Date of Award

May 2023

Degree Type


Degree Name

Doctor of Philosophy


Public Health

First Advisor

Emmanuel M Ngui

Committee Members

Young Cho, Amy Harley, Kaboni Gondwe, Musa Yahaya


Background: Quality of health care is an emerging concern across many low-and-middle-income countries. Particularly, there is limited empirical guidance in measuring Antenatal care (ANC) quality and its influence on maternal health promotion practices.

Purpose: The overall aim of this three-paper dissertation is to examine the relationship of ANC quality on three maternal child health promotion practices outcome measures, which included child vaccination, appropriate diarrhea prevention practices, and breastfeeding, in three neighboring East African countries of Kenya, Uganda, and Tanzania.

Methods: Data from the latest demographic and health survey (DHS) program for Kenya (2014), Uganda (2015) and Tanzania (2015/16) were used in this study. The main dependent variable -maternal child health promotion practices consisted of three separate measures, a) full child vaccination, b) appropriate diarrhea prevention practices, and c) breastfeeding (early initiation of breastfeeding [EIBF], exclusive breastfeeding [EBF] & continued breastfeeding [CBF] past six months). The main independent variable, ANC quality, was assessed using two measures a) ANC utilization, and b) essential ANC health promotion care practices (ANC HPCPs). While the level of ANC utilization focused on the extent to which the women engaged with the healthcare system (skilled care), the essential ANC HPCPs focused on the nature of interaction with the care providers by examining the type and level of care received across the pregnancy period. The analysis in all papers follow the same format beginning with descriptive statistics, bivariate analysis comparing the outcomes and other predictor variables and the results presented as crude(unadjusted) odds ratios and 95% confident intervals. Finally, multilevel binary logistic regression models to test the main hypothesis while adjusting for other covariates were conducted using Stata 16SE.

Results: The findings of this dissertation suggest that ANC quality is significantly associated with the various maternal health promotion practices tested in each of the three papers. While the association between ANC quality and each of the outcomes was comparable across all countries, the level of significance varied by country. Overall, the analysis of the pooled data showed that intermediate and adequate levels of ANC utilization were associated with higher odds of full vaccination compared to poor ANC utilization. Women with adequate ANC utilization had about six times greater odds of having their children fully vaccinated as compared to those with poor ANC utilization [AOR:5.90; 95% CI:(2.27,15.32)]. Moreover, the odds of full vaccination increased by 32% with every score on the number of essential ANC HPCPs [AOR: 1.32; 95% CI:(1.16,1.51)]. Similarly, women who had intermediate [AOR:1.31: 95% CI: (1.18,1.46)], and adequate ANC utilization, [AOR: 1.41; 95% CI: (1.23,1.63)], had greater odds of practicing appropriate diarrhea prevention measures. In addition, for every score in essential ANC HPCPs during pregnancy visit, the odds of women’s diarrhea prevention practices increased by 16% [AOR:1.16; 95% CI: (1.13,1.20)]. Finally, across all breastfeeding outcomes, majority of women had poor ANC utilization while the least had adequate ANC utilization. Adequate ANC utilization was significantly associated with 18% greater odds of early initiation of breastfeeding (EIBF) compared to poor ANC utilization [AOR:1.19; 95% CI (1.02,1.39)]. Although women with intermediate level of ANC utilization had significantly lower unadjusted odds (COR: 0.88; 95% CI (0.78,0.99) of exclusive breastfeeding (EBF) compared to those with poor ANC utilization, the association was not significant in the fully adjusted EBF model (AOR: 1.51; 95% CI (0.87,2.64). Compared to women with poor ANC utilization, women with intermediate [AOR: 1.74; 95% CI (1.07,2.85)] and adequate [AOR: 2.39; 95% CI (1.18,4.81)] ANC utilization had 74% and more than twice the odds of continued breastfeeding (CBF) past 6 months.

Conclusion: The findings provide additional evidence justifying the benefits of ANC quality on the health and growth trajectory of the child, especially in estimating the early initiation and progress in breastfeeding, vaccination coverage, and practice of diarrhea prevention measures. The findings also suggest that low maternal ANC service utilization may be an indication of future poor health seeking habits for children care services. Highlighting the importance of quality ANC and the possible social and structural factors that influence women decisions and child-health promotion practices is a step towards better child health and, eventually, reducing maternal and child mortality.

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