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Background: For the prevention of complications and death during pregnancy, adequate antenatal care (ANC) contacts are important. To achieve optimal obstetric care, the latest ANC guidance recommends eight or more ANC contacts. The aim of this analysis is to investigate the prevalence and socio-economic differences of eight or more Ghanaian ANC contacts. Methods: A total sample of 1404 women of reproductive age who had given birth after eight or more ANC contacts had been initiated, taking into account 9 months of gestation, was studied. The Ghana Malaria Indicator Survey of 2019 (GMIS) was used. In the univariate analysis, percentage was used. The curve and concentration index of Lorenz were used to assess socio-economic disparities for eight or more ANC contacts. Statistical significance was set at 5%. Results: The weighted prevalence of eight or more ANC contacts was 41.9% (95% CI: 37.9-45.9%). The prevalence of eight or more ANC contacts among the poorest, poorer, middle, richer and richest households was 34.0%, 36.1%, 35.8%, 42.4% and 59.6%, respec- tively. Similarly, 33.0%, 37.7% and 42.6% prevalence of eight or more ANC contacts were estimated among women with no formal education, primary, secondary or higher, respec- tively. In addition, women from rich household had greater coverage of eight or more ANC contacts (Conc. Index= 0.089; SE= 0.019) and educated women had greater coverage of eight or more ANC contacts in Ghana (Conc. Index= 0.053; SE= 0.017) (all p<0.001). Conclusion: Eight or more ANC contacts from the WHO in 2016 have yet to be fully institutionalized in Ghana. In order to increase access to the recommended prenatal care and for a healthy pregnancy experience, measures that resolve disparities in healthcare usage need to be prioritized for the country. Efforts should be made to expand the health insurance services available, as well as to enact policies that will increase free health care particularly among the poor and uneducated women.
For this study, a total sample of 1404 women of reproductive age who had given birth following the criteria of eight or more ANC contacts was initiated by WHO, taking into account 9 months of gestation. The Ghana Malaria Indicator Survey (GMIS) 2019 was used. All reproductive-age women (15–49 years) who were either visitors or who lived permanently in the chosen households were eligible to be interviewed. The 2019 GMIS sample also includes key elements of maternal health data such as ANC contacts, although it was intended to provide estimates of key malaria indicators for the country and for each of the 10 administrative regions (Western, Central, Greater Accra, Volta, Eastern, Ashanti, Brong Ahafo, Northern, Upper East, and Upper West) as identified in the 2010 Population and Housing Census of Ghana. The sampling method used for the 2019 GMIS is the 2010 PHC framework carried out by the Ghana Statistical Service in Ghana (GSS). A full list of all census enumeration areas (EAs) created for the PHC is the frame. An EA is the smallest geographic region that can be easily surveyed during an enumeration exercise by an enumerator. Details on the EA area, type of residence (rural or urban), the estimated number of residential households and the estimated population are included in the sampling frame. In two separate steps, the 2019 GMIS sample was stratified and selected from the sampling frame. Each region was split into rural and urban areas, resulting in 20 sampling layers. In two steps, samples of EAs were selected separately in each stratum. Approximately 200 EAs (103 in rural areas and 97 in urban areas) were selected in the first level, with a probability proportional to EA size and in-depth, respectively. In all of the selected EAs, a household listing procedure was conducted from 24 June to 10 August 2019. A fixed number of 30 households were chosen from each cluster in the second stage of selection to make up a total sample size of 6000 households. Details of the sampling method have already been published.36 We included women who had given birth after WHO launched the guideline of eight or more ANC contacts, considering 9 months of gestation. ANC models with a minimum of eight contacts are recommended in the Guideline to minimize perinatal mortality and enhance the experience of women in treatment.16 Dichotomous measurements were taken of the frequency of ANC encounters with physicians, nurses and midwives. In order to derive this variable, the GMIS asked the question “Number of antenatal visits during pregnancy?” The answers to this question were classified as <8 or ≥8 contacts. A review structure for the 2016 WHO ANC is provided in the WHO ANC guideline recommendations mapped to the eight suggested contacts.16,37,38 In order to assess socioeconomic status in line with previous research, women’s educational achievement and income quintiles were used.39–41 The achievement of women’s education was classified as no formal education, primary, secondary or higher. The wealth indicator weights were determined using the principal component analysis (PCA) technique to assign the wealth indicator weights. Wealth indicator variable scores were allocated and standardized using household assets such as wall type, floor type, roof type, water supply, sanitation facilities, radio, electricity, television, refrigerator, cooking fuel, furniture, number of persons per room. The factor loadings and z-scores have then been determined. The indicator values were multiplied by the factor loadings for each household and summarized to generate the wealth index value of the household. To categorize the overall scores into wealth quintiles, the standardized z-score was used; poorest, poorer, middle, richest and richest.42 Other explanatory variables include respondent age (year): 15–24, 25–34, 35+; residential status: urban, rural; religion: Christianity, Islam, traditional/no religion; timing to antenatal care booking: late (after 1st trimester), early (within 1st trimester); health insurance coverage: not covered, covered; household headship: male, female; preceding birth interval: first born, <2years, 2–3years, 4+years; parity: 1–2, 3–4, 5+; region: Western, Central, Greater Accra, Volta, Eastern, Ashanti, Brong Ahafo, Northern, Upper East, Upper West; ethnicity: Akan, Ga/Dangme, Ewe, Guan, Mole-Dagbani, Grusi, Gurma, Mande, Other. For sampling design, the survey module (“svy”) command was used. In univariate analysis, percentage was used. The Lorenz curve and concentration index for eight or more ANC contacts were used to analyze socio-economic disparities. When eight or more ANC contacts are higher among high socioeconomic classes, the concentration index value is positive. Conversely, when the concentration index value is negative, it indicates that among low socioeconomic classes, eight or more ANC contacts are higher. The explanatory variables for stratified analyses were used. The concentration index was used in eight or more ANC contacts to compute the contrast.43,44 Statistical significance was determined at p< 0.05. Stata version 14 (StataCorp., College Station, TX, USA) was used for data analysis.
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