Abstract
Introduction
Evidence from low- and middle-income countries (LMICs), especially using robust causal inference techniques to estimate the association between ≥8 antenatal care (ANC) contacts and adverse pregnancy outcomes, remains limited. This study examines the association between completing eight or more ANC contacts and adverse pregnancy outcomes, specifically low birth weight (LBW) and preterm birth (PTB).
Methods
A cross-sectional study was conducted using retrospective delivery data at Juaben Government Hospital, Ghana. LBW and PTB were compared between women who made ≥8 ANC contacts and those who did not. Propensity score matching (1:1), inverse probability of treatment weighting, and doubly robust estimates were employed to address confounding and estimate the association between completing ≥8 ANC contacts and LBW and PTB.
Results
At baseline, the sample included 2156 women, of whom over half (51.3%) had ≥8 ANC contacts before delivery. After matching, women in both groups had similar characteristics. After matching on covariates, women with ≥8 ANC contacts had approximately 31.0% (ATT: 0.69; 95%CI: 0.53–0.90) and 54.0% (ATT: 0.46; 95%CI: 0.37–0.57) lower risks of delivering a LBW infant and a PTB, respectively. Inverse probability of treatment weighting and doubly robust estimates yielded comparable estimates for both outcomes. In a secondary analysis of ≥4 ANC contacts, the magnitude of the association was weaker than that observed in the ≥8 ANC model.
Conclusion
This study demonstrated that completing ≥8 ANC contacts was consistently associated with lower odds of LBW and PTB among this cohort of pregnant women. This finding adds to the limited empirical evidence from LMICs on the implementation of the WHO eight-contact ANC model, suggesting that higher ANC contacts in a similar resource-constrained setting may be associated with improved maternal and infant outcomes.
Keywords: Antenatal care, Doubly robust, Ghana, Preterm birth, Propensity score matching, Low birth weight
Highlights
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≥ 8 ANC contacts are associated with lower odds of PTB and LBW.
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Propensity score matching, doubly robust, and inverse probability of treatment weighting analyses strengthened causal inference.
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Findings support making ≥8 ANC contacts for positive pregnancy outcomes.
Introduction
Despite efforts to decrease adverse pregnancy outcomes, including low birth weight (LBW), preterm birth (PTB), maternal and neonatal morbidity and mortality globally, its burden is still high in low- and middle-income countries (LMICs) [1], [2], [3], [4], with the latter accounting for 92% of the global 260,000 maternal deaths in 2023 [3]. The maternal mortality ratio of 346 per 100,000 live births in low-income countries for 2023 significantly falls short of the Sustainable Development Goal (SDG 3) target of 70 per 100,000 live births by 2030 [3], [5]. Furthermore, sub-Saharan Africa's neonatal mortality ratio of 27 deaths per 1000 live births in 2022 falls significantly short of the SDG target of 12 deaths per 1000 live births by 2030 [5], [6]. Providing prompt and appropriate care for pregnant women, including antenatal care (ANC), remains key to bridging these gaps.
In 2016, the WHO revised its recommended number of ANC physical contacts from a minimum of four to at least eight before delivery for all pregnant women, with a trained healthcare professional, as an essential strategy to enhance the health and safety of mothers and their unborn infants [7]. Early and regular attendance at ANC is crucial for the continuation of interventions such as iron and folic acid supplementation, vaccination, nutritional guidance, malaria prevention, and other related healthcare strategies. Despite its significance, evidence indicates that many pregnant women in sub-Saharan Africa initiate ANC late [8], [9], [10], and do not complete the WHO-recommended eight or more ANC contacts before delivery [11], [12], [13]. This has been associated with an increased vulnerability to pregnancy-related complications [14]. In sub-Saharan Africa, factors such as maternal age, at least secondary school education, exposure to media, insurance coverage, and early ANC booking have been reported as key predictors of compliance with eight or more ANC contacts among pregnant women [11], [12], [13].
Adverse pregnancy outcomes, including LBW and PTB, are influenced by an interplay of several factors, including clinical, individual, facility-level factors, and lifestyle choices [15], [16], [17], [18], [19]. Access to and utilization of maternal health services, such as ANC, are critical for achieving desirable birth outcomes [20]. In Ghana, recent evidence suggests that making at least 8 ANC contacts reduces the odds of delivering a LBW baby and a PTB by up to 87% [14], [21], [22]. This finding underpins the significance of making at least eight ANC contacts in promoting the health and safety of pregnant women and/or their neonates. Nevertheless, making at least eight physical ANC contacts on its own may not directly account for the reduced risk of the occurrence of adverse pregnancy outcomes such as LBW and PTB. Women who utilize ANC may have specific characteristics that are also independently associated with LBW and PTB [23].
Previous studies in Ghana have primarily used case-control or cross-sectional designs, with regression analysis, to examine the association between ≥8 ANC contacts and adverse pregnancy outcomes, including LBW and PTB [14], [20]. Despite the regression analysis's ability to adjust for measured confounders, it may be limited by residual bias if covariates are not fairly balanced between women in the two groups [24]. To address this limitation, the current study utilized propensity score matching and doubly robust analyses, which create a covariate-balanced comparison between women who received the treatment (≥8 ANC contacts) and those who did not (<8 ANC contacts), and produce causal estimates that are more robust to model misspecification [25], [26]. Additionally, the validity of the effect estimates was further enhanced by applying inverse probability of treatment weighting (IPTW) and doubly robust analyses. The application of these advanced causal inference techniques in this study strengthens confidence in the association between ≥8 ANC contacts and adverse pregnancy outcomes, providing more reliable evidence to guide public health strategies in resource-limited settings. This study addresses a methodological gap in Ghanaian literature by using an advanced causal inference technique to strengthen the evidence supporting at least eight ANC contacts. Therefore, the objective of this study was to assess the association between ≥8 ANC contacts and adverse pregnancy outcomes, specifically LBW and PTB, among women who delivered at a district hospital in Ghana.
Methods
Study design, setting, and population
This study employed a cross-sectional design, using retrospective data on pregnant women who delivered at Juaben Government Hospital (JGH) between January 1, 2021, and December 31, 2023. JGH is a district-level facility that provides healthcare services to over 30 communities, approximately 65% of which are rural. It is a 73-bed capacity facility with a 16-bed maternity block and a single operating theatre that serves both elective and emergency surgical procedures. Data were extracted from medical records using a standardized data extraction sheet (see Supplementary File 1).
The study population was all pregnant women who delivered at JGH between January 1, 2021, and December 31, 2023. We included all women of reproductive age who delivered at the hospital and for whom complete data on ANC visits were available. Women with missing records of their babies' gestational age at delivery and birth weight were excluded from the study.
Definition of variables
Outcome variable
The outcome variables of this study were adverse pregnancy outcomes, specifically, LBW and PTB. Both outcomes were treated as dichotomous variables. LBW was defined as a neonatal birth weight of less than 2500 g (5.5 pounds) [17], [27]. Also, PTB was defined as delivering a live baby before 37 completed weeks of gestation [15], [28], [29].
Treatment variable
The treatment variable was ANC contacts during the most recent pregnancy that resulted in a live birth at the facility. ANC was categorized as ≥8 contacts and < 8 contacts. This categorization was based on the 2016 WHO recommendation [7], which advocates a minimum of 8 ANC contacts to achieve a desirable pregnancy outcome.
Matching variables
The following variables were included in the matching process: maternal age, educational level, parity, national health insurance status, maternal HIV status, twin gestation, and short interpregnancy interval. These variables were selected a priori based on existing literature and their potential influence on ANC contacts, and adverse pregnancy outcomes, specifically LBW and PTB [30], [31], [32], [33], [34], [35], [36]. They were used to match and subsequently adjust for confounding variables to enhance comparability between women with ≥8 ANC contacts and those without. In this study, a short interpregnancy interval was defined as less than eighteen months between a woman's most recent live birth and the conception of the current pregnancy [37], [38], [39]. In this study, twin gestation was defined as the delivery of two infants.
Statistical analysis
All analyses were performed using the R Programming Language version 4.4.2 (R Core Team, 2024). Analysis was conducted using complete cases. Baseline characteristics of study participants before and after matching were summarized using means with standard deviations for continuous variables and frequencies with percentages for categorical variables.
A logistic regression model with the following covariates: maternal age, educational level, parity, national health insurance status, maternal HIV status, twin gestation, and short interpregnancy interval was used to estimate propensity scores, defined as the probability of ≥8 ANC and < 4 ANC contacts. Gestational age was included for LBW, but excluded for PTB.
To ensure that women with ≥8 ANC or ≥ 4 contacts and those with <8 or < 4 ANC contacts had similar characteristics, a 1:1 nearest-neighbor propensity score matching without replacement was performed using the logit of the propensity score, with a caliper width of 0.1. The average treatment effect on the treated (ATT) was the focus of the matching procedure, and the matched dataset was used for further analysis. Covariate balance before and after matching was assessed using standardized mean differences (SMDs) and variance ratios, with SMD values <0.1 regarded as sufficient balance. In addition, common support and overlaps between groups were evaluated by examining the distribution of propensity scores after matching.
A logistic regression analysis was fitted on the matched sample to assess the association between the number of ANC contacts (≥8 vs <8; ≥4 vs <4) and adverse pregnancy outcomes, specifically LBW and PTB, with ANC attendance as the main exposure. The results were reported as risk ratios with 95% confidence intervals (CIs), representing ATT estimates. E-values were computed for the effect estimates to evaluate the robustness of the observed association to possible unmeasured confounding [40]. This was computed using the EValue package in R, based on the relative risk and its 95% CI from the matched analysis. This shows the minimum magnitude of association that an unmeasured confounder would need to have, for both exposure (≥8 and 4 ≥ ANC contacts) and outcomes (LBW and PTB) to fully explain the observed effect [40].
IPTW was conducted as a secondary analysis to estimate both the average treatment effect (ATE) and ATT using the propensity scores. To reduce the effect of extreme values, weights were trimmed at the 1st and 99th percentiles [41]. Risk ratios were estimated for both LBW and PTB using weighted logistic regression models with robust standard errors, and were fitted for both ATE and ATT.
Doubly robust models were constructed by combining IPTW with outcome regression models that included the number of ANC contacts and relevant covariates, improving the robustness to model misspecification. Provided that the outcome model or propensity score model is correctly defined, these models yield reliable estimates [42].
Ethical clearance
The ethical approval to conduct this study was obtained from the Committee on Human Research, Publications and Ethics, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana (reference number: CHRPE/AP/359/24). Administrative approval was obtained from JGH management. The ethics committee waived consent to participate because the study used a retrospective review of patients' routine medical records.
Results
Baseline characteristics of study participants before and after matching
Of the 2351 women whose data were extracted, 2185 were included in the final analysis. A total of 166 women were excluded due to missing data on gestational age, birth weight, ANC contacts, or other covariates (Fig. 1). At baseline, over half (51.3%) of the women completed ≥8 ANC contacts before delivery. Women who completed ≥8 ANC contacts were comparatively older than those with <8 contacts before delivery (mean age: 29.4 ± 5.9 years vs 28.9 ± 6.4 years). Women with tertiary education were more likely to complete ≥8 ANC contacts (30.6%) than those with <8 ANC contacts (15.2%). Parity also differed between the two groups, with women who completed <8 contacts more likely to be multiparous (53.0%) (Table 1).
Fig. 1.
Flow diagram of participants' selection.
Table 1.
Baseline characteristics of study participants before matching.
| Characteristic | Overall N = 2,1851 |
<8 visits N = 1,0641 |
≥8 visits N = 1,1211 |
|---|---|---|---|
| Age of mother, mean (±SD) | 28.9 (6.4) | 28.4 (6.8) | 29.4 (5.9) |
| Education | |||
| No formal education | 874 (40.0) | 499 (46.9) | 375 (33.5) |
| Primary education | 100 (4.6) | 61 (5.7) | 39 (3.5) |
| Secondary education | 706 (32.3) | 342 (32.1) | 364 (32.5) |
| Tertiary education | 505 (23.1) | 162 (15.2) | 343 (30.6) |
| Parity | |||
| Nulliparous | 627 (28.7) | 288 (27.1) | 339 (30.2) |
| Primiparous | 503 (23.0) | 212 (19.9) | 291 (26.0) |
| Multiparous | 1055 (48.3) | 564 (53.0) | 491 (43.8) |
| NHIS status | |||
| Insured | 2169 (99.3) | 1053 (99.0) | 1116 (99.6) |
| Not insured | 16 (0.7) | 11 (1.0) | 5 (0.4) |
| Mother's HIV Status | |||
| Non-reactive | 2169 (99.3) | 1057 (99.3) | 1112 (99.2) |
| Reactive | 16 (0.7) | 7 (0.7) | 9 (0.8) |
| Gestational age (weeks) | 39.0 (2.2) | 38.6 (2.4) | 39.4 (2.1) |
| Twin gestation | 35 (1.6) | 21 (2.0) | 14 (1.2) |
| Short interval of last pregnancy | 27 (1.2) | 15 (1.4) | 12 (1.1) |
| Preterm birth | 418 (19.1) | 281 (26.4) | 137 (12.2) |
| Low birth weight | 311 (14.2) | 207 (19.5) | 104 (9.3) |
Mean (SD); n (%); NHIS: National Health Insurance Scheme.
After 1:1 propensity score matching for LBW and PTB, 1614 and 1746 women were included in each group (<8 ANC contacts vs ≥8 ANC contacts), respectively. Age of mother, parity, NHIS status, mother's HIV status, having twin gestation, and short interval of last pregnancy were similarly distributed across the two groups after the propensity score matching (Supplementary Table 1).
Covariates balance assessment
Before matching for LBW and PTB, the distribution of propensity scores differed between exposure groups (Fig. 2). After propensity score matching for PTB, the covariates achieved adequate balance between the treated and control groups, with all standardized mean differences below 0.10. There was substantial overlap and successful matching, with empirical cumulative distribution function (eCDF) differences minimal and variance ratios close to 1.0 (Supplementary Table 2). Similarly, after propensity score matching for LBW, the covariates achieved adequate balance between the treated and control groups, with all standardized mean differences below 0.10. There was substantial overlap and successful matching, with eCDF differences minimal and variance ratios close to 1.0 (Supplementary Table 3). This indicates that women in both groups had similar characteristics after matching for LBW and PTB, reducing the potential for confounding in subsequent outcome analyses (Supplementary Fig. 1).
Fig. 2.
Covariate balance before and after matching for low birth weight and preterm birth.
Love plot showing the absolute standardized mean difference for baseline covariates between participants who completed ≥8 ANC contacts and those who had <8 visits before (unadjusted) and after matching (IPTW) in both the low birth weight and preterm birth analyses. The green lines represent the adjusted model, whereas the red line represents the unadjusted one. The dashed vertical line at 0.10 indicates the threshold for an acceptable balance. Categorical variables have been marked with an asterisk (*). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
Effect of completing ≥ 8 ANC contacts on adverse pregnancy outcomes
Matched samples
Mothers who completed ≥8 ANC contacts had a lower risk of adverse pregnancy outcome compared to those who made <8 ANC contacts. Specifically, mothers who completed ≥8 ANC contacts had a 31.0% (ATT: 0.69; 95%CI: 0.53–0.90) lower risk of delivering a LBW infant. To fully explain the association between completing ≥8 ANC contacts and LBW and PTB, an unmeasured confounder would need to have a risk ratio of at least 2.26 and 3.97, respectively, based on the e-value analysis (Table 2).
Table 2.
Effect of ≥8 ANC contacts on adverse pregnancy outcomes (Matched Sample) with E-values.
| Outcome | Effect estimates |
RR | 95% CI | E-value (point) | E-value (lower CI) |
|---|---|---|---|---|---|
| Low birth weight | ATT | 0.69 | 0.53–0.90 | 2.26 | 1.47 |
| Preterm birth | ATT | 0.46 | 0.37–0.57 | 3.97 | 2.93 |
Low birth weight analysis includes gestational age; Preterm analysis excludes gestational age due to endogeneity.
In sensitivity analyses using multivariable modified Poisson regression, after adjusting for significant covariates, mothers who completed ≥8 ANC contacts consistently had a lower incidence of LBW (IRR: 0.57, 95%CI: 0.46–0.71) (Supplementary Table 4) and PTB (IRR: 0.45, 95%CI: 0.37, 0.54) (Supplementary Table 5).
Inverse probability of treatment weighting analysis
The IPTW estimates were comparable to those from the matched analysis, and the results were robust to trimming. Under the IPTW, the ATE for completing ≥8 ANC contacts was 77.0% lower (RR: 0.23, 95%CI: 0.06–0.86) for LBW and 56.0% lower (RR: 0.44, 95%CI: 0.36–0.54) for PTB, respectively. The ATT also showed a protective effect of 29.0% (RR: 0.71, 95%CI: 0.55–0.91) for LBW and 57.0% (RR: 0.43, 95%CI: 0.36–0.53) for PTB (Table 3).
Table 3.
Inverse probability of treatment weighting effects of ≥8 ANC contacts on adverse pregnancy outcomes.
| Outcome | Estimand | RR | 95% CI |
|---|---|---|---|
| Low birth weight | ATE | 0.23 | 0.06–0.86 |
| ATT | 0.71 | 0.55–0.91 | |
| ATE (Trimmed) | 0.67 | 0.53–0.84 | |
| ATT (Trimmed) | 0.70 | 0.55–0.90 | |
| Preterm birth | ATE | 0.44 | 0.36–0.54 |
| ATT | 0.43 | 0.36–0.53 | |
| ATE (Trimmed) | 0.44 | 0.37–0.54 | |
| ATT (Trimmed) | 0.44 | 0.36–0.53 |
ATE: average treatment effect; Note: Low birth weight analysis includes Gestational age; Preterm analysis excludes gestational age due to endogeneity.
Doubly robust estimates
The doubly robust analysis also yielded similar estimates, and the results were robust to trimming. Among women who made ≥8 ANC contacts, the ATT showed a 32.0% reduction (RR: 0.68, 95%CI: 0.53–0.87) and a 56.0% reduction (DR ATT: 0.44, 95%CI: 0.36–0.53) in LBW and PTB, respectively, compared to those who made <8 ANC contacts (Table 4).
Table 4.
Doubly robust effects of ≥8 ANC contacts on adverse pregnancy outcomes.
| Outcome | Estimand | RR | 95% CI |
|---|---|---|---|
| Low birth weight | ATT | 0.68 | 0.53–0.87 |
| ATE | 0.62 | 0.48–0.80 | |
| ATT (Trimmed) | 0.68 | 0.53–0.87 | |
| ATE (Trimmed) | 0.65 | 0.51–0.82 | |
| Preterm birth | ATT | 0.44 | 0.36–0.53 |
| ATE | 0.44 | 0.37–0.54 | |
| ATT (Trimmed) | 0.44 | 0.37–0.54 | |
| ATE (Trimmed) | 0.45 | 0.37–0.54 |
Note: Low birth weight analysis includes gestational age; Preterm analysis excludes gestational age due to endogeneity
Secondary analysis: Effect of ≥ 4 ANC contacts on adverse pregnancy outcomes
A secondary analysis was conducted to compare women who completed ≥4 ANC contacts with those who completed <4. The magnitude of the association was weaker than that observed for the ≥8 ANC model. In a matched analysis, completing ≥4 ANC contacts was associated with a 46.0% reduction in the risk of PTB (RR: 0.54; 95%CI: 0.33–0.90) (Table 5).
Table 5.
Estimated effects of ≥4 ANC contacts on adverse pregnancy outcomes, using matching, inverse probability weighting, and doubly robust methods.
| Outcome | Method | Estimand | RR | 95% CI | E-value (point) | E-value (lower CI) |
|---|---|---|---|---|---|---|
| Low birth weight | Matched | ATT | 0.84 | 0.57–1.22 | 1.68 | 1.00 |
| IPTW | ATE | 0.87 | 0.59–1.28 | |||
| IPTW | ATT | 0.89 | 0.59–1.34 | |||
| DR | ATT | 0.90 | 0.61–1.33 | |||
| DR | ATE | 0.87 | 0.60–1.26 | |||
| preterm birth | Matched | ATT | 0.54 | 0.33–0.90 | 3.09 | 1.45 |
| IPTW | ATE | 0.42 | 0.27–0.65 | |||
| IPTW | ATT | 0.43 | 0.27–0.67 | |||
| DR | ATT | 0.43 | 0.27–0.68 | |||
| DR | ATE | 0.43 | 0.28–0.66 |
Low birth weight analysis includes gestational age; Preterm analysis excludes gestational age due to endogeneity.
Discussion
This study examined the association between ≥8 ANC contacts and the risks of LBW and PTB using propensity score matching, IPTW, and doubly robust estimation. Across all analytic approaches, making ≥8 ANC was consistently associated with lower odds of adverse pregnancy outcomes (LBW and PTB). The consistent direction and magnitude of the ATT and ATE analyses increase confidence that the observed associations are robust across different techniques for confounder adjustment and may reflect a potential causal association between adequate ANC attendance (≥8 ANC contacts) and improved birth outcomes.
In the matched analysis, women who completed ≥8 ANC contacts had approximately 31.0% lower odds of delivering a LBW infant and 54.0% lower odds of PTB compared to women with similar observed characteristics who made <8 ANC contacts. These estimates represent the ATT and therefore describe the association among women who completed the recommended ≥8 ANC contacts. E-values were used to assess the robustness of these associations against potential unmeasured confounders. Regarding LBW, an unmeasured confounder would require a risk ratio of at least 2.26 for both ANC contacts and LBW to fully explain the observed effect, whereas for PTB, the magnitude is 3.97. This implies that the observed associations are unlikely to be wholly due to unmeasured confounding. The IPTW analysis produced similar ATE estimates, indicating that, assuming adequate adjustment for confounding and equal access to care, ≥8 ANC contacts could be associated with significant reductions in adverse birth outcomes at the population level.
The doubly robust analysis, which provides consistent estimates when either the propensity score model or outcome regression is correctly specified, produced effect estimates of similar or larger magnitude. Specifically, the doubly robust ATT estimates indicated reductions in LBW and PTB of 32.0% and 56.0%, respectively, while the doubly robust ATE suggested reductions of 38.0% and 56.0%, respectively. The observed reductions among participants who completed ≥8 ANC contacts may partly be explained by the facility-based design of the study. Women who engage with the facility more frequently may receive more prompt and intense care, which could enhance the observed effect. Additionally, despite matching, residual health-seeking behavior, including increased health awareness or compliance with medical advice, may persist and strengthen the associations. The coherence of findings across multiple causal inference methods strengthens confidence in the robustness of the observed associations, though residual confounding from unmeasured factors cannot be entirely ruled out.
In a secondary analysis of the original WHO-recommended ≥4 ANC contacts, the study observed that the magnitude of association was attenuated relative to ≥8 ANC contacts. While completing ≥4 ANC visits was associated with a 46.0% lower risk of PTB, the risk of delivering an LBW infant among women who completed ≥4 ANC contacts did not differ from that among those who attended <4 ANC visits. This finding suggests that while completing ≥4 ANC contacts conferred some protection, attending ≥8 ANC visits conferred greater benefits for birth outcomes.
Our findings are consistent with evidence from Ghana demonstrating the benefits of high ANC engagement. In northern Ghana, higher quality ANC, used as a proxy for more complete and consistent care, was associated with an 85.0–87.0% reduction in the odds of both PTB and LBW [21]. Similarly, another study conducted in Ghana reported that women who completed ≥8 prenatal contacts had 64.0% and 72.0% lower odds of LBW and PTB, respectively, compared with those with fewer contacts [43]. Although effect estimates vary across studies, the overall direction of the association is consistent, supporting the importance of ≥8 ANC contacts for improved birth outcomes.
The results are also consistent with evidence from other LMICs. For example, a propensity score-matching study conducted across West African countries reported higher mean birth weight among infants born to mothers with ≥8 ANC contacts than among those with fewer visits [44]. Analyses from sub-Saharan Africa similarly demonstrated a protective association between ≥8 ANC contacts and LBW [45], and a recent meta-analysis reported a pooled odds ratio indicating a 79.0% lower risk of LBW among women who regularly attended ANC [46]. Together, these findings are consistent with the WHO's 2016 recommendation of at least 8 ANC contacts to improve perinatal outcomes [7]. WHO modelling studies have projected that increasing ANC contacts from 4 to 8 could avert up to 8 perinatal deaths per 1000 births [7]. However, such projections are modelled based on assumptions rather than direct empirical evidence.
In the Ghanaian context, ANC contacts offer essential opportunities for pregnant women to receive preventive and promotive interventions, such as deworming, iron/folate supplementation, malaria prophylaxis, nutrition counseling, and screening for hypertensive disorders, thereby enabling the timely identification of pregnancy complications [47], [48], [49]. Higher ANC attendance could increase overall exposure to these interventions and facilitate early detection and treatment of maternal conditions, which may partly account for the better birth outcomes observed in this study. These findings underpin the need for early ANC booking (≤12 weeks of gestation), ensuring receipt of the full ANC package, and emphasize the need for enhanced service accessibility, including increasing the number of Community-based Health Planning and Services compounds and recruiting midwives to underprivileged areas to achieve optimal maternal and newborn outcomes. In contrast, a study conducted in Ethiopia found no significant association between ANC attendance and adverse birth outcomes (LBW and PTB) [50]. This highlights that the effectiveness of ANC may depend on several drivers, including timing of booking, service quality, and health system capacity.
This study contributes to the existing body of evidence by applying rigorous causal inference techniques to routine hospital data to approximate a counterfactual comparison of ANC attendance levels. The findings suggest that, even within a routine district hospital setting, achieving the WHO ≥8 ANC is associated with improved birth outcomes. Given the global burden of LBW, estimated at nearly 20 million infants annually [51], [52], [53], and the notably high prevalence in sub-Saharan Africa [12], [13], strengthening ANC utilization remains a key public health priority. Despite Ghana's recent increases in ANC coverage, which may be yielding tangible outcomes for neonatal health [21], [54], more work is required to ensure that gains are sustained and fairly distributed.
Implications for practice and research
The findings of the present study have important implications for maternal and neonatal health practice. Achieving the WHO-recommended ≥8 ANC visits was associated with substantially lower odds of adverse pregnancy outcomes. The observed ATE estimates suggest that addressing barriers to ANC and utilization could lead to broader population-level progress in birth outcomes. Stakeholders in health, including the Ghana Health Service, may therefore prioritize strengthening strategies that promote early booking, continuity of care, and completion of the full ANC schedule. Strategies such as appointment reminder systems, community health worker engagement, reducing geographic and financial barriers, and targeted health education may improve full ANC coverage.
The findings underscore the content and quality of ANC services. The benefits of increased contact frequency are likely dependent on the consistent delivery of core ANC components, including malaria prevention, nutritional counseling, tetanus vaccination, blood pressure monitoring, anaemia screening, and timely referral. The benefits of merely increasing the number of visits without providing appropriate service quality can be minimal.
Future research should focus on identifying barriers to completing ≥8 visits, particularly among women in rural or low-resource settings. Studies examining the relative contributions of specific components of ANC, the timing of visits, and measures of service quality will help inform targeted and effective strategies. Applying similar causal inference methods to multicenter or population-based datasets would further strengthen the evidence base and enhance the generalizability of the findings.
Strengths and limitations
The strengths of this study include the use of large, real-world hospital data and the application of multiple complementary causal inference methods to address confounding. The use of propensity score matching, IPTW, and doubly robust estimation enhances the robustness of the findings and offers convergent evidence supporting the observed associations.
The study has some limitations. First, as a retrospective, facility-based study, the findings may not be generalizable to women who delivered at home or in smaller facilities, as these women may differ systematically in ANC utilization and pregnancy risk. Second, despite adjusting for extensive covariates, unmeasured confounding may persist, particularly for factors such as maternal nutrition, socioeconomic status, body mass index, smoking status, gestational age at ANC booking, or care-seeking behavior that were not fully captured in the data. As a result, the potential influence of these factors on pregnancy outcomes could not be directly assessed. However, a sensitivity analysis using E-values indicated that the observed association was sufficiently robust and that an unmeasured confounder would need to be strongly associated with both ANC contacts and adverse pregnancy outcomes to fully explain the observed effect. Another limitation of this study is the potential for selection bias if prenatal care utilization affects delivery survival, given the restriction to live births. In the Ghanaian context, a previous study reported that adequate ANC contacts reduce women's risk of adverse pregnancy outcomes, including stillbirth or spontaneous abortion [55], [56]. As a result, women who made fewer ANC contacts in this study may be underrepresented in the study sample if fewer ANC contacts increased the risk of pregnancy loss before delivery. Hence, the results should be interpreted with caution. Finally, while ANC visit frequency was measured, the timing and quality of ANC services, which may modify the relationship between ANC attendance and birth outcomes, could not be directly assessed. Nonetheless, the study provides valuable data indicating that higher ANC contact is associated with favorable birth outcomes. Collectively, these methodological techniques strengthen the applicability and relevance of the findings for informing maternal health strategies and promoting adequate ANC contacts in similar settings.
Conclusion
This study demonstrated that completing eight or more ANC visits was consistently associated with significantly lower odds of LBW and PTB among women delivering at a district hospital in Ghana. The convergence of findings across multiple causal inference techniques strengthens confidence in the robustness of the association and supports the significance of the WHO eight-or-more ANC contact model in this context. The findings imply that increasing ANC attendance, along with improving the quality and content of ANC services, may significantly improve maternal and newborn outcomes in district-level health facilities and similar settings, despite the susceptibility of causal inference from observational data to residual confounding.
The following are the supplementary data related to this article.
Data extraction sheet
Propensity score distributions after matching for LBW & PTB.
Baseline characteristics of study participants after matching for LBW and PTB.
Covariate balance after propensity score matching for PTB.
Covariate balance after propensity score matching for LBW.
Modified Poisson regression analysis of factors associated with LBW.
Modified Poisson regression analysis of factors associated with PTB.
CRediT authorship contribution statement
Frederick Osei Owusu: Writing – review & editing, Writing – original draft, Supervision, Project administration, Conceptualization. Emmanuel Konadu: Writing – review & editing, Writing – original draft, Project administration, Methodology, Formal analysis, Data curation, Conceptualization. Helena Addai-Manu: Writing – review & editing, Writing – original draft, Supervision, Project administration, Conceptualization. Julius Kwabena Karikari: Writing – review & editing, Writing – original draft, Project administration, Methodology, Formal analysis, Conceptualization. Esther Serwah Agbedinu: Writing – review & editing, Writing – original draft, Supervision, Project administration, Conceptualization. Nuheila Ibrahim: Writing – review & editing, Supervision, Methodology, Investigation, Data curation. Lydia Asenso: Writing – review & editing, Writing – original draft, Supervision, Project administration. Mercy Addae: Writing – review & editing, Supervision, Methodology, Investigation, Data curation. Joseph Osarfo: Writing – review & editing, Supervision, Methodology, Investigation, Data curation. Bernice Enyonam Akpaloo: Writing – review & editing, Supervision, Methodology, Investigation, Data curation. Mawuse Kanfra: Writing – review & editing, Supervision, Methodology, Investigation, Data curation. Douglas Aninng Opoku: Writing – review & editing, Writing – original draft, Project administration, Methodology, Formal analysis, Data curation, Conceptualization.
Consent for publication
Not applicable.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
The authors declare that they have no competing interests.
Acknowledgement
We are grateful to the management and staff of JGH, and especially to the research assistants who reviewed the patients' medical records.
Data availability
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request, with written permission from the management of JGH.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data extraction sheet
Propensity score distributions after matching for LBW & PTB.
Baseline characteristics of study participants after matching for LBW and PTB.
Covariate balance after propensity score matching for PTB.
Covariate balance after propensity score matching for LBW.
Modified Poisson regression analysis of factors associated with LBW.
Modified Poisson regression analysis of factors associated with PTB.
Data Availability Statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request, with written permission from the management of JGH.