---
title: "Access to antenatal care in Twifo Hemang Lower Denkyira, Ghana: CHPS-era cross-sectional findings"
id: "plos-one-12-a-cross-sectional-study-to-evaluate-access-to-antenatal-care-services-in-twifo"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-12-a-cross-sectional-study-to-evaluate-access-to-antenatal-care-services-in-twifo"
content_type: "clinical_feed_article"
specialty: "General"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0359892"
published_at: "2026-10-07T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Access to antenatal care in Twifo Hemang Lower Denkyira, Ghana: CHPS-era cross-sectional findings
## Provenance & Clinical Metadata
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- **Specialty:** [General](https://medichelpline.com/clinical-feed/general.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0359892)
- **Published At:** 2026-10-07T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This cross-sectional study evaluated factors associated with access to **antenatal care (ANC)** in the Twifo Hemang Lower Denkyira (THLD) district of Ghana within the Community-Based Health Planning and Services (**CHPS**) context. - Researchers interviewed 310 women aged 15–49 years with a child under 12 months using a structured, pretested questionnaire and GPS coordinates to measure distances to CHPS zones. - Overall ANC attendance was high (93.9%), and 69.1% of women initiated ANC in the first trimester (0–12 weeks). - Women who were unmarried and those who delivered at home had significantly lower odds of attending at least one ANC visit. - Late ANC initiation (≥13 weeks) was associated with large household size (≥11 members), completing fewer than four ANC contacts, and receiving CHPS staff home visits. - Higher monthly income was associated with reduced odds of late ANC initiation. - Knowledge of ANC/pregnancy, receiving care in a CHPS zone, and measured distance to a CHPS zone were not significantly associated with ANC attendance or timing after multivariate adjustment. - The study used probability proportional to size sampling across all 13 CHPS zones, a sample size of 310 (including 10% allowance for nonresponse), interviewer-administered questionnaires in local languages, and STATA 17 for univariate and multivariate logistic regression reporting adjusted odds ratios (AORs) with 95% CIs. - Authors conclude that although ANC attendance and early initiation were relatively high, targeted community and multisectoral interventions addressing marital status, place of delivery, household crowding, income, ANC contacts, and CHPS home-visit practices may improve timely ANC use and maternal outcomes. - Data and supporting materials were provided as supplementary information; the study was supported by JICA scholarship and Nagasaki University School of Tropical Medicine and Global Health, with no competing interests declared.
## Clinical Analysis & Structured Key Points
A cross-sectional study to evaluate access to antenatal care services in Twifo Hemang Lower Denkyira district of Ghana | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Reader Comments Figures Figures Abstract Background Antenatal care (ANC) supports skilled delivery and maternal survival, but evidence on how Ghana’s Community-Based Health Planning and Services (CHPS) policy influences ANC access is limited. This study assessed factors associated with ANC access in the Twifo Hemang Lower Denkyira District, Central Region, Ghana. Methods In a cross-sectional study, we examined 310 women aged 15–49 years, having children less than 12 months, using a structured questionnaire administered through interviews. ANC initiation was defined as early when the first ANC visit occurred at 0–12 weeks’ gestation (first trimester) and late when it occurred at 13 weeks or later. We performed univariate and multivariate logistic regression analyses in Stata 17 and reported adjusted odds ratios (AORs) and 95% confidence intervals (CIs). Results ANC attendance was 93.9%, and 69.1% of women initiated ANC early. Unmarried women (AOR = 0.125, 95%CI:0.012–0.926, p = 0.047) and women who delivered at home (AOR = 0.013, 95%CI:0.001–0.176, p = 0.001) had lower odds of attending at least one ANC visit. Late ANC initiation was associated with household size of 11 or more members (AOR = 3.848, 95%CI:1.914–6.211, p = 0.046), fewer than four ANC contacts (AOR = 6.332, 95% CI: 2.049–9.571, p = 0.001), and CHPS staff home visits (AOR = 1.813, 95%CI:1.014–3.243, p = 0.045). Higher monthly income was associated with lower odds of late ANC initiation (AOR = 0.123, 95%CI:0.024–0.630, p = 0.012). ANC and pregnancy knowledge, receiving care in a CHPS zone, and distance to a CHPS zone were not significantly associated with ANC attendance or timing after adjustment. Conclusions ANC attendance and early initiation were relatively high. However, marital status, place of delivery, household size, income, ANC contacts, and CHPS home visits were associated with ANC access. Strengthening community-based and multisectoral interventions may improve timely ANC use and maternal health outcomes. Citation: Hammond J, Adjei-Gyamfi S, Brew Daniels D, Sarpong GK, Aiga H, Aoki T (2026) A cross-sectional study to evaluate access to antenatal care services in Twifo Hemang Lower Denkyira district of Ghana. PLoS One 21(10): e0359892. https://doi.org/10.1371/journal.pone.0359892 Editor: Joshua Sumankuuro, Simon Diedong Dombo University of Business and Integrated Development Studies, GHANA Received: April 26, 2024; Accepted: September 22, 2026; Published: October 7, 2026 Copyright: © 2026 Hammond et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: The datasets collected, generated, or analyzed during the present study have been attached as supplementary information. Funding: This study was supported by The Project for Human Resource Development Scholarship, Japan International Cooperation Agency (JICA), and Nagasaki University School of Tropical Medicine and Global Health, Japan. There was no additional external funding received for this study. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Abbreviations: ANC, Antenatal Care; CHN/O, Community Health Nurse/Officer; CHPS, Community-based Health Planning and Services; GHc, Ghana cedis; GHS, Ghana Health Service; GPS, Global Positioning System; MoH, Ministry of Health; PHC, Primary Health Care; RMNCH, Reproductive, Maternal, Newborn, and Child Health; SSA, Sub-Saharan Africa; THLD, Twifo Hemang Lower Denkyira; USD, United States of America Dollars; VIF, Variance Inflation Factor; WHO, World Health Organization; JH, John Hammond; SAG, Silas Adjei-Gyamfi; DBD, Doreen Brew Daniels; GKS, Godfred Kwabena Sarpong; HA, Hirotsugu Aiga; TA, Tsunoneri Aoki Introduction The international human rights law recognizes the right of women and adolescent girls to survive pregnancy and childbirth through the provision of appropriate sexual and reproductive health services [ 1 ]. According to the World Health Organization (WHO), access to adequate healthcare must be provided with sufficient and appropriate content [ 2 ]. However, globally, over 400 million people lack access to primary care [ 3 ], including pregnant women. Antenatal care (ANC), which is the care provided by skilled healthcare providers to women during pregnancy for positive birth outcomes, forms an essential part of the reproductive, maternal, newborn, and child health (RMNCH) continuum of care. Typically, the care package include health-promotion, screening, and preventive services provided throughout pregnancy, including routine checks, supplementation, malaria prevention, HIV testing and counseling, and birth-preparedness counseling. The WHO 2016 model recommends at least eight contacts, beginning in the first trimester [ 4 ]. ANC has become a global priority over the past decade, intending to increase its coverage [ 5 ]; as such, between 2015 and 2022, about 88.8% of pregnant women in SSA had at least one ANC visit with a skilled care provider, although only 58.4% attained the recommended four or more visits [ 6 ]. Also, in sub-Saharan Africa (SSA), the proportion of women who had at least one ANC visit during pregnancy has improved from 69% in 2006 [ 7 ] to 78.5% in 2021 [ 8 ]. RMNCH services like ANC not only reduce maternal and child mortalities [ 9 , 10 ] but also prevent adverse birth outcomes like low birthweight and preterm births [ 11 , 12 ], especially in poorly resourced countries [ 4 ]. Early identification of high-risk pregnancies through ANC, together with the timely provision of appropriate care by skilled health personnel throughout the continuum of care, is critical to preventing maternal and newborn deaths. Effective ANC enables the early detection and management of pregnancy complications such as severe bleeding, infections, pre-eclampsia/eclampsia, and complications related to abortion, which together account for nearly 80% of maternal deaths. Ensuring that women receive timely, quality care right from pregnancy and childbirth to the postnatal period remains one of the most effective strategies for saving the lives of women and their children [ 10 , 13 – 15 ]. Challenges that women face in accessing skilled care during pregnancy and childbirth in resource-poor settings are a significant contributor to maternal deaths [ 16 ]. Although SSA accounted for only 17% of global births, the region accounted for 57% of the estimated 358,000 maternal deaths that occurred worldwide due to pregnancy- and childbirth-related complications [ 17 ]. Most studies have attributed ANC accessibility to factors including geographic/availability barriers (distance to the nearest CHPS zone), affordability barriers (household income and out-of-pocket ANC payments), acceptability barriers (knowledge of ANC and pregnancy, socio-cultural beliefs), and utilization patterns (timing and frequency of ANC contacts), among others, as predictors of timely and continuous ANC attendance [ 9 , 18 , 19 ]. These inequities in ANC underscores the need to understand context-specific health-system responses such as Ghana’s CHPS policy. Over the past two decades, Ghana has been implementing the community-based health planning and services (CHPS) policy, aiming to reduce access barriers to healthcare through the provision of primary health care (PHC) services at the community level. The primary strategy of the policy is the deployment of a Community Health Officer (CHO) (a Community Health Nurse (CHN) who has undergone in-service training and orientation) and has been posted to a clearly defined CHPS zone supported by the community leadership structure to plan and mobilize resources for service delivery [ 20 – 22 ]. As the country’s leading approach to community-focused service provision, the initiative has contributed to a significant drop in maternal and child deaths and the increasing performance of ANC and vaccination services, particularly in rural areas [ 23 ]. According to the 2017 Ghana Maternal Health Survey, a nationally representative survey, 2.3% of women nationally did not attend ANC at all before their most recent delivery [ 24 ], 22% of all deliveries were assisted by unskilled personnel [ 25 ], and only 9.9% of births occurred within 8 km of CHPS zones [ 26 ], and this could partly explain why Ghana did not meet the Millenium Development Goal’s target on maternal and infant health. In the Central Region of Ghana, CHPS facilities which serve 52% of rural populations in the region, contribute to about 16% of all ANC registrants and 8% of skilled deliveries [ 27 ]. The Twifo Hemang Lower Denkyira (THLD) district is one of the rural districts with poor maternal health indicators, particularly low coverage in ANC registration, skilled delivery, PNC care, family planning services, and high teenage pregnancies, despite the increased investment in scaling up PHC services closer to the doorsteps of many more households and communities. This is reflected, for instance, in the district’s 2020 ANC coverage (56.4%) and skilled delivery coverage (32.5%), both of which were below the Central Region averages of 81% and approximately 66%, respectively [ 27 ], indicating a gap between ANC and skilled delivery, as seen in most SSA countries. There is a need to understand how pregnant women in rural settings interact with the healthcare system and what influences their access to ANC in the context of CHPS. Considering several pieces of evidence that make CHPS a very promising policy for the improvement of services, particularly for women, access to healthcare in the district remains poor. Evidence on access to ANC services provided through the CHPS strategy for women in the region and its impact on achieving quality maternal and child healthcare is limited. This study therefore aimed to explore factors that influence women’s access to ANC services provided through the CHPS strategy in the THLD district of the Central Region of Ghana. Materials and methods Study setting The study was conducted at THLD district which is one of the districts among the 22 districts in the Central region of Ghana, with its administrative capital at Twifo Hemang. It stretches about 75 km from the regional capital, Cape Coast, and lies between latitudes 5 o 50’ N and longitude 1 o 50’ W, located in the north-western part of the region with a total landmass of 674 sq. km ( Fig 1 ). The estimated population in 2020 was 67,341, of which 51% are females, with an estimated 4% (2,694) Women in Fertility Age (WIFA) and a population density of about 82 per square kilometer [ 28 ]. Whereas the number of women of reproductive age in 2020 was 16,073, the total ANC and postnatal visits were 7,502 and 1,324 respectively. THLD district is predominantly rural (86%) with 300 settlements and 84 clearly defined communities. Most of the remaining settlements are farmsteads, usually with a population below 500 people. The health delivery system in the district is made up of the orthodox and traditional systems, with the latter consisting of traditional birth attendants, herbalists, fetish priests, and spiritualists, and is thought to play a crucial role in the health-seeking behavior of most people in the district. Health delivery under the orthodox system in the district exists up to two levels (A and B) under the country’s PHC system, that is, the community and sub-district levels. It is divided into four sub-districts with no district hospital but has three health centres, one community clinic, and 13 functional CHPS zones [ 27 ] as shown in Fig 1 . Download: PNG larger image TIFF original image Fig 1. Map of the THLD district showing communities and measured distance to all CHPS zones. https://doi.org/10.1371/journal.pone.0359892.g001 Study design and population To explore access to ANC services in the THLD district of the Central Region under CHPS policy, we used a descriptive cross-sectional quantitative study design. This method allows simultaneous measurement of exposure and outcome status in a defined population and is well suited to estimating the prevalence of, and correlates associated with, ANC attendance and initiation timing in a population not previously characterized in this district [ 29 , 30 ]. This study targeted women of reproductive age (15–49 years) having at least one child aged 12 months or younger preceding data collection, living or residing within communities of all the demarcated CHPS zones of the district. Sample size The sample size was determined using Cochran’s (1977) formula for estimating a sample size for a categorical outcome in a population whose exact size is not precisely known, which is appropriate given that the exact number of eligible mother–child pairs in the THLD district at the time of the study was not available [ 31 , 32 ]. The formula is expressed as N0 = [{(Zα/2)2(1–p)p}/d2], where “ N0” is the estimated sample size, “Zα” is the confidence level at 95% (standard value of 1.96), “p” is the estimated proportion of women accessing maternal healthcare services in CHPS zones in Ghana (76%) [ 18 ], and “d” is the level of precision/margin of error of 0.05. Hence, N0 = [{(1.96)² × (1–0.76) × 0.76}/(0.05)²] = 280.3 ≈ 280. With a minimum sample of 280, a non-response rate of 10% was added to attain an estimated final sample size of 310. Sampling method During sampling, all 13 CHPS zones in the THLD district were selected for the study. We used the probability proportional to size (PPS) technique to determine sample sizes for each CHPS zone. This ensured each zone’s contribution to the final sample reflected its actual share of eligible mother–child pairs, preventing over-representation of smaller zones and under-representation of larger ones, and producing a self-weighting sample for CHPS zone-level population size. Using the vaccination records in the child welfare clinic register in each CHPS zone as the sampling frame [ 33 ], a total of 1751 eligible participants (children born under 12 months) were obtained. Thereafter, a simple random sampling method was used to select the required sample size of 310 from the CHPS zones and the selected children were directly linked to their mothers and sorted according to the community of residence. In total, 48 communities were obtained and the addresses (including telephone numbers) of the mothers were taken for identification at the community level. Within the community, research assistants were supported by the CHN/Os and the community volunteers to trace the mother-child pairs. The respondents were interviewed in their place of residence after booking an appointment with them and signing an informed consent and/or assent form. In the absence of a study respondent at the time of the visit, the research assistant rescheduled the interview to a later time. To maintain confidentiality, all personal identifiers such as addresses, and telephone numbers were stored separately from the research data in password-protected files accessible only to the research team. Each participant was assigned a unique identification code, and analyses were conducted using coded data rather than personal information. Hard-copy records were kept in locked cabinets, and no identifying details were disclosed in reports or publications. Data collection instrument Data were collected using a structured, interviewer-administered questionnaire comprising five sections: (i) socio-demographic characteristics; (ii) socio-economic characteristics, including a household-asset module used to construct the wealth index; (iii) antenatal and obstetric history; (iv) knowledge of ANC and pregnancy (seven items, described under Measurement of study variables); and (v) CHPS location/distance characteristics, supplemented by a GPS-coordinate capture field. The questionnaire, adapted from instruments used in comparable rural Ghanaian and West African maternal-health studies [ 9 , 33 , 34 ], was developed in English before being translated into Fantse for administration. The questionnaire was pretested among 31 mother-child pairs in Twifo Praso community, a neighboring community in Twifo Atti-Morkwa District, in January 2022. The pretest assessed question clarity, cultural appropriateness of the Fantse translation, question flow, logical flow, and average interview time. Following the pretest, 4 items were reworded for clarity, and 1 item was removed as redundant. Participant recruitment and rigor Participant recruitment followed the process described under the data collection method below, with research assistants supported by CHNs/CHOs and community volunteers to trace and approach eligible mothers at their place of residence. All five research assistants held a minimum qualification of Bachelor’s degree in Nursing, Public Health, or Health Informatics and underwent 2 days of training prior to data collection, covering research ethics and informed consent/assent procedures, standardized questionnaire administration and probing techniques, use of the ODK mobile data-collection platform, and GPS coordinate capture. Three of the five research assistants were residents of, or had prior professional experience working within, THLD district, and all were fluent in Fantse and/or Twi. Data collection The five trained research assistants conducted data collection from 15 th February to 15 th March 2022. Data was collected using a pretested standardized questionnaire with the aid of mobile data collection software (Open Data Kit Collect-version 2021.2.4). Moreover, two independent reseachers prevalidated the questionnaire (including knowledge related questions) and its content validity was confirmed by experts reviews and study authors. The information on socio-demographic, socioeconomic (household assets), antenatal, and CHPS location/distance characteristics as well as respondents’ knowledge of ANC and pregnancy were collected through face-to-face interviews with participants using the local dialect (Fantse and Twi). Other relevant information, including gestational age at first ANC visit, total number of ANC contacts completed, and any documented danger signs, was confirmed, where available, from the maternal and child health record books held by respondents. Before each session of the interview, global positioning system (GPS) coordinates were obtained from respondents which were used to estimate distances from the respondent’s place of residence to the nearest CHPS zone. Measurement of study variables A description of the key variables is shown in Table 1 . The outcome variables in the study were At least one ANC attendance (At least one ANC visit; No ANC visit) and time of ANC initiation categorized as Early initiation (first ANC ≤ 12 weeks of gestation) and Late initiation (first ANC ≥ 13 weeks of gestation). The exposure variables included all maternal background (sociodemographic, socioeconomic, and antenatal variables) and CHPS location/distance characteristics. Download: PNG larger image TIFF original image Table 1. Description of key study variables. https://doi.org/10.1371/journal.pone.0359892.t001 Data analysis Data analysis was conducted using STATA version 17 (Stata Corporation, Texas, USA) at a significance of p < 0.05. Simple descriptive statistics were performed on categorical variables and summarized into frequency distribution and percentages. Means and standard deviations we
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