Factors Associated with Utilization of Preconception Care Among Pregnant Women Attending Antenatal Care at a Tertiary Hospital, Northern Uganda

Abstract

Background

Preconception care (PCC) utilization is essential for improving maternal and neonatal health outcomes, yet its uptake remains low in low-resource settings like Uganda. This study aimed to determine the prevalence and factors associated with PCC utilization among pregnant mothers attending antenatal care (ANC) at Gulu Regional Referral Hospital (GRRH), Northern Uganda.

Methods

A facility-based cross-sectional study was conducted among pregnant mothers attending the ANC clinic at GRRH. Data were collected on sociodemographic, obstetric, and PCC-related characteristics using a semi-structured questionnaire. PCC utilization was defined as receiving any PCC service before the current pregnancy. Multivariable modified Poisson regression with robust variance estimation was used to identify factors associated with PCC utilization, reporting adjusted prevalence rate ratios (PRRs) with 95% confidence intervals (CIs) and p-values. P<0.05 was considered statistically significant.

Results

A total of 366 pregnant mothers were enrolled at GRRH, with 83.1% (n=304) residing in urban areas. The prevalence of PCC utilization was 35.0% (n=128). Among PCC users, the most common services were screening for infectious diseases (58.6%, n=75) and family planning counselling (55.5%, n=71). Lack of knowledge was the primary reason for non-utilization (88.2%, n=210). In multivariable Poisson regression, unemployed mothers had a 42% lower prevalence rate of PCC utilization compared to those in formal employment (PRR = 0.58, 95% CI: 0.35–0.97, p=0.038).

Conclusion

PCC utilization among pregnant mothers at GRRH is moderate at 35.0%, with lack of knowledge as the dominant barrier and occupation as the only significant independent factor. Interventions should prioritize economic empowerment for unemployed women alongside community and facility-based education to address awareness gaps and improve PCC uptake in this post-conflict setting.

Introduction

Preconception care (PCC) represents a pivotal public health strategy aimed at optimizing the health of women and men of reproductive age prior to pregnancy.¹ PCC reduces the risk of adverse maternal, fetal, and neonatal outcomes.² By addressing modifiable risk factors such as chronic diseases, nutritional deficiencies, infectious diseases, and harmful behaviours like smoking or alcohol use, PCC can significantly mitigate the global burden of maternal mortality and morbidity.² The World Health Organization (WHO) defines PCC as a set of interventions that identify and modify biomedical, behavioural, and social risks to women’s health or pregnancy outcomes through prevention and management.² In low- and middle-income countries, where maternal mortality ratios remain alarmingly high,³ PCC offers an opportunity to prevent complications such as preterm birth, low birth weight, and congenital anomalies, which contribute to over 2.4 million neonatal deaths annually 2.3 million children died in the first month of life.⁴ Recent global health reports underscore that effective PCC could avert up to 61·2% of maternal deaths in high-burden regions by promoting early interventions.⁵ Despite these benefits, PCC is often overlooked in favour of antenatal care (ANC),² limiting its potential to enhance reproductive health equity worldwide. Whereas ANC has expanded access to skilled birth attendance and emergency care, it begins only after conception and therefore cannot address pre-existing, modifiable risks such as nutritional deficiencies or chronic disease; this gap contextualises the complementary need for PCC as an earlier, preventive point of intervention.

The importance of PCC is particularly pronounced in Sub-Saharan Africa (SSA), where maternal mortality rates are the highest globally, accounting for approximately 70% of all maternal deaths in 2023 despite representing only 25% of global live births.⁵ In this region, factors such as high rates of unintended pregnancies, infectious diseases like HIV and malaria, and nutritional deficiencies exacerbate risks during pregnancy.⁵ Studies indicate that PCC can reduce maternal anaemia by up to 30% and improve birth outcomes through folic acid supplementation and vaccination.^6,7 However, utilization rates in SSA remain low, with a meta-analysis reporting a pooled prevalence of only 18–25% among women of reproductive age.⁸ This low uptake is linked to systemic challenges, including limited access to healthcare and cultural norms that prioritize curative over preventive care.^9,10 Global health initiatives, such as the Sustainable Development Goals (SDGs), emphasize integrating PCC into primary healthcare to achieve SDG 3 targets for reducing maternal mortality to less than 70 per 100,000 live births by 2030.¹¹ Yet, progress in SSA lags, highlighting the need for context-specific strategies to scale up PCC services.

Several sociodemographic and health system factors influence PCC utilization in low-resource settings. Higher education and urban residence are positively associated with PCC uptake, as educated women are more likely to seek preventive care.¹² Conversely, barriers such as poverty, low health literacy, and partner opposition significantly hinder access, particularly in rural areas.¹³ In post-conflict regions, additional challenges like disrupted health infrastructure and displacement exacerbate these issues, leading to even lower utilization rates.¹⁴ Knowledge of PCC benefits is a key predictor, with women aware of its role in preventing adverse outcomes being twice as likely to utilize services.¹⁵ Recent studies from East Africa show that obstetric history, including previous complications, also motivates PCC seeking, though systemic shortages in trained providers limit delivery.^16,17 These factors create a complex interplay, showing the need for planned interventions to address both individual and structural determinants.

In Northern Uganda, a post-conflict region recovering from decades of civil war, maternal health challenges are compounded by fragile health systems, poverty, and cultural barriers.¹⁸ The conflict disrupted healthcare delivery, leading to high maternal mortality rates exceeding the national average of 336 per 100,000 live births.^5,19 Limited access to family planning and preventive services persists.²⁰ Previous analysis highlight how displacement and economic instability in post-conflict areas reduce uptake of health services,²¹ while community-based education programs show promise in improving awareness.²² Despite global calls for integrated reproductive health services in fragile contexts,²³ evidence on PCC in Northern Uganda remains sparse.

The existing literature reveals significant gaps in PCC research in SSA, with no published study on its utilization in Northern Uganda. While global health frameworks advocate for PCC to reduce maternal mortality,²⁴ context-specific data are needed to inform policy and interventions in tertiary hospitals serving vulnerable populations. This study, therefore, aimed to determine the prevalence and factors associated with utilization of PCC among pregnant women attending antenatal care at a tertiary hospital in Northern Uganda.

Methods

Study Design

This study employed a facility-based cross-sectional design with a quantitative approach. The study was conducted from January to November 2025 at the antenatal care (ANC) department of Gulu Regional Referral Hospital (GRRH), Northern Uganda.

Study Setting

The study was carried out at GRRH, a public tertiary referral facility located in Gulu City, Northern Uganda, approximately 332 km north of Kampala, the capital city. GRRH serves as the main referral hospital for the Acholi sub-region, covering eight districts (Gulu, Amuru, Omoro, Nwoya, Kitgum, Lamwo, Agago, and Pader) and parts of neighbouring countries including South Sudan and Democratic Republic of Congo. The hospital has a bed capacity of 370 beds and serves as a teaching hospital for Gulu University Faculty of Medicine. The ANC unit operates daily, attending to an average of 60 pregnant women per day, providing routine antenatal services, health education, and screening for pregnancy-related complications. The unit is staffed by midwives, obstetricians, nurses, and support personnel (personal communication with the hospital records personal).

Study Population and Participants

The study population consisted of all pregnant women attending the ANC clinic at GRRH during the study period. Eligible participants were pregnant women of any gestational age who were attending ANC for the first time or for follow-up visits, aged 18 years and above, and willing to provide written informed consent. Exclusion criteria included pregnant women with severe mental illness (specifically: acute psychosis, severe depressive episode, or a documented diagnosis of a severe mental disorder such as schizophrenia or bipolar disorder in the medical record) that impaired their ability to provide informed consent or participate in the interview. Eligibility on this criterion was assessed by the attending midwife or clinician on duty at the ANC clinic, based on clinical observation and the patient’s medical record, and only women whose condition was confirmed as severely impairing capacity were excluded.

Sample Size Estimation

The sample size was calculated using the Kish and Leslie formula for a finite population²⁵

Where:

Z = 1.96 (standard normal value at 95% confidence level)

P = 0.309 (estimated prevalence of PCC utilization from a similar study in Ethiopia¹²)

e = 0.05 (margin of error)

We assume a 10% non-response rate (329/0.9); the Sample size was 366 participants.

Sampling Technique

Systematic random sampling was used to select participants. On each day of data collection, the names of all eligible pregnant women attending the ANC clinic were listed from the daily register. A sampling interval (k) was calculated by dividing the total expected daily attendees by the required daily sample; a random starting point was selected within the first interval, and thereafter every k^th eligible woman on the list was approached until the daily quota was met. This procedure was repeated daily until the target of 366 participants was reached. This approach ensured representativeness of the ANC population while minimising selection bias.

Data Collection Procedure

Data were collected using a pretested, semi-structured, researcher-developed questionnaire adapted from previous studies on preconception care utilization.^9,13 The questionnaire was available in English and translated into the local Acholi language bilingually, with back-translation to ensure accuracy and cultural appropriateness. Face-to-face interviews were conducted by three trained medical students in theor clinical years of study, fluent in both English and Acholi, and trained for two days on consent procedures, confidentiality, data quality and the questionnaire content in a private area within the ANC premises to ensure confidentiality. Each interview lasted approximately 20–30 minutes. The tool captured sociodemographic characteristics (eg, age, age group, marital status, education, occupation, residence, religion), obstetric history (gravidity, parity, history of pregnancy complications), knowledge and awareness of PCC (eg, heard of PCC, source of information, belief in importance), utilization of PCC services, reasons for non-utilization, and attitudes toward PCC. Data were collected electronically using KoboToolbox (KoboToolbox; Cambridge, MA, USA; developed by the Harvard Humanitarian Initiative) on Android tablets, with daily backups to prevent data loss.

Study Variables

The dependent variable was PCC utilization, defined as receipt of any PCC service (ie, nutritional counselling, folic acid supplementation, family planning counselling, screening for infectious diseases, or management of chronic conditions) before the current pregnancy. It was measured as a binary outcome (Yes/No). Independent variables included sociodemographic factors (age group, marital status, education level, occupation, residence, religion), obstetric factors (gravidity category, parity category, history of pregnancy complications), knowledge and awareness (heard of PCC, source of information, belief in importance of PCC), and other factors (reasons for non-utilization, services received among users).

Data Management and Analysis

Data were exported from KoboToolbox, cleaned for inconsistencies and missing values, and analysed using Stata version 18.0 (Stata Corp, College Station, TX, USA). Descriptive statistics summarized participant characteristics: categorical variables were presented as frequencies and percentages, while continuous variables were reported as medians with interquartile ranges (IQR) due to non-normal distribution (confirmed by Shapiro–Wilk test). Prior to analysis, missing data were assessed: fewer than 2% of values were missing for any variable and appeared to be missing completely at random, so complete-case analysis was used. Bivariable analysis then assessed associations between independent variables and PCC utilization using Chi-square tests (or Fisher’s exact test for small expected cell counts) for categorical variables Variables with p ≤ 0.2 in bivariable analysis were included in the Modified Poisson regression analysis with robust errors since the prevalence is above 15%. Adjusted prevalence rate ratios (PRR) with 95% confidence intervals (CI) were reported. A p-value < 0.05 was considered statistically significant in the final model.

Results

Sociodemographic Characteristics, Pregnancy History, and Preconception Care Knowledge Among Pregnant Women Attending ANC at GRRH, Gulu, Uganda (n=366)

Overall, 366 pregnant mothers attending ANC at GRRH, Northern Uganda, were enrolled and completed the survey. A significant number were aged 25 to 29 years, 122 (33.3%). The majority (83.1%, n=304) resided in urban areas, and 50.5% (n=185) had attained a secondary level of education. Most participants (87.7%, n=321) were married, and 93.2% (n=341) were Christian. Regarding occupation, 59.3% (n=217) were self-employed, 26.2% (n=96) were unemployed, and 14.5% (n=53) were in formal employment.

In terms of gravidity, 32.2% (n=118) of mothers were primigravida (PG), 57.4% (n=210) multigravida (G2-4), and 10.4% (n=38) grand multigravida (G4 and above). A history of pregnancy complications was reported by 23.2% (n=85) of participants. Among the 61 mothers reporting specific complications, abortion was the most common (85.2%, n=52), followed by abnormal bleeding (9.8%, n=6), stillbirth (3.3%, n=2), and malposition (1.6%, n=1), as shown in Reasons for Non-utilization of PCC among Non-users at GRRH (n=238). Values show count (n) and % of non-users. Details in Table 1.

Table 1.

Sociodemographic Characteristics of Participants (n=366)

Variable	Frequency (n)	Percentage (%)
Age (years), Median (IQR)	25.5	22-30
Age group
<20	45	12.3
20-24	103	28.2
25-29	122	33.3
30 and above	96	26.2
Place of Residence
Rural	62	16.9
Urban	304	83.1
Education Level
Primary	103	28.2
Secondary	185	50.5
Tertiary	78	21.3
Marital Status
Married	321	87.7
Single/Divorced	45	12.3
Religion
Christian	341	93.2
Muslim	25	6.8
Occupation
Formal Employment	53	14.5
Self-Employed	217	59.3
Unemployed	96	26.2
Gravidity
Primigravida (PG)	118	32.2
Multigravida (G2-4)	210	57.4
Grand Multigravida (G5 and above)	38	10.4
History of Pregnancy Complications
No	281	76.8
Yes	85	23.2
Specific Complications (n=61)
Abortion	52	85.2
Abnormal Bleeding	6	9.8
Stillbirth	2	3.4
Malposition	1	1.6
Have You Heard of Preconception Care?
Yes	105	28.7
No	261	71.3
Source of Information (n=105)
Health Facility	71	67.6
Friends/Family	20	19.1
Media (TV, Radio, etc)	14	13.3
Do You Believe Preconception Care Is Important?
Yes	343	93.7
No	23	6.3
Utilized Preconception Care
Yes	128	35.0
No	238	65.0

Abbreviation: IQR, Interquartile Range.

Utilization of Preconception Care Among Participants

Only 28.7% (n=105) of mothers had heard of preconception care. Among these, 67.6% (n = 71) learned about it from a health facility, 19.0% (n = 20) from friends or family, and 13.3% (n = 14) from the media (TV, radio, etc). The vast majority (93.7%, n = 343) believed that preconception care was important. The prevalence of PCC utilization was 35.0% (n=128). Table 1.

Among those who utilized PCC, the most common services received were screening for infectious diseases (58.6%, n=75) and family planning counselling (55.5%, n=71), followed by nutritional counselling (16.4%, n=21), folic acid supplementation (13.3%, n=17), management of chronic conditions (8.6%, n=11), and other services (7.8%, n=10) as shown in Figure 1 below. Lack of knowledge was the dominant barrier to preconception care utilization, reported by 88.2% (n=210) of non-users, far outweighing other reasons such as unplanned pregnancy (13.4%, n=32), distance to health facility (4.2%, n=10), financial constraints (2.5%, n=6), and cultural or religious beliefs (1.3%, n=3). Details in Figure 2.

Figure 1.

Preconception Care Services Received among PCC Users at GRRH (n=128). Horizontal bar chart showing the types of preconception care (PCC) services received by mothers who utilized PCC (n=128) attending the antenatal care (ANC) clinic at Gulu Regional Referral Hospital (GRRH), Gulu, Uganda. Values for each bar represent the absolute number of respondents (n) and the percentage (%) of PCC users who reported receiving that service.

Note: Participants could report more than one service; therefore percentages do not sum to 100%.

Abbreviations: PCC, preconception care; GRRH, Gulu Regional Referral Hospital.

Figure 2.

Reasons for Non-utilization of PCC among Non-users at GRRH (n=238). Horizontal bar chart showing the reasons reported by mothers who did not utilize PCC (n=238) attending the ANC clinic at GRRH, Gulu, Uganda. Values for each bar represent the absolute number of respondents (n) and the percentage (%) of non-users who cited that reason.

Abbreviations: ANC, Antenatal Care; GRRH, Gulu Regional Referral Hospital; PCC, Preconception Care; n, number of respondents; %, percentage of the relevant denominator group (PCC users for Figure 1A; non-users for Figure 1B).

Bivariable Analysis on Factors Associated with Utilization of PCC

Table 2 presents bivariable analysis on factors associated with utilization of PCC among the 366 pregnant mothers surveyed at GRRH. PCC utilization was significantly associated with marital status (p=0.010), occupation (p=0.012), and belief in the importance of PCC (p=0.074). Variables with p < 0.20 in the bivariable analysis (place of residence, education level, marital status, occupation, history of pregnancy complications, and belief in the importance of PCC) were carried forward into the multivariable model. Among married women (n=321), 37.4% (n=120) utilized PCC, compared with 17.8% (n=8) of single or divorced women (n=45) (p=0.010). Occupation showed a significant association, with 19.5% (n=25) of mothers who utilized PCC being in formal employment compared to 11.8% (n=28) of those who did not, and 18.0% (n=23) of PCC users being unemployed compared to 30.7% (n=73) of non-users (p=0.012). Belief in the importance of PCC was also significant, with 96.9% (n=124) of mothers who utilized PCC believing it was important compared to 92.0% (n=219) of those who did not (p=0.074, Fisher’s exact test).

Table 2.

Bivariable Analysis Showing Factors Associated with Utilization of PCC

Factors	All (n=366)	Did Not Utilize PCC (n=238)	Utilized PCC (n=128)	p-value
Age (years), Median (IQR)	25.5 (22–30)	25 (22–29)	27 (23–30)	0.206
Age (years)
<20	45 (12.3)	33 (13.9)	12 (9.4)	0.493
20-24	103 (28.1)	66 (27.7)	37 (28.9)
25-29	122 (33.3)	81 (34.0)	41 (32.0)
30 and above	96 (26.2)	58 (24.4)	38 (29.7)
Place of Residence
Rural	62 (16.9)	45 (18.9)	17 (13.3)	0.171
Urban	304 (83.1)	193 (81.1)	111 (86.7)
Education Level
Primary	103 (28.1)	75 (31.5)	28 (21.9)	0.069
Secondary	185 (50.5)	119 (50.0)	66 (51.6)
Tertiary	78 (21.3)	44 (18.5)	34 (26.6)
Marital Status
Married	321 (87.7)	201 (84.5)	120 (93.8)	0.010
Single/Divorced	45 (12.3)	37 (15.5)	8 (6.3)
Religion
Christian	341 (93.2)	224 (94.1)	117 (91.4)	0.327
Muslim	25 (6.8)	14 (5.9)	11 (8.6)
Occupation
Formal Employment	53 (14.5)	28 (11.8)	25 (19.5)	0.012
Self-Employed	217 (59.3)	137 (57.6)	80 (62.5)
Unemployed	96 (26.2)	73 (30.7)	23 (18.0)
History of Pregnancy Complications
No	281 (76.8)	188 (79.0)	93 (72.7)	0.171
Yes	85 (23.2)	50 (21.0)	35 (27.3)
Source of PCC Information (n=105)
Health Facility	71 (67.6)	20 (58.8)	51 (71.8)	0.405
Friends/Family	20 (19.0)	8 (23.5)	12 (16.9)
Media (TV, Radio, etc)	14 (13.3)	6 (17.6)	8 (11.3)
Do You Believe PCC Is Important?
Yes	343 (93.7)	219 (92.0)	124 (96.9)	0.074
No	23 (6.3)	19 (8.0)	4 (3.1)
Gravidity Category
Primigravida (PG)	118 (32.2)	79 (33.2)	39 (30.5)	0.860
Multigravida (G2-4)	210 (57.4)	135 (56.7)	75 (58.6)
Grand Multigravida (G5 and above)	38 (10.4)	24 (10.1)	14 (10.9)

Note: Bold: Variables taken to multivariable analysis because their p-value is less than 0.2.

Abbreviation: IQR, Interquartile Range.

Multivariable Analysis on Factors Associated with Utilization of PCC

After adjusting for all variables meeting the p < 0.20 criterion (place of residence, education level, marital status, occupation, history of pregnancy complications, and belief in the importance of PCC) in a modified Poisson regression model with robust variance estimation, only occupation remained significantly associated with PCC utilization. Unemployed mothers had a 42% lower prevalence rate of PCC utilization compared to those in formal employment (PRR = 0.58, 95% CI: 0.35–0.97, p=0.038). Details are presented in Table 3 below.

Table 3.

Multivariable Modified Poisson Regression of Factors Associated with Utilization of PCC (PRR, 95% CI)

Factors	All n (%)	PRR (95% CI)	p-value
Age (years)
<20	45 (12.3)	Reference
20-24	103 (28.1)	1.00 (0.57–1.75)	0.993
25-29	122 (33.3)	0.84 (0.47–1.48)	0.539
≥30	96 (26.2)	0.88 (0.48–1.60)	0.668
Marital status
Married	321 (87.7)	Reference
Single/Divorced	45 (12.3)	0.54 (0.29–1.01)	0.055
Occupation
Formal employment	53 (14.5)	Reference
Self-employed	217 (59.3)	0.82 (0.57–1.17)	0.268
Unemployed	96 (26.2)	0.58 (0.35–0.97)	0.038
Place of residence
Rural	62 (16.9)	Reference
Urban	304 (83.1)	1.19 (0.76–1.86)	0.438
History of pregnancy complications
No	281 (76.8)	Reference
Yes	85 (23.2)	1.15 (0.83–1.60)	0.405
Belief that preconception care is important
No	23 (6.3)	Reference
Yes	343 (93.7)	1.98 (0.74–5.32)	0.176

Abbreviations: PRR, Prevalence Rate ratio; CI, confidence interval.

Discussion

The prevalence of PCC utilization in this study was 35.0% among pregnant women attending ANC at GRRH, Northern Uganda. This finding indicates moderate utilization, higher than the pooled prevalence of 24.05% reported in a meta-analysis across SSA,⁹ and 18.72% in Africa.²⁴ The higher rate in the present study may be attributed to the facility-based setting at a tertiary referral hospital, where women are already engaged in ANC services, potentially increasing exposure to health education and referrals compared to community-based populations. In contrast, studies in Ethiopia have reported lower rates, with a pooled prevalence 16.27%,¹² while a private-sector study in Addis Ababa found 40%,²⁶ closer to our finding. A study in Kenya found that preconception care utilization in private hospital was 35.% compared to 16.1% in rural public hospital,²⁷ while 22.3% of women in Ghana had ever utilized PCC services.²⁸ These variations suggest that access to structured health services in urban tertiary facilities like GRRH may facilitate higher uptake, while rural, community-level barriers (eg, low awareness, distance, and cultural norms) suppress utilization in broader SSA contexts.

Despite this relatively higher prevalence, the overall utilization remains suboptimal, with lack of knowledge cited as the dominant barrier. This aligns with regional evidence showing low awareness as a persistent challenge, with pooled good knowledge levels of only 33.27% in SSA.⁸ In East Africa, knowledge gaps contribute to utilization rates as low as 25.73%,⁸ while in Ghana and Nigeria, awareness levels of 34.5% and 20.61%, respectively, still result in low routine uptake.^29,30 The high belief in PCC importance in our study, yet low actual utilization, highlights a knowledge-practice gap common in SSA, where even aware women face structural and socioeconomic barriers.^15,31 These trends emphasize the urgent need for integrated community and facility-based education to translate awareness into action.

Unemployed mothers had a 42% lower prevalence rate of PCC utilization compared to those in formal employment (PRR = 0.58, 95% CI: 0.35–0.97, p=0.038). This aligns with regional findings, where formal employment provides financial stability, enabling access to services and reducing opportunity costs.¹³ In Ethiopia and Kenya, employed women had 2–4 times higher PCC uptake due to income and time flexibility.^13,26 Unemployment is prevalent in post-conflict Northern Uganda,³² correlates with poverty and limited health-seeking behavior, a pattern seen across SSA.^33,34 Similar results reported in Ghana, where being employed is associated with utilization of health services.³⁵ These findings highlight the interplay of social support and economic empowerment in driving PCC utilization in a post-conflict setting.

Single or divorced mothers had a 46% lower prevalence rate of PCC utilization compared to married mothers (PRR = 0.54, 95% CI: 0.29–1.01, p=0.055), though this did not reach statistical significance in the multivariable model. This finding is consistent with evidence from SSA, where married women benefit from partner support in reproductive decision-making, increasing PCC uptake.^34,35 In Ethiopia, husband /partner support were the identified predictors of utilization of preconception care,³⁶ similar to our findings. In contrast, single women often lack such support, facing stigma or economic constraints that deter preventive care.³⁷ Globally, similar patterns appear in high-income settings, where unmarried women report lower engagement in sexual and reproductive health services due to social isolation.^38,39 In Northern Uganda’s post-conflict context, cultural norms emphasizing male involvement in family planning may further disadvantage single/divorced women.⁴⁰ This was, however, not statistically significant. The reason for non-significance could have been due to the relatively small number of single or divorced participants (n=45, 12.3% of the sample), which limited statistical power to detect a modest effect size in the adjusted model.

Strengths and Limitations of the Study

This study benefits from a relatively large sample recruited through systematic random sampling at a major tertiary referral hospital, achieving a 100% response rate and minimizing selection bias. The use of a pretested, bilingual questionnaire administered by trained research assistants fluent in English and Acholi enhanced data quality and cultural appropriateness. Multivariable modified Poisson regression with robust variance estimation and adjustment for confounders provided robust estimates of independent associations.

However, the study had a few limitations, first, the reliance on self-reported PCC utilization, which is susceptible to recall bias and social desirability bias, potentially leading to overestimation of uptake. Secondly, the facility-based, urban-tertiary design limits generalizability to rural or community populations in Northern Uganda, where access barriers are likely greater. Lastly, the cross-sectional nature precludes causal inference which may have influenced the observed associations. Future studies should incorporate prospective designs, objective verification of service use, and qualitative methods to explore contextual barriers in greater depth.

Conclusion

Despite global and national recommendations for PCC to improve maternal and neonatal outcomes, only 35.0% of pregnant women attending ANC at GRRH utilized any PCC service before their current pregnancy. This suboptimal uptake reveals a critical gap in preventive reproductive health services in Northern Uganda.

Occupation was the only independent factor associated with PCC utilization: unemployed mothers had a 42% lower prevalence rate compared to those in formal employment (PRR = 0.58, 95% CI: 0.35–0.97). Lack of knowledge was the leading barrier, despite high belief in PCC importance. These findings highlight the need for targeted interventions, including community education, economic empowerment for unemployed women, and outreach. Strengthening PCC integration into antenatal and primary care services is essential to reduce unintended pregnancies and advance reproductive health equity in this post-conflict setting.

Funding Statement

There was no funding for this research.

Data Sharing Statement

The datasets generated and analysed during the current study, along with the corresponding Stata do-files, are available from the corresponding author upon reasonable request.

Ethics Approval and Consent to Participate

This study was approved by the Gulu University Research Ethics Committee (GUREC-2025-1188). Administrative clearance was also obtained from Gulu Regional Referral Hospital (Admin no: +256 782 047694). Written informed consent was obtained from all participants before data collection. The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.

Consent for Publication

Not applicable, as this manuscript does not contain any individual person’s data in a form that requires consent for publication.

Author Contributions

GM, FCA, RO, TS, and JO conceptualised and designed the study. GM, FCA, RO, and TS led data collection. MOO conducted the formal data analysis and drafted the initial manuscript. JO and PFP supervised the entire research process. All authors (GM, MOO, FCA, RO, TS, JO, PFP) critically reviewed, revised, and approved the final manuscript. All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declared no competing interests in this work.