Women’s knowledge and its associated factors regarding optimum utilisation of antenatal care in rural Ghana: A cross-sectional study

Introduction Improving maternal health is a global public health challenge especially in sub-Saharan Africa. The optimum utilisation of antenatal care (ANC) by pregnant women is known to improve maternal health outcomes. Maternal morbidity and mortality rates in Ghana remain unacceptably high, particularly in rural settings where skilled delivery care often times is disproportionally low. This study assessed factors associated with optimum utilisation of antenatal care in rural Ghana. Methods A cross-sectional design was applied to collect data among eligible participants between October 2018 and January 2019. A total of 322 women who gave birth and attended the postnatal clinic were recruited for the study. Consecutive sampling was employed in recruiting participants. The associations between the dependent variables (ANC service utilisation and knowledge of ANC) and independent variables (socio-demographic characteristics) were examined using ordinary least squares logistic regression at 95% confidence interval in STATA version 14.0. Results Of the 322 participants, 69.0% reported utilising at least four or more times ANC services. Determinants of women attending ANC for four or more times was significantly associated with age [OR = 4.36 (95%CI: 2.16–8.80), p<0.001], educational level [OR = 10.18 (95%CI: 3.86–26.87), p<0.001], and insured with National Health Insurance Scheme [OR = 3.42 (95%CI: 1.72–6.82), p<0.001]. Not married [OR = 0.65 (0.39–1.09), p = 0.011] or divorced [OR = 0.33 (95%CI: 0.13–0.83), p = 0.019] was negatively associated with utilisation of four or more ANC services. The majority (79.0%) of the participants had a good level of knowledge regarding antenatal care. Conclusion Although the majority of women in this study had good knowledge of ANC services, a significant number of them did not complete the recommended number of ANC visits for at least four times during a normal pregnancy. Awareness and further education to reproductive-age women on the significant role adequate ANC attendance plays in advancing health and well-being require further investments, particularly among rural women in Ghana.

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Review comments 5. "Those who sought ANC services less than four times were classified as having poor ANC service utilisation (inadequate) and those who had ANC visits of 4 or more were considered as having good (adequate) ANC service utilisation." This information has been captured under the section on outcome variables already. Please delete it. Authors response Repetition deleted under data analysis section see page 10, lines… Review comment 6. Revise this statement: "Bivariate logistic regression analysis, computing odds ratio, was used to determine the strength of the association…" Because Logistic regression will report odds ratio. Bivariate logistic regression analysis reports more than strength of association. What about direction of the association? Authors response In page , lines this has been revised and now reads as; "Ordinary least square logistic regression analysis was applied where odds ratios were computed to determine how the independent variables is associated with the dependent variables (ANC service utilisation and knowledge of ANC)" Review comments 7. The statement "ANC service utilisation was coded as 0 for poor utilisation (<4 ANC visits) and 1 for good untilisation (4+ ANC visits)" has been repeated under the outcome variables and twice under data analysis sections. Please check and delete where appropriate. Authors response The repetition highlighted by the reviewer under data analysis have been deleted in the revised submission.
Review comments 8. Please provide the Ethics approval number. Authors response This has been provided in page line and now reads as "Ethics approval for the study was obtained from the University of Health and Allied Sciences Research Ethical Committee (UHAS-REC A. 10[27] 17-18)".
Review comments 9. What is purpose of running a chi-square test and crude logistic regression as reported in table 2? Authors response Chi-square results has been removed and replaced with tables only highlighting analysis of logistic regression (for adjusted and unadjusted) Review comments 10. Table 2 is titled "Regression analysis results for ANC attendance" but reported Chisquare results in addition. I suggest the authors present the results of the logistics regression only in tables 2 and 3 Authors response As suggested by the reviewer, authors have re-presented the results of the logistics regression only in tables 2 and 3.
Review comments 11. How were confounding effects accounted for in establishing the association between the dependent and independent variables? Think the authors have to explore association in presence of other explanatory variables. This part of the analysis is not clear. Authors response National health insurance was controlled for in the adjusted model. When NHIS was controlled for in the adjusted model there was a significant relationship with optimum ANC and these explanatory variables (Age, marital status, educational level, religion, and distance to health facility). There for NHIS was found to have confounder effect when included in the regression model. Review comments 12. How was the Family type defined? how was the question asked? Authors response Nuclear family was termed as a family group consisting of two parents and their children (one or more). Extended family: consisting of parents like father, mother, and their children, aunts, uncles, grandparents, and cousins, all living in the same household. Do you live with your husband and children alone or with your other extended family (grandfather etc) Review comments 13. In Figure 6, how is "Check-up" different from "Normal routine during pregnancy"? How were those two questions asked? Authors response Check-up: the main reason behind they attending ANC was to check their health status and that of their unborn baby. "Normal routine during pregnancy" mothers that were categorized here where those who mainly said their reason for attending ANC was because it is the routine thing to do during pregnancy and has been asked to come on this date by nurses.
Review comments 14. The statistical association cannot be strongly established with only crude results without accounting for explanatory variables. I suggest a revision of the statistical analysis to inform the conclusion of the study. Authors response Reviewer concerns have been addressed in table 2 and 3 Reviewer # 2 Review comments The study seems to assess optimal utilization (four or more visits) of ANC among utilizers of ANC and not utilization of ANC as suggested by the topic. Authors response Taking the reviewer suggestion into consideration, authors have revised the title as found in the revised manuscript submitted. See page 1 lines 2-3 Review comments Also, the authors should be adjusted the title to reflect that they only assessed sociodemographic factors. Authors response While acknowledging that this is a fair comment from reviewers, other factors outside individual socio-demographic factors were assessed i.e community and individual challenges affecting antenatal utilization; facility related barriers to ANC attendance; reasons for ANC Attendance etc. Hence, adjusting the title to reflect sociodemographic factors has a potential to limit the scope of factors considered in this study. Given the title change in this revised submission, authors think we have adequately addressed any concerns regarding the suitability of the title and that the title now reflects the aim/objectives of the study.
Introduction: review comment Some of the text require references. Authors response References have been provided in relevant areas in the introduction section.

Review comment
The justification is not compelling enough. According to you, ANC attendance is high but utilization for delivery is low. Isn't this a more interesting topic than exploring factors for ANC attendance? The authors need to better justify the investigation. Authors response This has been addressed in page 4 and 5 lines 89-104. The highlighted portions provide further clarity on areas these have been addressed.
Review comments Conceptual framework: Authors had a beautiful conceptual framework but limited the investigation to a few socio-demographic correlates of optimal ANC attendance. The reason for this is not clear. The authors seem to suggest that attendance of four or more ANC visits is synonymous with utilization rather than optimal utilization.

Authors response
We adapted the behavioural model framework of Andersen for use of health services to identify the factors that potentially facilitate or impede minimum number of antenatal health services seeking behavior at individuals and community levels.
In considering the review suggestion, authors have made changes and have maintained optimal utilisation instead of utilisation in this revised submission of the manuscript.

Review comments
Could the authors briefly explain the reasons for its (Anderson Behavioral Health care model) wide applicability? Why choose this model for the inquiry? Why not any other model? Authors response The frame work is widely used because the three factors identified by Andersons model to facilitate or impede healthcare access cuts across almost every health system across the globe including the developed and developing countries. And several studies have used the model to identify facilitating and impeding factors to healthcare access.
The framework predicts that a series of factors predisposing, enabling and need factors influence the utilization of health services by people. According to the model, predisposing factors are demographics and social structures. Enabling factors facilitates individuals to use services for example, availability of resources such as income, access to free services, availability and access to the service. Need factors motivates service use. We chose this model because we sought to determine factors that impede or facilitate ANC services utilization in health facilities. And Anderson behavioral model best suit our current study objective.
Methods: Review comments Study design: I am not convinced that the method is adequate to answer the research question. Assessing factors related to utilization of ANC services would be better answered by comparing utilizers and non-utilizers. Rather the design addresses correlates of optimum utilization (four or more) among utilizers. The authors need to clarify this. Authors response Reviewer suggestion and comments was helpful in making revisions to the design section of the revised manuscript. This study truly addresses correlates of optimum utilization among users and this has reflected in the revised manuscript under the study design section. See page 8 lines 137-140. Outcome variable: Review comments How many outcome variables did this study have? The first sentence suggests more than one but itemizes just one. Kindly correct. Authors response The outcome variables were optimum utilisation and Knowledge of ANC. This has been addressed under outcome variables. See page 9 lines 172-173. Review comments The authors should use "good" or "bad" knowledge for the sake of consistency and not knowledgeable or not.
Authors response Authors acknowledge this as a fair suggestion. However, to ensure consistency in the revised manuscript, authors have used good and poor knowledge.

Review comments
The characterization of participants seems unclear. A part of the manuscript suggests that 50% was used as cut-off, while another part suggests that the participants' mean score was used as cut-off. Kindly clarify and justify. Authors response Authors acknowledge the inconsistent reporting in the methods section with regard to the cut-off point in knowledge assessment. Author has corrected this inconsistency by deleting the 50% cut-off point.

Review comments
Validity and reliability of the study instrument: How was construct validity assured? Authors response construct validity pertains to a specific use of a scale and can often be context or population dependent. The current study instrument was contextually structured to identify factors that facilitate or impede optimal utilization of ANC services within the study population.
Multi-collinearity diagnostics were done and found that the Variance Inflation Factors (VIFs) were all below the 5-10 rule of thumb range, suggesting there is no collinearity among the independent variables to be fitted in the regression model! Effects of multicollinearity was therefore ruled out and did not have any effect on the validity of the study outcomes.

Review comments
What is the level of expertise of these researchers and clinicians? It may be helpful to state their qualification and give further background about their experience. Authors response Thomas B. Azongo (PhD) is a snr lecturer and a public health expert; Veronica Millicent Dzomeku (PhD) is a midwife and a Snr Lecturer, Hyeonkyeong Lee (PhD) is a professor in community health nursing; Peter Adatara (PhD) is a snr lecturer and his specialty area is in maternal and child health; Robert Kaba Alhassan (PhD), Snr research fellow; Martin Amogre Ayanore (PhD) is a Health Economist and a Public health expert, Paul Amuna (MB ChB, PhD) is a professor and his area of specialty is maternal and child health Clinicians: They both have degree in midwifery and have been practicing midwifery for over 10 years Review comments Questions 5, 6, 8, 9, 10 do not actually test what the women know? Authors response These questions were added to assess mothers knowledge on the other activities carried during ANC: Mothers that utilize ANC are taught these and they are expected to have basic knowledge in relation to the education or things taught during ANC attendance: for example during ANC, mothers are informed of the recommended ANC visits, so we expected mothers to know these. Additionally, mothers who utilized ANC are educated on the recommended place for safe delivery and the necessary items required for delivery. The items for assessing the mother's knowledge of ANC was developed in context with the study population methods section. Authors response The results section has been updated and review concerns above addressed. See  table 2 and 3 on pages 16 &17 lines 284-285   Review comment  There is a need to report the salient findings even if all has been presented on table 2.  Authors response  Authors acknowledge this and have done the needful by focusing on only the salient  findings. See page 15 lines 278-283. Review comment What is the mean age of the participants? Authors response Age of participants were categorized during data collection therefore the mean age could not be calculated.

Review comments
The title of table 2 need to be updated to bivariate and regression analysis. The authors need to make some comments about results of bivariate analysis in prose. Authors response Table 2 and 3 have been updated. Figure 3 is better presented as a pie chart. Authors response Figure 3 has been changed to a pie chart. Refer to page 18. On table 3 and age factor, if the reference group is the first group, then the Odds ratio need to be reviewed. Authors response This critical suggestion was reviewed and significant changes made to the odds ratios. Table 3 provide further details on the revised submission after addressing this concerns. See page 20.

Review comment
Review comments For figure 6, kindly remove the bars with zero responses. Authors response Changes has been made as suggested. Refer to page 14 Discussion: Review comment "The present finding of 69% is below the national coverage of at least four ANC visits of 75.9%". Is there something about the study population that could account for this disparity? Authors response This has been addressed in page 25 line 348-351 and now reads as; This difference may be due to the lack of awareness of optimal ANC visits. Also, the differences could have been caused by other potential inhibiting factors such as distance to health facilities and socio-economic factors.
Review comments "Our study finding is consistent with a study conducted in the southwest of Nigeria [39] but disagrees with a study conducted in Mozambique where the researchers found women's knowledge of ANC services not to have significant importance in their utilisation of ANC services [40]. It is established that women with good knowledge of ANC services have a better understanding and acceptance of the services provided during ANC [41], and this knowledge will, therefore, be a catalyst for the utilising ANC services during pregnancy." It seems more plausible that utilization of ANC services would result in better knowledge of ANC not the other way round as suggested by the authors. Anyway, the study is cross-sectional, hence the use of the word determinant is better replaced with association.

Authors response
We totally agree with assertion (It seems more plausible that utilisation of ANC services would result in better knowledge of ANC). In the discussion section, this emphasizes has been made in relation to the findings of the study.
Limitations: Review comments I can immediately think of some other limitations of this study e.g. cross-sectional nature, therefore, just associations can be measured, bias due to self-report, nonexploration of many other factors, etc. Kindly develop this section further. Authors response A section on limitations has been added and some potential limitation of the study acknowledged. See page 29 lines 448-458 Review comments Other comments" I have made some further suggestions on the text of manuscript Authors response Review concerns on inconsistencies in the manuscript have been addressed. Authors read thoroughly through the revised manuscript to identify these inconsistencies and sentences that were not clear and corrections effected. Review comment • "Instead, the current study found women with low socioeconomic status more likely to utilize ANC services at least four times due to their enrolment into the national health insurance scheme" where was this result presented? Authors response This was a general assumption for the study participants. This have been deleted because it lacked evidence from the current study.

Review comments
Are there any reasons why Bole had a lower than National ANC4+, What is the regional average? Authors response The difference may be due to the lack of awareness of optimal ANC visits. Also, the differences could have been caused by other potential inhibiting factors such as distance to health facilities and socio-economic factors. Refer to page 25 line 348-351.      Antenatal care (ANC) is the health care and education provided to pregnant women and 71 adolescent girls by skilled health care professionals to ensure the best health conditions for the 72 mother and the baby during pregnancy [1,5]. Antenatal care utilisation is an important 73 constituent of maternal health care, which reduces maternal and perinatal morbidity and 74 mortality both directly through identification and management of pregnancy-related 75 complications, and indirectly through the identification of pregnant women and girls most 76 likely to develop complications during labour and delivery, thus ensuring early referral to an 77 appropriate health facility for further care [1]. Globally, while most women now attend at least 78 one ANC visit (86%), only 62% attend four, with lower rates reported in sub-Saharan Africa 79 and South Asia [6].   services, and to support in formulating policies that will promote equitable access [16,17].  The study applied a cross-sectional analytical facility-based study design to recruit the 137 participants. Given the design type, quantitative data was collected among eligible participants 138 after applying the appropriate sampling methodology. This design was appropriate to enable 139 the study team to elicit answers to key questions that underpin the study.     Completeness of questionnaires was checked daily after completing each questionnaire before 205 participants were asked to leave. Where minor omissions were detected, immediate corrective 206 measures were taken with participants to ensure validity and to prevent missing information.  1. ANC can prevent complications in pregnancy? 2. Pregnant women may have problems without ANC? 3. Regular ANC medications can promote optimal growth of unborn child? 4. Health facility delivery is safer and better than home delivery? 5. Do you know the recommended place for delivery? 6. Do you know the recommended frequency and timing of ANC visits? 7. ANC is recommended regardless of complications? 8. Do you know items to prepare for before delivery? 9. Do have knowledge of family planning? 10. Do have knowledge of malaria prevention? computed and a score below the mean was considered poor knowledge whiles a mean score or 247 above was considered to be a good knowledge. Ordinary least square logistic regression 248 analysis, computing odds ratio, was used to determine the association between dependent 249 variables (ANC service utilisation and knowledge of ANC) and socio-demographic 250 characteristics. Statistical significance was determined at 95% confidence level.      312 Long-distance to the health facility (31.1%) and partner's perception of the importance of ANC 313 were major barriers to the effective utilisation of ANC services by the women. Also, about 27.6% 314 indicated not having enough money to attend antenatal clinic and cultural beliefs (7.9%) as some 315 of the challenges. This is shown in (Figure 4).            and South Asia [6].  services, and to support in formulating policies that will promote equitable access [16,17]. The study applied a cross-sectional analytical facility-based study design to recruit the study 137 participants. Given the design type, quantitative data was collected among eligible study 138 participants after applying the appropriate sampling methodology. This design was appropriate 139 to enable the study team to elicit answers to key questions that underpin the study.        315 Long-distance to the health facility (31.1%) and partner's perception of the importance of ANC 316 were major barriers to the effective utilisation of ANC services by the women. Also, about 27.6% 317 indicated not having enough money to attend antenatal clinic and cultural beliefs (7.9%) as some 318 of the challenges. This is shown in (Figure 4). This study applied an integrated conceptual framework to identified individual and facility based 338 factors that influence optimum utilisation of ANC services among mothers in rural areas.