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Anaemia in pregnancy remains a critical public health concern in many countries including Ghana and it poses severe consequences in the short to long-term for women and their unborn babies. Although antenatal care (ANC) is largely provided for pregnant women, the extent its utilisation protects against anaemia in pregnancy remains largely understudied. The study assessed the adequacy of ANC services utilisation and its effect on anaemia among pregnant women in the Wa Municipality of Ghana. A facility-based cross-sectional survey was conducted. Probability proportionate to size sampling and systematic random sampling were used to select the facilities and 353 respondents. While 80.2% of the pregnant women reported having received a sufficient number of ANC services provided, the prevalence of the overall ANC adequacy was only 44.2 %. After adjusting for potential confounders, pregnant women who could not achieve adequate ANC attendance were 2.3 times more likely to be anaemic in the third trimester of gestation AOR = 2.26 (95 % CI 1.05, 4.89), compared to their counterparts who maintained adequate ANC attendance. Adequate ANC attendance was a consistent and significant predictor of anaemia in pregnancy in the third trimester. Health and nutrition education on the need for early initiation of ANC attendance and support for the consumption of diversified diets are two possible interventions that can help contain anaemia in pregnancy.
Wa Municipality is sited in the northern savannah part of Ghana between Latitudes 8°30″–10° N and Longitude 0°30″–2°30″W but lies in the Southwestern part of the Region between Longitudes 9°32″W and 10°20″W and Latitudes 1°40″N and 2°45″N. The Wa Municipality is subdivided into six (6) sub-municipals with a total of twenty-six government health facilities including community-based health planning and services (CHPS) and four private facilities(19). However, data from 2017 showed the total number of health facilities in the Municipality to be forty-five(5). The Wa Municipal has 132 communities with one paramountcy, four area councils and one urban council(20). The municipality has an estimated total land area of 579⋅86 km2 and a projected population of 107 214 comprising of 52 996 males and 54 218 females. A facility-based cross-sectional survey was conducted. The study population comprised all women who had attended ANC in the municipality, delivered within the past 12 months preceding the study in a health facility and possessed a maternal health records booklet for the index pregnancy. The minimum sample size was calculated using single population proportion formula: where n is the required sample size, t is the confidence level at 95 %, P represents the population proportion of anaemia (35⋅6 %)(21) and m is the margin of error at 5 %. Considering a 2 % contingency to take care of incomplete/damaged questionnaires, a total of 353 mothers were required for the study. Health facilities for the study were selected from all six sub-districts in the Wa Municipality using probability proportionate to size sampling technique based on the total ANC registrants. The study participants were selected using systematic random sampling to draw respondents from ANC registers. Women were excluded if they were referred from other district’s ANC facilities but came to deliver in the Wa Municipality or attended ANC elsewhere for the most part of their pregnancy. Women without maternal health records or booklet for their index pregnancy were also excluded. A pre-tested structured questionnaire was used to collect information on socio-demographic characteristics, maternal behaviours and health status during last pregnancy, household wealth index, gravidity and parity. Information extracted from the ANC booklet included timing of ANC initiation, gestational age and Hb concentration levels. Data for the present study were collected in 2019 by trained nurses and midwives with a minimum qualification of Diploma. ANC registers were major sources of data. Permission was granted by the health authorities of the institutions to have access to the ANC registers where data were extracted. The main outcome (dependent) variable of interest was anaemia in the third trimester of pregnancy. The WHO’s definition and categorisation were applied whereby women with haemoglobin (Hb) concentration levels more than or equal to 11 and <11 g/dl were classified as ‘not anaemic’ and ‘anaemic’, respectively(2). The Hb levels were determined using a portable HemoCue301 photometer. Trained laboratory technicians drew capillary blood samples from the finger prick with a lancet after taking all aseptic precautions. The first drop of blood was wiped away using alcohol sterile wipes, and the next drop was placed into the HemoCue cuvette for immediate testing of Hb. The main exposure variable was the adequacy of ANC utilisation which was measured using a modified version of the adequacy of prenatal care utilisation (APNCU) index(22). The APNCU index is used for precise and comprehensive measurement of prenatal care(23). To be considered having adequate ANC attendance, a mother must have initiated ANC before gestational age (GA) week 12, and subsequent visits must be attended at recommended intervals throughout the pregnancy. The ultrasound technology was used to determine gestational age on first booking at the ANC. In the absence of ultrasound facility, gestational age was assessed using the last menstrual period (LMP) approach. The WHO recommends at least four antenatal visits to healthcare facility during pregnancy(20). Adequacy of ANC attendance in this study was therefore measured as having made the first visit in the first trimester of pregnancy and attended ANC at least four times during pregnancy. To assess ANC service content, participants were asked about the basic ANC services received as recommended by the WHO for all pregnant women at the first visit to ANC clinics(24). The content of ANC services received during antenatal period was assessed included height and weight measurements, blood pressure and blood sugar, deworming, toxoid immunisation, malaria testing and treatment, health and nutrition education, blood and urine testing, iron and folic acid supplementation. A score of ‘1’ was assigned to receiving any of the services and ‘0’ for non-receipt. The total score for each respondent was categorised as low, if that score was below the median score and high, if it was at least the median score. Another important exposure variable measured was a composite indicator that reflects an overall ANC adequacy. This was constructed using the three ANC utilisation indicators (that is, first ANC visit made during first trimester, making at least four ANC visits and receipt of adequate ANC core services(24). Thus, a woman was classified as having adequate overall ANC, if the woman had attended prenatal care early plus enough visits and sufficient services; otherwise, she was classified as having inadequate ANC. Based on the literature, the other potential predictor/covariate variables included were socio-demographic factors such as age, maternal education, occupation, marital status, religion, whether the women received health and nutrition education, child vaccinations and immunisations, the number of tetanus toxoid (TT) and sulphadoxine pyrimethamine (SP) received, household wealth index, as well as maternal dietary intake. Details of some of these variables are given below: The minimum dietary diversity for women (MDD-W) was used as measure of overall dietary quality since it has been shown to indicate adequate nutrient intake and can be used as a proxy indicator for measuring nutrient adequacy among pregnant women(25,26). The dietary assessment was made by asking the women to recall all foods and drinks consumed in the past 24 h prior to the study(26). The women's dietary diversity scores (WDDSs) were calculated by adding the values of all the food groups consumed by each participant. The ten food groups used to calculate WDDS were starchy staple foods, beans, peas, nuts, seeds, dairy, flesh foods, eggs, vitamin A-rich dark green leafy vegetables, other vitamin A-rich vegetables and fruits, other vegetables, and other fruits. The consumption of a food item from any of the groups was assigned a score of ‘1’ and a score of ‘0’ if the food was not consumed. The WDDSs were used to categorise the women into high (WDDS ≥ 5) and low (WDDS < 5). Also assessed was the household wealth index, which is a proxy indicator for socio-economic status (SES) of households. The principal component analysis (PCA) was used to quantify it from information collected on household assets and housing quality (floor, walls and roof material), source of drinking water, type of toilet facility, the presence of electricity, type of cooking fuel and ownership of modern household durable goods and livestock (e.g. bicycle, television, radio, motorcycle, sewing machine, telephone, cars, refrigerator, mattress, bed, computer and mobile phone)(27–30). The data were cleaned and coded for analysis using the Statistical Package for Social Science (SPSS) version 22 (SPSS Inc, Chicago). Data were cleaned by running preliminary frequencies of all the variables to check for entry inaccuracies. All incorrectly coded data were double-checked with the questionnaire after which all wrong entries were corrected. Bivariate analysis was performed using Chi-square test of independence to assess the association between the dependent variable anaemia, and categorical independent variables. The variables in the bivariate analysis with P < 0⋅10 were included in the multivariable binary logistic regression to control for possible confounding and the independent effect of each independent variable on the outcome variable. Forward stepwise LR (likely hood ratio) method was used for entering variables. The adjusted odds ratio (AOR) and 95 % confidence intervals were used to assess the strength of association at P-value < 0⋅05. Multicollinearity was checked using variance inflation factor (VIF) and no collinearity existed between the independent variables. The study protocol was approved by the School of Allied Health Sciences, University for Development Studies, Ghana. Ethical approval was obtained from the Kwame Nkrumah University of Science and Technology ethics committee (Reference no. CHRPE/AP/472/21). Permission was also granted by the Regional Health Directorate and District Director for Health Services of Wa Municipal to carry out the survey. Informed consent was obtained from the study participants prior to data collection. Confidentiality and anonymity of the study participants was also maintained by using identity numbers on the questionnaires other than participant's names.
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