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INOSR APPLIED SCIENCES 12(1):21-31, 2024 ISSN: 2705-165X
©INOSR PUBLICATIONS INOSR1.1.2120
International Network Organization for Scientific Research
https://doi.org/10.59298/INOSRAS/2024/1.1.2120

Factors Influencing Successful Implementation of Antenatal Care

Services in Selected Health Centre IV’s in Jinja District Eastern
Uganda
Akankwasa Prosper Kanya

Faculty of Clinical Medicine and Dentistry Kampala International University Western Campus Uganda.

ABSTRACT
Maternal mortality is a global public health issue, with an estimated 830 women dying daily due to pregnancy and
childbirth-related causes, primarily in the developing world. The use of antenatal care from trained providers is
crucial to monitor pregnancy and reduce morbidity and mortality risks for both mother and child during
pregnancy and delivery. A prospective descriptive cross-sectional study was conducted among health workers in
five health Centre IVs in Jinja district, eastern Uganda. The study found that only 17.65% of antenatal care
services were implemented fairly. Factors influencing successful implementation included service duration above
five years, formal training on implementing guidelines and having facility interventions in place. Factors such as
seeing 30 or fewer antenatal clients on each clinic day, not attending antenatal reproductive health training, not
having knowledge of antenatal care guidelines, and not using antenatal care guidelines also influenced successful
implementation. However, these factors did not show statistical significance in logistic regression analysis. More
efforts are needed to improve antenatal service implementation among healthcare providers to achieve the new
WHO antenatal care model for a positive pregnancy experience.
Keywords: Women, Pregnancy, Antenatal care services, Antenatal health.

INTRODUCTION
The number of registered maternal deaths due to
birth- or pregnancy-related complications per
100,000 registered live births[1]. Maternal
mortality is a global public health problem with an
estimated 830 women dying every day due to
pregnancy and childbirth-related causes most of
which occur in the developing world[2]. According
to the United Nations Inter-agency estimates, there
has been a tremendous decline in maternal mortality
between 1990 and 2015, however sub-Saharan Africa
(SSA) still contributes two-thirds of the world’s
annual maternal deaths [3]. Most maternal deaths
are preventable if women access timely and quality
obstetric care provided by skilled health personnel in to monitor the pregnancy and to reduce morbidity
adequately equipped health facilities. The lifetime
risk of dying due to childbirth is influenced by the
number of pregnancies and the probability of
experiencing a life-threatening obstetric condition
[4]. Unfortunately, the lifetime risk of maternal
death in low- and middle-income countries is 1 in 41
compared to 1 in 3,300 in high-income countries due
to challenges in access to timely emergency obstetric
care and the high fertility rates; Uganda has a
lifetime risk of dying in childbirth of 1 in 49 [5].
Antenatal care (ANC), a pillar in safe motherhood is
recommended as one of the strategies to reduce
maternal deaths given that it provides an
opportunity for the pregnant woman to interface
with the health care system to identify pre-existing
conditions that may complicate pregnancy and lead
to morbidity and or mortality[6]. However, the
coverage of ANC is low with about 78% and 49% of
women in SSA attending at least one ANC and four
or more visits respectively during the course of their
pregnancy [7]. This implies that fewer women in
SSA receive the benefits ANC. The utilization of
antenatal care from a trained provider is important
and mortality risks for the mother and child during
pregnancy and delivery. Therefore, the aim of this
study was to assess the factor influencing successful
implementation of ANC care services in Regional
Referral Hospitals in Uganda east Africa. In 2001, a
WHO study evaluated and recommended focus
antenatal care (FANC) – an approach that promotes
four antenatal visits that are goal oriented and
personalized with guidance on the services a
pregnant woman should receive when they interface

21
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with a health care worker[8]. Uganda adopted the
WHO guidelines for FANC in 2003[9, 10]. Recent
evidence suggests that the focused antenatal care
(FANC) model is associated with more perinatal
deaths than ANC models that comprise at least eight
contacts between the pregnant woman or adolescent
girl and the health care provider [11]. However, in a
recently published document, WHO now
recommends a minimum of eight visits to improve
neonatal outcomes and to provide a more positive
and women-centered experience for clients.
Maternal mortality rate has been a challenge since
the 1990s MMR has remained high in Uganda;
UDHS, 2006 found that MMR declined just 14% in
the past 10 years from 506 per 100,000 to 435 per
100,000 compared to 28% decline in previous 7
years[12]. And currently MMR stands at 336 per
100,000 live births[12].A pregnant woman’s chance
of getting all the components of the ANC package
increases with the number of visits they make to the
health facility[9]. However, in Uganda, the
proportion of pregnant women utilizing
comprehensive ANC services is low based on the
reported number of women attending four ANC
visits during the last five years [13]. Some studies
have shown that the more pregnant women attend
ANC the more likely they will have a skilled birth
attendance or health facility delivery and good
health outcomes[14]. It is thus not surprising that
Uganda still has a high maternal mortality rate,
given the low ANC attendance and health facility
deliveries. According to motivation and facilitation
theory, facilitation is the goal of the clinic to create
easy, open access to person-centered beneficial care.
This model directs the focus of research and changes
to the interface of the woman and the clinic and
encourages practice-level innovations that facilitate
women entering and maintaining prenatal care [8,
METHODOLOGY
Study design
A Prospective descriptive cross-sectional study
design was conducted, because it involved
observations, description, and documentation, of the
Area of Study
The study was conducted in all the five health
Centre iv’s, these included (Mpumudde HC IV,
Study population
The study population was ANC health care
providers in the selected health Centre IV’s in Jinja
district eastern Uganda. Inclusion criteria: Health
care providers of ANC services at selected health
Sample size determination
The minimum sample size was determined using
morgans table. The health care providers of ANC
services at walukuba health Centre IV are 11 in
number. Population size (N) = 11 and our Sample
22
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Kanya
15]. The pregnant woman’s perception, which can
be perceived susceptibility, and beliefs, about the
ANC service providers may affect the motivation of
pregnant mothers to attendances of ANC.
Globally, maternal health outcomes have seldom
improved despite improvements in other health
indicators. Maternal mortality is a global public
health problem with an estimated 830 women dying
every day due to pregnancy and childbirth related
causes most of which occur in the developing
world[2], maternal mortality is unacceptably high,
about 295000 women died during and following
pregnancy and childbirth in 2017. The vast majority
of these death (94%) occurred in low-resources
settings, and most could have been prevented.
Saharan Africa (SSA) still contributes two thirds of
the world’s annual maternal deaths. [16].The
Uganda Demographic Health Survey of 2016
reported that the maternal mortality rate (MMR)
stands at 336 per 100,000 live births. Furthermore,
the report also indicated that the proportion of
pregnant women who attend at least four ANC visits
during the course of their pregnancy is still low at
60% and only 73% of the deliveries happen at the
health facility[12]. These maternal deaths could
have been prevented if the pregnant women or
adolescent girls had been able to access quality
antenatal care[2]. Thus, understanding the factors
influencing successful implementation of antenatal
care services should be a matter of great policy
concern to the government and other stakeholders,
especially donors. Whereas studies had been done to
understand the factors influencing the utilization of
antenatal care services in Uganda[9, 17], no study
had been carried about the factors influencing
successful implementation of ANC services, using
the Uganda Demographic Health Survey (UDHS)
2016[4].
implementation of ANC services as they occurred
naturally using questionnaires and interviews.
Walukuba HC IV, Budondo HC IV, Buwenge HC IV
and Bugembe HC IV).
Centre IVs that consented to participate in the
study. Exclusion criteria: All other health care
providers in the selected health Centre IV’s not
working in ANC.
size (s) = 11. The above was done for other selected
health Centre IV’s these included (Mpumudde HC
IV, Walukuba HC IV, Budondo HC IV, Buwenge
 https://www.inosr.net/inosr-applied-sciences/ Kanya
HC IV and Bugembe HC IV). As shown in the table below.
Table 1: Showing Total Sample Size
Health centre Population size Sample size Total sample size
walukuba 7 7

33 participants

Budondo 6 6
Bugembe 10 10
Mpumude 6 6
Buwenge 4 4
There for the minimum sample size of the study was 33 participants.
Sampling procedures: It’ was a purposive sampling health workers as they are well acquitted with
because it selectively involved the departmental knowledge about the guidelines.
Data collection method and management
During research, the researcher took notes against questionnaires was sorted, edited and recorded for
each question asked and answered respectively in accuracy and completeness. Later on, it was entered
their corresponding orders. Data from into a data excel sheet for analysis.
Data analysis
After data collection, the raw data collected was ended items in the questionnaire. Data obtained
systematically organized and checked for missing from open-ended items in the questionnaires was
data to facilitate analysis. Completed questionnaires categorized according to themes relevant to the
and interview guides were cross examined for study and was presented in narrative form using
completeness and consistency. Categorical data was descriptions. Analysis of data employed STATA
presented as frequencies and percentages using version 14 software where descriptive statistics were
tables, bar graphs and pie charts. Descriptive generated.
statistics were used to summarize data on the closed
Antenatal service implementation
The level of implementation was rated as poor, fair service mentioned by the provider scored against the
or good with reference to the guidelines of target list was given a score of one. The total score (10)
antenatal care services stipulated in the Uganda was obtained for each respondent and computed into
Clinical Guidelines, the 14 WHO recommendations percentages. Good implementation included those
for a positive experience and established good that scored 75% and above, Fair implementation was
clinical practices. Each respondent was scored rated for those who scored 50% and above but below
against the list of services stipulated by the Uganda 75%, and poor for individuals who scored below
clinical guidelines as shown in the table. Each 50%.
Table 2
Guideline Score
T.T immunization 1
Screening for STIs 1
Art services 1
Prophylaxis management 1
Risk identification and management 1
Nutrition 1
Counselling 1
Birth preparedness 1
Health education 1
Male partner involvement 1
Total score 10

The factors that influence the implementation of association was determined using a Chi-square test
antenatal care services were determined using and odds ratio while statistical significance was set
bivariate regression analysis, the strength of at p-value <0.05 and 95% confidence interval (CI).

23
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Quality control methods
The researcher used pretested questionnaires and a corresponding orders. This objectively focused on
checklist. The researcher took notes against each the relevant information leaving out the irrelevant
question asked and answered respectively in their ones.
Ethical consideration
We obtained an introductory letter from the Dean of respondent was free to decide to or not to participate
Clinical Medicine and Dentistry Kampala in the study. Personal identity of respondents was
International University. This letter was introduced not revealed.
to authorities of the health care facilities. Each
RESULTS
Gender and Sex characteristics of the respondents
The study enrolled a total of 34 health care were 28 years or less while only about 13(38.24%)
providers, 28(82.35%) of these were female and the were above 28 years of age. The details are
rest 6(17.65%) were males. More than 60% of these demonstrated in the figures 1 and 2.

Pie chart showing sex characteristics of the study participants

18%

82%

Female Male

Figure 1: A pie chart demonstrating the sex characteristics of the participants

24
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Bar graph showing the age distribution of the study participants

70

60 61.76

50

40
38.24

30

20

10

0
Above 28 28 Below

Figure 2: The age distribution of the study participants

Healthcare provider factors of the study participants that are likely to influence implementation of ANC
services(N=34).
About a third 12(35.29%) of the study participants
reported to have worked for a period of over five
years and nearly three quarters reported antenatal
staff number of 5 or less. The antenatal opening days
were mostly on a daily basis 27(79.41%) while fewer
than a quarter 6(17.65%) of the study participants
reported opening twice a week or on a weekly basis.
Furthermore, a great part of the study participants
29(85.29%) reported seeing on average about 30 or
less antenatal clients on each clinic day while more
than a third of these reported failing to see their
clients in time. Regarding antenatal health trainings,
nearly a third 11(32.35%) of the study participants
reported to have attended an antenatal reproductive
health training while over a half 19(55.88%) did not
receive any formal training on antenatal
implementation guidelines. Notably, more than 75%
of the study participants reported having knowledge
on antenatal service implementation guidelines and
were using antenatal service implementation
guidelines. Nearly half 15(44.12%) reported that
there were no facility interventions in place for
successful implementation of antenatal care services.
On the other hand, however, the influence of the
factors on the successful implementation of antenatal
care services did not show any statistical significance
in the bivariate logistic regression analysis p-value
set at 0.05 and 95% confidence interval. The details
are demonstrated in table 1.

25
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Table 3: The healthcare provider factors of the study participants that influence successful
implementation of ANC services
Duration in Service N (%) OR P-Value 95% Confidence Interval (CI)

Above 5 Years 12(35.29) 2.1 0.4 0.4-12.6

5 Years or less 22(64.71) 1
ANC staff number
5 Below 25(73.53) 2 0.5 0.2-19.9
Above 5 9(26.47) 1

Number of ANC Clients

Above 30 16(47.06) 2.7 0.3 0.4-17.0

30 or less 18(52.94) 1

Manage ANC clients in time

Yes 21(61.76) 1.3 0.8 0.2-8.3
No 13(38.24) 1
ANC reproductive health training
No 11(32.35) 2.5 0.3 0.5-15.1
Yes 23(67.65) 1
Formal training on implementation guidelines
Yes 15(44.12) 1.7 0.6 0.3-11.1
No 19(55.88) 1
ANC guideline knowledge
No 7(20.59) 1.4 0.8 0.1-14.0
Yes 27(79.41) 1
Use of ANC guidelines
No 8(23.53) 1.8 0.5 0.3-12.5
Yes 26(76.47) 1
Health facility interventions for successful implementation of ANC services
Yes 19(55.88) 5 0.2 0.5-48.5
No 15(44.12) 1

26
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Health facility facilitating factors and barriers for successful implementation of antenatal care
Over 80% of the study participants reported
presence of trained health workers 33(97.06%),
adequate number of health workers 30(88.24%),
availability of required stock 30(88.24%), visual
chart aids 29(85.29%) and supervision of services
29(85.29%) as some of the health facility facilitating
factors for successful implementation of antenatal
care services. Similarly, majority (over 70%)
reported presence of empowered and informed
clients 25(73.53%) and organization service
24(70.59%) as some of the health facility facilitating
factors for successful implementation of antenatal
care services while fewer than a fifth 6(17.65%) of
the study participants reported having few pregnant
women as a health facility facilitating factor for
successful implementation of antenatal care services.
On the other hand, limited number of health workers
Table 4: A demonstration of the distribution of the health facility facilitating factors and barriers for successful implementation of
antenatal care services
Kanya
and inadequate stocks were reported by over 90% of
the study participants as part of the barriers for
successful implementation of antenatal care services.
Comparably, over 50% of the study participants
reported absenteeism of health workers, having too
many clients, and clients coming late for antennal
care as part of the barriers for successful
implementation of antenatal care services.
Conversely, nearly half of the study participants
reported lack of supervision and support and having
staff not trained as some of the barriers for
successful implementation of antenatal care services
while only about a fifth 7(20.59%) of the study
participants reported forgetfulness of health care
providers as part of the barriers for successful
implementation of antenatal care services.

Yes No
Health facility facilitating factor
N(%) N(%)

Trained health workers 33(97.06) 1(2.94)

Adequate number of health workers 30(88.24) 4(11.76)

Availability of required stock 30(88.24) 4(11.76)

Few pregnant women 6(17.65) 28(82.35)

Empowered and informed clients 25(73.53) 9(26.47)

Visual aid charts 29(85.29) 5(14.71)

Supervision of services 29(85.29) 5(14.71)

Organization service 24(70.59) 10(29.41)

Facility barriers Yes No

Staff not trained 15(44.12) 19(55.88)

Limited number of health work 32(94.12) 2(5.88)

Absenteeism of health workers 20(58.82) 14(41.18)

Inadequate stocks 32(94.12) 2(5.88)

Too many clients 20(58.82) 14(41.18)

Clients come too late 19(55.88) 15(44.12)

Lack of supervision and support 14(41.18) 20(58.82)

Providers forget 7(20.59) 27(79.41)

27
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Assessment of the level of implementation of antenatal care services amongst health workers as per the
main objectives of antenatal care services stipulated in the guidelines
Only fewer than a quarter of the study participants rest had a poor implementation of antenatal care
had a fair implementation of antenatal care services services.
as reported for the services they provided while the

Bar graph demonstrating the rating of implementation of antenatal

care services
90
80
82.35
70
60
50
40
30
20
10 17.65

0
Poor Fair
Figure 3: An illustration of the rate of implementation of antenatal care services by the study participants

DISCUSSION
A few benefits of receiving proper prenatal care are
educating women about exclusive breastfeeding and
complementary feeding techniques, lowering the risk
of HIV transmission from mother to child, and being
aware of postpartum symptoms [18-21]. This study
aimed to assess the factors influencing the successful
implementation of antenatal care services in selected
health Centre IV’s in Jinja district eastern Uganda.
The study enrolled a total of 34 health workers. The
study involved an assessment of health workers for
the services they offered during antenatal care and
the factors that influence the success of their
implementation of these services. The findings of
this study revealed that implementation of antenatal
care services was evidently suboptimal in our study
setting, with only about 6(17.65%) reporting a fair
implementation of antenatal care services.
Surprisingly, the gaps in the quality of antenatal care
services have been reported in previous studies. A
study conducted in eastern Uganda by[22] reported
poor quality of antenatal care services. In this study,
the researchers pointed out a staffing gap,
inadequate infection control facilities, drugs and
supplies. Additionally, the researchers also observed
that counselling for risk factors and birth
preparedness were poorly done. Comparably,
suboptimal quality of antenatal care was also
28
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reported by studies conducted in rural health
settings in Kenya[15] and in Lao[23] reported poor
quality and performance of antenatal care services in
rural health facilities. In these studies, pregnant
mothers did not receive the recommended antenatal
care services and poor performance was due to lack
of routines, scarce or insufficient equipment and
limited skills among providers. Our study also
revealed that, duration in service above five years
(OR=2.1, p- value=0.4 and CI=0.4-12.6), having had
a formal training on the implementation of
guidelines (OR=1.7, p-value=0.6, CI=0.3-11.1), and
having facility interventions in place to successfully
implement antenatal care (OR=5, p-value=0.2,
CI=0.5-48.5) increased the likelihood of having a fair
implementation of antenatal care guidelines.
Similarly, seeing 30 or less antenatal clients on each
clinic day (OR=2.7, p-value=0.3, CI=0.4-17.0), not
having attended an antenatal reproductive health
training (OR=2.5, p-value=0.3, CI=0.5-15.1), not
having knowledge on antenatal care guidelines
(OR=1.4, p-value=0.8, CI=0.11-14.0) and none use
of antenatal care guidelines (OR=1.8, p-value=0.5,
CI=0.3-12.5) appeared to influence fair successful
implementation of antenatal care guidelines. Notably
however, these factors did not show any statistical
significance in logistic regression analysis. This
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could however be attributed to the small sample size
of our study participants. Remarkably, however,
similar factors have been reported to influence
CONCLUSION
Implementation of antenatal care services was
strikingly suboptimal and the factors that were
reported to influence antenatal care service
implementation included duration in service above
five years, seeing more than 30 antenatal clients on
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 https://www.inosr.net/inosr-applied-sciences/ Kanya

CITE AS: Akankwasa Prosper Kanya (2024). Factors Influencing Successful Implementation of
Antenatal Care Services in Selected Health Centre IV’s in Jinja District Eastern Uganda. INOSR
APPLIED SCIENCES 12(1):21-31. https://doi.org/10.59298/INOSRAS/2024/1.1.2120

31
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(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.