The burden and predictors of late antenatal booking in a rural setting in Ghana

Abstract

Aim

The aim of the study was to determine the prevalence and key predictors of late booking among pregnant women accessing antenatal care services in a rural district of Ghana.

Design

Cross‐sectional study.

Methods

Data on demographic characteristics, knowledge of accessing antenatal care services and booking gestation were collected from 163 randomly selected pregnant women accessing accessing antenatal care in rural Ghana from 1 March 2022 to 30 April 2022 using a structured questionnaire. The chi‐square and logistic regression were used to explore associations between exposure and dependent variables.

Results

The prevalence of late accessing antenatal care booking among study participants was 44.8% (73/163). About 79.1% (129/163) of them had adequate knowledge of accessing antenatal care services. Maternal age of 35–49 years (AOR: 8.53, 95% CI: 2.41–30.12), participants whose partners had no formal education (AOR: 3.43, 95% CI: 1.03–11.39) and participants with adequate knowledge about accessing antenatal care services (AOR: 0.21, 95% CI: 0.07–0.62) were associated with late booking for accessing antenatal care services among study participants.

1. INTRODUCTION

Sustainable development goal three (SDG3) targets a reduction of the global maternal mortality ratio to 70 per 100,000 live births by 2030 (United Nations, 2015). One way of attaining this is through appropriate antenatal care (ANC) for pregnant women. Antenatal care is an effective means to reduce adverse pregnancy outcomes and services rendered include vitamin D supplementation, health promotion, screening for defects and complications, counselling on healthy eating habits and continuous care during the pregnancy period to enhance safe delivery (World Health Organization (WHO), 2016). The WHO recommends that every pregnant woman should have at least eight physical appearances for ANC (WHO, 2015) with their first booking in the first trimester (before the foetus reaches 12 weeks of gestation; WHO, 2016) to enhance early detection and treatment for all complications. The provision of ANC at an early foetal age has been reported to be critical for maintaining optimal care for the pregnant mother and foetus (Dorji et al., 2019). Pregnant mothers who do not fully utilize ANC coverage are unable to receive all the necessary care and this predisposes them and their unborn babies to adverse health outcomes (Appiah et al., 2020; Kuhnt & Vollmer, 2017; Shiferaw et al., 2021).

There has been a decline in global maternal mortality from 451,000 in 2000 to 295,000 in 2017 (WHO, 2019). However, the burden remains appreciable as over 800 maternal deaths are recorded daily all over the world (WHO, 2019). In sub‐Saharan Africa, the burden of maternal mortality is about 68% of the global maternal mortality with approximately 533 maternal deaths per 100,000 live births (200,000 deaths) a year (WHO, 2019). In Ghana, maternal mortality is still high with 310 deaths per 100,000 live births reported in the 2017 national maternal health survey (GHS/GSS/ICF, 2018). A good number of these maternal mortalities could have been prevented through receiving appropriate and timely ANC services (Blencowe et al., 2016) as it is a useful tool for reducing maternal mortality and is easily accessible in health facilities in rural areas (Raatikainen et al., 2007; Yeoh et al., 2016).

Despite the significance of full ANC coverage, a lot of pregnant women in sub‐Saharan Africa still report late in their second and third trimesters for their first ANC visit (Gidey et al., 2017; Tola et al., 2021; Wolde et al., 2019). This increases their risks of developing adverse pregnancy outcomes such as vaginal bleeding, hypertensive disorders of pregnancy and foetal death (Gidey et al., 2017; USAID, 2018). Several factors such as inadequate knowledge of ANC services, maternal age of 25 years and above, unintended pregnancy, and no formal or primary education have been widely reported to be associated with late booking for ANC services (Kluckow et al., 2018; Teshale & Tesema, 2020; Wolde et al., 2018). A Rwandan study reported that long distances to a health facility and an unwanted pregnancy favoured late booking (Munyaneza et al., 2016). Ghana, in an attempt to improve health and ANC services, adopted the WHO's Focus Antenatal Care (FANC) approach in 2002. Additionally, other interventions such as Free Maternal Healthcare Policy (FMHP) in 2008 and Community‐Based Health Planning and Services (CHPS) in 1999 were also adopted to help improve access to ANC services. One of the targets of the Ministry of Health's Sector Medium Term Development Plan (2018–2021) was for 80% of all pregnant women to have their first ANC visit in their first trimester (Ministry of Health, 2017). However, pregnant women booking late for ANC services remains a challenge in Ghana (Kotoh & Boah, 2019; Tibambuya et al., 2019). About 33%–39% and 4% of pregnant mothers had their first visit in their second and third trimesters, respectively (Manyeh et al., 2020).

The 2019, 2020 and 2021 annual district health reports for the Ahafo Ano South West district in the Ashanti Region of Ghana show the district has a marked burden of late ANC booking. In 2019, about 55% of ANC registrants in the district started ANC in the second and third trimesters. This figure declined to about 48% in 2020 and 2021. Similarly, approximately 60% and 30% of ANC registrants in the district made 4th and 8th ANC visits in 2021. These data indicate that ANC attendance, particularly late booking, is an issue in the Ahafo Ano South West District of Ghana. It is against this background that this study was conducted to determine the prevalence and factors contributing to late booking among pregnant women accessing ANC in the Ahafo Ano South West District, Ghana. The study also evaluated the knowledge of pregnant women on ANC services. Identifying these predictors will help to understand the reasons underlying the burden of late booking for ANC, improve health promotion interventions targeting pregnant women and help to inform policies to improve ANC booking in the district and possibly other parts of Ghana with similar demographics.

2. METHODS

2.1. Study setting

This study was conducted at Mankranso Government Hospital (MGH), a district hospital that serves as a referral centre for surrounding lower‐tier facilities and Kunsu Health Centre (KHC) in the Ahafo Ano South West District in Ghana. The Ahafo Ano South West District is one of the 43 administrative districts in the Ashanti Region of Ghana with Mankranso as the district capital. Mankranso Government Hospital and KHC were selected for this study due to their active involvement in ANC serin the district.

The 2021 annual health report of the district shows that about 2,220 pregnant women registered for ANC in the district in that year, and of these, 696 and 395 pregnant women registered at MGH and KHC respectively. The total ANC attendance for the district in 2021 was 11,380 with MGH and KHC recording 3,243 and 1,733 attendances, respectively. At MGH, ANC is conducted from Monday to Friday, while ANC is conducted at KHC from Wednesday to Friday.

2.2. Study design

This study adopted an analytical cross‐sectional design to determine the prevalence and key predictors of late ANC booking among rural pregnant women accessing ANC at MGH and KHC in the Ahafo Ano South West District. The chosen study design is justified as it allows reporting of a prevalence measure as well as inferential statistics including odds ratios that describe the strength of association between exposure and dependent variables (Wang & Cheng, 2020).

2.3. Study population

The study population comprised all pregnant women accessing ANC services, either for their first visit or a subsequent scheduled visit, at MGH and KHC from 1 March 2022 to 30 April 2022. The average monthly ANC attendances, over the preceding 3 months, for MGH and KHC were 268 and 145, respectively.

2.4. Inclusion criteria

1. All pregnant women accessing ANC at MGH and KHC over the study period were included in the study.

2. Minors (those below 18 years) that had their guardian or family member present were included in the study.

2.5. Exclusion criteria

1. All pregnant women that were transferred from different health facilities and did not have records of their gestational age at ANC booking captured in their ANC book were excluded from the study.

2. All pregnant women who looked ill or appeared to be in any form of discomfort at the time of sampling were excluded.

2.6. Sample size calculation and sampling procedure

The sample size for this study was estimated using the Charan and Biswas equation ($\text{sample size}=\left(Z^2\left(P\right)\left(1-P\right)\right)/E^2)$ (Charan & Biswas, 2013). At a 95% confidence interval (Z), 5% allowable margin of error (E) and 86.8% (Damme, 2015) of pregnant women who booked late for ANC (P), a sample size of 176 pregnant women were obtained. Using a non‐response rate of 10.0%, a total of 194 pregnant women were recruited for the study. The 10% non‐response rate was used based on the assumption that about 10% of the pregnant women that will be recruited may not be able to either complete or wait for the interview.

The number of participants to be selected from each of the study sites was calculated based on a proportional allocation ratio derived from the average number of pregnant women that attended the ANC clinic in each facility in the preceding 3 months. This proportional allocation ratio was then applied to the final sample size. One hundred twenty‐nine (129) and sixty‐five (65) participants were to be selected from MGH and KHC, respectively.

The study participants were selected using the simple random sampling approach. On each day of the data collection, the participants were sampled at 11:00 GMT at each facility. The cards of the pregnant women present at that time were retrieved, and their names were entered into balloting for the recruitment of study participants. At MGH, about six pregnant women were recruited out of about 13 pregnant women that reported for ANC services each day while about four out of about nine people were recruited each day at KHC.

2.7. Data collection

Data were collected using a structured questionnaire (see Appendix S1). The questionnaire was developed de novo by the investigators from the literature review and was not validated. It was administered to study participants by a final‐year medical student and two midwives in the local Asante Twi language. The study site was a rural setting, and it was reckoned very few women could read and understand English. The research assistants were trained over 3 days on the data collection instrument and consistency in translation from English to the local language. The questionnaire was pre‐tested on 15 pregnant women in another peripheral health facility in a neighbouring district and appropriate changes were made to its structure to improve its precision and reliability before it was used The questionnaire was used to collect data on participants' socio‐demographic characteristics (such as maternal age, occupation, education, partner's education and marital status), knowledge of ANC services (timing of ANC booking, benefits of ANC, number of ANC visits etc.) and ANC booking (booking time, health status at current booking and preference for birth attendant). Data on participants' gestational age at the first ANC visit was retrieved from participants' antenatal book. The gestational age for those coming for ANC for the first time was confirmed using their scan report. This was double‐checked from the ANC register. Late booking in this study was defined as participants that reported for the first ANC visit after 12 weeks of gestational age.

2.8. Data quality management and analysis

Data were double entered in Epi Info version 7.2.4.0 (Center for Disease Control and Prevention [CDC] USA), cleaned and exported into Stata version 16 for analysis. Descriptive data were expressed as means, frequencies and percentages and presented using tables. In this study, participants' knowledge of ANC services was measured by asking ten (10) questions about ANC services. Each correct response was scored ‘1’ with an incorrect response scoring ‘0’. The overall score was computed for each participant and expressed as a percentage of the total possible score of 10. The participants' knowledge of ANC services was rated as adequate knowledge of ANC services (≥70% scores) and inadequate knowledge of ANC services (<70% scores). The adoption of the 70% cut‐off was based on the preference of the investigators for pregnant women to have rationally adequate knowledge of ANC services considering its significance on maternal and child health. Such relatively arbitrary cut‐off scores have been used to categorize knowledge in previous studies (Afaya et al., 2020; Agbeno et al., 2022; Oppong Asante, 2013; Wolde et al., 2019).

Chi‐square analysis was employed to explore the association between independent variables (such as maternal age, knowledge of ANC services and occupation) and dependent variable (late ANC booking). Independent variables showing significant associations were entered in a logistic regression analysis. Crude odds ratios (COR) and adjusted odds ratios (AOR) were reported with 95% confidence intervals. Statistical significance was pegged at a p‐value of <.05.

3. RESULTS

3.1. Demographic characteristics of study participants

Of the 194 pregnant women that were recruited for the study, 84.0% (163/194) of them completed the questionnaire. About 41.7% (68/163) were between the ages of 25–34 years. The mean age (SD) of participants was 28.5 (±6.4) with a range of 15 to 43 years. About 46.0% (75/163) of the participants had secondary education. About 64.4%, (105/163) of the participants were married. Over 74.2% (121/163) of the participants were Christians. Approximately, 68.0% (111/163) of the participants had an informal occupation (Table 1).

TABLE 1.

Demographic characteristics of study participants

Variable	Total, n = 163 n (%)	Late booking n (%)	Early booking n (%)	p‐values
Age group (years)
15–24	53 (32.5)	14 (26.4)	39 (73.6)	.001
25–34	68 (41.7)	32 (47.0)	36 (52.9)
35–49	42 (25.8)	27 (64.3)	15 (35.7)
Mean age (±SD)	28.5 (±6.4)
Age Range	15–43
Level of education
Basic	49 (30.1)	28 (57.1)	21 (42.9)	.001 a
Secondary	75 (46.0)	27 (36.0)	48 (64.0)
Tertiary	9 (5.5)	0 (0.0)	9 (100.0)
No formal education	30 (18.4)	18 (60.0)	12 (40.0)
Relationship status
Single	23 (14.1)	8 (34.8)	15 (65.2)	.394
Married	105 (64.4)	51 (48.6)	54 (51.4)
Cohabiting	35 (21.5)	14 (40.0)	21 (60.0)
Religion
None	3 (1.8)	0 (0.0)	3 (100.0)	.143
Christianity	121 (74.2)	52 (43.0)	69 (57.0)
Islam	39 (23.9)	21 (53.9)	18 (46.2)
Occupation
Formal b	26 (16.0)	6 (23.1)	20 (76.9)	.006
Informal c	111 (68.0)	59 (53.2)	52 (46.9)
Unemployed	26 (16.0)	8 (30.8)	18 (69.2)
Partner's occupation
Formal	41 (25.2)	13 (31.7)	28 (68.3)	.052
Informal	122 (74.9)	60 (49.2)	62 (50.8)
Partner's education
Basic	43 (26.4)	25 (58.1)	18 (41.9)	<.001
Secondary	74 (45.4)	22 (29.7)	52 (70.3)
Tertiary	17 (10.4)	5 (29.4)	12 (70.6)
No formal education	29 (17.8)	21 (72.4)	8 (27.6)
Health facility
MGH	105 (64.4)
KHC	58 (35.6)

Abbreviations: KHC, Kunsu Health Centre; MGH, Mankranso Government Hospital; SD, standard deviation.

^a Analyzed using Fisher's exact test.

^b Includes teachers and office workers.

^c Includes farmers, traders, artisans and other forms of self‐employment.

3.2. Antenatal booking among study participants

Out of a total of 163 participants, over 44.8% (73/163) of the participants booked late for ANC. About 48.5% (79/163) of the participants indicated the health status of their current pregnancy determined when they booked for ANC (that is their decision to book for ANC was informed by their physical health status). About 38.0% (62/163) of the participants indicated their booking time depended on their partner's decision (Table 2).

TABLE 2.

Antenatal booking among study participants

Variable	Frequency	Percentage, %
Booking for current pregnancy
Early booking	90	55.2
Late booking	73	44.8
Health status in current pregnancy determine when you book for ANC
Yes	79	48.5
No	84	51.5
Booking time depend on partner's decision
Yes	62	38.0
No	101	62.0
Prefer traditional birth attendants to hospital health attendants?
Yes	10	6.1
No	153	93.9
Concerns about the hospital health system which affects your booking time
Yes	22	13.5
No	141	86.5

3.3. Knowledge of ANC services by study participants

Out of a total of 163 participants, about 79.1% (129/163) had adequate knowledge of ANC services. About 84.1% (137/163) indicated that the first ANC visit after a missed period must be within the first 3 months. About 98.2% (160/163) indicated that ANC is very important in detecting and treating pregnancy complications such as anaemia, diabetes and malaria in pregnancy. Over 47.9% (78/163) indicated that four ANC visits during pregnancy are enough (Table 3).

TABLE 3.

Participants' knowledge of ANC services

Variable	Frequency	Percentage, %
Overall knowledge
Inadequate	34	20.9
Adequate	129	79.1
The first ANC visit after a missed period must be within the 1st 3 months
Yes	137	84.1
No	26	15.9
ANC is very important in detecting and treating pregnancy complications such anaemia, diabetes and malaria
Yes	160	98.2
No	3	1.58
Structural deformities can be prevented during ANC
Yes	140	85.9
No	23	14.1
Micronutrients deficiency can be detected and improved during ANC
Yes	156	95.7
No	7	4.3
Foetal kick count can be used to monitor the well‐being of the foetus
Yes	95	58.3
No	68	41.7
Four ANC visits during pregnancy are enough
Yes	78	47.8
No	85	52.2
Regular and strenuous exercises may be unsafe for the baby
Yes	105	64.4
No	58	35.6
Micronutrient‐rich diet is required for a good pregnancy outcome
Yes	156	95.7
No	7	4.3
Pregnant women need to eat more food than non‐pregnant women
Yes	130	79.8
No	33	20.3
Knowledge of appropriate child breastfeeding is acquired naturally
Yes	123	75.5
No	40	24.5

Abbreviation: ANC, antenatal care.

3.4. Predictors of late antenatal booking among study participants

In the univariate regression analysis, participants' age, level of education, occupation, partner's education and knowledge of ANC services were significantly associated with late booking for ANC services. For participants with informal occupations, the odds of booking late for ANC services were at least 3 times more (OR: 3.78, 95% CI: 1.41–10.13, p = .008) compared with those that had a formal occupation.

The multivariate regression analysis showed that participants' age, partner's level of education and knowledge of ANC services were identified as significant predictors of late booking for ANC. The odds of participants aged 35 years and above booking late for ANC was nearly 9 times more (AOR: 8.53, 95% CI: 2.41–30.12, p = .001) compared with those between the ages of 15–24 years. The odds of late booking for ANC among participants whose partners had no formal education was 3 times more (AOR: 3.43, 95% CI: 1.03–11.39, p = .004) compared with those whose partners had basic education. Similarly, the odds of participants that had adequate knowledge of ANC services booking late for ANC was less (AOR: 0.21, 95% CI: 0.07–0.62, p = .005) compared with those that had inadequate knowledge of ANC services (Table 4).

TABLE 4.

Multivariate logistic regression analysis of the factors associated with late antenatal booking among study participants

Variables	OR (95% CI)	p‐value	AOR (95% CI)	p‐value
Age
15–24	1.00		1.00
25–34	2.48 (1.14–5.37)	.022	4.73 (1.55–14.44)	.006
35–49	5.01 (2.08–12.07)	<.001	8.53 (2.41–30.12)	.001
Education
Basic	1.00		1.00
Secondary	0.42 (0.20–0.88)	.022	0.57 (0.23–1.41)	.220
Tertiary	‐	‐	‐	‐
No formal education	1.13 (0.45–2.83)	.803	0.34 (0.10–1.17)	.087
Occupation
Formal	1.00		1.00
Informal	3.78 (1.41–10.13)	.008	1.57 (0.48–5.16)	.457
Unemployed	1.48 (0.43–5.10)	.533	1.61 (0.34–7.54	.544
Partner's education
Basic	1.00		1.00
Secondary	0.30 (0.14–0.67)	.003	0.62 (0.25–1.55)	.306
Tertiary	0.30 (0.09–1.00)	.050	1.42 (0.22–9.22)	.715
No formal education	1.89 (0.68–5.22)	.219	3.43 (1.03–11.39)	.044
Knowledge of ANC services
Inadequate	1.00		1.00
Adequate	0.30 (0.14–0.67)	.003	0.21 (0.07–0.62)	.005

Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; NB, significant variables were adjusted for in the multivariate regression; OR, crude odds ratio.

4. DISCUSSION

This study assessed the prevalence and key predictors of late booking for ANC among pregnant women attending antenatal care in a rural district in Ghana. The study also assessed the knowledge of study participants on ANC services. The prevalence of late booking among study participants was 44.8%, with maternal age, partner's level of education and knowledge of ANC services identified as the key predictors of late booking for ANC services. About 79.1% of the study participants had adequate knowledge of ANC services.

In the present study, the proportion of pregnant women that booked late for ANC was high (44.8%) in light of the WHO recommendation of ANC booking for all pregnant women in the first trimester (WHO, UNPF, 2015). This reinforces reports that many pregnant women in low and middle‐income countries (LMICs) including Ghana begin ANC services late (Alem et al., 2022; Jiwani et al., 2020; Tesfaye et al., 2017; WHO, 2017). Pregnant women who present late for ANC will likely not benefit sufficiently from appropriate and timely care for conditions such as anaemia in pregnancy that can be deleterious to the pregnancy if not detected and managed early (Bankanie & Moshi, 2022; Floridia et al., 2014; Govender et al., 2018). This finding is comparable with the findings of a study in Ethiopia where about 42.2% of pregnant women booked late for ANC (Tufa et al., 2020). In the present study, the proportion of participants that booked late for ANC was higher than the one reported in South Africa (28.0%) among pregnant women in a peri‐urban centre (Ebonwu et al., 2018). The difference in study findings could be because the South African study (Ebonwu et al., 2018) was conducted among peri‐urban women while this study was conducted among women in a rural centre. It has been reported that pregnant women in rural areas are more likely to book late for ANC compared with their counterparts in urban areas (Ewunetie et al., 2018).

The data from the 2021 annual health report of the Ahafo Ano South West District suggest a decline in late ANC booking in the district from about 55.0% in 2019 to 48.0% in 2020/2021 to the current study's finding of 44.8%. The apparent decline in late booking in the district may be attributed to some interventions started in 2018 in the district to improve ANC services. The district health directorate embarked on ANC outreach in deprived communities by midwives, intensified health education on early ANC booking at the out‐patient departments of all health facilities and Child Welfare Clinics (CWC) points, involved male partners in ANC attendance and also collaborated with non‐governmental organization (Women's Health to Wealth) to motivate pregnant women attending ANC.

In the present study, about 79.1% of the study participants had adequate knowledge of ANC services. Having adequate knowledge of ANC services was associated with about 80% reduced odds of late ANC booking. This is comparable with studies that reported that inadequate knowledge of ANC services was significantly associated with late ANC booking among pregnant women (Banda et al., 2012; Wolde et al., 2019). This suggests that the knowledge of pregnant women about ANC services is extremely important for early ANC booking. Pregnant women with inadequate knowledge of ANC services may be unaware of the recommended time to book for ANC and the risks associated with the late booking. It is therefore important to increase awareness of ANC services among rural women.

Though close to 80% of participants were deemed to have adequate knowledge of ANC services in the present study, late booking for ANC was remarkably high. It could be that the participants were unable to identify their last menstruation date as this has been reported to affect late booking for ANC (Jinga et al., 2019). Again, this study was conducted among pregnant women in a rural setting and inherent cultural norms such as not deliberately showing off your pregnancy until it is obvious, which is when you are expected to start ANC services (this usually starts after the first trimester) could affect their late booking for ANC services (Chimatiro et al., 2018; Mgata & Maluka, 2019).

In this study, maternal age was identified as a predictor for late booking with participants that were between the ages of 25–34 years and 35–49 years having increased odds of late booking for ANC services compared with those between 15–24 years. This is comparable with studies that reported maternal age as a significant predictor of late booking for ANC services (Ejeta et al., 2017; Tola et al., 2021). A possible explanation could be that these older women may have had higher gravidity, and better experience from their previous pregnancies and subsequently may become over‐confident in not prioritizing early booking for ANC services. Comparatively, younger women may consider themselves at risk of pregnancy complications and may be more careful and book early for ANC services to receive timely and appropriate care. This suggests that interventions to improve early booking, aside from being universal, should also be designed to target older age groups (25 years and above). The study did not report on participants' gravidity and parity and this is acknowledged as an important limitation as it restricts contextual nuances. While maternal age may somehow be a proxy for gravidity/parity, it is not always the case that older and younger women will have higher or lower gravidity/parity, respectively.

Also, the partner's level of education in this study was identified as an independent predictor of late booking for ANC services. In this study, late booking was more prevalent among participants whose partners had no formal education compared with those whose partners had basic education. This is consistent with other studies (Gudu, 2018; Tesfaye et al., 2017; Tufa et al., 2020) that found a partner's educational status as a predictor of timely booking for ANC services. Partners with no formal education may not have adequate information on timely ANC booking and its significance and may not be able to guide their women to make better health‐seeking decisions on ANC services that will benefit them. This also suggests health promotion messages regarding the advantages of initiating ANC services early in the pregnancy should target partners of pregnant women and should preferably be done in the local language to ensure some equity in awareness. This can be evident in the present study considering that about 38.0% of the women said that their ANC booking time depended on their partners' decisions. Partners (males) are typically household heads and their influence extends into the health‐seeking behaviour of the household members including pregnant women (Bougangue & Ling, 2017; Nabieva & Souares, 2019; Teklesilasie & Deressa, 2018).

In the present study, about 13.5% of the participants raised concerns about the health system and how it affected their time for ANC booking. This is particularly worrying due to its public health significance because the very place where they are to seek care may itself become a barrier to early ANC services booking. This is consistent with other studies that reported health system barriers such as poor staff attitude and long waiting times at ANC clinics as a reason for booking late for ANC services (Chimatiro et al., 2018; Mgata & Maluka, 2019). It is therefore important to effectively and frequently train health workers in quality improvement and client service delivery that hammers respect for clients. This is important for patient satisfaction with the quality‐of‐service delivery (Escribano‐Ferrer et al., 2016; Larson et al., 2019; Worsley et al., 2016).

The study observed that 6.1% of the participants preferred traditional birth attendants (TBAs) for ANC services. These TBAs not only offer birthing services but also offer ‘traditional ANC services’ (Adatara et al., 2018). Preference for TBAs by pregnant women raises a public health concern considering their negative consequences on maternal and child morbidity and mortality (Fronczak et al., 2007). This is because women that utilize the ‘traditional ANC services’ may not have the opportunity to benefit from interventions to improve pregnancy and birth outcomes. One reason why these women go to the ‘traditional ANC carers’ is to achieve ‘spiritual’ protection for their pregnancies firstly and secondly themselves (Aziato & Omenyo, 2018). One way to drive pregnant women away from the utilization of the ‘traditional ANC services’ is to strengthen the healthcare system by improving interpersonal relationships between healthcare workers and pregnant women and offering patient‐centred care to all pregnant women.

4.1. Limitations of the study

One of the limitations of this study is the use of only two public health facilities in a district which affects our ability to generalize the study findings. Again, the confidence intervals around some of the odds ratio estimates in the regression analysis were rather wide and suggest diminished precision of the study findings. This was particularly true for maternal age in the multivariate analysis. This situation likely arose from the reduced number of participants recruited and these findings should be interpreted with caution. Another limitation is that the use of a quantitative approach limited the exploration of some issues such as health system challenges that affect the timing of ANC services booking. Finally, the data collection tool was not validated but its validity and reliability were improved through pretesting.

Despite the limitations, the present study provides some useful data on the predictors of late booking for ANC such as maternal age, knowledge of ANC services and partner's education among pregnant women in a rural setting in Ghana.

5. CONCLUSION

In this study, we observed that late antenatal booking among pregnant women was 44.8% and remains a challenge for improving maternal and child health among this cohort of rural women in Ghana. This indicates that a significant proportion of pregnant women in these areas are more likely to miss the early detection and management of some pregnancy‐related complications, leading to an increased risk for maternal and child morbidity/mortality. Maternal age, knowledge of ANC services and partner's level of education were identified as the independent predictors of late booking for ANC in this study. As part of efforts to improve maternal and child health, interventional strategies designed to promote the early initiation of ANC among pregnant women could address the challenges peculiar to women in rural Ghana and perhaps the entire nation. For instance, messages on early initiation should be given to women even before they get pregnant, and these messages can be delivered at community durbars, churches and mosques. We also recommend future qualitative studies to get more nuanced insight into the problem of late booking for ANC services.

AUTHOR CONTRIBUTIONS

CAO, DAO and AM: Conceptualization. COA, DAO, AF, AAA, EOA, SI, EFK, AB and JO: Data collection. All the authors were involved in the data quality management, analysis and interpretation. All the authors were involved in the first and final draft of the manuscript and approved it for publication.

All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/recommendations/)]:

• substantial contributions to conception and design, acquisition of data or analysis and interpretation of data;

• drafting the article or revising it critically for important intellectual content.

FUNDING INFORMATION

We confirm that we did not receive any funding from any specific organization or government funding agencies. This study was solely funded by all the authors.

CONFLICT OF INTEREST

The authors declare that no conflict of interest existed for this study.

Ethics statement

This study received ethical approval from the Committee on Human Research, Publications and Ethics (CHRPE), School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, KUmasi, Ghana with a reference number CHRPE/AP/089/22. Permission was obtained from the District Health Directorate in the Ahafo Ano South West District, Ghana before commencing the processes for ethical approval.

All participants either thumb printed or signed an informed consent form. Assent was obtained from all minors and their accompanying guardians also signed the informed consent form.

Supporting information

Appendix S1

Oduro, C. A. , Opoku, D. A. , Osarfo, J. , Fuseini, A. , Attua, A. A. , Owusu‐Ansah, E. , Issah, S. , Barfi, A. , Kwadzodeh, E. F. , & Mohammed, A. (2023). The burden and predictors of late antenatal booking in a rural setting in Ghana. Nursing Open, 10, 2182–2191. 10.1002/nop2.1467

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.