title: Predictors of Antenatal Care, Skilled Birth Attendance, and Postnatal Care Utilization among the Remote and Poorest Rural Communities of Zambia: A Multilevel Analysis.
abstract: OBJECTIVE
  Optimal utilization of maternal health-care services is associated with reduction of mortality and morbidity for both mothers and their neonates. However, deficiencies and disparity in the use of key maternal health services within most developing countries still persist. We examined patterns and predictors associated with the utilization of specific indicators for maternal health services among mothers living in the poorest and remote district populations of Zambia.
  
  
  METHODS
  A cross-sectional baseline household survey was conducted in May 2012. A total of 551 mothers with children between the ages 0 and 5 months were sampled from 29 catchment areas in four rural and remote districts of Zambia using the lot quality assurance sampling method. Using multilevel modeling, we accounted for individual- and community-level factors associated with utilization of maternal health-care services, with a focus on antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC).
  
  
  RESULTS
  Utilization rates of focused ANC, SBA, and PNC within 48 h were 30, 37, and 28%, respectively. The mother's ability to take an HIV test and receiving test results and uptake of intermittent preventive treatment for malaria were positive predictors of focused ANC. Receiving ANC at least once from skilled personnel was a significant predictor of SBA and PNC within 48 h after delivery. Women who live in centralized rural areas were more likely to use SBA than those living in remote rural areas.
  
  
  CONCLUSIONS
  Utilization of maternal health services by mothers living among the remote and poor marginalized populations of Zambia is much lower than the national averages. Finding that women that receive ANC once from a skilled attendant among the remote and poorest populations are more likely to have a SBA and PNC, suggests the importance of contact with a skilled health worker even if it is just once, in influencing use of services. Therefore, it appears that in order for women in these marginalized communities to benefit from SBA and PNC, it is important for them to have at least one ANC provided by a skilled personnel, rather than non-skilled health-care providers.
authors.affiliation: School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa; Department of Public Health, School of Medicine, University of Zambia, Lusaka, Zambia.
authors.forename: Choolwe
authors.initials: C
authors.lastname: Jacobs
authors.affiliation: School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa; Africa Centre for Population Health, Mtubatuba, South Africa.
authors.forename: Mosa
authors.initials: M
authors.lastname: Moshabela
authors.affiliation: UNICEF , Lusaka , Zambia.
authors.forename: Sitali
authors.initials: S
authors.lastname: Maswenyeho
authors.affiliation: UNICEF , Lusaka , Zambia.
authors.forename: Nildah
authors.initials: N
authors.lastname: Lambo
authors.affiliation: Department of Public Health, School of Medicine, University of Zambia , Lusaka , Zambia.
authors.forename: Charles
authors.initials: C
authors.lastname: Michelo
keywords: antenatal care; focused antenatal care; maternal health-care utilization; postnatal care; skilled birth attendance