A Theory of Change to Increase First Trimester Antenatal Care (Anc1) Attendance at Nsiika Health Centre IV, Buhweju District, Uganda

Abstract

Early initiation of antenatal care (ANC) during the first trimester is a critical determinant of maternal and neonatal health outcomes. However, despite national and World Health Organization recommendations, first-trimester antenatal care (ANC1) attendance remains suboptimal in many rural settings in Uganda. At Nsiika Health Centre IV in Buhweju District, only 62% of pregnant women initiated ANC within the first trimester in 2025, indicating persistent gaps in timely maternal health service utilization. This paper presents a context-specific Theory of Change (ToC) developed to improve first-trimester ANC attendance at Nsiika Health Centre IV by addressing locally relevant socio-cultural, geographical, and health system barriers influencing maternal health-seeking behavior. This study aimed to design a practical, evidence-informed framework to guide district-level interventions for increasing early ANC uptake and improving maternal and neonatal outcomes. The ToC was developed using routine District Health Information Software (DHIS2) data, facility performance reviews, maternal health indicators, and district health priorities. Key barriers identified included delayed pregnancy confirmation, limited community awareness of early ANC benefits, long distances to health facilities, and inadequate community-level follow-up. The proposed framework integrates community-based strategies such as Village Health Team (VHT) engagement, home-based pregnancy screening using human chorionic gonadotropin (HCG) tests, targeted health education, and integrated community outreaches with facility-level interventions focused on improving service readiness, client experience, and continuity of care. The Theory of Change assumes that early identification of pregnancy, strengthened community facility linkages, and improved service responsiveness will lead to timely ANC initiation, increased institutional deliveries, and improved maternal and neonatal outcomes. By tailoring interventions to the Nsiika context, this ToC provides a scalable model for improving early ANC uptake in rural, resource-constrained settings and supports district efforts to increase ANC1 attendance to 95% by 2027.