Noncompliance with the WHO's Recommended Eight Antenatal Care Visits among Pregnant Women in Sub-Saharan Africa: A Multilevel Analysis

Influence of women's decision-making autonomy and partner support on adherence to the 8 antenatal care contact model in Eastern Uganda: A multicenter cross-sectional study

OBJECTIVE

Maternal and child health outcomes remain a challenge in Uganda. Antenatal care (ANC) is effective in mitigating pregnancy and childbirth risks. Women's decision-making autonomy and partner support are crucial for adherence to ANC contacts and better pregnancy outcomes. We assessed the impact of women's decision-making autonomy and partner support on adherence to the 8 + ANC contact schedule among post-partum mothers in Eastern Uganda.

METHODS

A multicenter cross-sectional study was conducted in four tertiary health facilities in Eastern Uganda, utilizing quantitative techniques to collect data from 1077 postnatal mothers. Eligible participants were those who had given birth within the previous 48 h and had documentation of ANC contacts from their pregnancy. Data was collected using structured questionnaires and analyzed using multivariable logistic regression to assess factors associated with adherence to the WHO-recommended 8 + ANC contacts.

RESULTS

Most women were aged 20-34 years (792; 73.5 %). Only 253 (23.5 %) women adhered to the 8 + ANC contacts. A significant proportion lacked decision-making autonomy (839; 77.9 %), and over half reported partner support (550; 51.2 %). Decision-making autonomy and partner support were significantly associated with adherence to the 8 + ANC contacts (aOR: 1.6, 95 % CI: 1.2 - 2.2, p = 0.005) and (aOR: 1.9, 95 % CI: 1.4 - 2.7, p < 0.001), respectively. Women with at least five children had lower adherence to the 8 + ANC contacts (aOR=0.4, 95 % CI: 0.2 - 0.7, p = 0.002).

CONCLUSION

Empowering women and engaging their partners can improve maternal health service utilization and increase ANC contact adherence, leading to better maternal and neonatal health outcomes.

High rate of inadequate antenatal contacts among mothers in eastern Sudan: a cross-sectional study

This study assesses the prevalence and determinants of inadequate (less than eight contacts) and late antenatal care (ANC) initiation (starting after 12 weeks) among mothers delivered at Gadarif Maternity Hospital in eastern Sudan. A hospital-based cross-sectional study was conducted at Gadarif Maternity Hospital. A questionnaire was used to collect sociodemographic, clinical, and obstetric data through face-to-face interviews. Seven hundred mothers were enrolled with the median (interquartile range) of mothers' age, and parity was 28(24-32) years and 3(2-5), respectively. Of these 700 mothers, 79.3 percent and 10.3 percent had inadequate and late ANC, respectively. In multivariable logistic regression analysis, being a housewife (adjusted odds ratio [AOR] 1.93, 95 percent CI 1.09, 3.43) was associated with inadequate ANC. High parity (AOR 1.27, 95 percent CI 1.07-1.52) was positively associated with late ANC initiation. There was no association between age, residence, education, preexisting medical disorder, and history of miscarriage) with inadequate or late ANC initiation In eastern Sudan, four out of five mothers did not comply with the World Health Organization's recommendation of a minimum of eight ANC contacts for positive pregnancy outcomes. This study is crucial for policy-makers to take further strategic actions to ensure adequate and early ANC initiation for all mothers in Sudan.

Antenatal care coverage and early childhood mortality in Zimbabwe: new interpretations from nationally representative household surveys

Zimbabwe has implemented universal antenatal care (ANC) policies since 1980 that have significantly contributed to improvements in ANC access and early childhood mortality rates. However, Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), two of Zimbabwe's main sources of health data and evidence, often provide seemingly different estimates of ANC coverage and under-five mortality rates. This creates confusion that can result in disparate policies and practices, with potential negative impacts on mother and child health in Zimbabwe. We conducted a comparability analysis of multiple DHS and MICS datasets to enhance the understanding of point estimates, temporal changes, rural-urban differences and reliability of estimates of ANC coverage and neonatal, infant and under-five mortality rates (NMR, IMR and U5MR, separately) from 2009 to 2019 in Zimbabwe. Our two samples z-tests revealed that both DHS and MICS indicated significant increases in ANC coverage and declines in IMR and U5MR but only from 2009 to 2015. NMR neither increased nor declined from 2009 to 2019. Rural-urban differences were significant for ANC coverage (2009-15 only) but not for NMR, IMR and U5MR. We found that there is a need for more precise DHS and MICS estimates of urban ANC coverage and all estimates of NMR, IMR and U5MR, and that shorter recall periods provide more reliable estimates of ANC coverage in Zimbabwe. Our findings represent new interpretations and clearer insights into progress and gaps around ANC coverage and under-five mortality rates that can inform the development, implementation, monitoring and evaluation of policy and practice responses and further research in Zimbabwe.

Multilevel modelling of factors associated with eight or more antenatal care contacts in low and middle-income countries: findings from national representative data

Background

Antenatal care (ANC) is the care provided by skilled healthcare professionals to pregnant women in order to ensure the best health conditions for both mother and baby. Antenatal care provides a platform for important healthcare functions including risk identification, prevention and management of pregnancy-related diseases. Inadequate ANC utilization is a global problem especially for low and middle-income countries. The 2016 WHO ANC model with a minimum of eight ANC visits was aimed to provide pregnant women with person specific care at every contact. However, there are limited studies that investigate the associated factors of inadequate ANC after the endorsement of the WHO 2016 guideline. Therefore, to enrich the evidence in the low and middle-income countries (LMICs), this study aimed to determine the pooled prevalence and associated with eight or more ANC contacts during pregnancy.

Methods

This study used data from 20 LMICs that have a recent Demographic and Health Survey. About 43 720 women aged 15-49 years who had live births within the year prior to the surveys were included. To identify associated factors of 8 or more ANC contacts, we used multilevel binary logistic regression, and four models were constructed. The results have been presented as odds ratios with 95% CIs, and P values less than 0.05 were considered significant factors for greater than or equal to 8 ANC contacts.

Results

In LMICs, the pooled utilization of 8 or more ANC contact was 18.11% (95% CI: 12.64, 23.58), and it ranged from 0.27% in Rwanda to 76.62% in Jordan. In the final multilevel logistic regression model, women with higher education [adjusted odds ratio (AOR)=3.83, 95% CI: 3.32, 4.41], husbands with higher education (AOR=1.98, 95% CI: 1.72, 2.28), women who have access to media (AOR=1.32, 95% CI: 1.19, 1.45), women with decision-making autonomy (AOR=1.52, 95% CI: 1.39, 1.66), women aged 35-49 years (AOR=1.70, 95% CI: 1.5, 1.91), women from communities with high media access (AOR=1.38, 95% CI: 1.23, 1.53), and husbands residing in communities with high literacy (AOR=1.76, 95% CI: 1.55, 1.98) were associated with higher odds of greater than or equal to 8 ANC contacts. Conversely, women with a birth order of greater than or equal to 6 (AOR=0.65, 95% CI: 0.56, 0.76), women who perceive the distance to a health facility as a significant problem (AOR=0.90, 95% CI: 0.83, 0.96), those with unwanted pregnancies (AOR=0.85, 95% CI: 0.78, 0.93), delayed initiation of ANC (AOR=0.26, 95% CI: 0.23, 0.3), women from households with the richest wealth index (AOR=0.45, 95% CI: 0.40, 0.52), and rural residents (AOR=0.47, 95% CI: 0.43, 0.51) were associated with lower odds of ≥8 ANC contacts.

Conclusion and recommendations

In compliance with the WHO guideline, the number of ANC contacts is low in LMICs. Individual-level, household-level, and community-level variables were associated with greater than or equal to 8 ANC contacts. Therefore, implementation strategies should focus on the identified factors in order to achieve the new WHO recommendation of greater than or equal to 8 ANC contacts.

Compliance towards WHO recommendations on antenatal care for a positive pregnancy experience: Timeliness and adequacy of antenatal care visit in Sub-Saharan African countries: Evidence from the most recent standard Demographic Health Survey data

BACKGROUND

Timely and adequate antenatal care (ANC) visits are known to reduce maternal mortality by 20%. Despite the World Health Organization updating its recommendations from four to eight antenatal care contacts, data reporting in the SSA region focused primarily on four visits, and evidence on the timing and adequacy of ANC based on the current recommendation was limited. Hence, this study aimed at assessing the level of timely and adequate ANC visits and their determinants in the 18 Sub-Saharan African countries with the most recent DHS report (2016-2021).

METHODS

The data for this study were pooled from the most recent standardized Demographic and Health Survey data of sub-Saharan African countries from 2016-2021. A total of 171,183 (with a weighted frequency of 171,488) women were included and analyzed by using STATA version 16. To account for data clustering, a multivariable multilevel mixed-effect logistic regression analysis was run to determine the effects of each predictor on the receipt of timely and adequate ANC. Adjusted odds ratio with its corresponding 95% confidence interval was used to declare the statistical significance of the independent variables.

RESULTS

The receipt of timely and adequate antenatal care visits was 41.2% (95% CI: 40.9, 41.4) and 10.4% (95% CI: 9.9, 10.2), respectively. Wontedness of pregnancy [AOR = 1.18; 95% CI: 1.13, 1.24], being 1st birth order [AOR = 1.48; 95% CI: 1.41, 2.54], having a mobile phone [AOR = 1.49; 95% CI: 1.26, 2.32], and enrolled in Health insurance schemes [AOR = 2.03; 95% CI: 1.95, 2.42] were significantly associated with early initiation of ANC. Living in a lower community poverty level[AOR = 2.23; 95% CI: 1.90,2.66], being in the richest wealth quintile [AOR = 1.49; 95% CI: 1.36, 1.62], higher educational level [AOR = 3.63; 95% CI: 3.33, 3.96], the timing of ANC visit [AOR = 4.26; 95% CI: 4.08, 4.44], being autonomous in decision making [AOR = 2.29; 95% CI: 1.83, 2.54] and having a mobile phone [AOR = 1.89; 95% CI: 1.76, 2.52] were identified as significant predictors of adequate ANC uptake.

CONCLUSION

The findings revealed a low coverage of timely and adequate ANC visits in SSA countries. Governments and healthcare managers in sub-Saharan African countries should leverage their efforts to prioritize and implement activities and interventions that increase women's autonomy, and economic capability, to improve their health-seeking behavior during pregnancy. More commitment is needed from governments to increase mobile phone distribution across countries, and then work on integrating mHealth into their health system. Finally, efforts should be made to increase the coverage of health insurance schemes enrolment for the citizens.

A secondary analysis of the factors associated with women´s adequate utilization of antenatal care services during their last pregnancy in Uganda

BACKGROUND

Adequate antenatal care services (ANC) use is critical to identifying and reducing pregnancy risks. Despite the importance placed on adequate antenatal care service utilization, women in Uganda continue to underutilize antenatal care services. The primary goal of this study is to identify the factors associated with women's adequate utilization of antenatal care services in Uganda.

METHODS

Secondary data from the 2016 Uganda Demographic and Health Survey were used in this study. The study sample consists of 9,416 women aged 15 to 49 who reported giving birth in the five years preceding the survey. The adequate use of antenatal care services is the dependent variable. A woman who used antenatal care services at least four times is considered to have adequately used antenatal care services. We used univariate, bivariate, and multilevel logistic regression modelling to identify the factors associated with adequate utilization of antenatal care services. STATA version 14.2 was used to analyze the data.

RESULTS

The prevalence of adequate utilization of antenatal care services in Uganda was found to be 61.4%. Women with secondary or higher education were 32.0% (AOR = 1.32, 95% CI;1.07-1.63), employed women were 26.0% (AOR = 1.26, 95% CI;1.10-1.44), women who received high-quality antenatal care content were 78.0% (AOR = 1.78, 95% CI;1.58-2.02), and women who belong to the rich category of the wealth index bracket were 27.0% (AOR = 1.27, 95% CI;1.09-1.49), more likely to use antenatal care services adequately. Finally, the study discovered that women from less diverse ethnic communities were 15.0% (AOR, 0.85, 95%CI; 0.73-0.99) less likely to use antenatal care services adequately.

CONCLUSION

Women's adequate utilization of antenatal care was influenced by both community and individual-level characteristics. Policymakers must use a multi-sectoral approach to develop policies that address both individual and community-level characteristics.

Effectiveness of eight or more antenatal contacts on health facility delivery and early postnatal care in low- and middle-income countries: a propensity score matching

Background

Despite progress in reducing maternal and child mortality, many low- and middle-income countries (LMICs) still experience an unacceptably high level of the problem. The World Health Organization (WHO) recently recommended pregnant women should have at least eight antenatal care visits (ANC8+) with a trained healthcare provider as a key strategy to promote pregnant women's health. Antenatal care is an imperative factor for subsequent maternal healthcare utilization such as health facility delivery and early postnatal care (EPNC). This study aimed to examine the net impact of ANC8+ visits on health facility delivery and EPNC in LMICs using a propensity score matching analysis.

Methods

We used the recent Demographic and Health Survey (DHS) datasets from 19 LMICs. Women of reproductive age (15-49 years) who had given birth within 1 year preceding the survey were included. A propensity score matching analysis was employed to assess the net impact of eight or more antenatal care visits on health facility delivery and early postnatal care.

Result

After matching the covariates, women who attended ANC8+ visits had a 14% (ATT = 0.14) higher chance of having their delivery at health facilities compared with women who attended less than eight ANC visits. This study further revealed that women who had ANC8+ visits were associated with a 10% (ATT = 0.10) higher probability of early PNC compared with their counterparts.

Conclusion and recommendation

This study confirmed that ANC8+ visits significantly increased the likelihood of health facility-based delivery and early PNC utilization in LMICs. These findings call for public health programs to focus on pregnant women attending adequate ANC visits (according to revised WHO recommendation) as our study indicates that ANC8+ visits significantly improved the chances of subsequent care.

Compliance with the World Health Organization's 2016 prenatal care contact recommendation reduces the incidence rate of adverse birth outcomes among pregnant women in northern Ghana

BACKGROUND

Children born with adverse birth outcomes (ABOs) have a greater risk of mortality, stunting, and poor cognitive development. In 2016, the World Health Organization (WHO) recommended at least eight antenatal care (ANC) contacts before delivery for a healthy mother and baby. We examined the association between compliance with this recommendation and the risk of ABOs, such as low birthweight (LBW) and preterm birth (PTB), in the Tamale Metropolitan Area of the northern region of Ghana.

METHODS

We conducted a cross-sectional study in the Tamale Metropolis of the northern region of Ghana. We analysed a systematic random sample of 402 postnatal women aged 15-49 drawn from five public health facilities. We gathered information electronically on their birth outcomes, specifically their birthweight and gestation at delivery, using a structured questionnaire. Information on women's background characteristics, including the number of ANC contacts made before delivery, was also collected. The association between the number of ANC contacts and ABOs was investigated using regression models.

RESULTS

We found that 37.6% (95% CI: 32.9, 42.4) of our sample had at least eight ANC contacts before delivery. We estimated that 18.9% of babies were born prematurely and 9.0% were born LBW. ABOs were found in 22.9% (95% CI: 19.0, 27.3) of babies. A minimum of eight ANC contacts before delivery reduced the risk of ABOs (adjusted IRR = 0.43; 95% CI: 0.25, 0.73), PTB (AOR = 0.28; 95% CI: 0.14, 0.58), and LBW (AOR = 0.36; 95% CI: 0.14, 0.91).

CONCLUSION

In the current study's setting, about a quarter of newborns have ABOs, jeopardising their survival, health, and development. Compliance with at least eight ANC contacts prior to birth was associated with a reduced incidence rate ratio of ABOs. However, less than four out of every ten pregnant women make at least eight ANC contacts before delivery. Efforts are needed to increase coverage of eight contacts among pregnant women before delivery to reduce the risk of ABOs in the study setting.

Non-adherence to WHO's recommended 8-contact model: geospatial analysis of the 2017 Maternal Health Survey

INTRODUCTION

Evidence shows that most women in Ghana do not meet the minimum 8-contact model for antenatal care as recommended by WHO with only 31.2%-41.9% of them meeting the recommendation. To the best of our knowledge, no study in Ghana has examined women's noncompliance with the WHO's recommended 8-contact model for antenatal care using geospatial analysis, as this study sets out to do.

METHODS

We sourced data from the recent version of the Ghana Maternal Health Survey which was executed in 2017. A sample of 10,077 women with complete data participated in this study. The link between the explanatory variables and the outcome variable was investigated using binary and multivariate logistic regression models and Spatial analyses such as spatial autocorrelation (Moran's I), hotspot, cluster and outlier analysis, and geographically weighted regression were conducted using ArcMap version 10.7.

RESULTS

Districts found in the north-eastern and south-western parts of the country were more likely to experience noncompliance with ANC. Women staying within the middle belt without health insurance were more likely (17-29%) to be noncompliant with ANC. Women with low community socioeconomic status were found to be more likely (17-34%) to be noncompliant with ANC in the eastern parts of Ghana.

CONCLUSION

The study has shown that in order to achieve targets one and three of Sustainable Development Goal 3, the government of Ghana, the Ministry of Health, together with the Ghana Health Service may have to intensify health education in the identified areas to highlight the importance of adherence to the WHO recommendations on ANC 8-contact model.

Spatial distribution and multilevel analysis of factors associated with child marriage in Nigeria

BACKGROUND

Child marriage among women has become a major threat to the rights of women, especially in low- and middle-income countries. The marriage of girls below age 18 y is a major public and global health challenge. Therefore, this study examined the spatial pattern and factors associated with child marriage in Nigeria.

METHODS

The data were sourced from the 2018 Nigeria Demographic and Health Survey. The study included a total of 4283 young women aged 20-24 y. The findings were provided in the form of spatial maps and adjusted ORs (aORs) with 95% confidence interval (CI).

RESULTS

Hotspot areas for child marriage in Nigeria were located in Sokoto, Kebbi, Katsina, Kano, Jigawa, Yobe, Bauchi, Niger, Borno, Gombe, and Adamawa. The prevalence of child marriage in Nigeria was 41.50%. The likelihood of child marriage in Nigeria was high among those currently working (aOR=1.31; 95% CI 1.11 to 1.55) compared with young women who were not working. On the other hand, young women whose partners had secondary education and above (aOR=0.57; 95% CI 0.45 to 0.73) were less likely to report child marriage in Nigeria compared with those whose partners had no education.

CONCLUSIONS

The findings of the study indicate that there are several hotspots in Nigeria that need to be targeted when implementing interventions aimed at eliminating child marriage in the country.

Status of the latest 2016 World Health Organization recommended frequency of antenatal care contacts in Sierra Leone: a nationally representative survey

Background

Timely and increased frequency of quality antenatal care (ANC) contacts is one of the key strategies aimed at decreasing maternal and neonatal deaths. In 2016, the World Health Organization (WHO) revised the ANC guidelines to recommend at least eight ANC contacts instead of four. This study aimed to determine the proportion of women who received eight or more ANC contacts and associated factors in Sierra Leone.

Methods

We used Sierra Leone Demographic and Health Survey (UDHS) 2019 data of 5,432 women aged 15 to 49 years who had a live birth, within three years preceding the survey. Multistage stratified sampling was used to select study participants. We conducted multivariable logistic regression to identify factors associated with utilisation of eight or more ANC contacts using SPSS version 25 complex samples package.

Results

Out of 5,432 women, 2,399 (44.8%) (95% CI: 43.1–45.7) had their first ANC contact in the first trimester and 1,197 (22.0%) (95% CI: 21.2–23.4) had eight or more ANC contacts. Women who had their first ANC contact after first trimester (adjusted odds ratio, aOR, 0.58, 95% CI 0.49–0.68) and women aged 15 to 19 years had less odds of having eight or more contacts (aOR 0.64, 95% CI 0.45 to 0.91). Working (aOR 1.33, 95%CI 1.10 to 1.62) and wealthier women had higher odds of having eight or more contacts compared to poorer ones and those not working respectively. Women residing in the southern region, those using internet and less parous (less than five) women were associated with higher odds of having eight or more ANC contacts. Women who had no big problem obtaining permission to go health facilities also had higher odds of having eight or more ANC contacts compared to those who had big problems.

Conclusion

Sierra Leone’s adoption of eight or more ANC contacts is low and less than half of the women initiate ANC in the first trimester. To ensure increased access to recommended ANC visits, timely ANC should be encouraged. Attributes of women empowerment such as workings status, socio-economic status, and decision-making should also be emphasized.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08594-y.

Factors Affecting Nonadherence to WHO’s Recommended Antenatal Care Visits among Women in Pastoral Community, Northeastern Ethiopia: A Community-Based Cross-Sectional Study

Introduction. More than half of the pregnant women in Ethiopia do not receive the recommended number of antenatal care visits. In the Afar region, where women have limited access to healthcare services due to pastoral livelihood, evidence on noncompliance to the adequate number of antenatal care visits is scarce. Therefore, this study was intended to examine the level of nonadherence to the recommended antenatal care visits and its associated factors in the pastoral community of Northeast Ethiopia. Methods. A community-based cross-sectional study was conducted from 04 February to 22 March 2020 among randomly selected 703 women who gave birth within 24 months preceding the survey in the Transform HDR districts of the Afar region. Data were collected using a pretested structured interviewer-administered questionnaire. Data were entered into Epi-data version 4.2 and finally exported to Stata version 16 for further analysis. Bivariable and multivariable binary logistic regression analyses were done to identify factors affecting the nonadherence to the recommended antenatal care visits. Odds ratio with the corresponding 95% confidence interval were computed and the statistical significance of the explanatory variables was declared at a $p$ -value <0.05. Results. Nonadherence to the recommended antenatal care visits was 57.0% (95% CI: 53.3%–60.7%). Attending primary (AOR (95% CI): 0.39 (0.22–0.72)) and secondary education and above (AOR (95% CI): 0.25 (0.08–0.77)), being married at the age of 18 years or older (AOR (95% CI): 0.48 (0.36–0.71)), and attending antenatal care at a health center (AOR (95% CI): 0.46 (0.26–0.81)) were associated decreased odds of nonadherence to the recommend visits. Moreover, a higher likelihood of nonadherence was found among women from households not possessing communication media (AOR (95% CI): 1.85 (1.18–2.88)) and those who initiated antenatal care attendance during the second (AOR (95% CI): 5.23 (3.54–7.72)) and third trimesters (AOR (95% CI): 8.81 (1.88–41.20)). Conclusions. Nearly six in ten women do not receive the recommended antenatal care visits, consistent with the national prevalence. Women’s education, age at marriage, type of health facility, possession of mass media, and timing of antenatal care attendance were associated with nonadherence to the recommended antenatal care visits. Thus, improving women’s literacy, dissemination of information regarding antenatal care through mass media, and strengthening interventions targeted to end child marriage are important in scaling up the level of adherence. Moreover, supporting community-based health education through health extension programs is crucial in reaching women with limited access to mass media.

Antenatal screenings and maternal diagnosis among pregnant women in Sao Tome & Principe-Missed opportunities to improve neonatal health: A hospital-based study

Newborn mortality and adverse birth outcomes (ABOs) in Sao Tome & Príncipe (STP) are overwhelmingly high, and access to quality-antenatal care (ANC) is one of the strategies to tackle it. This study aimed to fill the gaps in ANC screenings with a focus on how to improve neonatal outcomes. We conducted a retrospective hospital-based study in which ANC pregnancy cards were reviewed. Screenings were described and compared according to the total number of ANC contacts: 1-3 (inadequate), 4-7 (adequate), and ≥8 (complete). The collected data were entered into QuickTapSurvey and exported to SPSS version 25 for analysis. Statistical significance was considered at a p-value ≤0.05. A total of 511 ANC pregnancy cards were reviewed. Mothers' mean age was 26.6 (SD = 7.1), 51.7% had a first trimester early booking, 14.9% (76) had 1-3 ANC contacts, 46.4% (237) had 4-7 and 38.7% (198) ≥8. Screening absence was found in 24%-41%, lack of money was registered in 36%. Pregnant women had no screening performed for HIV in 4.5%, syphilis in 8.8%, HBV 39.3%, malaria 25.8%, hemoglobin 24.5%, blood glucose 45.4%, urine 29.7%, stool exams 27.8% and 41.1% had no ultrasound. Screening completion for blood group, HIV, malaria, urine, hemoglobin, and coproparasitological exam were found to have a statistically significant difference (p<0.001) for the complete ANC group when compared to other groups. Antenatal problems identified were: 1) bacteriuria (43.2%); 2) maternal anemia (37%); 3) intestinal parasitic infections (59.2%); 4) sickle cell solubility test positive (13%); and 5) a RhD-negative phenotype (5.8%). Missed-ANC treatments were up to 50%. This study reveals a coverage-quality gap in STP since no pregnant woman is left without ANC contact, although most still miss evidence-based screenings with an impact on neonatal outcomes. Strategies such as implementing a total free ANC screening package in STP would enhance maternal diagnosis and prompt treatments.