Utilization and quality of antenatal care in Mathonkara area, rural Sierra Leone: A cross- sectional study

Abstract Introduction: Maternal and neonatal mortality remain major public health challenges in sub-Saharan Africa, with Sierra Leone among the affected countries. Antenatal care (ANC) is crucial for improving maternal and fetal health, yet disparities remain in both coverage and quality. This study examines ANC utilization and quality in rural Sierra Leone including factors influencing service uptake. Methods from February 25th to May 12th, 2023, we interviewed 513 women who had given birth within the past year in the Mathonkara catchment area, Tonkolili district, Sierra Leone. Structured questionnaires were used to collect data on demographics and ANC history. High quality ANC was defined as receipt of WHO-recommended ANC services including uptake of ANC visits, pregnancy drugs (e.g. iron and folic acid), injections (e.g. tetanus vaccination) and ultrasound scanning. ANC visits and uptake of ANC components were assessed using descriptive analysis. Associations between ANC uptake and socio-economic factors were explored with bivariate and multivariate analyses. Results While 86.6% of women attended ≥ 4 ANC visits, only 3.1% received all the ANC services assessed in this study. High ANC quality was received by 31.8% of the women. Only 4.9% of participants received ≥ 8 ANC visits, 20.5% received three doses of malaria prophylaxis, 42.1% received an early ultrasound, and 42.7% received two tetanus vaccinations. Women with ≥ 4 ANC visits were nearly three times more likely to receive iron and folic acid supplements, two doses of malaria prophylaxis, and ≥ 2 tetanus vaccinations. High-quality ANC was less likely among women living ≥ 9 km from a health facility (AOR = 0.52, 95% CI: 0.28–0.96) and among illiterate women (AOR = 0.70, 95% CI: 0.48–1.02), while employed women were more likely to receive high-quality ANC (AOR = 2.1, 95% CI: 0.98–4.56) Conclusion Our study highlights severe deficiencies in ANC quality in the Tonkolili district of rural Sierra Leone, with nearly no women receiving the full range of recommended services. While more ANC visits were associated with higher uptake of key interventions, overall quality remained low. Targeted interventions, such as improved infrastructure, community education, and supply-chain strengthening, are needed to ensure that ANC visits translate into comprehensive care.