Introduction

Sub-Saharan Africa (SSA) has the highest global burden of maternal deaths and stillbirths [1,2]. Lesotho has one of the highest maternal mortality ratios globally, with 478 deaths per 100,000 live births [3] and 39 infant deaths per 1000 [4]. Obstetric hemorrhage, hypertensive disorders, and complications of unsafe abortion are the leading causes [5].

Antenatal care (ANC) is defined as skilled healthcare provided to women during pregnancy [6]. ANC is the cornerstone of pregnancy-related complications detection, treatment, and prevention through counseling and advice, maternal and fetal assessments, vaccination, and micronutrient supplementation [7,8].

Lesotho has made strides to improve quality ANC coverage through reforms, including the 2014 National Health Reform, village health worker expansion, and stronger ANC-HIV integration [3,5]. As a result, the percentage of women attending one and four ANC contacts was 93 and 82 respectively. Despite this remarkable achievement in contact coverage, the expected reductions in maternal and neonatal mortality have not been achieved [4]. This discrepancy highlights the critical quality-contact gap, which can widen due to women starting ANC late, not attending the recommended number of contacts, receiving incomplete care content, scarcity of skilled providers, and inaccessible care because of geographic barriers [9–13]. Measuring the current ANCq coverage is a critical part of monitoring and evaluation of Lesotho’s move towards achieving quality ANC coverage.

However, traditional ANC coverage metrics cannot measure the actual adequacy and quality of ANC coverage because they rely on the mere number of ANC contacts [14,15]. These binary measures of “adequate” ANC mask quality gradations, exclude women with no ANC contacts, and are restricted to those with at least one visit, limiting their usefulness for tracking inequities and population-level coverage [16,17].

Content-qualified antenatal care (ANCq) addresses this limitation by measuring both service contact (initiation timing and number of visits) and content (receipt of core ANC components from a skilled provider) [17]. In this study, ANCq is a composite score ranging from 0 to 16, where higher scores indicate coverage [16,17]. ANCq has been validated as a reliable indicator of ANC service coverage in low- and middle-income countries [17,18].

Despite Lesotho’s health reforms, including the 2014 National Health Reform, village health worker expansion, and stronger ANC-HIV integration, the content and quality of care remains uneven [19,20]. The 2023−24 Lesotho Demographic and Health Survey (LDHS) provides data on indicators of ANC coverage at the national level (timing of initiation, number of contacts, provider skill, and essential services) [4,16,17]. To date, no study has examined ANCq coverage or its determinants in Lesotho using the most recent data. This study addresses this gap by assessing the level of ANCq coverage and identifying factors associated with higher ANCq categories among women who had their last birth within the two years preceding the survey.

Methods and materials

Results

Content-qualified antenatal care coverage in Lesotho

Overall, 28.2% (n = 313) of women fell into the low ANCq tertile (scores 0–12), 44.3% (n = 493) into the moderate tertile (score 13), and 27.5% (n = 306) into the high tertile (scores 14–16). Combining moderate and high categories, 71.8% of women achieved moderate or high ANCq coverage, indicating that a substantial minority (28.2%) experienced low coverage while the majority received a reasonable level of content-qualified care. The median ANCq score was 14 (interquartile range: 13–15), reflecting a skewed distribution with clustering at higher values.

Regarding service contact dimensions, 51% of women started ANC in the first trimester, 24% attended eight or more visits, while 93.2% received care from a skilled provider at least once. Individual content component coverage was generally high for blood pressure measurement and fetal heart rate assessment (95.2%) and for blood and urine sampling and fundal height measurement (94.9%). Lower coverage was observed for receipt of at least two doses of tetanus toxoid vaccination (59.2%), counseling on maternal diet (76.5%), and being asked about vaginal bleeding (78.2%) (Table 1).

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Table 1. Content-qualified antenatal care coverage dimensions in Lesotho (n = 1112).

https://doi.org/10.1371/journal.pone.0348679.t001

Background characteristics of the study participants

The median age of the participants was 25 years (interquartile range: 21–31). Most women were married or living with a partner (72.7%), were not currently employed (73.2%), and had attained secondary or higher education (73.3%). More than half (54.7%) reported using the internet almost every day in the past month. The majority of the respondents (61.2%) resided in rural areas, and 67.3% lived in communities with lower poverty levels (Table 2).

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Table 2. Distribution of receipt of content-qualified antenatal care by background characteristics of women in Lesotho (N = 1112).

https://doi.org/10.1371/journal.pone.0348679.t002

Determinants of content-qualified antenatal care coverage

Several factors were significantly associated with higher ANCq categories in the multivariable ordinal logistic regression analysis (Table 3).

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Table 3. Bi-variable and multivariable ordinal logistic regression analysis of factors associated with receiving content-qualified antenatal care in Lesotho 2023−24.

https://doi.org/10.1371/journal.pone.0348679.t003

Women who were married or living with a partner had 60% higher odds of being in a higher ANCq category than unmarried or unpartnered women (AOR 1.60, 95% CI: 1.19–2.16). Women with secondary education (AOR 2.05, 95% CI: 1.44–2.92) and higher education (AOR 1.90, 95% CI: 1.13–3.19) had higher odds than those with no or primary education.

Women who used the internet at least once per week had 61% higher odds than those who did not use the internet (AOR 1.61, 95% CI: 1.02–2.56). Women whose last pregnancy was wanted at the time of conception had nearly three times higher odds than those whose pregnancy was not wanted (AOR 2.87, 95% CI: 2.04–4.05).

Smaller household size (≤ 4 members) was associated with 36% higher odds (AOR 1.36, 95% CI: 1.04–1.78). At the community level, residence in clusters with a higher proportion of women who had completed secondary or higher education was associated with 38% higher odds (AOR, 1.38; 95% CI: 1.02–1.81) (Table 3).

Discussion

This study provides the first assessment of ANCq coverage and its determinants in Lesotho using the 2023–2024 DHS. Overall, 71.9% of women achieved moderate or high ANCq scores, with a median score of 14, indicating that the full package of recommended services is not universally received although ANC attendance is high.

The magnitude of ANCq coverage in Lesotho is relatively higher than that of earlier multi-country analyses from SSA and South Asia, which reported much lower proportions using narrower content indicators or stricter binary definitions of adequacy. For example, previous studies reported low adequate ANC coverage in SSA (3%) [23], Rwanda (8.9%) [28], Tanzania (43%) [29], India (13–32%) [30–32], and Bangladesh (18%) [33]. These discrepancies can be explained by differences in measurement approaches, survey instruments, and contextual factors.

ANCq coverage was measured using an ordered scoring system that captures variation across low, medium, and high levels rather than collapsing women into only “adequate” versus “inadequate” categories. In addition, the DHS-8 questionnaire includes a broader set of ANC content indicators and applies a shorter recall period than earlier DHS phases, which may improve reporting accuracy and increase observed ANCq coverage. Differences in the number, type, and accessibility of ANC services across countries also contribute to variation in ANCq coverage. For instance, this analysis included fundal height measurement, and Lesotho’s integrated HIV-ANC programs may have strengthened the delivery of comprehensive services compared with other SSA settings.

In contrast, many previous studies [28–33] defined ANCq coverage using strict binary (adequate vs. inadequate) criteria requiring fulfilment of all recommended contacts and services for adequate ANCq coverage. This binary definition also condenses the scores to two extremes.

Several factors, including current marital status, maternal education level, frequency of internet use, household size, wantedness of the last pregnancy, and community-level education, were significantly associated with ANCq coverage.

Marital status was significantly associated with women’s receiving of ANCq, with married or living in union having 60% higher odds of being in a higher ANCq category compared with unmarried women. This finding is consistent with evidence from the SSA [34,35]. The association likely reflects the economic and social support from partners. Financial security within marriage facilitates allocation of resources to ANC, including transport, user fees, and compensation for lost income during clinic visits, while spousal involvement can enhance women’s autonomy, provide emotional support, and promote completion of recommended contacts. In Lesotho, where family and spousal structures strongly influence health-seeking behavior, these effects are amplified. Moreover, stigmatization of pregnancy outside marriage is Lesotho could discourage unmarried women from engaging with ANC services [36], whereas women in unions are more likely to receive encouragement and practical assistance from partners and extended family networks [37]. Evidence from culturally similar Sesotho-speaking communities shows that male involvement reduces maternal stress, improves couple communication, and promotes shared responsibility for health decisions, thereby strengthening ANC content and effectiveness [38–41]. Male partner involvement is also associated with earlier initiation, higher attendance, and better adherence to key interventions such as blood testing, contributing to improved overall ANC quality through consistent follow-up and compliance with care protocols [42].

Maternal education is a key determinant of ANCq. Women who had attained secondary or higher education had nearly twice the odds of being in a higher ANCq category than those with primary education or none. This finding is consistent with those of previous DHS analyses from Lesotho and across SSA [23,43]. The association likely reflects differences in knowledge and health literacy: more educated women are better informed about the benefits of early booking and adherence to the recommended number and content of ANC contacts, and therefore place greater value on these services. Higher educational attainment also enhances women’s ability to recognize danger signs of pregnancy and understand the consequences of unqualified care [44]. In the Lesotho context, education further improves women’s awareness of recommended ANC components and their capacity to effectively navigate the health system, reinforcing receipt of higher ANCq [45].

Frequency of internet use has emerged as an important determinant of ANCq coverage. Women who reported using the internet at least once per week had 60% higher odds of being in a higher ANCq category than those who reported no use. A recent Tanzanian DHS analysis found that women who reported using internet had lower dropping out from the maternal continuum of care compared to those with no internet exposure [46]. Regular internet use may expose women to maternal health information that improves their understanding of recommended services and danger signs [47]. In Lesotho, where misconceptions and cultural beliefs can delay ANC care-seeking [36], access to reliable online information may help counter misinformation and support appropriate use of ANC services [37].

Intention to last pregnancy by the time of conception was also strongly associated with ANCq. Women whose last pregnancy was wanted at the time had nearly three times the odds of being in a higher ANCq category compared with pregnancies unwanted at the time of conception. This finding is consistent with DHS analyses from Rwanda, Somalia, and Bangladesh, as well as systematic reviews from Ethiopia [28,48,49]. Unintended pregnancies are often accompanied by emotional stress, reduced motivation, and delayed engagement with health services. These factors can lead to later initiation of ANC, fewer visits, and reduced uptake of recommended service components, ultimately lowering ANC quality. Unintended pregnancies are often accompanied by emotional stress, reduced motivation, and delayed engagement with health services [48]. These factors can lead to later ANC initiation, fewer visits, and reduced uptake of recommended service components, ultimately lowering ANC quality [43].

Household size showed an inverse relationship with the ANCq coverage. Women living in smaller households had higher odds of being in a higher ANCq category than those living in larger households. This finding is supported by a DHS analysis report in SSA [23]. Women in larger households in extended family structures common in Lesotho may face competing domestic and caregiving responsibilities, reduced autonomy, and time constraints that limit repeated ANC attendance [50]. Women with several children may also rely on prior pregnancy experience or avoid facilities because of fear of criticism, reducing their likelihood of receiving complete ANC content [36].

Higher community-level education was significantly associated with greater ANCq coverage. Women residing in communities with higher levels of education had approximately 40% greater odds of being in a higher ANCq category compared with those from less educated communities. This finding is consistent with multilevel analyses from sub-Saharan Africa showing that community education strongly influences the quality and adequacy of antenatal care received by women [51,52]. The association likely reflects the broader social and cultural environment shaped by community-level education, which promotes maternal healthcare norms. Women are more likely to utilize antenatal care services adequately in communities with higher female literacy and more gender-equitable norms, independent of their individual socioeconomic status.

Conclusion

This study highlights that while most women in Lesotho attend antenatal care, many do not receive the full package of recommended services. ANCq coverage is strongly shaped by socioeconomic position and information access rather than by simple service contact alone. Marital status, maternal education, internet use frequency, pregnancy intention, household size, and community-level education were found to be significant determinants of being in a higher ANCq coverage category.

These findings indicate that, beyond contact coverage, Lesotho needs to emphasize on provision of quality and equitable ANC. Strengthening educational opportunities for women, expanding access to the internet, and promoting planned pregnancy are essential steps toward ensuring that all pregnant women receive content-qualified antenatal care.

Strength and limitations

This study measured ANCq coverage at the population level and included a wider range of ANC contents. This helps to better understand Lesotho’s progress in ensuring quality ANC. This study employed an ordinal logistic regression analysis, preserving the natural ordering inherent in the outcome variable, preventing arbitrary dichotomization of ordinal data, which would have resulted in information loss. Research demonstrates that “for categorical data with ordered categories, ordinal logistic regression works well” and provides advantages over other models [24].

The study used a self-reported data, which may be affected by recall or social desirability bias, although the shorter DHS-8 recall period likely minimized it. The ANC content indicators available in DHS-8 do not encompass all components recommended by the WHO 2016 ANC mode; therefore, the ANCq measure reflects only the interventions captured in the survey. Moreover, the dataset does not provide information on the timing or sequencing of individual ANC components, limiting the assessment of whether services were delivered at clinically appropriate points during pregnancy. Important facility- and system-level determinants, such as provider adherence to ANC protocols and service readiness, were not captured, restricting the examination of ANCq coverage’s structural drivers.