Antenatal care (ANC) is a core component of reproductive, maternal, newborn and child health, providing health promotion, screening, preventive interventions and birth-preparedness counseling. The World Health Organization recommends early initiation of ANC and multiple contacts during pregnancy. Ghana’s Community-Based Health Planning and Services (CHPS) policy aims to reduce access barriers by deploying community health staff and delivering primary healthcare at the community level. Despite CHPS scale-up, some districts—such as Twifo Hemang Lower Denkyira—have persistently low maternal health indicators. This study assessed factors associated with ANC access and timing among women in THLD to inform community-level strategies.
The study was conducted in THLD, a predominantly rural district in Ghana’s Central Region with an estimated 2020 population of 67,341 and about 16,073 women of reproductive age. THLD comprises four sub-districts, three health centres, one community clinic and 13 functional CHPS zones. The district had relatively low facility-based maternal health indicators (2020 ANC coverage 56.4% and skilled delivery coverage 32.5%), which motivated investigation of ANC access in the CHPS context.
Researchers used a descriptive cross-sectional quantitative design targeting women aged 15–49 years with a child aged 12 months or younger. Sample size was computed using Cochran’s formula with an assumed proportion (p) of 0.76, yielding a target of 280; a 10% nonresponse allowance produced a final sample size of 310. All 13 CHPS zones were included. Probability proportional to size (PPS) determined zone-level sample allocation from a sampling frame of 1,751 eligible children; simple random sampling selected respondents. Field teams traced participants in 48 communities and obtained informed consent before interviews.
Data were collected from 15 February to 15 March 2022 using a structured interviewer-administered questionnaire adapted from prior regional studies. The instrument covered sociodemographic and socioeconomic characteristics, antenatal and obstetric history, knowledge of ANC/pregnancy, and CHPS location/distance with GPS capture. The questionnaire was developed in English, translated into Fantse, pretested among 31 mother–child pairs, and refined. Five trained research assistants with relevant health qualifications conducted face-to-face interviews in local dialects and validated clinical details against maternal and child health record books where available.
Primary outcomes were: (1) attendance at least once for ANC (yes/no), and (2) timing of ANC initiation defined as early (first visit at 0–12 weeks’ gestation) or late (first visit at ≥13 weeks). Exposure variables included sociodemographic and socioeconomic factors, antenatal history (including total number of ANC contacts), and CHPS location/distance characteristics (distance to nearest CHPS zone measured via GPS). Knowledge of ANC and pregnancy comprised a seven-item module incorporated into analysis.
Analyses were performed in STATA 17 at a significance threshold of p < 0.05. Descriptive statistics summarized categorical variables as frequencies and percentages. Univariate and multivariate logistic regression models were fitted to identify factors associated with (a) attending at least one ANC visit and (b) late ANC initiation. Results are reported as adjusted odds ratios (AORs) with 95% confidence intervals (CIs).
Among 310 respondents, ANC attendance was 93.9%, and 69.1% initiated their first ANC visit during the first trimester (0–12 weeks). These findings indicate relatively high overall attendance and early initiation compared with some district-level historical indicators.
After adjustment, marital status and place of delivery were significantly associated with attending at least one ANC visit. Specifically, unmarried women had lower odds of attending at least one ANC visit (AOR = 0.125, 95% CI: 0.012–0.926, p = 0.047). Women who delivered at home also had markedly lower odds of attending at least one ANC visit (AOR = 0.013, 95% CI: 0.001–0.176, p = 0.001). Variables such as ANC knowledge, receiving care in a CHPS zone, and measured distance to a CHPS zone were not significant predictors of attending at least one visit after multivariable adjustment.
Late initiation (first ANC at ≥13 weeks) was positively associated with household size of 11 or more members (AOR = 3.848, 95% CI: 1.914–6.211, p = 0.046), completing fewer than four ANC contacts (AOR = 6.332, 95% CI: 2.049–9.571, p = 0.001), and having CHPS staff conduct home visits (AOR = 1.813, 95% CI: 1.014–3.243, p = 0.045). In contrast, higher monthly income was associated with lower odds of late ANC initiation (AOR = 0.123, 95% CI: 0.024–0.630, p = 0.012). Notably, ANC and pregnancy knowledge, receiving care in a CHPS zone, and physical distance to CHPS zones showed no significant association with timing after adjustment.
The study found high reported ANC attendance and a majority initiating in the first trimester among women in THLD, yet gaps remain in equitable and timely access. Social and household factors—marital status, place of delivery, household crowding and income—were important determinants, as were patterns of ANC contacts and the effect of CHPS home visits. The authors suggest strengthening community-based and multisectoral interventions to improve timely ANC use and maternal health outcomes. Specific operational implications include targeting unmarried women and households with high occupancy, reviewing home-visit practices, and addressing economic barriers to earlier initiation and adequate contacts.
The study reported that datasets collected were attached as supplementary information. Funding support came from the Project for Human Resource Development Scholarship (JICA) and Nagasaki University School of Tropical Medicine and Global Health, with no additional external funding. The authors declared no competing interests. Details on ethical approvals were provided in the original article but are not reproduced here beyond the study’s use of informed consent procedures and confidentiality safeguards.