Disparities in Facility Delivery Among Women Receiving Antenatal Care in Zambia: A DHS-Based Analysis

Abstract Background Facility-based delivery is a key intervention for reducing maternal and neonatal mortality. While antenatal care (ANC) attendance is high in Zambia, disparities in access to skilled delivery persist. This study examined the determinants of facility-based delivery among women who attended ANC, focusing on sociodemographic and health system factors. Method We conducted a cross-sectional analysis using data from the 2018 Zambia Demographic and Health Survey. The sample included women aged 15–49 who had a live birth in the five years preceding the survey and attended at least one ANC visit during their most recent pregnancy. The primary outcome was facility-based delivery. Multivariable logistic regression models, adjusted for survey design, were used to estimate associations between facility delivery and factors including wealth, education, residence, ANC utilization, perceived distance barriers, and media exposure. Results Among 4,630 ANC-attending women, 93.0% delivered in a health facility. In adjusted models, women in the richer wealth quintile had higher odds of facility delivery compared to the poorest (AOR: 2.19; 95% CI: 1.08–4.43; p=0.03). Surprisingly, women who attended four or more ANC visits were less likely to deliver in a health facility compared to those with fewer visits (AOR: 0.75; 95% CI: 0.59–0.96; p=0.02). Exposure to media showed a borderline positive association with facility-based delivery (AOR: 1.29; 95% CI: 1.00–1.66; p=0.05). No significant associations were observed for education level, rural residence, or parity. Conclusion Improving the quality and content of ANC is essential to strengthen the link between antenatal contact and facility-based delivery, particularly among economically disadvantaged women. Policies that incorporate birth preparedness counseling, offer transport or delivery incentives, and explore the role of media exposure as a tool for promoting safe delivery may help reduce access barriers and advance equity in skilled childbirth services in Zambia.