% and richer 40% households. Health Management Information System (HMIS) data from 2018 to 2021 were used to compute service volumes and coverage rates for ANC1 and ANC4, and institutional delivery and C-sections by facility level and type in planned and unplanned settlements. Although the correlation is not exact, our data analysis showed close alignment; and thus, we opted to use the 60% poorer and 40% richer groups as a proxy for households in unplanned versus planned settlements. Unplanned settlements were serviced by primary centers or first-level hospitals. ZDHS findings show that by 2018, at least one ANC visit and institutional delivery became nearly universal throughout Lusaka, but early and four or more ANC visits, C-sections, and neonatal mortality rates remained worse among poorer than richer women in ZDHS. In HMIS, ANC and institutional delivery volumes were highest in public facilities, especially in unplanned settlements. The volume of C-sections was much greater within facilities in planned than unplanned settlements. Our study exposed persistent gaps in timing and use of ANC and emergency obstetric care between unplanned and planned communities. Closing such gaps requires strengthening outreach early and consistently in pregnancy and increasing emergency obstetric care capacities and referrals to improve access to important MNH services for women and newborns in Lusaka's unplanned settlements.

Coverage, Trends, and Inequalities of Maternal, Newborn, and Child Health Indicators among the Poor and Non-Poor in the Most Populous Cities from 38 Sub-Saharan African Countries.

Rapid urbanization is likely to be associated with suboptimal access to essential health services. This is especially true in cities from sub-Saharan Africa (SSA), where urbanization is outpacing improvements in infrastructure. We assessed the current situation in regard to several markers of maternal, newborn, and child health, including indicators of coverage of health interventions (demand for family planning satisfied with modern methods, at least four antenatal care visits (ANC4+), institutional birth, and three doses of DPT vaccine[diphtheria, pertussis and tetanus]) and health status (stunting in children under 5 years, neonatal and under-5 mortality rates) among the poor and non-poor in the most populous cities from 38 SSA countries. We analyzed 136 population-based surveys (year range 2000-2019), contrasting the poorest 40% of households (referred to as poor) with the richest 60% (non-poor). Coverage in the most recent survey was higher for the city non-poor compared to the poor for all interventions in virtually all cities, with the largest median gap observed for ANC4+ (13.5 percentage points higher for the non-poor). Stunting, neonatal, and under-5 mortality rates were higher among the poor (7.6 percentage points, 21.2 and 10.3 deaths per 1000 live births, respectively). The gaps in coverage between the two groups were reducing, except for ANC4, with similar median average annual rate of change in both groups. Similar rates of change were also observed for stunting and the mortality indicators. Continuation of these positive trends is needed to eliminate inequalities in essential health services and child survival in SSA cities.

Assessment of non-tuberculosis abnormalities on digital chest x-rays with high CAD4TB scores from a tuberculosis prevalence survey in Zambia and South Africa.

BACKGROUND: Chest X-rays (CXRs) have traditionally been used to aid the diagnosis of TB-suggestive abnormalities. Using Computer-Aided Detection (CAD) algorithms, TB risk is quantified to assist with diagnostics. However, CXRs capture all other structural abnormalities. Identification of non-TB abnormalities in individuals with CXRs that have high CAD scores but don't have bacteriologically confirmed TB is unknown. This presents a missed opportunity of extending novel CAD systems' potential to simultaneously provide information on other non-TB abnormalities alongside TB. This study aimed to characterize and estimate the prevalence of non-TB abnormalities on digital CXRs with high CAD4TB scores from a TB prevalence survey in Zambia and South Africa. METHODOLOGY: This was a cross-sectional analysis of clinical data of participants from the TREATS TB prevalence survey conducted in 21 communities in Zambia and South Africa. The study included individuals aged ≥ 15 years who had high CAD4TB scores (score ≥ 70), but had no bacteriologically confirmed TB in any of the samples submitted, were not on TB treatment, and had no history of TB. Two consultant radiologists reviewed the images for non-TB abnormalities. RESULTS: Of the 525 CXRs reviewed, 46.7% (245/525) images were reported to have non-TB abnormalities. About 11.43% (28/245) images had multiple non-TB abnormalities, while 88.67% (217/245) had a single non-TB abnormality. The readers had a fair inter-rater agreement (r = 0.40). Based on anatomical location, non-TB abnormalities in the lung parenchyma (19%) were the most prevalent, followed by Pleura (15.4%), then heart & great vessels (6.1%) abnormalities. Pleural effusion/thickening/calcification (8.8%) and cardiomegaly (5%) were the most prevalent non-TB abnormalities. Prevalence of (2.7%) for pneumonia not typical of pulmonary TB and (2.1%) mass/nodules (benign/ malignant) were also reported. CONCLUSION: A wide range of non-TB abnormalities can be identified on digital CXRs among individuals with high CAD4TB scores but don't have bacteriologically confirmed TB. Adaptation of AI systems like CAD4TB as a tool to simultaneously identify other causes of abnormal CXRs alongside TB can be interesting and useful in non-faculty-based screening programs to better link cases to appropriate care.

Going deeper with health equity measurement: how much more can surveys reveal about inequalities in health intervention coverage and mortality in Zambia?

BACKGROUND: Although Zambia has achieved notable improvements in reproductive, maternal, newborn and child health (RMNCH), continued efforts to address gaps are essential to reach the Sustainable Development Goals by 2030. Research to better uncover who is being most left behind with poor health outcomes is crucial. This study aimed to understand how much more demographic health surveys can reveal about Zambia's progress in reducing inequalities in under-five mortality rates and RMNCH intervention coverage. METHODS: Using four nationally-representative Zambia Demographic Health Surveys (2001/2, 2007, 2013/14, 2018), we estimated under-five mortality rates (U5MR) and RMNCH composite coverage indices (CCI) comparing wealth quintiles, urban-rural residence and provinces. We further used multi-tier measures including wealth deciles and double disaggregation between wealth and region (urban residence, then provinces). These were summarised using slope indices of inequality, weighted mean differences from overall mean, Theil and concentration indices. RESULTS: Inequalities in RMNCH coverage and under-five mortality narrowed between wealth groups, residence and provinces over time, but in different ways. Comparing measures of inequalities over time, disaggregation with multiple socio-economic and geographic stratifiers was often valuable and provided additional insights compared to conventional measures. Wealth quintiles were sufficient in revealing mortality inequalities compared to deciles, but comparing CCI by deciles provided more nuance by showing that the poorest 10% were left behind by 2018. Examining wealth in only urban areas helped reveal closing gaps in under-five mortality and CCI between the poorest and richest quintiles. Though challenged by lower precision, wealth gaps appeared to close in every province for both mortality and CCI. Still, inequalities remained higher in provinces with worse outcomes. CONCLUSIONS: Multi-tier equity measures provided similarly plausible and precise estimates as conventional measures for most comparisons, except mortality among some wealth deciles, and wealth tertiles by province. This suggests that related research could readily use these multi-tier measures to gain deeper insights on inequality patterns for both health coverage and impact indicators, given sufficient samples. Future household survey analyses using fit-for-purpose equity measures are needed to uncover intersecting inequalities and target efforts towards effective coverage that will leave no woman or child behind in Zambia and beyond.

How Zambia reduced inequalities in under-five mortality rates over the last two decades: a mixed-methods study.

BACKGROUND: Zambia experienced a major decline in under-five mortality rates (U5MR), with one of the fastest declines in socio-economic disparities in sub-Saharan Africa in the last two decades. We aimed to understand the extent to which, and how, Zambia has reduced socio-economic inequalities in U5MR since 2000. METHODS: Using nationally-representative data from Zambia Demographic Health Surveys (2001/2, 2007, 2013/14 and 2018), we examined trends and levels of inequalities in under-five mortality, intervention coverage, household water and sanitation, and fertility. This analysis was integrated with an in-depth review of key policy and program documents relevant to improving child survival in Zambia between 1990 and 2020. RESULTS: The under-five mortality rate (U5MR) declined from 168 to 64 deaths per 1000 live births between 2001/2 and 2018 ZDHS rounds, particularly in the post-neonatal period. There were major reductions in U5MR inequalities between wealth, education and urban-rural residence groups. Yet reduced gaps between wealth groups in estimated absolute income or education levels did not simultaneously occur. Inequalities reduced markedly for coverage of reproductive, maternal, newborn and child health (RMNCH), malaria and human immunodeficiency virus interventions, but less so for water or sanitation and fertility levels. Several policy and health systems drivers were identified for reducing RMNCH inequalities: policy commitment to equity in RMNCH; financing with a focus on disadvantaged groups; multisectoral partnerships and horizontal programming; expansion of infrastructure and human resources for health; and involvement of community stakeholders and service providers. CONCLUSION: Zambia's major progress in reducing inequalities in child survival between the poorest and richest people appeared to be notably driven by government policies and programs that centrally valued equity, despite ongoing gaps in absolute income and education levels. Future work should focus on sustaining these gains, while targeting families that have been left behind to achieve the sustainable development goal targets.

Assessment of contextual factors shaping delivery and uptake of isoniazid preventive therapy among people living with HIV in Dar es salaam, Tanzania.

BACKGROUND: Tuberculosis has remained a leading cause of death among people living with HIV (PLHIV) globally. Isoniazid preventive therapy (IPT) is the recommended strategy by the World Health Organization to prevent TB disease and related deaths among PLHIV. However, delivery and uptake of IPT has remained suboptimal particularly in countries where HIV and TB are endemic such as Tanzania. This study sought to assess contextual factors that shape delivery and uptake of IPT in Dar es Salaam region, Tanzania. METHODOLOGY: We employed a qualitative case study design comprising of in-depth interviews with people living with HIV (n = 17), as well as key informant interviews with clinicians (n = 7) and health administrators (n = 7). We used thematic data analysis approach and reporting of the results was guided by the Consolidated Framework for Implementation Research (CFIR). RESULTS: Characteristics of IPT such as aligning the therapy to individual patient schedules and its relatively low cost facilitated its delivery and uptake. On the contrary, perceived adverse side effects negatively affected the delivery and uptake of IPT. Characteristics of individuals delivering the therapy including their knowledge, good attitudes, and commitment to meeting set targets facilitated the delivery and uptake of IPT. The process of IPT delivery comprised collective planning and collaboration among various facilities which facilitated its delivery and uptake. Organisational characteristics including communication among units and supportive leadership facilitated the delivery and uptake of IPT. External system factors including HIV stigma, negative cultural and religious values, limited funding as well as shortage of skilled healthcare workers presented as barriers to the delivery and uptake of IPT. CONCLUSION: The factors influencing the delivery and uptake of IPT among people living with HIV are multifaceted and exist at different levels of the health system. Therefore, it is imperative that IPT program implementers and policy makers adopt multilevel approaches that address the identified barriers and leverage the facilitators in delivery and uptake of IPT at both community and health system levels.

Effects of economic support, comprehensive sexuality education and community dialogue on sexual behaviour: Findings from a cluster-RCT among adolescent girls in rural Zambia.

Adolescent girls in Sub-Saharan Africa are at high risk of poor sexual and reproductive health outcomes. We present findings from a cluster-randomised trial in rural Zambia on the effects of economic support, comprehensive sexuality education (CSE) and community dialogue on sexual activity, contraceptive use and beliefs among adolescent girls. We recruited 157 schools in 2016, and all girls in grade 7 were invited to participate. Schools were randomised to either economic support, combined economic support, CSE and community dialogue, or control. Economic support consisted of unconditional cash transfers to girls and their guardians, and payment of school fees for girls continuing to grades eight and nine. CSE and community dialogue meetings focused on practices around girls' fertility, marriage and education. The interventions lasted two years from 2016 to 2018, with follow-up for another two years. The effects on outcomes were measured in 2018 and 2019 and compared using generalised estimating equations. We found that economic support lowered sexual activity (risk ratio (RR) 0.70; 95% C.I. 0.54 to 0.91), with a small added benefit of CSE and community dialogue. Economic support and the additional CSE and community dialogue were effective in lowering unprotected sexual activity (RR 0.53 for combined support vs. control; 95% C.I. 0.37 to 0.75). There was no evidence of intervention effects on contraceptive use among those ever sexually active, but the addition of CSE and community dialogue improved contraceptive use among those recently sexually active (RR 1.26; 95% C.I. 1.06 to 1.50) and knowledge regarding contraceptives (RR 1.18; 95% C.I. 1.01 to 1.38) compared to economic support alone. Perceived community support regarding contraceptives was lower in both intervention arms compared to the control. These findings indicate that economic support in combination with CSE and community dialogue can improve the sexual and reproductive health of adolescent girls.

Health service utilisation during the COVID-19 pandemic in sub-Saharan Africa in 2020: a multicountry empirical assessment with a focus on maternal, newborn and child health services.

INTRODUCTION: There are concerns about the impact of the COVID-19 pandemic on the continuation of essential health services in sub-Saharan Africa. Through the Countdown to 2030 for Women's, Children's and Adolescents' Health country collaborations, analysts from country and global public health institutions and ministries of health assessed the trends in selected services for maternal, newborn and child health, general service utilisation. METHODS: Monthly routine health facility data by district for the period 2017-2020 were compiled by 12 country teams and adjusted after extensive quality assessments. Mixed effects linear regressions were used to estimate the size of any change in service utilisation for each month from March to December 2020 and for the whole COVID-19 period in 2020. RESULTS: The completeness of reporting of health facilities was high in 2020 (median of 12 countries, 96% national and 91% of districts ≥90%), higher than in the preceding years and extreme outliers were few. The country median reduction in utilisation of nine health services for the whole period March-December 2020 was 3.9% (range: -8.2 to 2.4). The greatest reductions were observed for inpatient admissions (median=-17.0%) and outpatient admissions (median=-7.1%), while antenatal, delivery care and immunisation services generally had smaller reductions (median from -2% to -6%). Eastern African countries had greater reductions than those in West Africa, and rural districts were slightly more affected than urban districts. The greatest drop in services was observed for March-June 2020 for general services, when the response was strongest as measured by a stringency index. CONCLUSION: The district health facility reports provide a solid basis for trend assessment after extensive data quality assessment and adjustment. Even the modest negative impact on service utilisation observed in most countries will require major efforts, supported by the international partners, to maintain progress towards the SDG health targets by 2030.

Gender disparities and associated factors to intention to getting a second dose of COVID-19 AstraZeneca vaccine among adult populations in selected facilities of Lusaka, Zambia.

As COVID-19 vaccines are becoming more available, there is also a growing need to understand the population receiving the doses, existing inequalities and the intention to getting the second vaccine dose among the populations that receive the vaccines. We evaluated gender inequalities and intention to uptake of the second dose of COVID-19 AstraZeneca vaccine among adult populations in selected urban facilities of Lusaka, Zambia. A cross-sectional study design was conducted between May and June 2021 among adults who received AstraZeneca vaccine from three selected urban facilities of Lusaka, Zambia. Phone-based interviews were conducted 6 weeks after the first dose of the vaccine. Descriptive analysis and mixed-effect logistic regression were done using STATA version 16.2. Of the 1321 adults who had received AstraZeneca vaccine, 868 respondents completed the questionnaire. About, 47% (408/868) were females and 53% (460/868) were males. Median age in the study was 40 years. Majority of males were educated (54%) and employed (57%). Furthermore, majority of females that got the first dose of AstraZeneca reported experiencing side effects (76.98%) compared to males (64.24%). Among study participants, 93.7% intended to receive the AstraZeneca vaccine, of whom 46.7% (380/814) were females and 52.9% (434/814) were males. Majority of participants that did not intend to get a second dose were not married (55.56%). Only age (AOR, 1.05; 95% CI, 1.02-1.08) predicted intention to getting a second dose of AstraZeneca vaccine. We found important gender-dependent differences in the side effects reported by females that received the first dose of Astra Zeneca. Finding that intention to get the second dose of the vaccine increased with age suggests a need for enhancing COVID-19 vaccination programmes targeting young people and a need for further research to identify specific adverse effects of COVID-19 Astra Zeneca vaccines.

Access barriers to maternal healthcare services in selected hard-to-reach areas of Zambia: a mixed methods design.

INTRODUCTION: poor access to maternal health services is a one of the major contributing factors to maternal deaths in low-resource settings, and understanding access barriers to maternal services is an important step for targeting interventions aimed at promoting institutional delivery and improving maternal health. This study explored access barriers to maternal and antenatal services in Kaputa and Ngabwe; two of Zambia´s rural and hard-to-reach districts. METHODS: a concurrent mixed methods approach was therefore, undertaken to exploring three access dimensions, namely availability, affordability and acceptability, in the two districts. Structured interviews were conducted among 190 eligible women in both districts, while key informant interviews, in-depth interviews and focus group discussions were conducted for the qualitative component. RESULTS: the study found that respondents were happy with facilities´ opening and closing times in both districts. By comparison, however, women in Ngabwe spent significantly more time traveling to facilities than those in Kaputa, with bad roads and transport challenges cited as factors affecting service use. The requirement to have a traditional birth attendant (TBA) accompany a woman when going to deliver from the facility, and paying these TBAs, was a notable access barrier. Generally, services seemed to be more acceptable in Kaputa than in Ngabwe, though both districts complained about long queues, being delivered by male health workers and having delivery rooms next to male wards. CONCLUSION: based on the indicators of access used in this study, maternal health services seemed to be more accessible in Kaputa compared to Ngabwe.

Factors shaping the implementation of the SAFE strategy for trachoma using the Consolidated Framework for Implementation Research: a systematic review.

BACKGROUND: The SAFE strategy (surgery for trichiasis, antibiotics for active infection, facial cleanliness and environmental improvement) is the World Health Organization (WHO) recommended guideline for the elimination of blindness by trachoma by the year 2020. OBJECTIVE: While evaluations on the implementation of the SAFE strategy have been done, systematic reviews on the factors that have shaped implementation are lacking. This review sought to identify these factors. METHODS: We searched PUBMED, Google Scholar, CINAHL and Cochrane Collaboration to identify studies that had implemented SAFE interventions. The Consolidated Framework for Implementation Research (CFIR) guided development of the data extraction guide and data analysis. RESULTS: One hundred and thirty-seven studies were identified and only 10 papers fulfilled the eligibility criteria. Characteristics of the innovation - such as adaptation of the SAFE interventions to suit the setting and observability of positive health outcomes from pilots - increased local adoption. Characteristics of outer setting - which included strong multisectoral collaboration - were found to enhance implementation through the provision of resources necessary for programme activities. When community needs and resources were unaccounted for there was poor compatibility with local settings. Characteristics of the inner setting - such as poor staffing, high labour turnovers and lack of ongoing training - affected health workers' implementation behaviour. Implementation climate within provider organisations was shaped by availability of resources. Characteristics of individuals - which included low knowledge levels - affected the acceptability of SAFE programmes; however, early adopters could be used as change agents. Finally, the use of engagement strategies tailored towards promoting community participation and stakeholder involvement during the implementation process facilitated adoption process. CONCLUSION: We found CFIR to be a robust framework capable of identifying different implementation determinants in low resource settings. However, there is a need for more research on the organisational, provider and implementation process related factors for trachoma as most studies focused on the outer setting.

Acceptability of option B+ among HIV positive women receiving antenatal and postnatal care services in selected health centre's in Lusaka.

BACKGROUND: In 2013, Zambia accepted the immediate operationalization of Option B+, a policy used to try and eliminate mother to child transmission. This policy requires all HIV-positive pregnant and breastfeeding women to initiate antiretroviral treatment for life regardless of CD4 count. However, not all HIV positive women accept treatment for life. This study aimed to investigate acceptability of lifelong ART (Option B+) among HIV positive women receiving antenatal and postnatal services at the university teaching hospital and Lusaka urban city clinics. METHODS: This was a cross sectional study conducted in November, 2016 to March 2017. The study population comprised of HIV positive women in their reproductive age (15-49 years). A Structured questionnaire was used to collect data in a face to face interview with the participants. Data was entered in EpiData version 3.1 and analysed using Stata version 13. Multivariate logistic regression analysis was performed to determine predictors of acceptability. RESULTS: Overall, 427 women participated in this study. Their mean age was 30 years. Of the 427, over half (54%) had inadequate knowledge and about 30% of the women in the study still experience stigma and discrimination.63.2% of the women had good attitude towards Option B+ and overall, the majority (77.8%) were willing to accept antiretroviral therapy for life. Multivariate analysis showed that only women with good attitude were 9.4 times more likely to accept Option B+ than those with a bad attitude [OR: 9.4: 95%CI, 5.8-15.2)]. CONCLUSION: This study showed that in general, women accepted initiation of Option B+. However, there is still a gap in the level of knowledge of Option B+ as well as stigma and discrimination in some communities, hence there is need to intensify programs that are aimed at educating the community on the importance of ART for life, combat stigma and discrimination and consequently promote acceptability of Option B+.

Effectiveness of a girls' empowerment programme on early childbearing, marriage and school dropout among adolescent girls in rural Zambia: study protocol for a cluster randomized trial.

BACKGROUND: Adolescent pregnancies pose a risk to the young mothers and their babies. In Zambia, 35% of young girls in rural areas have given birth by the age of 18 years. Pregnancy rates are particularly high among out-of-school girls. Poverty, low enrolment in secondary school, myths and community norms all contribute to early childbearing. This protocol describes a trial aiming to measure the effect on early childbearing rates in a rural Zambian context of (1) economic support to girls and their families, and (2) combining economic support with a community intervention to enhance knowledge about sexual and reproductive health and supportive community norms. METHODS/DESIGN: This cluster randomized controlled trial (CRCT) will have three arms. The clusters are rural schools with surrounding communities. Approximately 4900 girls in grade 7 in 2016 will be recruited from 157 schools in 12 districts. In one intervention arm, participating girls and their guardians will be offered cash transfers and payment of school fees. In the second intervention arm, there will be both economic support and a community intervention. The interventions will be implemented for approximately 2 years. The final survey will be 4.5 years after recruitment. The primary outcomes will be "incidence of births within 8 months of the end of the intervention period", "incidence of births before girls' 18th birthday" and "proportion of girls who sit for the grade 9 exam". Final survey interviewers will be unaware of the intervention status of respondents. Analysis will be by intention-to-treat and adjusted for cluster design and confounders. Qualitative process evaluation will be conducted. DISCUSSION: This is the first CRCT to measure the effect of combining economic support with a community intervention to prevent adolescent childbearing in a low- or middle-income country. We have designed a programme that will be sustainable and feasible to scale up. The findings will be relevant for programmes for adolescent reproductive health in Zambia and similar contexts. TRIAL REGISTRATION: ISRCTN registry: ISRCTN12727868 , (4 March 2016).

Higher Educational Attainment Associated with Optimal Antenatal Care Visits among Childbearing Women in Zambia.

OBJECTIVE: Attendance of at least four antenatal care (ANC) visits over the period of pregnancy has been accepted by World Health Organization to comprise the optimal and adequate standard of ANC because of its positive association with good maternal and neonatal outcomes during the prenatal period. Despite free ANC being provided, many pregnant women have been found not to meet this minimum number of ANC visits in Zambia. We investigated if educational attainment is associated with optimal ANC visits among childbearing women in Zambia. METHODS: Data stem from the 2007 Zambia Demographic and Health Survey for women, aged 15-49 years, who reported ever having been pregnant in the 5 years preceding the survey. The linked data comprised sociodemographic and other obstetrical data, which were cleaned, recoded, and analyzed using STATA version 12 (Stata Corporation, College Station, TX, USA). Multivariate logistic regression was used to examine the association of educational attainment and other background variables. RESULTS: Women who had higher education level were more likely to attend at least four ANC visits compared to those with no education (AOR 2.8, 95% CI 1.51-5.15; p = 0.001); this was especially true in the urban areas. In addition, women with partners with higher education level were also more likely to have optimal ANC attendance (OR 2.0, 95% CI 1.3-3.1; p = 0.002). CONCLUSION: Educational attainment-associated differentials found to be linked with optimal ANC attendance in this population suggests that access to health care is still driven by inequity-related dynamics and imbalances. Given that inequity stresses are heaviest in the uneducated and probably rural and poor groups, interventions should aim to reach this group. SIGNIFICANCE: The study results will help program managers to increase access to ANC services and direct interventional efforts towards the affected subpopulations, such as the young, uneducated, and rural women. Furthermore, results will help promote maternal health education and advise policy makers and program implementers.

Factors associated with late antenatal care booking: population based observations from the 2007 Zambia demographic and health survey.

INTRODUCTION: In spite of the extreme importance of an early antenatal care visit, more than 50% of Zambian pregnant women book for antenatal care late. We aimed to determine factors associated with late antenatal care booking in Zambia. METHODS: Data stem from the 2007 Zambia Demographic and Health Survey where information on socio-demographic, social-economic, obstetrical characteristics and timing of the first antenatal visit were extracted on all women aged 15 to 49 years. A weighted survey analysis using STATA version 12 was applied. Firstly, we explored proportions of ANC booking at 0-3 months, 4-5 month and 6-9 months. Secondly, we investigated the association between predictor variables and late antenatal care booking using univariate and multivariate logistic regression. RESULTS: Overall (n= 3979), the proportion of late ANC booking (booking between 4th to 9th month) was 81% disaggregated as 56% and 19% at 4 to 5 months and 6 to 9 months respectively. Women who wanted their last child later were more likely to book late than those with wanted pregnancies then (AOR: 1.35 95% CI 1.10-1.66). Women with higher education were 55% less likely to book for ANC late compared to women with no education (AOR: 0.45 95%CI: 0.27-0.74). Women aged 20-34 years were 30% more likely to book earlier than women younger than 20 years (AOR: 0.69 95% CI 0.50-0.97). CONCLUSION: We found high proportion of late ANC booking associated with presence of unplanned or unwanted pregnancies in this population. The concentration of this problem in lower or no education groups may be an illustration of existing inequalities which might further explain limitations in health promotion messages meant to mitigate this challenge. There is thus urgent need to re-pack health promotion message to specifically target this and related poor groups.