High coverage, persistent gaps: quality of Antenatal Care and its determinants in Zambia based on the 2024 Demographic and Health Survey.

Technical Summary: High coverage, persistent gaps: quality of Antenatal Care and its determinants in Zambia based on the 2024 Demographic and Health Survey

Problem Statement
While Zambia has achieved high rates of basic antenatal care (ANC) attendance, there is a critical lack of comprehensive national evidence regarding the clinical content and quality of these services. Previous assessments in Zambia relied on outdated data (2005–2007) or focused primarily on utilization metrics (visit counts) rather than the effective coverage of WHO-recommended interventions. Despite the World Health Organization's 2016 shift from a minimum of four visits to a model of at least eight contacts emphasizing a comprehensive package of care, it remains unclear how well current services in Zambia align with these updated guidelines. This study addresses a 17-year data gap by evaluating the current state of ANC quality and identifying the sociodemographic and health-system determinants associated with it.

Methodology
This study conducted a cross-sectional analysis using secondary data from the 2024 Zambia Demographic and Health Survey (ZDHS). The final analytic sample consisted of 4,829 women aged 15–49 who had a live birth in the five years preceding the survey and provided complete information on ANC components.

• Outcome Measure: The primary outcome was a composite ANC quality index comprising 15 equally weighted, WHO-recommended components across four domains:
  1. Clinical Assessment: Weight measurement, blood pressure recording, urine testing, blood testing, and fetal heart auscultation.
  2. Counseling/Screening: Advice on diet, breastfeeding promotion, health/diet/physical activity guidance, vaginal bleeding screening, and HIV counseling/testing.
  3. Preventive Interventions: Iron/folate supplementation, deworming, and receipt of ≥2 doses of sulfadoxine-pyrimethamine (IPTp-SP).
  4. Utilization: Initiation of care in the first trimester and attendance of at least four visits.
     Note: Counseling on danger signs was excluded due to extensive missing data.
• Scoring: A continuous score (0–15) was calculated. "Adequate ANC quality" was defined as receiving ≥12 components (80% threshold).
• Statistical Analysis: Survey-weighted Poisson regression was used to estimate adjusted incidence rate ratios (aIRRs) for the count of ANC components received. Sensitivity analyses were performed using logistic regression with alternative adequacy thresholds (≥60%, ≥80%, and ≥90%).

Key Results

• Overall Quality: The mean ANC quality score was 12.5 out of 15 (95% CI: 12.4–12.6). Approximately 78.5% of women received adequate ANC (≥12 components).
• Component Coverage: Individual clinical and counseling indicators showed high coverage, generally exceeding 90% (e.g., weight measurement, blood pressure, HIV testing). Preventive interventions were also high for iron/folate (93.6%) and basic antimalarial prophylaxis (94.2%).
• Critical Gaps: Significant disparities existed in utilization metrics. Only 47.2% of women initiated care in the first trimester, and a mere 4.8% achieved the WHO-recommended ≥8 ANC contacts.
• Determinants of Quality:
  • Maternal Education: The strongest and most stable predictor. Women with higher education had an 8.0% higher expected quality score compared to those with no education (aIRR = 1.080). A clear dose-response relationship was observed.
  • Pregnancy Intention: Unwanted pregnancies (specifically those where women wanted no more children) were significantly associated with lower quality scores (aIRR = 0.970).
  • Regional Disparities: Significant geographic inequities persisted. Women in Western (aIRR = 0.923) and North-Western (aIRR = 0.966) provinces had significantly lower quality scores compared to the Central province. Conversely, Eastern and Luapula provinces showed higher scores.
  • Other Factors: Living with a partner, having a preceding birth interval of ≥48 months, and possessing commercially purchased health insurance were associated with higher quality. The absence of a formal ANC provider was associated with drastically lower scores (aIRR = 0.041).
  • Attenuated Factors: While wealth and rural residence were significant in bivariate analysis, these associations were fully attenuated in the multivariable model, suggesting they operate through other mediators like education.

Significance and Claims
The authors claim that this study provides the first nationally representative evidence of ANC quality in Zambia using the 2024 ZDHS and updated WHO guidelines. The findings indicate that while Zambia has made substantial progress in the content of ANC (clinical assessments and preventive measures) compared to data from two decades ago, improvements in utilization (early initiation and frequency of visits) have not kept pace.

The paper concludes that maternal education is the primary driver of ANC quality, suggesting that investments in girls' education have downstream effects on maternal health outcomes. Furthermore, the persistence of regional disparities, particularly in Western and North-Western provinces, underscores the need for differentiated, targeted interventions rather than uniform national strategies. The study highlights that achieving universal quality ANC requires addressing structural barriers in underserved regions and integrating family planning services to mitigate the negative impact of unintended pregnancies on care quality.

Limitations
The authors acknowledge that the reliance on maternal self-reporting introduces potential recall bias. Additionally, the cross-sectional design precludes causal inference. The study could not verify the clinical utility of collected blood or urine samples, and missing data on specific counseling components (e.g., danger signs) necessitated their exclusion from the composite index.