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Barriers to Early Antenatal Care and Its Effect on Malaria Prevention During Pregnancy in the Volta Regional Hospital

This study reveals that despite high knowledge levels regarding antenatal care and malaria prevention among pregnant women in the Hohoe Municipality, early ANC attendance remains low due to significant socio-economic and service delivery barriers, ultimately compromising the effectiveness of malaria prevention strategies.

Original authors: Richard Awuah, Reina Mrayeba Addo, Livingstone Asem

Published 2026-06-24

📖 5 min read🧠 Deep dive

CC BY 4.0

Original authors: Richard Awuah, Reina Mrayeba Addo, Livingstone Asem

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

The Big Picture: A Knowledge Gap

Imagine the Volta Regional Hospital in Ghana as a busy train station. The goal is to get every pregnant woman on the "Early Care Train" as soon as she discovers she is pregnant. This train stops at important stations like Malaria Prevention and Risk Checks.

The researchers, Richard, Reina, and Livingstone, wanted to know: Why are so many women missing the first stop on this train, even though they seem to know the schedule?

They found a strange contradiction: Most women know the rules, but they aren't following them. It's like a group of people who all know that eating vegetables is healthy, but still skip the salad bar.

The Study: Who Was Asked?

The team interviewed 278 pregnant women at the hospital. Think of this as taking a quick snapshot of a crowd to see what they are thinking and doing. They asked about:

Who they are (age, job, religion, how many kids they already have).
What they know about malaria and pregnancy.
Whether they are using mosquito nets and taking malaria medicine.
What stops them from coming to the hospital early.

The Findings: The "What" and The "Why"

1. The Knowledge is High (The Map is Clear)

About 86% of the women knew exactly when to start prenatal care (within the first 3 months) and understood that malaria is dangerous for babies.

The Analogy: It's like everyone in the village has a perfect map of the forest and knows where the dangerous bears (malaria) live. They aren't lost; they just aren't moving fast enough.

2. The Action is Lagging (The Walk is Slow)

Even though they know the map, the actual behavior is mixed:

Mosquito Nets: About 76% own a net (they have the umbrella), but only 69% actually sleep under it (they don't always open the umbrella).
Malaria Medicine: About 66% took the preventive medicine (SP), but many didn't take it under the watchful eye of a nurse, or they missed doses.
The Analogy: Imagine you have a fire extinguisher in your kitchen (the medicine/net), but you only grab it when you smell smoke, rather than checking it regularly to prevent the fire.

3. The Roadblocks (Why the Train is Delayed)

The researchers found specific reasons why women wait too long to start their care. Think of these as potholes on the road to the hospital:

The "I've Done This Before" Trap (Parity): Women who already have four or more children were much more likely to delay.
- The Analogy: It's like a veteran driver who thinks, "I've driven this route a hundred times; I don't need a co-pilot." They feel so experienced they skip the safety check.
The Location Problem (Residence): Women living in peri-urban areas (the edge of town) were actually less likely to delay than those in deep rural areas.
- The Analogy: If the hospital is a lighthouse, people living right next to the shore (peri-urban) can see it easily. People living in the foggy hills (rural) have a harder time finding the path.
The Wallet Factor (Insurance): Having the National Health Insurance Scheme (NHIS) was a huge game-changer. Women with insurance were 5 times less likely to delay.
- The Analogy: Insurance is like having a toll pass. Without it, the road feels expensive and scary; with it, the path is smooth and free.
The Waiting Room (Health System): Long wait times and feeling like the care wasn't "good enough" made women wait.
- The Analogy: If the hospital is a restaurant with a 2-hour wait and rude waiters, people will keep eating at home (or not eating at all) instead of coming in, even if they know the food is good.
Religion: The study found that a woman's religion played a role in her timing, though the specific reasons weren't detailed in the results other than it being a statistical factor.

The Conclusion: Fixing the Road

The paper concludes that knowing the answer isn't enough. You can have the map, the umbrella, and the fire extinguisher, but if the road is full of potholes (long waits, no insurance, feeling unsafe) or if you think you don't need help because you're experienced, you won't get to the hospital on time.

The authors suggest:

Fix the Road: Make the hospital experience faster and friendlier so people want to come early.
Expand the Toll Pass: Get more women on the National Health Insurance scheme.
Target the Veterans: Specifically remind women who have had many children that every pregnancy is new and needs a fresh check-up.
Bridge the Gap: Turn "knowing" into "doing" by making sure the nets are used and the medicine is taken exactly as prescribed.

In short: The women in Hohoe are smart and informed, but the system and their own habits are creating a delay that puts them and their babies at risk from malaria.

Technical Summary: Barriers to Early Antenatal Care and Its Effect on Malaria Prevention During Pregnancy in the Volta Regional Hospital

Problem Statement
Maternal and newborn health remains a critical public health challenge in low- and middle-income countries, where progress has been limited despite sustained intervention efforts. While Antenatal Care (ANC) is a cornerstone for risk assessment and the delivery of preventive interventions—specifically for malaria, which poses severe risks to both maternal and fetal health—many pregnant women delay initiating ANC. This delay limits the timely provision of interventions such as Intermittent Preventive Treatment in pregnancy (IPTp) and counseling on Insecticide-Treated Nets (ITNs). In the Hohoe Municipality of Ghana, there is a need to understand the specific barriers preventing early ANC attendance and how these delays impact malaria prevention strategies.

Methodology
The study employed a descriptive cross-sectional design conducted at the Volta Regional Hospital in the Hohoe Municipality.

Study Population: 278 pregnant women attending ANC services who consented to participate.
Sampling: A simple random sampling method was used. The sample size was calculated using the Cochrane formula based on a prevalence of 20.8%, resulting in a target of 253, adjusted to 278 to account for non-respondents.
Data Collection: Structured questionnaires were administered to capture socio-demographic characteristics, determinants of early ANC attendance, and health system factors. For participants with limited proficiency in English, trained interpreters facilitated translation into local languages (e.g., Ewe).
Data Analysis: Data were entered into Kobo Collect and analyzed using Stata version 17.0. The analysis included descriptive statistics (frequencies, percentages, means) and inferential statistics (Chi-square tests and binary logistic regression) to determine relationships between independent variables and delayed ANC initiation at a 95% confidence level ( $p < 0.05$ ).

Key Results

Knowledge vs. Practice: While 85.9% of respondents demonstrated good knowledge regarding ANC timing and malaria prevention, this awareness did not translate into optimal early attendance or consistent preventive practices.
Malaria Prevention Uptake:
- LLIN Ownership: 75.9% of women owned Long-Lasting Insecticide Nets (LLINs).
- LLIN Usage: Only 69.4% reported sleeping under an LLIN.
- IPTp (SP) Uptake: 65.7% had taken Sulfadoxine-pyrimethamine (SP). However, adherence to Directly Observed Therapy (DOT) was low, with only 43.1% of those who took SP doing so in the presence of a drug administrator.
Determinants of Delayed ANC: Logistic regression identified several significant predictors for delayed ANC initiation:
- Parity: Women with four or more children were significantly more likely to delay ANC compared to primigravidae (aOR = 0.1; $p=0.013$ ).
- Residence: Women in peri-urban areas were less likely to delay ANC compared to rural dwellers (aOR = 2.7; $p=0.041$ ).
- Health Insurance: Enrollment in the National Health Insurance Scheme (NHIS) was a strong protective factor; insured women were five times less likely to delay ANC (aOR = 5.0; $p=0.028$ ).
- Knowledge: High knowledge levels were associated with a reduced likelihood of delay (aOR = 1.5; $p<0.001$ ).
- Health System Factors: Favorable waiting times and perceived high quality of care were significantly associated with early ANC attendance.
- Religion: Significant associations were found between religion and ANC timing ( $p=0.005$ ).

Key Contributions
The study provides empirical evidence from the Volta Region highlighting the disconnect between high levels of maternal health knowledge and the actual utilization of early ANC services. It identifies specific socio-economic and health-system barriers—particularly parity, residence, insurance coverage, and service delivery quality—that hinder timely care. The findings underscore that while ownership of malaria prevention tools (LLINs) is relatively high, consistent usage and adherence to IPTp protocols remain suboptimal, largely due to delayed ANC initiation.

Significance and Claims
The authors claim that despite high awareness of ANC and malaria prevention among pregnant women in the Hohoe Municipality, early attendance remains inadequate. The study concludes that knowledge alone is insufficient to drive optimal preventive practices.

The significance of the work lies in its identification of multifaceted barriers that require integrated solutions. The authors assert that addressing these gaps necessitates strategies extending beyond awareness campaigns to include:

Strengthening service delivery and reducing waiting times.
Expanding NHIS coverage to ensure financial accessibility.
Ensuring consistent availability of preventive commodities (SP and LLINs).
Implementing targeted education for specific subgroups, such as multiparous women and rural populations.

The study posits that these multifaceted interventions are essential to enhancing early ANC uptake, optimizing malaria prevention during pregnancy, and ultimately improving maternal and neonatal health outcomes in the study area.

Limitations
The authors acknowledge that the cross-sectional design limits the ability to establish causality. Additionally, reliance on self-reported data may introduce recall or social desirability bias. The findings are specific to one hospital and may not be fully generalizable to other parts of the municipality or region with different socio-cultural contexts.