Maternal mortality remains a major public health concern in low-resource settings, particularly in sub-Saharan Africa. According to the World Health Organization (WHO), nearly 99% of maternal deaths occur in countries with limited access to quality care [1]. In the Democratic Republic of Congo (DRC), the maternal mortality ratio is estimated at 473 deaths per 100,000 live births [2], a figure that reflects persistent gaps in the health system and the urgent need for targeted interventions.

Antenatal care (ANC) is widely recognized as a key strategy to reduce maternal and neonatal morbidity and mortality. The WHO recommends at least 8 prenatal visits, with the first ideally occurring before 12 weeks of gestation [3]. Early and high-quality ANC enables timely screening, prevention of complications, and health education. However, in the DRC, fewer than 8% of pregnant women initiate ANC in the first trimester [4], and many consultations are conducted by providers lacking formal medical training [5].

The Malemba Nkulu health zone, located in the rural province of Haut-Lomami, exemplifies these challenges. It was selected for this study due to its high maternal risk profile, limited access to qualified health personnel, and absence of recent data on ANC quality. Preliminary data from this region reveal that over half of pregnant women (52.4%) attend their first ANC visit in the third trimester, limiting the effectiveness of preventive measures. Additionally, nearly 43% of consultations are conducted by traditional birth attendants without advanced medical qualifications, and more than 60% of health facilities lack essential equipment for complete prenatal assessments, including tests for anemia and maternal infections [6]. These findings suggest that the quality of the first antenatal consultation (ANC1) may be a critical determinant of maternal outcomes. While previous studies in West Africa have linked ANC quality to provider training, infrastructure, and community engagement [7], few have examined this issue in depth within the DRC. Evidence from Rwanda and Ethiopia shows that integrating ANC into community health programs and investing in provider capacity can significantly improve maternal care [8].

This study aims to assess the quality of the first antenatal consultation in the Malemba Nkulu health zone using national and international standards as benchmarks. It seeks to identify structural, procedural, and contextual factors that influence care quality and to inform strategies for improving maternal health in rural Congolese settings.

This study used a descriptive cross-sectional design to assess the quality of ANC1s in the Malemba Nkulu health zone. The study was conducted over a 2-month period from November to December 2023. This design was selected to provide a snapshot of service delivery and identify gaps in compliance with national and WHO standards.

This study took place in the Malemba Nkulu health zone, located in the rural province of Haut-Lomami in southeastern DRC. The area is characterized by limited access to qualified health personnel, inadequate infrastructure, and high maternal risk indicators, making it a relevant setting for evaluating ANC quality.

This study used a mixed sampling approach, combining probabilistic and nonprobabilistic techniques to ensure both representativeness and feasibility in a resource-limited rural context.

Data were collected using a standardized observation grid adapted from national guidelines and WHO recommendations. Ten key dimensions of ANC1 were assessed, as outlined in Table 1.

Each consultation was directly observed by trained data collectors. Medical records were reviewed to confirm procedures, and structured interviews were conducted with pregnant women to assess their perceptions of care.

Independent variables included the following: (1) type of health facility (health center or general hospital), (2) provider profile (level of qualification and professional experience), (3) patient characteristics (age, education level, parity, and trimester of pregnancy at the time of ANC1), (4) availability of resources (medical equipment and access to laboratory tests), and (5) accessibility of care (distance from home to facility and consultation cost).

Dependent variables included the following: (1) overall conformity of the consultation (compliant or noncompliant), (2) completion of clinical and laboratory examinations, (3) quality of information provided to the patient (nutrition, danger signs, and birth planning), (4) preventive and curative interventions (prescription of iron or folic acid, tetanus vaccination, and malaria treatment), and (5) patient satisfaction (reception, waiting time, cost, and quality of counseling received).

Missing data were identified through systematic review of observation grids and medical records. Completely missing data were excluded from the analysis, and partially missing data were imputed using weighted averages and predictive modeling. Sensitivity analyses were conducted to assess the impact of missing data on key indicators.

Data were entered and analyzed using SPSS version 25.0 (IBM Corporation). Descriptive statistics were used to calculate frequencies, proportions, means, and SDs. The results were stratified by facility type and provider qualification, and 95% CIs were calculated for key indicators. P values were reported where applicable, with statistical significance set at P<.05.

This study was conducted in full compliance with the ethical principles outlined in the Declaration of Helsinki and the guidelines of the National Ethics Committee of the Democratic Republic of Congo. Ethical approval was obtained from the Ethics Committee of the School of Public Health at the University of Kinshasa, under reference number ESP/CE/099/2023, in accordance with institutional procedures.

Before any data collection, written informed consent was obtained from each pregnant woman included in the study, following a clear explanation of the study’s objectives and participation procedures. Participation was entirely voluntary, with no form of pressure or financial or material incentive.

Data confidentiality was ensured through anonymized records and the use of secure identification codes. All data were stored in protected files, accessible only to authorized members of the research team.

The authors declare no conflicts of interest related to this research. The study is part of a broader effort to strengthen local maternal public health capacities and to promote medical practices in rural settings.

The findings of this study revealed that only 2% of ANC1s met minimum quality standards in the Malemba Nkulu health zone. This reflects broader systemic challenges in rural maternal health care, including limited provider training, lack of diagnostic tools, and delayed access to care.

Similar challenges have been documented in other Central and West African contexts. In Lubumbashi, DRC, a study found that only 0.2% of pregnant women initiated ANC in the first trimester, and most consultations were conducted by nurses with limited qualifications [9]. In Mali, research conducted in Sélingué highlighted gaps in counseling and continuity of care, despite satisfactory physical examinations and reception [10]. Another study in Bougouni emphasized the importance of integrating ANC into reproductive health programs and strengthening provider training [11].

These regional findings reinforce the relevance of our results and suggest that targeted interventions—such as community-based outreach, provider certification, and subsidized diagnostic services—could improve ANC quality across similar settings. They also support evidence from Rwanda and Ethiopia, where continuous training and integration of ANC into community health systems have led to measurable improvements in maternal outcomes [12,13].

The results obtained in this study are consistent with those reported in other research in sub-Saharan Africa. For example, a study conducted in Nigeria showed that more than 60% of antenatal consultations were carried out by unqualified personnel, leading to insufficient follow-up [14]. Research in Ghana has shown a direct link between the quality of antenatal consultations and obstetric complication rates [15]. Additionally, in Rwanda and Ethiopia, the quality of antenatal care has improved considerably thanks to policies targeting continuous training of providers and integration of antenatal services into community care [12,13]. These successes suggest that adapted strategies could be implemented in the DRC to improve the effectiveness of prenatal consultations and reduce maternal morbidity [16].

Among the main causes of the insufficient quality of prenatal consultations in the health zone studied, the following elements stand out:

These results highlight the urgency of implementing strategies to strengthen the quality of prenatal care. Among the possible measures, several recommendations can be made, including:

The study highlights several challenges related to the quality of antenatal consultations in the Malemba Nkulu health zone. These findings underscore the need for concrete interventions to improve the effectiveness of maternal care and reduce maternal and neonatal mortality. In particular, we highlight 4 measures that may contribute to a lasting improvement in the care of pregnant women and a significant reduction in maternal morbidity and mortality:

This study has several methodological limitations that must be taken into account.

This study reveals the poor quality of ANC1s in the Malemba Nkulu health zone, with only 2% meeting established standards. The findings underscore critical gaps in provider training, limited access to essential diagnostic tests, and insufficient awareness among pregnant women regarding the importance of early and comprehensive prenatal care. Addressing these deficiencies requires targeted interventions to strengthen health worker capacity, improve service availability, and enhance community engagement in maternal health.

Among the challenges identified, 43% of consultations were conducted by midwives without advanced medical qualifications, compromising the quality of follow-up. Furthermore, 52.4% of women had their ANC1 in the third trimester, limiting the impact of preventive measures.

To improve the quality of prenatal care, several recommendations can be made, including (1) strengthening the training of service providers through practical sessions and adapted certifications, (2) subsidy for prenatal services to ensure better access to care, (3) community awareness to encourage early consultations, and (4) integration of prenatal care into maternal health programs. These measures could contribute to a significant reduction in maternal morbidity and mortality. Further research is needed to evaluate the impact of the proposed interventions and ensure effective management.