Introduction:

The fifth millennium development goal aims at reducing maternal mortality by

75% by the year 2015[1]. According to the WHO, there was an estimated 358,000

maternal deaths globally in 2008. Developing countries accounted for 99% of these

deaths of which three fifths occurred in Sub-Saharan Africa where Uganda lies [2].

Abortion, obstetric complications such as hemorrhage, dystocia, eclampsia, sepsis

and infections such as tuberculosis and HIV are the major causes of maternal

deaths in developing countries[3]. Although antenatal care (ANC) is not in itself

very effective in reducing maternal mortality, it provides an entry for interventions

which give health workers the opportunity to detect these risky conditions and

therefore refer them for early management leading to better maternal outcomes[4].

 ANC involves screening for health and socioeconomic conditions likely to

increase the possibility of specific adverse pregnancy outcomes, providing

therapeutic interventions known to be effective and educating pregnant women

about planning for safe birth, emergencies during pregnancy and how to deal with

them [5]. ANC is therefore relevant for the improvement of maternal health as it

enables the monitoring of the health of the mother and anticipation of any

difficulties during pregnancy, labor and birth [6]. Some studies have estimated that

ANC alone can reduce maternal mortality by 20% [7] given good quality and

regular attendance. In addition ANC attendance during pregnancy has been shown

to have a positive impact on the use of postnatal healthcare services, which also

play a key role in detecting risky conditions after child birth consequently leading

to better maternal health outcomes[8].

 WHO evidence shows that four ANC visits are sufficient for uncomplicated

pregnancies and more are necessary only in cases of complications[9]. The WHO,

therefore recommends four visits, however in developing countries, many women

do not attend all the four visits [10] [11]. This has been attributed to poor

accessibility, inability to afford the costs of seeking care, cultural barriers and lack

of knowledge or illiteracy [12] [13].

 The quality of ANC is critical in enabling women and health workers identify

risks and danger signs during pregnancy which should lead to appropriate

action[14]. Whether or not women can identify danger signs during pregnancy and

act appropriately depends on quality aspects such as the depth of the information

and counseling given during an ANC visit[15].

  Provision of quality ANC service requires the presence of relevant Infrastructure,

adequate trained health workers, infection control facilities, diagnostic equipment,

supplies and essential drugs. Furthermore, the ANC process requires the use of

guidelines that health providers should follow while offering care to ensure

prevention, diagnosis and treatment of complications[16].

 This study assessed the quality of ANC services by looking at the health facilities

capacity to deliver ANC services, the completeness of the ANC consultation

process and patient satisfaction with ANC services offered. maternal health

services using vouchers.

Previous studies:

Christoph Boller et al (2003) in Tanzania compare the quality of public and

private first-tier antenatal care services using defined criteria Structural attributes

of quality were assessed through a checklist, and process attributes, including

interpersonal and technical aspects, through observation and exit interviews. A

total of 16 health care providers, and 166 women in the public and 188 in the

private sector, were selected by systematic random sampling for inclusion in the

study. Quality was measured against national standards, and an overall score

calculated for the different aspects to permit comparison. Findings The results

showed that both public and private providers were reasonably good with regard to

the structural and interpersonal aspects of quality of care.

However, both were poor when it came to technical aspects of quality. For

example, guidelines for dispensing prophylactic drugs against anemia or malaria

were not respected, and diagnostic examinations for the assessment of gestation,

anemia, and malaria or urine infection were frequently not performed. In all

aspects, private providers were significantly better than public ones. [17]

Nicholas N A Kyei1,3 et al ( 2005) Zambia in analyzed two national

datasets with detailed antenatal provider and user information, to describe the

level of ANC service provision at 1,299 antenatal facilities 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.

Br J Obstet Et al (1999) in  UK a pilot list of indicators of quality of antenatal

care across a range of maternity care settings. For each indicator to determine what

is achieved in current clinical practice, to facilitate the setting of audit standards

and calculation of appropriate sample sizes for audit. RESULTS: Nine of the

eleven suggested indicators were successfully piloted. Two indicators require

further development. In seven of the nine hospitals external cephalic version was

not commonly performed. There were wide variations in the proportions of women

screened for asymptomatic bacteriuria. Screening of women from ethnic minorities

for haemoglobinopathy was more likely in hospitals with a large proportion of

non-caucasian women. A large number of Rhesus negative women did not have a

Rhesus antibody check performed after 28 weeks of gestation and did not receive

anti-D immunoglobulin after a potentially sensitising event during pregnancy. As a

result of the study appropriate sample sizes for future audit could be calculated.

[18]

Delvaux, T. et al (2008) in Cote d'Ivoire assess whether implementation of a

prevention of mother-to-child HIV transmission (PMTCT) programme in Cote

d'Ivoire improved the quality of antenatal and delivery care services. METHODS:

Quality of antenatal and delivery care services was assessed in five urban health

facilities before (2002-2003) and after (2005) the implementation of a PMTCT

programme through review of facility data; observation of antenatal consultations

(n = 606 before; n = 591 after) and deliveries (n = 229 before; n = 231 after) and

exit interviews of women; and interviews of health facility staff. RESULTS: HIV

testing was never proposed at baseline and was proposed to 63% of women at the

first ANC visit after PMTCT implementation. The overall testing rate was 42%

and 83% of tested HIV-infected pregnant women received nevirapine. In addition,

inter-personal communication and confidentiality significantly improved in all

health facilities. In the maternity ward, quality of obstetrical care at admission,

delivery and post-partum care globally improved in all facilities after the

implementation of the programme although some indicators remained poor, such

as filling in the partograph directly during labour. Episiotomy rates among

primiparous women dropped from 64% to 25% (P < 0.001) after PMTCT

implementation. Global scores for quality of antenatal and delivery care

significantly improved in all facilities after the implementation of the program me

[19]

Fekede, B et al(2007) in Ethiopia assess antenatal care service utilization and

factors associated with antenatal care non attendance. METHODS: A community

based cross-sectional study was conducted among pregnant women from January

26 to February 06, 2006 in Jimma Town, Jimma zonal administration south west

Ethiopia. Structured interviewer administered questionnaire was used for data

collection. The data collected on study variables were tabulated in frequency tables

and significance of association between variables was tested using chi2--test of

significance. RESULT: A total of 360 pregnant women were enrolled in the study.

The study, revealed that about 76.7% of the women have attended antenatal care

and 23.3% have not attended at all. Literacy status, income, Gravidity, Religion

and occupation showed statistically significant association (P < 0.05) with

utilization of antenatal care. But marital status, Ethnicity and parity showed no

statistically significant association (P > 0.05) with antenatal care utilization. The

study showed that about 42.8% of the attendants have made their first antenatal

visit in the 3rd trimester of pregnancy. Out of the total only 6.5% the studied

women had the recommended four visits. Women in the age group 15-24 are more

likely to attend ANC 2.75 times larger than that of women in the age group 25-34

(OR = 2.74, 95% CI: 1.37, 4.38). Similarly others (students and farmers) are about

four times likely to attend ANC than House wives (OR = 4.06. 95% CI: 1.50,

11.40). [20]

Khatun, S. et al (2008) in Dhaka, Bangladesh studied Four hundred and sixty-

five pregnant women and their newborn babies were at a maternal and child health

training institute, between July 2002 and June 2003 with the objective of (1)

examining the relationship between birth weight and maternal factors, and, if there

was a dose-response relationship between quality of antenatal care and birth

weight, (2) predicting the number of antenatal visits required for women with

different significant characteristics to reduce the incidence of low-birth-weight

babies. The study revealed that 23.2% of the babies were of low birth weight

according to the WHO cut-off point of <2500 g. Mean birth weight was 2674.19+/-

425.31 g. A low birth weight was more common in younger (<20 years) and older

(> or =30 years) mothers, the low-income group and those with little or no

education. The mean birth weight of the babies increased with an increase in

quality of antenatal care. The babies of the mothers who had 6+ antenatal visits

were found to be 727.26 g heavier than those who had 1-3 visits and 325.88 g

heavier than those who had 4-5 visits. No significant relationship was found

between number of conception, birth-to-conception interval, BMI at first visit, sex

of the newborn and birth weight. Further, from multiple regression analysis

(stepwise), it was revealed that number of antenatal visits, educational level of the

mother and per capita yearly income had independent effects on birth weight after

controlling the effect of each variable. Using multiple regression analysis, the

estimated number of antenatal visits required to reduce the incidence of low-birth-

weight babies for women with no education and below-average per capita income

status was 6; the number required for women with no education and above-average

per capita income status was 5; and that for women with education and with any

category of income status was 4 visits. [21]

General objective:

To access perception of pregnant women and providers about Quality off

Antenatal care.

Specific Objectives:

To access availability of service

To access availability of drugs

To access availability of infrastructure

To reduce infant mortality,

Preventing people from dying prematurely.

Ensuring that people have a positive experience of care.

Justification:

This study gives important baseline information that could be used in informing

the intervention design and implementation of projects that seek to improve

maternal health.

Treating and caring for people in a safe environment and protecting them from

avoidable harm.

Methodology:

Type of study:

Descriptive cross section study

Study population :

There are 1107 pregnant women in Khartoum state receiving antenatal

care services every month in public health centers

The study populations are all pregnant women in reproductive age

attending antenatal clinic in 5 public health centers (Alshajara , Alremaila, Algoz,

Alamab, Almygoma Health centers).

Sample size determination:

n=N/1+n (e) 2

n=sample size

N=population size in last month who attending antenatal care

in clinics of health centers.

5 health centers=350

e=margin of error=0, 05

n=350/1+350/,0025

n=187

Data Colletion:

Data will be collected via questionnaire.

Plan for analysis:

Data will entered spss program , statistical significant will tested by using chi

squired test and using proportion between sub groups and mean and stander

diviation.

Ethical Issues

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