Mapping the consumer foodshed of the Kampala city region shows the importance of urban agriculture.

Due to rapid urbanisation, food systems in sub-Saharan African cities are increasingly under pressure. Through the lens of a foodshed, this paper quantitatively analyses the spatial extent of the food provisioning area for consumers of different socio-economic status in Kampala (Uganda). Based on a primary dataset of surveys with households and food vendors, we map the foodshed by registering where consumers obtain their food, and the origin of where it is grown. We show that 50% of the food consumed in the city originates from within a 120 km proximity to Kampala, including 10% from within the city itself. At present, urban agricultural activities are twice as important as international imports for the urban food provision. Established, high-income urban dwellers have a more local foodshed due to their broad participation in urban agriculture, while low-income newcomers rely heavily on retailers who source food from rural Uganda.

Interactions between climate and COVID-19.

In this Personal View, we explain the ways that climatic risks affect the transmission, perception, response, and lived experience of COVID-19. First, temperature, wind, and humidity influence the transmission of COVID-19 in ways not fully understood, although non-climatic factors appear more important than climatic factors in explaining disease transmission. Second, climatic extremes coinciding with COVID-19 have affected disease exposure, increased susceptibility of people to COVID-19, compromised emergency responses, and reduced health system resilience to multiple stresses. Third, long-term climate change and prepandemic vulnerabilities have increased COVID-19 risk for some populations (eg, marginalised communities). The ways climate and COVID-19 interact vary considerably between and within populations and regions, and are affected by dynamic and complex interactions with underlying socioeconomic, political, demographic, and cultural conditions. These conditions can lead to vulnerability, resilience, transformation, or collapse of health systems, communities, and livelihoods throughout varying timescales. It is important that COVID-19 response and recovery measures consider climatic risks, particularly in locations that are susceptible to climate extremes, through integrated planning that includes public health, disaster preparedness, emergency management, sustainable development, and humanitarian response.

Do socio-demographic factors modify the effect of weather on malaria in Kanungu District, Uganda?

BACKGROUND: There is concern in the international community regarding the influence of climate change on weather variables and seasonality that, in part, determine the rates of malaria. This study examined the role of sociodemographic variables in modifying the association between temperature and malaria in Kanungu District (Southwest Uganda). METHODS: Hospital admissions data from Bwindi Community Hospital were combined with meteorological satellite data from 2011 to 2014. Descriptive statistics were used to describe the distribution of malaria admissions by age, sex, and ethnicity (i.e. Bakiga and Indigenous Batwa). To examine how sociodemographic variables modified the association between temperature and malaria admissions, this study used negative binomial regression stratified by age, sex, and ethnicity, and negative binomial regression models that examined interactions between temperature and age, sex, and ethnicity. RESULTS: Malaria admission incidence was 1.99 times greater among Batwa than Bakiga in hot temperature quartiles compared to cooler temperature quartiles, and that 6-12 year old children had a higher magnitude of association of malaria admissions with temperature compared to the reference category of 0-5 years old (IRR = 2.07 (1.40, 3.07)). DISCUSSION: Results indicate that socio-demographic variables may modify the association between temperature and malaria. In some cases, such as age, the weather-malaria association in sub-populations with the highest incidence of malaria in standard models differed from those most sensitive to temperature as found in these stratified models. CONCLUSION: The effect modification approach used herein can be used to improve understanding of how changes in weather resulting from climate change might shift social gradients in health.

Socio-demographic associations with pregnancy loss among Bakiga and Indigenous Batwa women in Southwestern Uganda.

OBJECTIVE: To assess the extent of pregnancy loss (i.e., miscarriage and/or stillbirth) and examine its association with socio-demographic characteristics among Bakiga and Indigenous Batwa women in Kanungu District, southwest Uganda. METHODS: As part of a larger community-based, participatory project, a retrospective survey of maternal health histories was conducted in ten Batwa and ten Bakiga communities (n = 555 participants) collecting data on self-reported pregnancy loss (i.e., miscarriage and stillbirth) and socio-demographic characteristics. Socio-demographic associations with pregnancy loss (i.e., total miscarriages and stillbirths) were examined using multivariable Poisson and negative binomial regression. RESULTS: Batwa women experienced pregnancy loss more commonly than Bakiga women did (149.8/1000 vs. 96.3/1000 pregnancies). In the final adjusted model for Batwa women, being in the middle (RR 1.92; CI: 1.21-3.07) and highest (RR 1.79; CI: 1.14-2.82) wealth tertiles (compared to lowest wealth tertile) and living in Community X (RR 4.33; CI 2.27-8.28) (compared to all other communities) were associated with increased pregnancy loss. For Bakiga women, the proportion of pregnancy loss was higher for those who reported drinking alcohol during pregnancy (RR: 1.54; CI: 1.04-2.13) and being food insecure (RR 1.39; CI: 1.02-1.91). CONCLUSION: The proportion of, and the socio-demographic associations with, pregnancy loss differed for Bakiga and Indigenous Batwa women. These differences underscore the importance of collecting Indigenous health data to understand not only the extent of, but also the varied contextual circumstances that are associated with pregnancy loss. This nuanced and stratified information is critical for planning meaningful health programming to reduce pregnancy loss for Indigenous women.

Antenatal Care Research in East Africa During the Millennium Development Goals Initiative: A Scoping Review.

INTRODUCTION: The global burden of maternal mortality remains high and inequitably distributed between countries. Antenatal care (ANC) was identified as critical component in achieving the Millennium Development Goal of improving maternal health. This scoping review aimed to summarize trends and critically explore research about ANC attendance for East African women conducted during the Millennium Development Goals initiative, with a specific focus on barriers to ANC access. METHODS: Using a scoping review methodology, aggregator databases were searched for relevant articles. Articles were screened by independent reviewers using a priori inclusion criteria. Eligible articles were retained for data charting and analysis. RESULTS: Following screening, 211 articles were analyzed. The number of relevant articles increased over time; utilized primarily quantitative methods; and involved authors with affiliations from various African countries. Many interrelated physical, social, and cultural factors influenced women's seeking, reaching, and receiving of quality ANC. The extent of studies identified suggest that ANC is a priority research area, yet key gaps in the literature exist. Limited qualitative research, and few articles examining ANC experiences of women from vulnerable groups (e.g. adolescents, women with a disability, and Indigenous women) were identified. DISCUSSION: These context-specific findings are important considering the Sustainable Development Goals aim to nearly triple the maternal mortality reductions by 2030. In order to achieve this goal, interventions should focus on improving the quality of ANC care and patient-provider interactions. Furthermore, additional qualitative research examining vulnerable populations of women and exploring the inclusion of men in ANC would help inform interventions intended to improve ANC attendance in East Africa.

'We don't use the same ways to treat the illness:' A qualitative study of heterogeneity in health-seeking behaviour for acute gastrointestinal illness among the Ugandan Batwa.

The Batwa (Twa), an Indigenous People of southwest Uganda, were evicted from their ancestral forest lands in 1991 due to establishment of the Bwindi Impenetrable Forest. This land dispossession forced Batwa to transition from a semi-nomadic, hunting-gathering livelihood to an agricultural livelihood; eliminated access to Indigenous food, medicines, and shelter; and shifted their healthcare options. Therefore, this exploratory study investigated why Batwa choose Indigenous or biomedical treatment, or no treatment, when experiencing acute gastrointestinal illness. Ten gender-stratified focus groups were conducted in five Batwa settlements in Kanungu District, Uganda (n = 63 participants), alongside eleven semi-structured interviews (2014). Qualitative data were analysed thematically, using a constant comparative method. Batwa emphasised that health-seeking behaviour for acute gastrointestinal illness was diverse: some Batwa used only Indigenous or biomedical healthcare, while others preferred a combination, or no healthcare. Physical and economic access to care, and also perceived efficacy and quality of care, influenced their healthcare decisions. This study provides insight into the Kanungu District Batwa's perceptions of biomedical and Indigenous healthcare, and barriers they experience to accessing either. This study is intended to inform public health interventions to reduce their burden of acute gastrointestinal illness and ensure adequate healthcare, biomedical or Indigenous, for Batwa.

Are Indigenous research principles incorporated into maternal health research? A scoping review of the global literature.

BACKGROUND: Indigenous women world-wide are diverse and heterogenous, yet many have similar experiences of colonization, land dispossession, and discrimination. These experiences along with inequitable access to, and quality of, maternal healthcare increase adverse maternal health outcomes. To improve health outcomes for Indigenous women, studies must be conducted with Indigenous involvement and reflect Indigenous research principles. Objectives/Aim: The aim of this review was to explore the range, extent, and nature of Indigenous maternal health research and to assess the reporting of Indigenous research principles in the global Indigenous maternal health literature. METHODS: Following a systematic scoping review protocol, four scholarly electronic databases were searched. Articles were included if they reported empirical research published between 2000 and 2019 and had a focus on Indigenous maternal health. Descriptive data were extracted from relevant articles and descriptive analysis was conducted. Included articles were also assessed for reporting of Indigenous research principles, including Indigenous involvement, context of colonization, Indigenous conceptualizations of health, community benefits, knowledge dissemination to participants or communities, and policy or intervention recommendations. RESULTS: Four-hundred and forty-one articles met the inclusion criteria. While studies were conducted in all continents except Antarctica, less than 3% of articles described research in low-income countries. The most researched topics were access to and quality of maternity care (25%), pregnancy outcome and/or complications (18%), and smoking, alcohol and/or drug use during pregnancy (14%). The most common study design was cross-sectional (49%), and the majority of articles used quantitative methods only (68%). Less than 2% of articles described or reported all Indigenous research principles, and 71% of articles did not report on Indigenous People's involvement. CONCLUSIONS: By summarizing the trends in published literature on Indigenous maternal health, we highlight the need for increased geographic representation of Indigenous women, expansion of research to include important but under-researched topics, and meaningful involvement of Indigenous Peoples.

Socio-economic and environmental factors affecting breastfeeding and complementary feeding practices among Batwa and Bakiga communities in south-western Uganda.

Improving breastfeeding and complementary feeding practices is needed to support good health, enhance child growth, and reduce child mortality. Limited evidence is available on child feeding among Indigenous communities and in the context of environmental changes. We investigate past and present breastfeeding and complementary feeding practices within Indigenous Batwa and neighbouring Bakiga populations in south-western Uganda. Specifically, we describe the demographic and socio-economic characteristics of breastfeeding mothers and their children, and individual experiences of breastfeeding and complementary feeding practices. We investigate the factors that have an impact on breastfeeding and complementary feeding at community and societal levels, and we analysed how environments, including weather variability, affect breastfeeding and complementary feeding practices. We applied a mixed-method design to the study, and we used a community-based research approach. We conducted 94 individual interviews (n = 47 Batwa mothers/caregivers & n = 47 Bakiga mothers/caregivers) and 12 focus group discussions (n = 6 among Batwa & n = 6 among Bakiga communities) from July to October 2019. Ninety-nine per cent of mothers reported that their youngest child was currently breastfed. All mothers noted that the child experienced at least one episode of illness that had an impact on breastfeeding. From the focus groups, we identified four key factors affecting breastfeeding and nutrition practices: marginalisation and poverty; environmental change; lack of information; and poor support. Our findings contribute to the field of global public health and nutrition among Indigenous communities, with a focus on women and children. We present recommendations to improve child feeding practices among the Batwa and Bakiga in south-western Uganda. Specifically, we highlight the need to engage with local and national authorities to improve breastfeeding and complementary feeding practices, and work on food security, distribution of lands, and the food environment. Also, we recommend addressing the drivers and consequences of alcoholism, and strengthening family planning programs.

A Community-Based Approach to Integrating Socio, Cultural and Environmental Contexts in the Development of a Food Database for Indigenous and Rural Populations: The Case of the Batwa and Bakiga in South-Western Uganda.

Comprehensive food lists and databases are a critical input for programs aiming to alleviate undernutrition. However, standard methods for developing them may produce databases that are irrelevant for marginalised groups where nutritional needs are highest. Our study provides a method for identifying critical contextual information required to build relevant food lists for Indigenous populations. For our study, we used mixed-methods study design with a community-based approach. Between July and October 2019, we interviewed 74 participants among Batwa and Bakiga communities in south-western Uganda. We conducted focus groups discussions (FGDs), individual dietary surveys and markets and shops assessment. Locally validated information on foods consumed among Indigenous populations can provide results that differ from foods listed in the national food composition tables; in fact, the construction of food lists is influenced by multiple factors such as food culture and meaning of food, environmental changes, dietary transition, and social context. Without using a community-based approach to understanding socio-environmental contexts, we would have missed 33 commonly consumed recipes and foods, and we would not have known the variety of ingredients' quantity in each recipe, and traditional foraged foods. The food culture, food systems and nutrition of Indigenous and vulnerable communities are unique, and need to be considered when developing food lists.

Developing an online food composition database for an Indigenous population in south-western Uganda.

OBJECTIVE: To develop an online food composition database of locally consumed foods among an Indigenous population in south-western Uganda. DESIGN: Using a community-based approach and collaboration with local nutritionists, we collected a list of foods for inclusion in the database through focus group discussions, an individual dietary survey and markets and shops assessment. The food database was then created using seven steps: identification of foods for inclusion in the database; initial data cleaning and removal of duplicate items; linkage of foods to existing generic food composition tables; mapping and calculation of the nutrient content of recipes and foods; allocating portion sizes and accompanying foods; quality checks with local and international nutritionists; and translation into relevant local languages. SETTING: Kanungu District, south-western Uganda. PARTICIPANTS: Seventy-four participants, 36 Indigenous Batwa and 38 Bakiga, were randomly selected and interviewed to inform the development of a food list prior the construction of the food database. RESULTS: We developed an online food database for south-western Uganda including 148 commonly consumed foods complete with values for 120 micronutrients and macronutrients. This was for use with the online dietary assessment tool myfood24. Of the locally reported foods included, 56 % (n 82 items) of the items were already available in the myfood24 database, while 25 % (n 37 items) were found in existing Ugandan and Tanzanian food databases, 18 % (n 27 items) came from generated recipes and 1 % (n 2 items) from food packaging labels. CONCLUSION: Locally relevant food databases are sparse for African Indigenous communities. Here, we created a tool that can be used for assessing food intake and for tracking undernutrition among the communities living in Kanungu District. This will help to develop locally relevant food and nutrition policies.

Seasonality, climate change, and food security during pregnancy among indigenous and non-indigenous women in rural Uganda: Implications for maternal-infant health.

BACKGROUND: Climate change is expected to decrease food security globally. Many Indigenous communities have heightened sensitivity to climate change and food insecurity for multifactorial reasons including close relationships with the local environment and socioeconomic inequities which increase exposures and challenge adaptation to climate change. Pregnant women have additional sensitivity to food insecurity, as antenatal undernutrition is linked with poor maternal-infant health. This study examined pathways through which climate change influenced food security during pregnancy among Indigenous and non-Indigenous women in rural Uganda. Specific objectives were to characterize: 1) sensitivities to climate-associated declines in food security for pregnant Indigenous women; 2) women's perceptions of climate impacts on food security during pregnancy; and 3) changes in food security and maternal-infant health over time, as observed by women. METHODS: Using a community-based research approach, we conducted eight focus group discussions-four in Indigenous Batwa communities and four in non-Indigenous communities-in Kanungu District, Uganda, on the subject of climate and food security during pregnancy. Thirty-six women with ≥1 pregnancy participated. Data were analysed using a constant comparative method and thematic analysis. RESULTS: Women indicated that food insecurity was common during pregnancy and had a bidirectional relationship with antenatal health issues. Food security was thought to be decreasing due to weather changes including extended droughts and unpredictable seasons harming agriculture. Women linked food insecurity with declines in maternal-infant health over time, despite improved antenatal healthcare. While all communities described food security struggles, the challenges Indigenous women identified and described were more severe. CONCLUSIONS: Programs promoting women's adaptive capacity to climate change are required to improve food security for pregnant women and maternal-infant health. These interventions are particularly needed in Indigenous communities, which often face underlying health inequities. However, resiliency among mothers was strong and, with supports, they can reduce food security challenges in a changing climate.

Integrating climate in Ugandan health and subsistence food systems: where diverse knowledges meet.

BACKGROUND: The effects of food insecurity linked to climate change will be exacerbated in subsistence communities that are dependent upon food systems for their livelihoods and sustenance. Place-and community-based forms of surveillance are important for growing an equitable evidence base that integrates climate, food, and health information as well as informs our understanding of how climate change impacts health through local and Indigenous subsistence food systems. METHODS: We present a case-study from southwestern Uganda with Batwa and Bakiga subsistence communities in Kanungu District. We conducted 22 key informant interviews to map what forms of monitoring and knowledge exist about health and subsistence food systems as they relate to seasonal variability. A participatory mapping exercise accompanied key informant interviews to identify who holds knowledge about health and subsistence food systems. Social network theory and analysis methods were used to explore how information flows between knowledge holders as well as the power and agency that is involved in knowledge production and exchange processes. RESULTS: This research maps existing networks of trusted relationships that are already used for integrating diverse knowledges, information, and administrative action. Narratives reveal inventories of ongoing and repeated cycles of observations, interpretations, evaluations, and adjustments that make up existing health and subsistence food monitoring and response. These networks of local health and subsistence food systems were not supported by distinct systems of climate and meteorological information. Our findings demonstrate how integrating surveillance systems is not just about what types of information we monitor, but also who and how knowledges are connected through existing networks of monitoring and response. CONCLUSION: Applying conventional approaches to surveillance, without deliberate consideration of the broader contextual and relational processes, can lead to the re-marginalization of peoples and the reproduction of inequalities in power between groups of people. We anticipate that our findings can be used to inform the initiation of a place-based integrated climate-food-health surveillance system in Kanungu District as well as other contexts with a rich diversity of knowledges and existing forms of monitoring and response.

The impact of interventions in the global land and agri-food sectors on Nature's Contributions to People and the UN Sustainable Development Goals.

Interlocked challenges of climate change, biodiversity loss, and land degradation require transformative interventions in the land management and food production sectors to reduce carbon emissions, strengthen adaptive capacity, and increase food security. However, deciding which interventions to pursue and understanding their relative co-benefits with and trade-offs against different social and environmental goals have been difficult without comparisons across a range of possible actions. This study examined 40 different options, implemented through land management, value chains, or risk management, for their relative impacts across 18 Nature's Contributions to People (NCPs) and the 17 Sustainable Development Goals (SDGs). We find that a relatively small number of interventions show positive synergies with both SDGs and NCPs with no significant adverse trade-offs; these include improved cropland management, improved grazing land management, improved livestock management, agroforestry, integrated water management, increased soil organic carbon content, reduced soil erosion, salinization, and compaction, fire management, reduced landslides and hazards, reduced pollution, reduced post-harvest losses, improved energy use in food systems, and disaster risk management. Several interventions show potentially significant negative impacts on both SDGs and NCPs; these include bioenergy and bioenergy with carbon capture and storage, afforestation, and some risk sharing measures, like commercial crop insurance. Our results demonstrate that a better understanding of co-benefits and trade-offs of different policy approaches can help decision-makers choose the more effective, or at the very minimum, more benign interventions for implementation.

Neglected Tropical Diseases in the Context of Climate Change in East Africa: A Systematic Scoping Review.

East Africa is highly affected by neglected tropical diseases (NTDs), which are projected to be exacerbated by climate change. Consequently, understanding what research has been conducted and what knowledge gaps remain regarding NTDs and climate change is crucial to informing public health interventions and climate change adaptation. We conducted a systematic scoping review to describe the extent, range, and nature of publications examining relationships between NTDs and climatic factors in East Africa. We collated all relevant English and French publications indexed in PubMed®, Web of Science™ Core Collection, and CAB Direct© databases published prior to 2019. Ninety-six publications were included for review. Kenya, Tanzania, and Ethiopia had high rates of publication, whereas countries in the Western Indian Ocean region were underrepresented. Most publications focused on schistosomiasis (n = 28, 29.2%), soil-transmitted helminthiases (n = 16, 16.7%), or human African trypanosomiasis (n = 14, 14.6%). Precipitation (n = 91, 94.8%) and temperature (n = 54, 56.3%) were frequently investigated climatic factors, whereas consideration of droughts (n = 10, 10.4%) and floods (n = 4, 4.2%) was not prominent. Publications reporting on associations between NTDs and changing climate were increasing over time. There was a decrease in the reporting of Indigenous identity and age factors over time. Overall, there were substantial knowledge gaps for several countries and for many NTDs. To better understand NTDs in the context of a changing climate, it would be helpful to increase research on underrepresented diseases and regions, consider demographic and social factors in research, and characterize how these factors modify the effects of climatic variables on NTDs in East Africa.

Acute gastrointestinal illness in an African Indigenous population: the lived experience of Uganda's Batwa.

INTRODUCTION: Indigenous populations in low-income regions are often the most acutely affected by social gradients that impact health, including high burdens of infectious disease. Using a mixed methods approach, this study characterized the lived experience of acute gastrointestinal illness (AGI) in an Indigenous Batwa population in south-western Uganda. METHODS: Quantitative data analyses were conducted on data from three cross-sectional census surveys of Batwa conducted in January 2013 (n=583), January 2014 (n=569) and April 2014 (n=540). Using a 14-day recall period, cases of AGI were defined as three or more loose stools or any vomiting in a 24-hour period. These analyses were supplemented by qualitative data from key informant interviews (n=11 interviews) and Batwa focus group discussions (n=61 participants). RESULTS: From the surveys, episodes of diarrhea and episodes of vomiting lasted on average 3.6 (95%CI 2.3-4.3) and 3.0 (95%CI 2.1-3.9) days, and individuals experienced an average of 4.3 (95%CI 3.9-4.8) and 2.6 (95%CI 2.1-3.1) loose stools and vomiting episodes in 24 hours. Focus group participants and key informants indicated that episodes of AGI for Batwa were not limited to symptom-based consequences for the individual, but also had economic, social and nutritional impacts. CONCLUSION: Despite efforts to increase health literacy in disease transmission dynamics, risks and prevention measures, the perceived barriers and a lack of benefits still largely underscored adopting positive AGI prevention behaviors. This study moved beyond surveillance and provided information on the broader community-level burden of AGI and highlighted the current challenges and opportunities for improved uptake of AGI prevention measures for the Batwa.

Which practices co-deliver food security, climate change mitigation and adaptation, and combat land degradation and desertification?

There is a clear need for transformative change in the land management and food production sectors to address the global land challenges of climate change mitigation, climate change adaptation, combatting land degradation and desertification, and delivering food security (referred to hereafter as "land challenges"). We assess the potential for 40 practices to address these land challenges and find that: Nine options deliver medium to large benefits for all four land challenges. A further two options have no global estimates for adaptation, but have medium to large benefits for all other land challenges. Five options have large mitigation potential (>3 Gt CO2 eq/year) without adverse impacts on the other land challenges. Five options have moderate mitigation potential, with no adverse impacts on the other land challenges. Sixteen practices have large adaptation potential (>25 million people benefit), without adverse side effects on other land challenges. Most practices can be applied without competing for available land. However, seven options could result in competition for land. A large number of practices do not require dedicated land, including several land management options, all value chain options, and all risk management options. Four options could greatly increase competition for land if applied at a large scale, though the impact is scale and context specific, highlighting the need for safeguards to ensure that expansion of land for mitigation does not impact natural systems and food security. A number of practices, such as increased food productivity, dietary change and reduced food loss and waste, can reduce demand for land conversion, thereby potentially freeing-up land and creating opportunities for enhanced implementation of other practices, making them important components of portfolios of practices to address the combined land challenges.

Assessing the determinants of antenatal care adherence for Indigenous and non-Indigenous women in southwestern Uganda.

BACKGROUND: With an increasing number of women attending antenatal care for the recommended number of contacts, focus now must be placed on the quality and utility of care; without understanding adherence, the true contribution of antenatal care to improved maternal health outcomes is difficult to determine. OBJECTIVE: This research explored the practicality of antenatal care recommendations for women and the factors which facilitate or hinder adherence and shape the overall utility of care. DESIGN: Qualitative data were collected using a community-centred approach by means of focus group discussions with women and key informant interviews with healthcare providers throughout May and June of 2017. Data were analysed via thematic analysis guided by an essentialist/realist paradigm. SETTING: Kanungu District, Uganda; a district in southwestern Uganda. PARTICIPANTS: A convenience sample of 38 Indigenous Batwa and non-Indigenous Bakiga women from four matched communities and three healthcare providers. FINDINGS: A number of barriers to antenatal care adherence were identified which included a lack of monetary and material resources, a lack of a shared understanding and perceived value of care, and gender and position-based power dynamics, all of which were compounded by previous experiences with antenatal care. The factors identified which influenced adherence were highly complex and non-linear, affected by individual, community, health centre, and health system-level factors. Promotion of spousal involvement in antenatal care had different effects based on pre-existing individual levels of spousal support, either improving or hindering adherence. A lack of resources created a double burden for women through which maternal health was jeopardized by the inability to adhere to antenatal care recommendations and the poor quality patient-provider relationships which resulted and deterred future antenatal care attendance. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The capacity to avail oneself of antenatal care varied significantly for women based on their socio-economic status, levels of autonomy, and spousal support. Strategies to improve antenatal care need to focus on health equity to ensure care has a high degree of utility for all women. The interconnectedness of care and those who deliver care necessitates healthcare providers to develop strong patient-provider relationships through their attitudes, behaviours, and the delivery of equitable care. In light of a historical emphasis on attendance, this research highlights the significance of improving the quality and utility of antenatal care, inclusive of Indigenous perspectives, to deliver high-value care.