Adherence and barriers to key antenatal interventions among pregnant women in an urban district of Ghana: A cross-sectional study

Abstract

Objective:

This study assessed Adherence and Barriers to Key Antenatal Interventions among Pregnant Women in an Urban District of Ghana.

Methods:

The study used a cross-sectional design to quantitatively assess the uptake and barriers to key interventions among 200 pregnant women who were selected through simple random sampling. Data was first entered into a Microsoft Excel sheet and exported to Stata version 16 in the same format.

Results:

The uptake of Sulfadoxine–Pyrimethamine for Intermittent Preventive Treatment in pregnancy (SP-IPTp) was found to be inadequate among 48.0%, those with adequate SP-IPTp uptake, 58.34% were in their third-trimester gestation, 8.33% were in their first trimester and 85.58% of third-trimester expectant mothers had inadequate uptake of SP-IPTp. The uptake of Iron and Folic Acid Supplementation (IFAS) was high (81.5%). Barriers influencing the uptake of ANC interventions were financial constraints (62.07%), lack of permission from work (19.54%), feeling healthy and therefore not needing ANC (10.34%), and distance to the hospital (8.05%). For SP-IPTp, the leading barrier was drug unavailability at health facilities (63.71%), forgetfulness (31.82%) and adverse reactions during previous pregnancies (29.55%) were the most frequently cited barriers to IFAS uptake. For deworming therapy, 94.12% of participants reported that the medication was not administered at ANC.

Conclusion:

Keywords

adherence barriers key interventions pregnant women antenatal care urban district

Introduction

The World Health Organisation (WHO) evaluated existing Antenatal Care (ANC) delivery models, considering the full range of interventions, and recommended ANC models with at least eight contacts to decrease perinatal mortality and enhance women’s antenatal care experiences.¹ According to a global study, there were 31 deaths per 1000 live births in 2016, with 61% occurring during the first 28 days of life.² Despite notable improvements, the global maternal mortality rate remains high at 216 deaths per 100,000 live births.¹ In Sub-Saharan Africa, infant mortality is estimated at 53 deaths per 1000 live births, neonatal mortality at 28 deaths per 1000 live births, and maternal mortality at 547 deaths per 100,000 live births.² It has been projected that if all pregnant women worldwide had access to ANC, intrapartum, and postnatal care (PNC) interventions, approximately 41%–72% of neonatal deaths could be prevented.³

Although there is limited causal evidence, a recent meta-analysis revealed that ANC attendance is associated with reduced neonatal mortality in most low- and middle-income countries, including those in Sub-Saharan Africa.⁴ A related study reported that 43.65% of pregnant women achieved optimal uptake, defined as two or more doses of Intermittent Preventive Treatment in pregnancy with Sulfadoxine-Pyrimethamine (SP-IPTp).⁵ Meanwhile, 28.5% and 27.9% of pregnant women received only one dose or none at all, respectively, resulting in an overall 72.1% coverage of at least one SP dose. These results exceeded the national estimates reported in the 2010 Tanzania Demographic and Health Survey,⁶ indicating regional disparities in SP-IPTp coverage. Similarly, a study has reported a 66.0% coverage for SP-1 and 27.0% for SP-2.⁶ However, subsequent research showed that the goal of 80% SP-IPTp coverage was not achieved.⁷

Iron and folic acid (IFA) supplementation remains one of the most widely recommended maternal health interventions for preventing anaemia and improving maternal survival.⁸ Recent studies also suggest that IFA supplementation contributes to improved survival rates among newborns and children.⁹ The WHO updated its recommendations in 2012, advising a daily oral intake of IFA (30–60 mg elemental iron and 400 μg folic acid) throughout pregnancy to reduce the risks of low birth weight, maternal anaemia, and iron deficiency.^1,10 In addition, the WHO recommends deworming or preventive chemotherapy for pregnant women after the first trimester, using a single dose of mebendazole (500 mg) or albendazole (400 mg), especially in regions with anaemia prevalence above 40% and whipworm or hookworm prevalence above 20% among pregnant women.¹¹ Several previous studies have shown that antenatal chemotherapy or deworming significantly improves haemoglobin levels and nutritional outcomes in both pregnant women and children.¹²

Between 1997 and 2003, the number of women in Mozambique receiving ANC services from nurses increased considerably.¹³ Similarly, data from the Ghana Demographic and Health Surveys (GDHS) between 1988 and 2014 indicated that the majority of women in Ghana obtained ANC services from nurses.¹⁴ Specifically, nurses provided about 90% of ANC services in 2014, compared to 55% in 1988, demonstrating a notable improvement in access to skilled maternal care. Conversely, the proportion of women receiving care from traditional birth attendants declined from 3% in 1988 to 0.1% in 2014, while those receiving no ANC reduced from 13% to 3% within the same period.¹⁴

In Ghana’s Sunyani Municipality, 8.5% of pregnant women received at least one SP dose, about 91% received two doses, and 71% received three or more doses.¹⁵ The national target in 2014 was to achieve 100% coverage of at least two SP doses.¹⁶ Although SP-IPTp use remains relatively high, it still falls short of the national target, as evidenced by the 91% coverage of at least two doses.¹⁷ Transportation challenges and delays in distributing malaria commodities hindered SP delivery to many peripheral health facilities in 2014, leading to artificial shortages nationwide.^17,18 The Ghana National Malaria Control Programme (NMCP) should therefore ensure a consistent supply of SP across all health facilities to sustain and improve coverage.

The suboptimal uptake of the recommended three or more SP-IPTp doses, compared with national coverage levels, has been attributed to contextual challenges affecting policy implementation.¹⁹ Moreover, pregnant adolescents in Ghana are reportedly less likely to seek ANC compared to older women due to the stigma associated with teenage pregnancy.^20,21 Current guidelines recommend administering SP-IPTp monthly, except during the first trimester, with doses spaced at least 1 month apart, implying that pregnant women must commence ANC early to complete the required SP doses. Innovative strategies, such as the Transforming IPT for Optimal Pregnancy (TIPTOP) initiative, have been developed to enhance SP-IPTp coverage. TIPTOP identifies pregnant women in their first trimester, educates them on the benefits of early ANC and SP-IPTp, links them to health facilities, and supports direct SP distribution within communities.²² Such community-based delivery models can substantially increase SP-IPTp coverage and ensure equitable access to preventive interventions across diverse sociodemographic groups.

In this context, the present study was conducted to assess the uptake of key antenatal interventions, including SP-IPTp, IFA supplementation, and deworming therapy, among pregnant women attending antenatal clinics at the University Hospital in Kumasi, Ghana.

Methods

The study was conducted at the University Hospital in Kumasi, Ghana. The University Hospital is designed as a District Hospital by the Ministry of Health and complements other public and private health institutions in Kumasi. It serves the university community and surrounding communities with an estimated population of about 300,000. The study used a cross-sectional design to quantitatively assess the uptake and barriers to key interventions among pregnant women. The study population covered all Pregnant women of all ages, parity, and gestation who access maternal health services at the antenatal clinic at the University Hospital. The study took place between 3 months (from August to October, 2023). The sample size was determined using single population proportion formula for cross-sectional research to obtain the required sample size for the study.²³ An estimated proportion of 50% of either anaemia or parasitaemia was used for the maximum number of pregnant women sampled for the survey. Thus, at a confidence interval of 95%, a precision of 5%, and a power of 90%, the sample size was estimated to be 385 using the formula below:

Where the estimated sample size of the pregnant women, is the Z-score at a confidence interval of 95% = 1.96, is the estimated proportion of anaemia = 50%, and is the precision = 5% the estimated sample size is given as;

n \geq \frac{z^{2} p (1 - p)}{d^{2}}

n \geq \frac{{1.96}^{2} \times 0.5 (1 - 0.5)}{{0.05}^{2}}

n = 385 .

This figure was then substituted into the finite population correction formula: $n = \frac{n o}{1 + n 0 / N}$ a total of 200 pregnant women were selected as the sample size. The purposive sampling technique was used to select 200 pregnant women at the maternal and child health (MCH) unit at the University Hospital for this study. The simple random sampling technique was used for this study because the maternal and child health units/wards visited for the study delivered ANC services to pregnant women as prescribed by the Ministry of Health, which equally qualified them for the study site, once the clinic was opened for services during the visit. The other condition that made the use of the simple random sampling technique successful was the presence of pregnant women at the clinic during the visit. Data was collected through the use of a structured questionnaire where options and responses were provided for respondents to select from.

Responses of a historical event, such as gestation at registration and delivery, number of monthly visits, number of general visits, and number of visits before the second trimester, were taken from the ANC record books of the pregnant women. The inclusion criteria for the participants were: must be pregnant, above 18 years of age. The team visited maternal health wards for this exercise within the time frame. Each pregnant woman was identified with the inclusion criteria, and agreement was reached at a convenient time for the administration of the questionnaire, with the help of the healthcare staff. This was done in turn for the selected women available at the maternal health clinic each day and the respective clinics. The data were collected onto an Open Data Kit (ODK)²⁴ and saved as an Excel file automatically as single files that do not need to be merged from the four devices used. Open Data Kit (ODK) offers data editing platforms both in online platform and in Excel file mode. To ensure accuracy in data entry, all completed submitted questionnaires on the electronic device were checked from day to day. Gaps were instantly addressed to make up for any lost data. Daily discussions were held with the research assistants to find out if there were problems observed during the day. At the end of data collection, the Excel version of the completed questionnaires was saved on the personal computer for data analysis. Data was first entered into a Microsoft Excel sheet and exported to Stata version 16 in the same format. Before the analysis, an inspection of all study variables was done for outliers, irregularities, and missing data to ensure accuracy. Descriptive statistical analysis was done to describe the characteristics of the respondents. A frequency distribution table was used to describe study variables with nominal and ordinal levels of measurement while measures of central tendency and variability were used to describe interval and ratio level measurement. The reporting of this study conforms to the STROBE statement checklist for cross-sectional study (Supplemental Appendix file attached). The various outcome variables were uptake of SPI-IPTp, Iron and Folic Acid Supplementation and uptake of deworming therapy interventions. The independent variables were the socio-demographic factors, ANC-related factors, knowledge and awareness, treatment adherence and health system barriers.

Ethical considerations

The study sought approval from the Committee on Human Research and Publication Ethics at the Kwame Nkrumah University of Science and Technology, Kumasi, Ghana with approval number CHRPE/AP/148/22. Also, Approved copies were shown in the Directory of the University Hospital, the in-charges, and the staff at the ANC for permission to be granted before the data collection. The ethical procedures followed the principles outlined in the Declaration of Helsinki. Prior to the data collection, all the participants were informed about the purpose, potential risks, and benefits of the study. Informed consent was obtained from all the participants, with full respect for their autonomy, including their right to withdraw from the study at any time without consequences. The participants were assured of the confidentiality of all information obtained, their privacy, and anonymity during the data collection, storage, and publication of the study materials.

Results

Demographic characteristics of respondents²⁵

Expectant mothers 63.00% were aged 26–34 years and were mostly married (80.00%), 61.00% were Christians, secondary school leavers were 38.50% and tertiary 36% graduates, 39.00% were traders and 21.50% of them were housewives. On obstetric records, 53.50% had been pregnant 2 or 3 times. The average gestation at the time of the study was 28.7 ± 6.6 weeks with 72.5% in their third-trimester gestation (25–40 weeks) with 97.08% having past deliveries at a health facility (Table 1).

Table 1.

Sociodemographic characteristics of respondents.

Variables	Frequency (n)	Percent (%)
Maternal age (average = 28.5 ± 4.8 years)
18–25	55	27.50
26–34	126	63.00
35–43	19	9.50
Marital status
Married	160	80,00
Single/cohabiting/divorced/widowed	40	20.00
Religion
Christian	122	61.00
Islam	77	38.50
Other	1	0.50
Education level
No formal	14	7.00
Basic	37	18.50
Secondary	77	38.50
Tertiary	72	36.00
Occupation
Salary worker	48	24.00
Trader	78	39.00
Farmer/other	31	15.50
Housewife	43	21.50
Income level
Low	68	34.00
Middle	76	38.00
High	56	28.00
Gravidity
1	24	12.00
2–3	107	53.50
4 or more	69	34.50
Parity
Nulliparous	29	14.5
Primiparous	55	27.5
Multiparous	116	58.00
Child death
<1	176	88.00
≥1	24	12.00
Age of current gestation (28.7 ± 6.6 weeks)
1–12	8	4.00
13–24	47	23.50
25–40	145	72.50
Place of last delivery (n = 171)
Health facility	166	97.08
TBA	2	1.17
Unknown	3	1.75

Source: Fieldwork, 2023.

The uptake of key intervention of ANC²⁵

The uptake of Sulfadoxine–Pyrimethamine for Intermittent Preventive Treatment in pregnancy (SP-IPTp) was found to be inadequate among 48.0% of expectant mothers. Among those with adequate SP-IPTp uptake, 58.34% were in their third-trimester gestation (25–40 weeks), whereas only 8.33% were in their first trimester (1–12 weeks). Conversely, 85.58% of third-trimester expectant mothers had inadequate uptake of SP-IPTp. Gestational age was significantly associated with SP-IPTp uptake (p < 0.001). Expectant mothers who had attended four or five ANC visits (48.42%) were more likely to have adequate SP-IPTp uptake, and this association was statistically significant (p < 0.005). However, although 60% of participants reported missing at least one ANC appointment, and 64.76% of those with inadequate SP-IPTp uptake had missed appointments, the difference was not statistically significant (p > 0.05). Similarly, while 89% of respondents knew the importance of SP-IPTp medication during pregnancy, no significant relationship was observed between knowledge and uptake outcome (p > 0.05). The uptake of Iron and Folic Acid Supplementation (IFAS) was high (81.5%), while 18.5% of expectant mothers exhibited inadequate uptake. Adequate IFAS uptake was most common among women in their third trimester (80.37%), while those with inadequate uptake were primarily in their second trimester (56.76%). Gestational age was significantly associated with IFAS uptake (p < 0.001). Expectant mothers who had attended four or more ANC visits (63.80%) were more likely to have adequate IFAS uptake compared to those who attended fewer visits (p < 0.001; Table 2).

Table 2.

Showing uptake of key intervention by respondents.

	Frequency (F) and percentage (%)	SP-IPTp outcome			Iron and folic acid outcome			De-wormer outcome
Variables	Total (200)	Yes(N = 96)	No(N = 104)	$χ^{2}$ p-value	Yes (N = 163)	No(N = 37)	$χ^{2}$ p-value	Yes(N = 25)	No (N = 175)	$χ^{2}$ p-value
Gestation				<0.001			<0.001			0.011
1–12	8 (4.00)	8 (8.33)	0 (0.00)		6 (3.68)	2 (5.41)		0 (0.0)	8 (4.57)
13–24	47 (23.50)	32 (33.33)	15 (14.42)		26 (15.95)	21 (56.76)		12 (48.00)	35 (20.00)
25–40	145 (72.50)	56 (58.34)	89 (85.58)		131 (80.37)	14 (37.84)		13 (52.00)	132 (75.43)
ANC attendance				0.005			<0.001			0.131
1–3	54 (27.00)	35 (36.84)	19 (18.10)		32 (19.63)	22 (59.46)		9 (36.00)	45 (25.71)
4–5	116 (58.00)	46 (48.42)	70 (66.67)		103 (63.19)	13 (35.14)		10 (40.00)	106 (60.57)
≥6	30 (15.00)	14 (14.74)	16 (15.24)		28 (17.18)	2 (5.41)		6 (24.00)	24 (13.71)
Missing ANC				0.236			0.034			0.513
Yes	120 (60.00)	52 (54.74)	68 (64.76)		104 (63.80)	16 (43.24)		12 (48.00)	68 (38.86)
No	80 (40.00)	43 (45.26)	37 (35.24)		59 (36.20)	21 (56.76)		13 (52.00)	107 (61.14)
Knowledge on medication				0.631			0.012
Yes	178 (89.00)	87 (91.58)	91 (86.67)		161 (98.77)	33 (89.19)
No	22 (11.00)	8 (8.42)	14 (13.33)		2 (1.23)	4 (10.81)
Drug intake				<0.001			<0.001
<3	137 (68.50)	36 (37.89)	101 (96.19)		5 (3.07)	34 (91.89)
≥3	63 (31.50)	59 (62.11)	4 (3.81)		158 (96.93)	3 (8.11)

Source: Author’s Construct, 2023.

The bold values show that they are statistically significant.

Barriers to uptake of key interventions²⁵

Barriers influencing the uptake of ANC interventions were predominantly financial constraints (62.07%), followed by lack of permission from work (19.54%), feeling healthy and therefore not needing ANC (10.34%), and distance to the hospital (8.05%). For SP-IPTp, the leading barrier was drug unavailability at health facilities (63.71%), followed by adverse reactions such as vomiting and diarrhoea (17.74%), forgetfulness (12.10%), and lack of health insurance (4.55%). Similarly, forgetfulness (31.82%) and adverse reactions during previous pregnancies (29.55%) were the most frequently cited barriers to IFAS uptake. For deworming therapy, 94.12% of participants reported that the medication was not administered at ANC, while 5.79% cited high cost as a deterrent (Table 3).

Table 3.

Showing barriers to uptake of key interventions.

	Frequency (F) and percentage (%)	Barriers of intervention
Barriers	Total (200)	ANC (N = 87)	SP-IPTp (N = 124)	IFA (N = 44)	De-wormer (N = 190)
Distance to hospital	7 (3.50)	7 (8.05)
Felt well and do not need ANC	9 (4.50)	9 (10.34)
No money	54 (27.00)	54 (62.07)
No permission from work	17 (8.50)	17 (19.54)
Forgetfulness	29 (14.50)		15 (12.10)	14 (31.82)
No NHIS	10 (5.00)		8 (6.45)	2 (4.55)
Unavailability at the hospital	86 (43.00)		79 (63.71)	7 (15.91)
Reaction/vomiting/diarrhoea	35 (14.50)		22 (17.74)	13 (29.55)
Drug expensive at this hospital	19 (9.50)			8 (18.18)	11 (5.79)
Drug not given	179 (89.50)				179 (94.21)

Source: Author’s Construct, 2023.

Adjusted measures of association²⁵

There was a significant association between the absorption of the recommended three (3) or more doses of SP-IPTp and the uptake outcome (AOR = 2.56, 95%CI: 1.38–4.73, p < 0.01). Other variables such as gestational age (AOR = 1.91, 95%CI: 1.20–3.03, p < 0.01) and number of ANC visits (AOR = 2.10, 95%CI: 1.23–3.57, p < 0.005) were also significantly associated with SP-IPTp uptake, whereas missing ANC appointments (AOR = 0.83, 95%CI: 0.52–1.34, p = 0.28) and knowledge of medication (AOR = 1.25, 95%CI: 0.71–2.22, p = 0.39) showed no statistically significant associations. There was high uptake of Iron and Folic Acid Supplementation (IFAS; 81.5%), and several predictors were significantly associated: Expectant mothers who missed ANC appointments were less likely to have adequate IFAS uptake (AOR = 0.61, 95%CI: 0.39–0.96, p < 0.05). Mothers knowledgeable about IFAS were more likely to have adequate uptake (AOR = 2.45, 95%CI: 1.42–4.21, p < 0.01). Absorption of the recommended three (3) or more boxes of IFAS was strongly associated with adequate uptake (AOR = 3.08, 95%CI: 1.89–5.03, p < 0.001; Table 4).

Table 4.

Shows the adjusted measures of association.

Variable	Intervention	Adjusted odds ratio (AOR)	95% confidence interval (CI)	p-value
Absorption of ≥3 SP doses	SP-IPTp	2.56	1.38–4.73	<0.01
Gestational age (third trimester)	SP-IPTp	1.91	1.20–3.03	<0.01
≥4 ANC visits	SP-IPTp	2.10	1.23–3.57	<0.005
Missing ANC appointments	SP-IPTp	0.83	0.52–1.34	0.28
Knowledge of SP medication	SP-IPTp	1.25	0.71–2.22	0.39
Missing ANC appointments	IFAS	0.61	0.39–0.96	<0.05
Knowledge of medication	IFAS	2.45	1.42–4.21	<0.01

Source: Author’s Construct, 2023.

Discussion

The observed improvement in antenatal care (ANC) visits and the coverage of key ANC interventions such as SP-IPTp and IFAS underscores Ghana’s progress in strengthening maternal health service delivery.¹⁴ The findings align with evidence that consistent ANC attendance is positively associated with reduced neonatal mortality across low- and middle-income countries.⁴ However, the persistent quality coverage gap for SP-IPTp reveals systemic challenges in ensuring that increased contact translates into effective intervention uptake. This reinforces the argument that the quality of care, rather than the quantity of visits alone, determines maternal and neonatal health outcomes. The 44.5% quality gap observed, which exceeds earlier findings,²⁶ highlights inefficiencies in service provision and the need for quality assurance mechanisms in ANC delivery. As has been emphasised, insufficient quality in ANC services contributes significantly to preventable neonatal deaths, revealing an urgent policy need for standardised supervision and monitoring protocols across ANC facilities.²⁷

The recommendation for initiating SP-IPTp administration in the second trimester¹ has proven essential in maximising uptake. Studies have shown that adherence to this timing significantly improves coverage rates when SP is consistently available at each ANC contact.²⁸ The finding that women with fewer ANC visits, adjusting for gestation, had lower SP-IPTp uptake reinforces the necessity of early ANC initiation and consistent attendance. This pattern is reflective of broader maternal health literature emphasising continuity of care as a critical determinant of maternal and child outcomes. Missed appointments, though common, did not show a direct correlation with SP uptake, suggesting that other contextual and structural barriers, such as medication availability, play a more decisive role in influencing uptake patterns.²⁹

The study further confirms that knowledge of the SP-IPTp intervention alone may not be sufficient to guarantee compliance. This deviates from the general understanding that awareness and knowledge predict adherence to preventive interventions.⁵ The lack of significant association between awareness and uptake may reflect structural deficiencies in the healthcare delivery system, such as stockouts or inadequate counselling, rather than attitudinal resistance among pregnant women. Strengthening health education and ensuring consistent drug availability could jointly address this gap.

The World Health Organisation’s directive that all pregnant women should receive at least three doses of SP-IPTp before delivery¹ continues to face implementation challenges in Ghana. National reports show uptake levels below the recommended threshold,¹⁷ a finding mirrored by the present study. In comparison, higher SP uptake in other Ghanaian municipalities, such as Sunyani,¹⁵ points to regional disparities that may be shaped by contextual factors such as resource allocation, healthcare accessibility, and the consistency of drug supply chains. The current finding that over half of the pregnant women attributed low uptake to the unavailability of SP reinforces this interpretation. Furthermore, delayed initiation of ANC visits beyond 12 weeks of gestation remains a barrier to achieving adequate SP coverage, as documented in Nigeria.³⁰ This aligns with the broader literature linking late ANC initiation with suboptimal preventive intervention coverage. Reported adverse reactions such as vomiting and diarrhoea also contributed to reduced compliance, consistent with earlier findings that side effects can deter future SP-IPTp use.²⁶ These issues point to the importance of patient-centred education and pharmacovigilance mechanisms that address side effects and enhance medication acceptability.

The high uptake of IFAS observed supports earlier assertions that maternal awareness and understanding of the benefits of iron and folic acid supplementation foster adherence.²⁶ The association between adequate knowledge and IFAS uptake reflects effective health education among participants. This finding is consistent with studies in Tamale²⁹ and elsewhere, which suggest that knowledge is a powerful enabler of preventive health behaviour. The pattern of higher IFAS adherence among third-trimester women may be attributed to their increased frequency of ANC visits, as well as improved exposure to continuous health education during the later stages of pregnancy. This reaffirms the importance of sustained engagement throughout pregnancy to improve supplementation adherence. The indication that some women continued taking IFAS despite missing ANC appointments suggests a degree of self-efficacy and awareness, possibly linked to their ability to identify and purchase the correct medication from pharmacies. This behaviour implies that health literacy campaigns are achieving some success, although it also signals gaps in supply consistency at healthcare facilities.

While the IFAS coverage rate was near universal, the slight difference between expected and observed uptake points to the persistent challenge of supply chain interruptions and patient-level adherence barriers. Nonetheless, the narrow gap compared to SP-IPTp suggests better implementation fidelity for IFAS distribution. This could be attributed to its easier accessibility, lower cost, and longer-standing integration into routine ANC protocols.

Deworming coverage, on the other hand, remains the weakest link among the three major interventions assessed. The low uptake aligns with global observations that deworming remains underutilised in antenatal care despite its known benefits in preventing anaemia and improving birth outcomes.^31,32 The relatively lower uptake recorded compared to studies across sub-Saharan Africa and Cameroon^12,31,32 may reflect both supply-side limitations and sociocultural perceptions of deworming drugs during pregnancy. Given the evidence that deworming reduces infant mortality by 14%³² and contributes to the prevention of low birth weight, the observed underutilisation represents a missed opportunity for improving maternal and neonatal health outcomes. Integrating deworming more strongly into ANC protocols, coupled with targeted education on its safety and benefits, could help improve uptake rates.

Collectively, these findings illustrate that while Ghana has made commendable strides in expanding ANC coverage, persistent disparities in the uptake of specific interventions reveal structural, behavioural, and systemic bottlenecks. The inconsistencies between coverage and quality underscore the need for a paradigm shift from access-driven to quality-focussed ANC strategies. Ensuring drug availability, encouraging early ANC initiation, and strengthening provider-client communication should be prioritised in future maternal health programming. Additionally, incorporating continuous professional training for healthcare providers on updated WHO recommendations and evidence-based counselling strategies will enhance service quality and client satisfaction.

Ultimately, this study provides a critical empirical contribution to maternal health policy discourse by highlighting the multidimensional barriers to optimal ANC intervention uptake. Its implications extend beyond Ghana to similar low-resource contexts, where ensuring consistent drug supply, enhancing service quality, and promoting maternal empowerment are pivotal to achieving Sustainable Development Goal 3, reducing maternal and neonatal mortality. The study had some limitations, which included self-reported bias where variables, such as missed appointments, medication adherence, and prior adverse reactions, were based on participants’ recall and self-reporting. This introduces potential recall or social desirability bias. Again, the study was conducted in a specific district or health facility setting, which may limit the generalisability of findings to all pregnant women in Ghana or other low- and middle-income contexts. Finally, although quantitative data effectively identified significant predictors, qualitative insights from healthcare providers or pregnant women could have provided richer explanations for observed behaviours and barriers. Despite these limitations, this study makes a novel and practical contribution to maternal health and health policy research in Ghana and comparable low-resource settings. It provides empirical evidence on the real-world uptake of essential ANC interventions—SP-IPTp, IFAS, and deworming—and identifies both individual and system-level barriers that hinder optimal preventive care during pregnancy. Again, the study addresses a critical evidence gap by integrating the analysis of multiple ANC interventions within a single study framework, offering actionable recommendations for improving coverage, adherence, and health outcomes among pregnant women.

Conclusion

This study makes significant contributions to maternal and child health research and policy by providing empirical evidence on the gaps between the coverage and actual uptake of key antenatal care (ANC) interventions such as SP-IPTp, IFAS, and deworming therapy among pregnant women in Ghana. Empirically, the findings enrich existing literature by quantifying adherence levels and identifying determinants of low uptake, thereby offering a robust evidence base for future intervention studies. From a policy and programmatic perspective, the results highlight the need for strengthened supply chain management of ANC medications, improved timing and frequency of ANC visits, and enhanced health education strategies targeting pregnant women’s knowledge and perceptions of ANC interventions. Practically, the study informs frontline healthcare workers and maternal health programme implementers on strategies to enhance adherence through patient-centred communication and consistent follow-up. Developmentally, the research underscores the critical role of quality ANC services in achieving Sustainable Development Goal 3 (SDG 3) targets—particularly those related to reducing maternal and neonatal mortality. Despite contextual limitations, the study provides actionable insights for policymakers, researchers, and practitioners seeking to improve maternal health outcomes and strengthen ANC delivery systems in resource-limited settings.

Recommendation

The Management of the University Hospital, in collaboration with the District Health Directorate, should endeavour to solicit aid in the distribution and accessibility of the preventive intermittent malaria and deworming therapy in all public health facilities nationwide. The Public Health Unit of the hospital should embark on public education among pregnant women to increase maternal health service utilisation and the significance of absorbing the recommended doses of each intervention.

Supplemental Material

sj-docx-1-phj-10.1177_22799036261423655 – Supplemental material for Adherence and barriers to key antenatal interventions among pregnant women in an urban district of Ghana: A cross-sectional study

Supplemental material, sj-docx-1-phj-10.1177_22799036261423655 for Adherence and barriers to key antenatal interventions among pregnant women in an urban district of Ghana: A cross-sectional study by Enoch Acheampong, Rosemond Serwaa Appiah, Grace Kisiwaa Agyei, Frederick Inkum Danquah, Kofi Baffoe-Sarpong and Abena Kyerew Abebrese in Journal of Public Health Research

Footnotes

Acknowledgements

We wish to express our gratitude to the management of University Hospital for their support during the field data collection. Again, we wish to thank the respondents of this study for their immense contribution.

ORCID iDs

Enoch Acheampong

Rosemond Serwaa Appiah

Grace Kisiwaa Agyei

Frederick Inkum Danquah

Kofi Baffoe-Sarpong

Abena Kyerew Abebrese

Author contributions

Enoch Acheampong: Conceptualisation, Methodology, Investigation, Review & Editing

Rosemond Serwaa Appiah: Methodology, Formal Analysis, Writing – Original draft, Review & Editing

Grace Kisiwaa Agyei: Visualisation, Investigation, Review & Editing, Resources

Frederick Inkum Danquah: Investigation, Validation, Formal Analysis, Data Curation

Kofi Baffoe-Sarpong: Investigation, Writing – Review and editing, Data Curation

Abena Kyerew Abebrese: Investigation, Writing – Review and editing, Resources, Formal Analysis, Data Curation

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental material

Supplemental material for this article is available online.

References

World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. WHO, 2016.

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Supplementary Material

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Adherence and barriers to key antenatal interventions among pregnant women in an urban district of Ghana: A cross-sectional study

Abstract

Objective:

Methods:

Results:

Conclusion:

Keywords

Introduction

Methods

Ethical considerations

Results

Demographic characteristics of respondents 25

The uptake of key intervention of ANC 25

Barriers to uptake of key interventions 25

Adjusted measures of association 25

Discussion

Conclusion

Recommendation

Supplemental Material

sj-docx-1-phj-10.1177_22799036261423655 – Supplemental material for Adherence and barriers to key antenatal interventions among pregnant women in an urban district of Ghana: A cross-sectional study

Footnotes

Acknowledgements

ORCID iDs

Author contributions

Funding

Declaration of conflicting interests

Supplemental material

References

Supplementary Material

Demographic characteristics of respondents²⁵

The uptake of key intervention of ANC²⁵

Barriers to uptake of key interventions²⁵

Adjusted measures of association²⁵