Introduction: The fifth millennium development goal aims at reducing maternal mortality by 75% by the year 2015[1].

According to the WHO, there was an estimated 358,000 maternal deaths globally in 2008. Developing countries accounted for 99% of these deaths of which three fifths occurred in Sub-Saharan Africa where Uganda lies [2]. Abortion, obstetric complications such as hemorrhage, dystocia, eclampsia, sepsis and infections such as tuberculosis and HIV are the major causes of maternal deaths in developing countries[3]. Although antenatal care (ANC) is not in itself very effective in reducing maternal mortality, it provides an entry for interventions which give health workers the opportunity to detect these risky conditions and therefore refer them for early management leading to better maternal outcomes[4]. ANC involves screening for health and socioeconomic conditions likely to increase the possibility of specific adverse pregnancy outcomes, providing therapeutic interventions known to be effective and educating pregnant women about planning for safe birth, emergencies during pregnancy and how to deal with them [5]. ANC is therefore relevant for the improvement of maternal health as it enables the monitoring of the health of the mother and anticipation of any difficulties during pregnancy, labor and birth [6]. Some studies have estimated that ANC alone can reduce maternal mortality by 20% [7] given good quality and regular attendance. In addition ANC attendance during pregnancy has been shown

to have a positive impact on the use of postnatal healthcare services, which also play a key role in detecting risky conditions after child birth consequently leading to better maternal health outcomes[8]. WHO evidence shows that four ANC visits are sufficient for uncomplicated pregnancies and more are necessary only in cases of complications[9]. The WHO, therefore recommends four visits, however in developing countries, many women do not attend all the four visits [10] [11]. This has been attributed to poor accessibility, inability to afford the costs of seeking care, cultural barriers and lack of knowledge or illiteracy [12] [13]. The quality of ANC is critical in enabling women and health workers identify risks and danger signs during pregnancy which should lead to appropriate action[14]. Whether or not women can identify danger signs during pregnancy and act appropriately depends on quality aspects such as the depth of the information and counseling given during an ANC visit[15]. Provision of quality ANC service requires the presence of relevant Infrastructure, adequate trained health workers, infection control facilities, diagnostic equipment, supplies and essential drugs. Furthermore, the ANC process requires the use of guidelines that health providers should follow while offering care to ensure prevention, diagnosis and treatment of complications[16].

This study assessed the quality of ANC services by looking at the health facilities capacity to deliver ANC services, the completeness of the ANC consultation process and patient satisfaction with ANC services offered. maternal health services using vouchers. Previous studies: Christoph Boller et al (2003) in Tanzania compare the quality of public and private first-tier antenatal care services using defined criteria Structural attributes of quality were assessed through a checklist, and process attributes, including interpersonal and technical aspects, through observation and exit interviews. A total of 16 health care providers, and 166 women in the public and 188 in the private sector, were selected by systematic random sampling for inclusion in the study. Quality was measured against national standards, and an overall score calculated for the different aspects to permit comparison. Findings The results showed that both public and private providers were reasonably good with regard to the structural and interpersonal aspects of quality of care. However, both were poor when it came to technical aspects of quality. For example, guidelines for dispensing prophylactic drugs against anemia or malaria were not respected, and diagnostic examinations for the assessment of gestation, anemia, and malaria or urine infection were frequently not performed. In all aspects, private providers were significantly better than public ones. [17]

Nicholas N A Kyei1,3 et al ( 2005) Zambia in analyzed two national datasets with detailed antenatal provider and user information, to describe the level of ANC service provision at 1,299 antenatal facilities and the quality of ANC received by 4,148 mothers Between 2002 and 2007. Results: We found that only 45 antenatal facilities (3%) fulfilled our developed criteria for optimum ANC service, while 47% of facilities provided adequate service, and the remaining 50% offered inadequate service. Although 94% of mothers reported at least one ANC visit with a skilled health worker and 60% attended at least four visits, only 29% of mothers received good quality ANC, and only 8% of mothers received good quality ANC and attended in the first trimester. Br J Obstet Et al (1999) in UK a pilot list of indicators of quality of antenatal care across a range of maternity care settings. For each indicator to determine what is achieved in current clinical practice, to facilitate the setting of audit standards and calculation of appropriate sample sizes for audit. RESULTS: Nine of the eleven suggested indicators were successfully piloted. Two indicators require further development. In seven of the nine hospitals external cephalic version was not commonly performed. There were wide variations in the proportions of women screened for asymptomatic bacteriuria. Screening of women from ethnic minorities for haemoglobinopathy was more likely in hospitals with a large proportion of non-caucasian women. A large number of Rhesus negative women did not have a

Rhesus antibody check performed after 28 weeks of gestation and did not receive anti-D immunoglobulin after a potentially sensitising event during pregnancy. As a result of the study appropriate sample sizes for future audit could be calculated. [18] Delvaux, T. et al (2008) in Cote d'Ivoire assess whether implementation of a

prevention of mother-to-child HIV transmission (PMTCT) programme in Cote d'Ivoire improved the quality of antenatal and delivery care services. METHODS: Quality of antenatal and delivery care services was assessed in five urban health facilities before (2002-2003) and after (2005) the implementation of a PMTCT programme through review of facility data; observation of antenatal consultations (n = 606 before; n = 591 after) and deliveries (n = 229 before; n = 231 after) and exit interviews of women; and interviews of health facility staff. RESULTS: HIV testing was never proposed at baseline and was proposed to 63% of women at the first ANC visit after PMTCT implementation. The overall testing rate was 42% and 83% of tested HIV-infected pregnant women received nevirapine. In addition, inter-personal communication and confidentiality significantly improved in all health facilities. In the maternity ward, quality of obstetrical care at admission, delivery and post-partum care globally improved in all facilities after the implementation of the programme although some indicators remained poor, such as filling in the partograph directly during labour. Episiotomy rates among

primiparous women dropped from 64% to 25% (P < 0.001) after PMTCT implementation. Global scores for quality of antenatal and delivery care significantly improved in all facilities after the implementation of the program me [19] Fekede, B et al(2007) in Ethiopia assess antenatal care service utilization and factors associated with antenatal care non attendance. METHODS: A community based cross-sectional study was conducted among pregnant women from January 26 to February 06, 2006 in Jimma Town, Jimma zonal administration south west Ethiopia. Structured interviewer administered questionnaire was used for data collection. The data collected on study variables were tabulated in frequency tables and significance of association between variables was tested using chi2--test of significance. RESULT: A total of 360 pregnant women were enrolled in the study. The study, revealed that about 76.7% of the women have attended antenatal care and 23.3% have not attended at all. Literacy status, income, Gravidity, Religion and occupation showed statistically significant association (P < 0.05) with utilization of antenatal care. But marital status, Ethnicity and parity showed no statistically significant association (P > 0.05) with antenatal care utilization. The study showed that about 42.8% of the attendants have made their first antenatal visit in the 3rd trimester of pregnancy. Out of the total only 6.5% the studied women had the recommended four visits. Women in the age group 15-24 are more

likely to attend ANC 2.75 times larger than that of women in the age group 25-34 (OR = 2.74, 95% CI: 1.37, 4.38). Similarly others (students and farmers) are about four times likely to attend ANC than House wives (OR = 4.06. 95% CI: 1.50, 11.40). [20] Khatun, S. et al (2008) in Dhaka, Bangladesh studied Four hundred and sixtyfive pregnant women and their newborn babies were at a maternal and child health training institute, between July 2002 and June 2003 with the objective of (1) examining the relationship between birth weight and maternal factors, and, if there was a dose-response relationship between quality of antenatal care and birth weight, (2) predicting the number of antenatal visits required for women with different significant characteristics to reduce the incidence of low-birth-weight babies. The study revealed that 23.2% of the babies were of low birth weight according to the WHO cut-off point of <2500 g. Mean birth weight was 2674.19+/425.31 g. A low birth weight was more common in younger (<20 years) and older (> or =30 years) mothers, the low-income group and those with little or no education. The mean birth weight of the babies increased with an increase in quality of antenatal care. The babies of the mothers who had 6+ antenatal visits were found to be 727.26 g heavier than those who had 1-3 visits and 325.88 g heavier than those who had 4-5 visits. No significant relationship was found between number of conception, birth-to-conception interval, BMI at first visit, sex

of the newborn and birth weight. Further, from multiple regression analysis (stepwise), it was revealed that number of antenatal visits, educational level of the mother and per capita yearly income had independent effects on birth weight after controlling the effect of each variable. Using multiple regression analysis, the estimated number of antenatal visits required to reduce the incidence of low-birthweight babies for women with no education and below-average per capita income status was 6; the number required for women with no education and above-average per capita income status was 5; and that for women with education and with any category of income status was 4 visits. [21]

General objective: To access perception of pregnant women and providers about Quality off Antenatal care. Specific Objectives:

To access availability of service To access availability of drugs To access availability of infrastructure To reduce infant mortality, Preventing people from dying prematurely. Ensuring that people have a positive experience of care. Justification:

This study gives important baseline information that could be used in informing the intervention design and implementation of projects that seek to improve maternal health.

Treating and caring for people in a safe environment and protecting them from avoidable harm.

Methodology: Type of study: Descriptive cross section study Study population : There are 1107 pregnant women in Khartoum state receiving antenatal care services every month in public health centers The study populations are all pregnant women in reproductive age attending antenatal clinic in 5 public health centers (Alshajara , Alremaila, Algoz, Alamab, Almygoma Health centers). Sample size determination: n=N/1+n (e) 2 n=sample size N=population size in last month who attending antenatal care in clinics of health centers. 5 health centers=350 e=margin of error=0, 05 n=350/1+350/,0025 n=187 Data Colletion: Data will be collected via questionnaire.

Plan for analysis: Data will entered spss program , statistical significant will tested by using chi squired test and using proportion between sub groups and mean and stander diviation. Ethical Issues

References: 1. Bhutta ZA . Countdown to 2015 decade report (2000-10): taking stock of maternal, newborn, and child survival. Lancet. . 2010. 5;375((9730)): p.:2032-44. . 2. WHO. Trends in Maternal Mortality: 1990 to 2008, Estimates developed by WHO, UNICEF, UNFPA and the World Bank. World Health Organisation. . 2010. 3. Eijk, v., . Use of antenatal services and delivery care among women in rural western Kenya: a community based survey. Reproductive Health. 2006;(3(1): ): p. 2. 4. MagadiM, Factors associated with unfavourable birth outcomes in Kenya. Journal of Biosocial Science.; : . 2001. 33((02)): p. 199-225. 5. WHO. WHO, programme to map best reproductive health practices. WHO/RHR/01. 30,(W). 2002. 6. Wirth, M., "Delivering" on the MDGs?: Equity and Maternal Health in Ghana, Ethiopia and Kenya. East African Journal of Public Health. . 2008; . 5:((3)): p. 133-141. 7. Nikiema, Quality of Antenatal Care and Obstetrical Coverage in Rural Burkina Faso. . . 2010. Vol. 28.

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Chakraborty, N., et al., Utilisation of postnatal care in Bangladesh: evidence from a longitudinal study. Health Soc Care Community, 2002. 10(6): p. 492-502.

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Khatun, S. and M. Rahman, Quality of antenatal care and its dose-response relationship with birth weight in a maternal and child health training institute in Bangladesh. J Biosoc Sci, 2008. 40(3): p. 321-37.