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Background: Improving maternal health is a global challenge. In Ghana, maternal morbidity and mortality rates remain high, particularly in rural areas. Antenatal care (ANC) attendance is known to improve maternal health. However, few studies have updated current knowledge regarding determinants of ANC attendance. Objective: This study examined factors associated with ANC attendance in predominantly rural Ghana. Methods: We conducted a cross-sectional study at three sites (i.e. Navrongo, Kintampo, and Dodowa) in Ghana between August and September 2013. We selected 1500 women who had delivered within the two years preceding the survey (500 from each site) using two-stage random sampling. Data concerning 1497 women’s sociodemographic characteristics and antenatal care attendance were collected and analyzed, and factors associated with attending ANC at least four times were identified using logistic regression analysis. Results: Of the 1497 participants, 86% reported attending ANC at least four times, which was positively associated with possession of national health insurance (AOR 1.64, 95% CI: 1.14– 2.38) and having a partner with a high educational level (AOR 1.64, 95% CI: 1.02–2.64) and negatively associated with being single (AOR 0.39, 95% CI: 0.22–0.69) and cohabiting (AOR 0.57, 95% CI: 0.34–0.97). In site-specific analyses, factors associated with ANC attendance included marital status in Navrongo; marital status, possession of national health insurance, partners’ educational level, and wealth in Kintampo; and preferred pregnancy timing in Dodowa. In the youngest, least educated, and poorest women and women whose partners were uneducated, those with health insurance were more likely to report at least four ANC attendances relative to those who did not have insurance. Conclusions: Ghanaian women with low socioeconomic status were less likely to report at least four ANC attendances during pregnancy if they did not possess health insurance. The national health insurance scheme should include a higher number of deprived women in predominantly rural communities.
This cross-sectional study was conducted as a situational analysis before starting the intervention of the Ghana Ensure Mothers and Babies Regular Access to Care (EMBRACE) Implementation Research [29] conducted between August and September 2013. This was a collaborative study involving the Ghana Health Service (GHS), the University of Tokyo, and the Japan International Cooperation Agency (JICA). It was implemented at three Health Demographic Surveillance System (HDSS) sites in Navrongo (Upper East Region), Kintampo (Brong Ahafo Region), and Dodowa (Greater Accra Region). The HDSS is used to examine population dynamics in these settings and involves regular collection and processing of information concerning household characteristics, pregnancies, births, deaths, migrations, morbidity, marriages, and vaccination in the districts involved [30]. In Navrongo, the surveillance population numbered approximately 153,000 in 2011 [31]. Navrongo is located in the northern belt of the country, 777 km from the national capital, Accra. With 36 CHPS compounds, the Navrongo area contained a higher number of compounds relative to those recorded for the other two study sites. The program began in Navrongo and spread throughout the Upper East Region. For Kintampo, a surveillance population of approximately 200,000 was reported in 2011 [32]. Kintampo is located in the middle belt of the country, 429 km from Accra, and contains 24 CHPS compounds. For the Dodowa HDSS site, a surveillance population of approximately 115,000 was recorded in 2011. It is approximately 40 km from Accra [33] and contains 20 CHPS compounds. We used the three HDSS databases to identify women aged 15–49 years who had experienced live birth or stillbirth within the two years preceding the survey. We then used a two-stage random sampling method to select 1500 women (500 from each of the 3 HDSS sites). During the first stage, we randomly selected clusters, or primary sampling units (subdistricts or zones), from the target areas. During the second stage, we randomly selected a specific number of eligible women from each cluster. We included data for 1497 women in the analysis, with data for 3 women excluded because of missing key background information. The inclusion criteria were female sex; reproductive age (15–49 years old); and delivery, including stillbirth, within the two years preceding the survey. We collected data using a structured questionnaire, which included items concerning social and demographic characteristics such as age, religion, marital status, educational level, partner’s educational level, geographical location (i.e. Navrongo, Kintampo, Dodowa), household assets, national health insurance status, preferred pregnancy timing, ethnicity, religion, and ANC attendance during the pregnancy preceding the most recent birth. We generated a quintile rank for wealth, based on the possession of 18 items representing household assets. In addition, preferred pregnancy timing reflected whether respondents had wished to become pregnant when the pregnancy had occurred, at a later date, or not at all. The questionnaire was developed in the English language and pretested in communities outside the study sites. The fieldworkers underwent two weeks of training prior to the survey and visited households to interview eligible women. We produced descriptive statistics to summarize respondents’ background characteristics. Multivariable logistic regression analysis was performed to identify determinants of attending ANC at least four times across all study sites and at each study site. We determined whether respondents had attended ANC at least four times using the question, ‘How many times did you receive ANC during your last pregnancy?’ The following explanatory variables were analyzed: geographical location, age, marital status, educational level, partner’s educational level, religion, national health insurance status, wealth index, and preferred pregnancy timing. The wealth index consisted of 18 household-related items. These independent variables were selected based on previous studies [25–28]. We generated quintile ranks for wealth status using principal component analysis. In addition, we performed a chi-square test to examine differences in the proportions of women who reported at least four ANC attendances according to health insurance status in women with low socioeconomic status (i.e. women aged 15–24 years, unmarried women, uneducated women, women whose partners were uneducated, and the poorest women). All p- values were two-tailed, and the significance level was set at p < 0.05. We performed all statistical analyses using Stata Version 12 (Stata Corp., TX). We obtained ethical approval for the study from the research ethics committees at the Graduate School of Medicine, The University of Tokyo, and the GHS; the institutional review boards at Navrongo Health Research Centre and Dodowa Health Research Centre; and the institutional ethics committee at Kintampo Health Research Centre. We also obtained written informed consent from all women and the parents/guardians of those aged 15–17 years prior to initiation of the interviews.
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