Abstract / Summary
Abstract Background Adverse pregnancy outcomes (APOs) remain high in Sub-Saharan Africa. These include miscarriages, stillbirths and newborn deaths. Uganda’s neonatal mortality rate is approximately 21.3 per 1,000 live births, with a stillbirth rate of 24.4 per 1,000 total births. This is despite global and national guidelines, plus targeted programs to reduce mortality. This study identified pathways to occurrence of APOs and contributing factors amongst mothers and fathers who experienced them in eastern Uganda. Methods A secondary analysis of qualitative data was conducted between 2025 and 2026. The primary study in 2021 involved narratives with 51 purposively selected respondents. This secondary data analysis applied a thematic analysis approach. Contributing factors were later mapped against the WHO Quality of Care Standards for Maternal, Newborn and Child Health. Results Care seeking pathways were rarely straightforward. While some families never sought formal health care, others attended one facility. Frequently, there were multiple transitions between public and private facilities or facility levels, amidst deterioration of the mother or baby’s condition. Challenges identified included missed opportunities during antenatal care and poorly monitored labour. Newborn care and preterm care were inadequate, with no kangaroo mother care done. Delayed or absent referrals were common, amidst lack of emergency transport and shortages of supplies. Diagnostic and health worker competency gaps were evident, alongside disrespectful care. When mapped against WHO Quality of Care standards, evidence-based practices and competent, motivated human resources were the most common contributors to APOs, followed by functioning referral systems. Social-cultural and environmental barriers, including community births and poor danger sign recognition were key. Conclusion Reducing APOs requires integrated health system strengthening, prioritizing evidence-based clinical practice and a competent, motivated workforce. This should be paired with functional referral and transport systems, consistent supplies and respectful maternity care, especially in rural, lower-level and private facilities. Many outcomes are rooted in factors manageable earlier, during antenatal care, making this a critical entry point. Enhancing community health literacy and behavioral change will improve danger sign recognition. Bridging the gap between guidelines and frontline care is essential to improving outcomes for mothers, babies and families, and receiving care is a human right.