Maternal mortality remains a substantial public health challenge in low- and middle-income countries. Sudan has one of the highest maternal mortality ratios globally. Antenatal care (ANC) is a core intervention to detect and manage pregnancy-related complications, deliver preventive measures and provide health education. Previous Sudanese studies have focused on coverage and utilisation; evidence on the content and women’s perceptions of ANC quality is limited. This study aimed to assess women’s perceived quality of ANC in public primary healthcare centres in Khartoum State, evaluating both the technical service provision and the experience of care.
This was a facility-based cross-sectional study conducted from 30 October to 29 November 2023. The study used a standardised, previously validated questionnaire adapted for the local context. Interviews were face-to-face and conducted by trained data collectors after obtaining verbal and written informed consent. The questionnaire captured sociodemographic and obstetric information and items assessing the content and experience of ANC. Data entry and analysis were performed using SPSS V.26.
The study took place in public primary healthcare centres providing ANC services in Khartoum State, which comprises seven localities and, at the time of the study, 432 functional primary healthcare centres. Eligible participants were women who had attended at least one ANC visit at the selected centres and whose most recent pregnancy had ended within the previous 12 months (live births, stillbirths or miscarriages at ≥24 weeks). Women with ongoing pregnancies, pregnancies ending more than 12 months earlier, or those unable to participate were excluded. The final sample included 473 women.
A multistage cluster sampling approach was used. Three localities (Khartoum, Bahri and Omdurman) were randomly selected from the seven in the state. From each locality, three public primary healthcare centres were randomly selected, for a total of nine centres. Within selected centres, consecutive sampling was used to recruit eligible attendees until the allocated sample size was reached. The final sample size (n=473) was calculated using Cochran’s formula with a 95% confidence level, 5% margin of error, assumed proportion 0.5 and an allowance for non-response and design effect.
The instrument was adapted from validated ANC quality assessment tools, translated into Arabic and back-translated into English. Public health and ANC experts reviewed the translation; the questionnaire was pilot-tested on 30 women not included in the final sample, and minor wording adjustments were made. Data collectors received training; daily supervision and review of questionnaires were performed, and data entry was double-checked to reduce errors.
Primary outcomes were two continuous scores derived from self-reported items: a service provision score (maximum 56) and a care experience score (maximum 84). Descriptive statistics (means, SDs, frequencies and percentages) described participant characteristics and item-level responses. Linear regression models examined associations between independent variables (residency, education, occupation, marital status, parity and age) and the two outcome scores. A p value <0.05 was considered statistically significant.
Among the 473 participants, mean age was 29.39 years (SD 6.19). The majority lived in urban areas (81.4%) and were housewives (79.3%). Nearly all were married (98.5%). Educational distribution included 44.2% with university or college degrees, 19.7% with secondary education and 16.1% who were illiterate. Most participants were multiparous (78.4%), and 81.4% initiated ANC in the first trimester. Pregnancy outcomes were predominantly live births (91.1%), with 6.8% reporting abnormal outcomes and 2.1% reporting stillbirths.
Service provision was assessed by women’s self-report of services received during ANC visits. The mean service provision score was 19.96 ± 3.03 out of 56, indicating below-average provision across the measured items. Specific findings:
Height measurement was infrequent: 85.0% reported that their height was not measured during ANC visits.
Weight measurement was also often omitted: 64.5% reported no weight measurement, and only 17.3% reported weight being measured at every visit.
Laboratory investigations were more commonly provided: blood tests at every visit were reported by 87.1% and urine tests at every visit by 82.5%.
Ultrasound examination was reported at every visit by 88.4% of women; smaller proportions reported occasional or no ultrasound.
Preventive interventions varied: 52.6% received tetanus toxoid during the index pregnancy, 30.4% had completed tetanus vaccination prior to pregnancy, and 11.2% reported receiving no tetanus vaccination at all. Iron supplementation was widely reported (93.2%).
Overall, while many women received key investigations and ultrasound, consistent delivery of the full recommended ANC package and routine measurement of clinical parameters (height and weight) were uncommon.
The mean care experience score was 58.68 ± 8.22 out of 84. Findings on communication and client experience included:
Understanding: 74.0% of participants reported understanding the purpose of tests performed during ANC.
Patient voice: 87.3% felt free to ask questions during visits.
Counselling gaps: only half of women were told about signs of pregnancy complications and approximately one-third were informed about where to go if complications occurred.
Measurement communication: only 29.2% of women reported being informed of their weight.
These results indicate acceptable levels of some aspects of interpersonal communication (e.g., opportunity to ask questions) but shortcomings in structured counselling and information provision about danger signs and referral pathways.
Linear regression identified sociodemographic associations with perceived ANC quality:
Service provision score: being married and older age had significant positive associations with higher perceived service provision (p=0.004 and p=0.003, respectively).
Care experience score: older age was positively associated with better experience (p=0.038). Conversely, rural residency (p=0.044), being illiterate (p<0.001), having only primary education (p=0.002) and nulliparity (p=0.019) were significantly associated with lower care experience scores.
These associations suggest inequities in perceived quality related to residence, education and parity.
Strengths of the study include a dual-dimensional framework assessing both technical provision and experiential elements of ANC, a multistage cluster sampling design with a sample size calculated to support regression analyses, use of an adapted and validated questionnaire, expert review and pilot testing, and procedures for data quality assurance. Limitations include reliance on retrospective self-reported data up to 12 months after pregnancy—introducing potential recall bias—and limited generalisability because the study sampled women attending public primary healthcare centres and may not reflect care in private facilities or among women who do not seek ANC.
Women attending public primary healthcare centres in Khartoum State reported below-average perceived quality of ANC in both service provision and care experience. Measured gaps included infrequent routine anthropometry (height and weight), variable uptake of tetanus vaccination and counselling deficits regarding danger signs and referral. Sociodemographic disparities affected perceptions: younger, rural, less-educated and nulliparous women reported poorer experience. The authors recommend further investigation of the identified factors and targeted quality-improvement interventions to strengthen both the technical components and the communication/counselling aspects of ANC in these settings.
(Data availability: datasets are available from the corresponding author upon reasonable request.)