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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.
The 2007 Zambia Demographic and Health Survey (ZDHS), a nationally representative survey of 7146 women aged 15–49 years and 6500 men aged 15–59 years. The ZDHS used a two-stage stratified sampling. Clusters were selected with probability proportional to size at first stage, and equal probability systematic sampling was applied at second stage. Details of the ZDHS methodology are recorded in the reports (24, 25). The ANC attendance study was based on data that stem from the 2007 ZDHS Women’s Questionnaire. Women who reported having ever been pregnant and ever attended ANC defined the sampling frame for the study (n = 7146). From the 7146 women aged 15–49 years who were captured in the survey, 4099 pregnant women who reported attending ANC in the ZDHS (24) comprised the de facto eligible sample. Among the records of the de facto eligible sample, the information recorded and extracted included the women’s demographic characteristics, their full birth history, and history of ANC for the most recent birth within a 5-year period preceding the survey, including socioeconomic status and educational attainment. Both descriptive and inferential statistics were used to examine if educational attainment was associated with ANC attendance. In the first step, univariate analysis (initially by cross tabulations by Pearson’s chi-squared test) and later multiple logistic regression, incorporating survey weights, were performed to examine if educational attainment is associated with ANC attendance and also to control for any confounding or interaction. A p value of <0.05 was taken as significant with 95% confidence intervals. The distribution of age as a continuous variable conformed to normality, as assessed by probability plots. Interactions were looked for using the likelihood ratio test, and when identified, they were only reported if considered important in estimating the influence of the background factors. Model diagnostics were done using the Hosmer–Lemeshow goodness-of-fit. The variables in the multivariate logistic regression model were age (grouped and continuous), residence (urban or rural), education, marital status, wealth index, distance to facility, financial constraints, decision-making, intention of pregnancy, timing of first ANC booking, partner age, and educational level as well as maternal and delivery information. The ZDHS survey obtained ethical approval from the Tropical Diseases Research Centre (TDRC) in Ndola, Zambia and the US Centers for Disease Control and Prevention (CDC) Atlanta research ethics review board (24). Participation in the survey was based on informed and voluntary consent. The reanalysis of the data reported in this study did not infringe on participants’ privacy and was judged by ourselves to pose minimal to no risk, since these data were already anonymized, approved, and made available for public use. In addition to the above ethical measures, we sought a waiver from Excellency in Research Ethics and Science (ERES) Committee that granted us permission to conduct the study on factors influencing maternal and neonatal mortality based on the 2007 ZDHS (Ref. no. 2014-May-023).
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