Abstract: Background: Stillbirths, particularly macerated stillbirths linked to delayed antenatal care (ANC) and chronic placental insufficiency, remain a critical public health challenge in low-resource settings. In Tanzania, 34% of women initiate ANC after 16 weeks, exacerbating risks of undetected maternalfetal complications. This study investigated the association between delayed ANC attendance and macerated stillbirths at Mwananyamala Regional Referral Hospital in Dar es Salaam, Tanzania. Methods: A retrospective cross-sectional study analyzed medical records of women with stillbirths (≥28 weeks) from January- December 2024. Data on ANC timing, maternal demographics, comorbidities, and pregnancy outcomes were collected. Logistic regression and ANOVA were used to assess associations, adjusting for confounders (e.g., age, parity, HIV). Results: Among 199 participants (57.6% response rate), 73.9% initiated ANC after 12 weeks and 94.5% attended fewer than the recommended 8 visits. Macerated stillbirths accounted for 74.9% of cases, with 42.2% of women reporting prior stillbirths. Late ANC initiation independently increased macerated stillbirth risk (AOR=3.46, 95% CI:0.182-0.742). Grand multiparity (≥5 births) was strongly associated with fresh stillbirths (OR=164.5, 95% CI:13.1-206.7), while multiparity (2-4 births) predicted macerated stillbirths (AOR=2.69, P=0.008). Hypertensive disorders (41.2% prevalence), particularly preeclampsia (OR=2.78, P=0.017), and HIV (43.2% prevalence) were linked to adverse outcomes. Higher education showed a protective trend (OR=0.39, P=0.089). Conclusion: Delayed ANC initiation, multiparity, and hypertensive disorders are critical, modifiable risk factors for macerated stillbirths in urban Tanzania. Community-driven ANC promotion and targeted prenatal monitoring for high-parity women are urgently needed to reduce preventable stillbirths.