Determinants of loss to follow-up among pregnant women living in a high malaria burden setting in Northern Uganda

Malaria remains a significant global health challenge, disproportionately affecting Sub-Saharan Af- rica. Pregnant women represent one of the most vulnerable populations. Despite numerous advances in malaria control measures, lost-to-follow-up (LTFU) in antenatal care (ANC) programs poses a critical barrier to achieving optimal maternal and neonatal outcomes and the success of public health interventions. The factors driving LTFU, particularly in rural, high-burden settings, are not complete- ly understood. This study investigates the determinants of LTFU among pregnant women receiving malaria screening in the context of the ERASE-Rise Against Malaria project in Northern Uganda. An observational retrospective cohort study was conducted on 1,558 women, recruited from July 2022 to June 2024, during the operational research held to assess the impact of antimalarial resistance on malaria care among pregnant women in three healthcare facilities in Oyam and Kole districts. Data on individual level (sociodemographic and clinical) and health care-related factors were analyzed using a multilevel logistic regression model to identify predictors of LTFU, defined as the absence of cohort outcome data 30 days after the expected delivery date. Efforts to recover missing data includ- ed delivery register consultation, active phone calls, and contact tracing by village health team work- ers. 871 (55.9%) of the 1,558 women were LTFU. Recovery strategies reduced the missing data rate to 29.1% (n=454). Protective factors against LTFU included higher education (aOR=0.75, 95% CI: 0.54–1.03, p=0.0798), being primigravida (aOR=0.73, 95% CI: 0.56–0.97, p=0.0275), and experiencing malaria during pregnancy (aOR=0.61, 95% CI: 0.48–0.78, p<0.0001). Women attending Aboke Health Center IV (n=385) were over five times more likely to be LTFU than those at Aber Hospital (n=955) (aOR=5.57, 95% CI: 4.08–7.71, p<0.0001), highlighting significant geographic and structural barriers. The high rate of LTFU in malaria screening programs underscores the need for targeted interventions addressing individual, systemic and structural barriers. Strengthening community-level support, im- proving healthcare infrastructures, and integrating malaria prevention into broader maternal health services are crucial for enhancing retention in care. Addressing determinants of LTFU, systematical- ly, through further qualitative and quantitative research, is essential to improving maternal and neo- natal health outcomes and achieving malaria eradication goals in high-burden settings.