Continuum of maternity care in Zambia: a national representative survey

BMC Pregnancy and Childbirth, Volume 21, No. 1, Year 2021

Ukuhunyushwa

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.

I-AI Digest

Study Justification:

– Maternal deaths related to pregnancy-related complications are a significant global issue.
– Providing a continuum of care during pregnancy, childbirth, and the postnatal period can reduce maternal and neonatal morbidity and mortality.
– This study aimed to determine the prevalence of the continuum of care and its determinants among women in Zambia.

Study Highlights:

– The study used data from the Zambian Demographic and Health Survey (ZDHS) of 2018, which included 7,325 women aged 15 to 49 years.
– The prevalence of complete continuum of maternal healthcare was found to be 38.0%.
– Factors positively associated with utilization of the entire continuum of care included higher education levels of women and their partners, early initiation of antenatal care (ANC), exposure to information through radio, and residing in provinces other than the Western province.

Study Recommendations:

– Improving literacy levels among women and their partners can help increase the utilization of maternity services.
– Promoting maternity services through radio can also be an effective way to increase awareness and utilization of the continuum of care.
– Efforts should be made to ensure early initiation of ANC, as it was found to be positively associated with the utilization of the entire continuum of care.
– Attention should be given to the Western province, where women were found to be less likely to utilize the entire continuum of care, to identify and address any barriers to accessing maternity services.

Key Role Players:

– Ministry of Health: Responsible for implementing policies and programs related to maternal healthcare.
– Healthcare Providers: Including doctors, nurses, midwives, and other healthcare professionals involved in providing antenatal, childbirth, and postnatal care.
– Community Health Workers: Involved in educating and supporting women in accessing and utilizing maternity services.
– Non-Governmental Organizations (NGOs): Engaged in promoting maternal healthcare and providing support services to women.
– Media Organizations: Collaborating to disseminate information and raise awareness about the importance of the continuum of care.

Cost Items for Planning Recommendations:

– Educational Programs: Budget for developing and implementing literacy programs for women and their partners.
– Radio Campaigns: Allocation for producing and broadcasting radio advertisements and programs promoting maternity services.
– Training and Capacity Building: Funds for training healthcare providers and community health workers on best practices in maternal healthcare.
– Infrastructure and Equipment: Investment in healthcare facilities, including equipment and supplies needed for antenatal, childbirth, and postnatal care.
– Monitoring and Evaluation: Resources for monitoring the implementation and impact of the recommendations, including data collection and analysis.
Please note that the cost items provided are general categories and not actual cost estimates. The actual budget would depend on the specific context and implementation plan.

Amandla Obufakazi

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a nationally representative survey and includes a large sample size. The study uses multivariable logistic regression to explore the continuum of care in Zambia. However, the abstract does not provide information on the specific methodology used in the survey or the validity and reliability of the questionnaires. To improve the strength of the evidence, the abstract could include more details on the sampling process, the validation of the questionnaires, and any limitations of the study.

Abstract

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.

Izinto zokwakha

Emisha

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Solutions: Develop mobile applications or SMS-based systems to provide pregnant women with information and reminders about antenatal care visits, postnatal check-ups, and childbirth in health facilities. These technologies can help overcome barriers such as lack of awareness and transportation.

2. Community-Based Maternal Health Workers: Train and deploy community health workers who can provide essential maternal health services, including antenatal care, postnatal care, and education on safe childbirth practices. This approach can improve access to care, particularly in remote or underserved areas.

3. Telemedicine: Establish telemedicine services that allow pregnant women to consult with healthcare providers remotely, reducing the need for travel and increasing access to specialized care. This can be particularly beneficial for women in rural areas who may have limited access to healthcare facilities.

4. Maternity Waiting Homes: Set up maternity waiting homes near health facilities to accommodate pregnant women who live far away. These homes provide a safe and comfortable place for women to stay before and after childbirth, ensuring timely access to skilled care.

5. Financial Incentives: Implement financial incentive programs to encourage pregnant women to seek and complete the continuum of care. This could include cash transfers, vouchers, or insurance schemes that cover the costs of maternal health services.

6. Quality Improvement Initiatives: Implement quality improvement initiatives in health facilities to ensure that pregnant women receive high-quality care throughout the continuum. This can involve training healthcare providers, improving infrastructure and equipment, and implementing standardized protocols.

7. Public Awareness Campaigns: Launch public awareness campaigns to educate communities about the importance of maternal health and the availability of services. These campaigns can address cultural beliefs and misconceptions, promoting the utilization of maternal health services.

It is important to note that the specific context and needs of Zambia should be taken into consideration when implementing these innovations.

AI Innovations Description

Based on the information provided, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Improve literacy levels: The study found that women with higher levels of education and whose partners also had higher levels of education were more likely to utilize the entire continuum of care. Therefore, implementing programs and initiatives that focus on improving literacy levels among women and their partners can help increase access to maternal health services.

2. Promote maternity services through radio: The study also found that women who had exposure to information through radio were more likely to utilize the entire continuum of care. Utilizing radio as a medium to disseminate information about the importance of maternal health services, available resources, and the benefits of seeking care can help reach a wider audience and improve access to maternal health services.

By implementing these recommendations, it is possible to improve access to maternal health services and reduce maternal and neonatal morbidity and mortality in Zambia.

AI Innovations Methodology

To improve access to maternal health in Zambia, the following innovations could be considered:

1. Mobile Health (mHealth) Applications: Develop and implement mobile health applications that provide pregnant women with information, reminders, and access to healthcare services. These apps can provide guidance on antenatal care, postnatal care, and childbirth, as well as facilitate communication with healthcare providers.

2. Telemedicine Services: Establish telemedicine services that allow pregnant women in remote areas to consult with healthcare professionals through video calls or phone calls. This can help address the issue of limited access to healthcare facilities and specialists.

3. Community Health Workers: Train and deploy community health workers to provide maternal health education, conduct antenatal and postnatal visits, and facilitate referrals to healthcare facilities. These workers can play a crucial role in reaching women in underserved areas and ensuring continuity of care.

4. Maternity Waiting Homes: Establish maternity waiting homes near healthcare facilities to accommodate pregnant women who live far away. These homes can provide a safe and comfortable environment for women to stay before and after childbirth, ensuring timely access to healthcare services.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify key indicators that reflect access to maternal health, such as the percentage of women receiving adequate antenatal care, the percentage of women delivering in healthcare facilities, and the percentage of women receiving postnatal check-ups.

2. Collect baseline data: Gather data on the current status of these indicators in the target population. This can be done through surveys, interviews, or analysis of existing data sources such as the Zambian Demographic and Health Survey.

3. Develop a simulation model: Create a mathematical or statistical model that simulates the impact of the recommended innovations on the identified indicators. This model should take into account factors such as population size, geographical distribution, and existing healthcare infrastructure.

4. Input intervention parameters: Define the parameters of the recommended innovations, such as the number of mobile health app users, the coverage of telemedicine services, the number of community health workers deployed, and the capacity of maternity waiting homes.

5. Run simulations: Use the simulation model to project the potential impact of the recommended innovations on the identified indicators. This can be done by varying the intervention parameters and observing the resulting changes in the indicators.

6. Analyze results: Analyze the simulation results to assess the potential effectiveness of the recommended innovations in improving access to maternal health. Identify the most promising interventions and their expected impact on the indicators.

7. Refine and validate the model: Continuously refine and validate the simulation model based on new data and feedback from stakeholders. This will help improve the accuracy and reliability of the simulations.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of different innovations on improving access to maternal health and make informed decisions on which interventions to prioritize and implement.

Umbhali

Dima Health

Statistics:

Citations: 18

Identifiers:

DOI: 10.1186/s12884-021-04080-1

Research Areas:

Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Zambia

Study Design:

Case-Control Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female

Yabelana ngalokhu: