Pregnancy in the Context of Urbanicity and Climate Change. The Overall Aim of the Project is to Co-create, Implement, and Test New Clinical Guidelines in Order to Improve the Quality of Care in Antenatal Clinics in the Context of Urbanisation and Climate Change in Dar es Salaam, Tanzania.

Tanzania's population is growing quickly, and Dar es Salaam is one of the fastest-growing cities in the world. At the same time, the city is increasingly affected by very hot weather, flooding, and air pollution. Many parts of Dar es Salaam do not have enough roads, drainage, housing, or public services for the number of people living there. About 70% of people live in unplanned neighborhoods, often in areas that are more exposed to flooding, heat, and pollution. This means many families face greater environmental risks in their daily lives.

The health system has also struggled to keep up with the city's rapid growth. Maternity services are often overcrowded, and many women and children in urban Tanzania now face worse birth outcomes than those in rural areas. Poverty, large gaps between rich and poor, weak infrastructure, and congested hospitals all make it harder for pregnant women to get the care they need.

This makes Dar es Salaam an important place to study how antenatal care can better respond to climate-related risks and the realities of urban life.

The study is expected to provide useful lessons not only for Tanzania, but also for other countries in sub-Saharan Africa and other low- and middle-income settings. This is especially important because more than half of the world's population now lives in cities, and most future urban growth is expected to happen in Africa and Asia.

The study will evaluate whether a co-created antenatal care program can improve the quality of pregnancy care and reduce serious pregnancy problems among pregnant women receiving care in government health facilities in Temeke District, Dar es Salaam, Tanzania. The program is designed for busy urban public clinics and includes guidance for pregnant women and their families, guidance for health providers, training for providers, a booklet for women, and text messages to support antenatal care visits and health information sharing. The study will be implemented in all 21 government facilities in the district that provide antenatal care and/or gynecological and childbirth care.

The study will use a pre-post implementation comparison design. Researchers will compare pregnancy care and outcomes before the program is introduced with pregnancy care and outcomes after implementation. The primary outcome is antepartum stillbirth, meaning a baby dies before labor starts. Secondary outcomes are preterm birth and the quality of uncomplicated postabortion care. The study will also examine whether the program improves the quality of antenatal care by helping health providers better identify and manage problems in pregnancy, especially high blood pressure disorders and early pregnancy complications such as miscarriage, and by improving women's understanding of key health information, the timing of the first antenatal visit, and the number of antenatal visits attended.

Information for the evaluation will be collected from antenatal cards, case files, hospital registers, medical records, interviews, and other study activities involving pregnant women and health providers. Researchers hope the findings will show whether a locally developed antenatal care improvement program can help prevent avoidable harm to mothers and babies and improve pregnancy care in a high-volume urban setting.