<![CDATA[Background: Low birth weight (LBW) remains a maternal and newborn health concern requiring continuity of care throughout pregnancy and after childbirth. Gaps between antenatal risk detection and follow-up may undermine coordinated care. Objective: To assess antenatal care responses to maternal risk factors and develop recommendations supporting LBW prevention at Kulisusu Primary Health Center, Indonesia. Methods: A descriptive, collaborative field assessment was conducted on 23–30 September 2026 through program record reviews and semi-structured interviews with six informants representing healthcare personnel, community volunteers, and mothers. Records covered 25 LBW infants born in 2025 and 17 born during January–August 2026. Descriptive statistics and thematic analysis using a Five Lenses framework informed proposed action priorities. Results: Antenatal screening, education, iron supplementation, and referral services were available. Among mothers of LBW infants, the last recorded hemoglobin level was below 11 g/dL in 47.8% in 2025 and 56.3% in 2026. However, risk detection dates, missed appointments, tracing outcomes, referral completion, and maternal–newborn care linkages were not consistently documented. Reported barriers included stigma, nausea, mobility, and dispersed follow-up responsibilities. Proposed actions included an at-risk maternal register, missed-appointment tracking, referral feedback, and linked maternal–newborn records. Conclusion: The assessment identified documentation and coordination gaps and generated phased recommendations for strengthening care continuity. Implementation and outcome evaluation are required before effectiveness can be established.]]>
