“No visible signs of pregnancy, no sickness, no antenatal care”: Initiation of antenatal care in a rural district in Northern Ghana

Background: Attending antenatal care (ANC) early contribute to better birth outcomes. Studies have shown that many pregnant women in Sub-Saharan Africa do not initiate ANC early (i.e. in the first trimester). This study determined the gestational age of pregnancy at first ANC attendance. It also explored factors that influence initiation of ANC. Methods: This cross-sectional study, conducted in Ghana, used mixed methods to collect data from women aged 15-45 years who delivered 6 months prior to the study. Crosstabs, chi-square test and logistic regression were used to analyse quantitative data. Also, 33 participants were engaged in focus group discussions (FGDs). Thematic content analysis was used to develop themes from the data. Results: Of the 431 participants, 8.9, 8, 25.4, 45.3 and 10.7% started ANC in the first, second, third, fourth and fifth months of pregnancy respectively. Formal education, employment and number of living children were predictors of initiating ANC early; by 12 weeks of gestation. Women who attained primary, junior high, secondary education and above had 5.6, 57.5 and 163.2 higher odds respectively of initiating ANC in the first trimester compared to women with no education (p ≤ 0.05). Women with two, three and four to nine living children were 4.1, 3 and 3.5 times respectively more likely to access ANC early compared to primigravidae women. However, women with five or more children and primigravidae women are more likely to initiate ANC late; after 12 weeks gestation. The FGD data also show that most of the participants initiated ANC late. Two themes: Visible signs of pregnancy and or sickness influence ANC attendance in the first trimester. The themes that explain late initiation of ANC are: Healthy, do not value the benefits of early ANC attendance, desire to avoid embarrassment associated with the pregnancy, unplanned pregnancy, indirect cost of accessing ANC and traditional rites and practices. Conclusion: Contextual factors influence ANC initiation. Investment in female education, intensification of health promotion activities by health workers, non-governmental organisations, community and religious leaders to sensitise communities on the benefits of initiating ANC at the onset of pregnancy is needed to improve first trimester attendance. This cross-sectional study was conducted in 2016 in the Builsa South District of the Upper East Region (UER) of Ghana. It used mixed methods (quantitative and qualitative) to collect data from women who had delivered within the previous 6 months. The district is predominantly rural with a population of 38,298 projected from the 2010 Ghana’s Population and Housing Census. Women within reproductive age (15–49 years) form 24% of the total population. The district was selected based on the consistent low (less than 40%) first trimester ANC attendance between 2010 and 2014. Compared to the national average of 64% of pregnant women who started ANC before the fourth month of pregnancy in 2014, Builsa South recorded 37.5% first trimester attendance [15, 16]. The predominant ethnic group is Builsa with few Mamprusis, Sissalas and Fulani nomads in sections of the district. Christians, adherents to traditional religion and Muslims are the dominant religious groups in the district. The population is generally dispersed with poor road network; making access to health care services by some communities difficult especially during the rainy season [16]. The district has 24 primary schools, 15 junior high schools (JHS) and one senior high school (SHS). Builsa South district is divided into six sub-districts by the GHS for easy management. Concerning health infrastructure, the district has three health centres and 14 CHPS compounds spread across the sub-districts. A single population proportion formula was used to calculate the sample size for quantitative data collection: N = (Z21 − α/2) P (1 − P)/ d2; because the outcome variable is categorical [23]. Where P is the estimated proportion of women who initiate ANC in the first trimester, d is the acceptable margin of error. The following assumptions were made: proportion of first trimester registrants is 49% based on findings from a previous study in Ghana [17], an acceptable margin of error (d) is 5%, (Z1 − α/2) is 1.96 at 95% confidence interval. With a non-response rate of 10%, the final sample size was 431. A multi-stage sampling technique was used to select women aged 15–49 years old who have delivered in the 6 months preceding the survey. First, a lottery method was used to randomly select one community in each of the six sub-districts. Second, a sampling frame of households with women who had delivered in the past 6 months in the selected communities was developed from the existing filariasis and child health registers in health facilities. Third, systematic random sampling technique was used to select households from the listed households prepared for each community. The eligibility criteria was that the woman should have her ANC record card. Whenever a selected household had two or more eligible respondents, one of them was selected using a lottery method. The number of households selected from each community was proportionate to the number listed on the register. A structured questionnaire, developed for this study [Additional file 1:] was administered by experienced data collectors and supervisors in English or Buili (the local language) based on participants’ preference. The questions were based on published studies [12–14, 18–21, 24–31]. The data collected covered the socio-demographic characteristics and obstetric history of respondents, gestation of pregnancy at first ANC and factors associated with initiation of ANC. The gestation of pregnancy is stated in calendar months of 4 weeks. The outcome variable: the gestational age of pregnancy at first ANC visit was dichotomised and categorised into ‘early’ for those who initiated ANC in the first trimester (i.e. by 12 weeks of gestation) and ‘late’ for women who made their first ANC attendance in the second and third trimesters (i.e. after 12 weeks and 24 weeks respectively). The explanatory variables were maternal age, marital status, educational attainment, employment status, religion, ethnicity, parity, health insurance status and exposure to information on ANC. Quantitative data was analysed using STATA version 13. Crosstabs, Chi-square test, Fishers exact test and multiple logistic regression model were used to analyse the quantitative data. Adjusted odds ratio (AOR), 95% confidence interval (CI) and p-value< 0.05 show the strength of the statistically significant association between explanatory variables and the outcome variable. A possible correlation between the exposure variables was explored before including them in the model. None were found to be collinear. Thirty-three eligible participants who could not participate in the survey were purposively selected from one rural and one urban community out of the six compiled community register used in the survey for focus-group discussions (FGDs). The participants were selected based on age, education, marital and employment status, religion, insurance status, parity and having their ANC record book. Four FGDs, each consisting of about eight participants (two for young women aged 18–30 years and two for older women 31–44 years) were conducted in Buili and English using a discussion guide. This was to ensure that younger women were comfortable expressing their views freely during discussions since the presence of older women may hinder them from expressing their views freely on the domain of the discussion: factors that influence ANC initiation. The FGDs were audio recorded and detailed notes taken to capture participants’ views and non-verbal cues. All recordings were transcribed verbatim and translated using the back translation method. The data was analysed using five-steps thematic analysis approach by Braun and Clarke [32] to generate themes from the data. The following measures were taken to ensure that the data is reliable. (1) Back translation method was used to translate the questions and interview guides from English to Buili and back to English to ensure that participants understand the questions as intended. (2) Data collectors and supervisors were trained and equipped with interviewing skills. (3) Simulation interviews were conducted by interviewers to ensure they understand the questions as intended and follow all ethical procedures regarding data collection. (4) Data collection tools were pretested in Builsa North District. (5) Study participants were women who delivered in the past 6 months preceding the survey to minimise recall bias. (6) The first ANC visit, and health insurance status were confirmed using participants’ ANC record books. Both authors met to critically review the transcripts and themes to ensure participants’ views were accurately captured. The Ghana Health Service Ethics Review Committee approved the study. Participants’ consent was obtained after explaining the purpose of the study to them, their right to withdraw from the study at any time. Anonymity, confidentiality and participants’ comfort was ensured.