Uganda is one of the countries in sub-Saharan Africa with high maternal and neonatal morbidity and mortality rates. According to the Uganda Demographic Health Survey (UDHS) 2001, the maternal mortality ratio is estimated to be 504 per 100,000 live births, with a neonatal mortality rate of 40 per 1000, and these indicators have barely changed for the last two decades. Over 90% of the population live in highly endemic areas with perennial transmission while the 10% live in low transmission areas which are prone to malaria epidemics. Children are most vulnerable to malaria, with mortality rates being highest among children under five years of age. Malaria during pregnancy contributes to high maternal morbidity and mortality as a result of its contribution to severe anaemia, low birth weight, foetal loss and still births .
The threat of malaria in pregnancy to maternal and neonatal survival in Uganda is well-recognized by local communities in the country. Occult malaria in pregnancy (womb fever) is known by the local communities to be responsible for spontaneous abortions and foetal deaths. Consequently, these complications are believed to be responsible for some of the women's emotional stress, stigma, superstition, self-hatred, indulgence, divorce and ostracization in society . One study in the country estimated the prevalence of malaria parasitaemia in pregnancy to be 62.1% , while severe maternal anaemia (Hb < 8 gdl-1) and low birth weight were found to be 18% and 12.4% respectively . Sleeping under an insecticide-treated bed net (ITN) can reduce the risk of a pregnant woman being infected with malaria and reduce the risks of maternal anaemia and low birth weight . Another preventive measure of intermittent preventive therapy with Sulfadoxine-pyrimethamine for malaria in pregnancy (IPTp-SP) in areas of high or seasonal transmission has been has been shown to increase both maternal haemoglobin levels and the infants' birth weight [5–8]. Sulphadoxine-pyrimethamine may act by treatment or prevention of new infections. The World Health Organization (WHO) recommends that all pregnant women in areas of stable malaria transmission should receive at least two doses of IPT after quickening (first noted movement of the foetus) during regularly/routinely scheduled antenatal clinic visits.
The Uganda Reproductive Health (RH) policy guidelines of 2000 recommend a schedule of a minimum four ANC visits , in which a complete antenatal care package can be delivered appropriately. According to this recommendation, a woman with an uncomplicated pregnancy is expected to make ANC visits; once in each of the first and second trimesters, and twice in the 3rd trimester. The current antenatal care package includes: health education and counselling on pregnancy and emergency preparedness, nutrition, hygiene, birth plan, postpartum care, breast feeding, sexually-transmitted infection prevention and family planning. It also involves antenatal examinations, inter-current disease treatment, routine screening for syphilis, voluntary counselling and testing for HIV, prevention of mother to child transmission of HIV (PMTCT), periodic de-worming, nutrition supplementation and tetanus immunisations . The National Malaria Control Programme priority intervention areas in 2001 included (IPTp-SP), vector control with emphasis on promoting large-scale use of insecticide-treated materials, indoor residual spraying and improved appropriate case management. Through this strategy the country expects to achieve a target of 75% pregnant women receiving complete IPTp-SP, 70% of households each with an insecticide treated net (ITN), and 100% clinical malaria cases receiving appropriate case management by the year 2010 . It was observed that on average women make only two ANC visits during pregnancy and often at late gestational ages (>28 weeks) irrespective of parity, education or economic status , resulting in poor uptake of RH services by communities . This is demonstrated by the fact that two years after implementation of the malaria in pregnancy control strategy, the two dose IPTp-SP coverage stood at only 5% in the central region despite efforts to improve these services (Quarterly PHC Monitoring Report January 2002). Pregnant women from rural areas are more likely to have placental malaria compared to women from urban areas , thus the need for more studies on antenatal care performance and IPTp-SP coverage in rural settings. A baseline community household survey was therefore conducted in rural central Uganda among women who had recently delivered to assess the use of antenatal care, maternal services, IPTp-SP and ITNs with the aim of improving uptake of an optimal antenatal care package.