Uganda has one of the highest maternal deaths with a mortality ratio of 336 per 100,000 live births, mostly in{FormattingCitation} rural, resource limited, hard-to-reach settings [1]. Maternal deaths are often from hemorrhage, hypertension, sepsis, unsafe abortions and other indirect causes like malnutrition, HIV, malaria, poor utilization of health services, poor quality care, critical shortages of skilled attendants and socio-cultural, economic factors [2,3,4].
Components of antenatal care (ANC), involving investigations and interventions by a Midwife, Nurse or Doctor on a pregnant woman are important in averting maternal deaths [5, 6]. The current Uganda clinical guidelines recommend at least four goal oriented ANC visits, far below the current WHO recommendations of at least eight contacts for a positive pregnancy experience and reduction of perinatal mortality [7, 8]. The ANC visits should provide components of care that include blood pressure measurement, fetal growth monitoring, urine testing, iron-folic acid supplementation, tetanus vaccination, at least three doses of Intermittent Preventive Treatment with Sulphadoxine/pyrimethamine (IPTp), deworming after the first trimester, blood group typing if not done previously, HIV and syphilis testing [7]. The 2016 Uganda demographic and Health survey indicates that almost all women from island communities with a childbirth during the preceding 5 years, had at least one ANC visit [1]. However, ANC visits attendance per se doesn’t directly translate into receipt of care components, yet these impact on the quality process, affecting subsequent visits, cost of care, skilled birth attendance and eventual prevention of maternal-child deaths [9,10,11,12].
Per the Avedis Donabedian model for quality of care [13], ANC components may be an important element in assessing quality, especially in situations where there is a barely adequate availability of structural inputs. Blood pressure measurement aids the diagnosis, prevention, and management of hypertensive conditions of pregnancy including chronic hypertension, gestational hypertension, preeclampsia, eclampsia, and preeclampsia superimposed on chronic hypertension [14]. Urine testing is key in the early diagnosis, prevention and management of urinary tract infections, gestational diabetes, preterm labor, low birth weight and pre-eclampsia [14, 15]. Urine testing also facilitates decisions to start ANC through early diagnosis of pregnancy [16]. ANC tetanus vaccination injections help prevent the fatal tetanus among women and their babies. Blood sample provision helps in screening and prompt management of anemia which can lead to low birth weight and maternal mortality [17]. Maternal infections detrimental to the woman and her unborn baby like malaria, hepatitis B, syphilis, HIV, gonorrhea and chlamydia are identified early during pregnancy through provision of a blood sample [18,19,20,21,22]. HIV testing during antenatal care, often done through blood samples is an entry point to elimination of mother to child HIV transmission (eMTCT), prevention and treatment for the partner and community at large. Provision of deworming treatment helps treat maternal infections that also have effects on the unborn baby, especially in helminths endemic areas [23]. Iron and folic acid supplementation is key in preventing anemia, including adverse effects of postpartum hemorrhage, preterm births and low birth weight babies [24]. Some components of ANC like counseling help improve early initiation of exclusive breast feeding, uptake of childhood immunization and attendance of postnatal care.
Women in hard to reach geographically isolated locations like island fishing communities (FCs) on Lake Victoria, may be at increased risk of maternal death due to inadequate or no provision of care components during ANC visits [25]. These island fishing communities are considered.
hard to reach, resource limited settings, due to maritime challenges and rural location.
Kalangala district has 64 habitable islands FCs with only 17 health facilities (mainly level II and III) serving these islands, of which none is a hospital [26]. There is poor geographic accessibility across one island to another with a health facility, often the nearest health facility being 8–12 km away. The cost of transporting a mother who needs ANC and delivery is about 55 US dollars, which includes hiring a boat with an engine, a coxswain and buying fuel for the trip [27]. Kalangala district also has a shortage of skilled birth attendants (Doctor, Nurse and Midwife), with only 16.4 skilled birth attendants per 10,000 people, still far below WHO target for sustainable development [26, 28, 29].
We assessed the components of care received by women in these island fishing communities, to inform antenatal care services provision among these hard to reach settings.