Quality of antenatal care in Zambia: a national assessment

Abstract

Background: Antenatal care (ANC) is one of the recommended interventions to reduce maternal and neonatal mortality. Yet in most Sub-Saharan African countries, high rates of ANC coverage coexist with high maternal and neonatal mortality. This disconnect has fueled calls to focus on the quality of ANC services. However, little conceptual or empirical work exists on the measurement of ANC quality at health facilities in low-income countries. We developed a classification tool and assessed the level of ANC service provision at health facilities in Zambia on a national scale and compared this to the quality of ANC received by expectant mothers.

Methods: We analysed two national datasets with detailed antenatal provider and user information, the 2005 Zambia Health Facility Census and the 2007 Zambia Demographic and Health Survey (DHS), to describe the level of ANC service provision at 1,299 antenatal facilities in 2005 and the quality of ANC received by 4,148 mothers between 2002 and 2007.

Results: We found that only 45 antenatal facilities (3%) fulfilled our developed criteria for optimum ANC service, while 47% of facilities provided adequate service, and the remaining 50% offered inadequate service. Although 94% of mothers reported at least one ANC visit with a skilled health worker and 60% attended at least four visits, only 29% of mothers received good quality ANC, and only 8% of mothers received good quality ANC and attended in the first trimester.

Conclusions: DHS data can be used to monitor "effective ANC coverage" which can be far below ANC coverage as estimated by current indicators. This "quality gap" indicates missed opportunities at ANC for delivering effective interventions. Evaluating the level of ANC provision at health facilities is an efficient way to detect where deficiencies are located in the system and could serve as a monitoring tool to evaluate country progress.

Figure 1

Core ANC service provision attributes at Zambian ANC facilities (n=1299). The percentage of Zambian ANC facilities fulfilling four core antenatal service provision attributes is shown separately. Most facilities offer ANC 1–2 days per week and provide 3–4 ANC functions, both criteria for adequate level of service provision. However, nearly half of all ANC facilities do not offer any ANC screening tests which was considered inadequate. For each attribute, less than 40% of facilities fulfilled the criteria for optimum level of ANC provision.

Figure 2

Cumulative presence of minimum requirements for levels of ANC provision at Zambian health facilities. This figure illustrates the effect of combining various attributes required for optimum level (A) or adequate level (B) of service provision. Of 1299 ANC facilities, 1101 also offered delivery services, considered important for the continuum of care. Out of these, 357 employed at least 3 skilled health workers (SHW) and 156 also had services 3 or more days a week. Only 45 also offered 5 ANC functions and at least 3 screening tests and were thus categorised as optimum level of ANC provision (A). Nearly all ANC facilities opened once a week and 1142 also had 1 skilled health worker. Of these, 1032 offered at least 3 ANC functions and 653 also offered at least one screening test, thus fulfilling all minimum requirements for adequate level of ANC provision (B). Uprot= Urine protein test.

Figure 3

Level of service provision at Zambian ANC facilities (n=1299), by facility type. Hospitals offered mainly optimum or adequate ANC, as did urban health centres. More than half of rural health centres, the main ANC providers, and of health posts provided an inadequate level of service.

Figure 4

Quality of ANC received by Zambian mothers (n=4148). Although 94% of mothers had at least one ANC visit with a skilled health worker and 58% had at least four visits – the indicators commonly tracked -, only 29% of mothers in Zambia received good quality ANC and only 8% received good quality ANC and attended in the first trimester.