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Background: Globally, over half of maternal deaths are related to pregnancy-related complications. Provision of a continuum of care during pregnancy, childbirth and the postnatal period results in reduced maternal and neonatal morbidity and mortality. Hence this study determined the prevalence of the continuum of care and its determinants among women in Zambia. Methods: We used weighted data from the Zambian Demographic and Health Survey (ZDHS) of 2018 for 7325 women aged 15 to 49 years. Multistage stratified sampling was used to select study participants. Complete continuum of care was considered when a woman had; at least four antenatal care (ANC) contacts, utilized a health facility for childbirth and had at least one postnatal check-up within six weeks. We conducted multivariable logistic regression to explore continuum of care in Zambia. All our analyses were done using SPSS version 25. Results: Of the 7,325 women, 38.0% (2787/7325) (95% confidence interval (CI): 36.9-39.1) had complete continuum of maternal healthcare. Women who had attained tertiary level of education (adjusted odds ratio (AOR): 1.93, 95% CI: 1.09-3.42) and whose partners had also attained tertiary level of education (AOR: 2.58, 95% CI: 1.54-4.32) were more likely to utilize the whole continuum of care compared to those who had no education. Women who initiated ANC after the first trimester (AOR: 0.46, 95% CI: 0.39-0.53) were less likely to utilize the whole continuum of care compared to those who initiated in the first semester. Women with exposure to radio (AOR: 1.58, 95% CI: 1.27-1.96) were more likely to utilize the whole continuum of care compared to those who were not exposed to radio. Women residing in the Western province were less likely to utilize the entire continuum of care compared to those in the other nine provinces. Conclusion: Level of education of the women and of their partners, early timing of ANC initiation, residing in other provinces other than the Western province, and exposure to information through radio were positively associated with utilization of the entire continuum of care. Improving literacy levels and promoting maternity services through radio may improve the level of utilization of maternity services.
The Zambian Demographic and Health Survey (ZDHS) was a nationally representative cross-sectional study conducted using validated questionnaires between 18th July 2018 and 24th January 2019 [22]. It is a periodic survey that is carried out every five years as part of the MEASURE DHS global survey and collects information on demographic, health, and nutrition indicators. The survey used stratified two-stage cluster sampling design that resulted in the random selection of a representative sample of 13,625 households [22]. The first stage involved 545 cluster (sample points) selection which consisted of enumeration areas using a sampling frame that was used during the 2010 census of population and housing (CPH) [22]. Zambia is divided into 10 provinces which are further divided into districts, constituencies, and wards [22]. Wards, the smallest administrative units, were further divided during the 2010 CPH into census supervisory areas which were later divided into enumeration areas. Enumeration areas were selected with a probability proportional to their size within each sampling stratum. Systematic sampling was applied to select households in the second stage. A detailed explanation of the sampling process is available in the ZDHS 2018 report [22]. Women aged 15-49 years who were either permanent residents or visitors who had stayed in the selected households the night before the survey were eligible for interviews and a total of 13,683 women being interviewed. Four questionnaires were used in the survey and our study used data that was obtained using validated women’s and household questionnaires. Our secondary analysis included women of reproductive age (15-49 years) who had given birth in the last five years preceding the survey that yielded a weighted sample of 7,325 women. Written informed consent was provided by all participants of the survey. Written permission to access the whole ZDHS database was obtained through DHS program website at this address https://dhsprogram.com/ Complete continuum of maternal healthcare is the outcome variable, Complete continuum of care was constructed into binary variable with complete coded as 1 and incomplete coded as 0. Complete continuum of maternal healthcare was considered when a woman reported having had: Continuum of care was considered discontinued if the woman skipped any of the steps above [4, 24, 25]. Additionally, having four or more ANC contacts was considered as continued care during pregnancy while utilizing health facility during childbirth with four or more ANC contacts was considered as continued care during delivery. Independent variables were categorized into women, partners’ and household characteristics which were chosen basing on previous studies [26–28] and availability in the ZDHS database. This included the partner’s highest level of education (no education, primary, secondary, and tertiary). Wealth index of household (categorized into quintiles: richest, richer, middle poorer and poorest), type of residence (urban and rural), and province/region that included the official 10 provinces of Zambia. Wealth index is a measure of relative household economic status and was calculated by DHS from information on household asset ownership using principal component analysis [22, 29]. Age (15-24, 25-34, and 35-49), level of education (no education, primary, secondary, and tertiary), exposure to newspapers/magazines, radio and TV (yes and no), preceding birth interval ( less than 24 months and 24 months and above), parity (one, two and three or more), age at firth birth (less than 20 and 20 and above), ANC timing (first trimester and second or third trimester), marital status (married and not married), age at first sex (less than 18 and 18 and above), working status (working and not working) and decision making for seeking healthcare (involved and not involved). We used the SPSS analytic software version 25.0 complex samples package. Weighted data was used to account for the unequal probability sampling in different strata. Frequency distributions were used to describe the background characteristics of the women. Bivariable and multivariable logistic regression analyses were conducted to identify the association among various independent variables at all the three levels of continuum of care. Independent variables found significant at p-value less than 0.25 in the bivariable analysis were included in the multivariable models. We presented two models; the primary model, which adjusted for only factors without missing data, and the secondary model, which included all the factors (with and without missing data) and adjusted for those with missing data. The secondary model included residence, provinces, exposure to mass media, working and marital status, level of education, wealth index, timing of ANC initiation, preceding birth interval, age at first sexual intercourse and first birth and healthcare seeking decision making. Adjusted odds ratios (AOR), 95% confidence intervals (CI) and p-values were calculated with statistical significance level set at p-value < 0.05. Sensitivity analysis was done by analyzing continued care during pregnancy with having eight or more ANC contacts as the outcome.
