Women's empowerment and quality antenatal care in Ghana: analysis using the survey-based women's empowerment global index in the Ghana demographic and health survey.

Abstract

To examine the association between women's empowerment, measured using the Survey-based Women's emPowERment (SWPER) Global Index, and receipt of quality antenatal care (ANC) in Ghana. Cross-sectional analysis of nationally representative survey data. Ghana. A total of 3837 women aged 15-49 years who had a live birth or stillbirth in the 3 years preceding the 2022 Ghana Demographic and Health Survey and reported at least one ANC visit for the most recent pregnancy. Quality ANC was defined as receipt of four essential ANC components: blood pressure measurement, urine testing, blood sample collection and iron supplementation. Women's empowerment was assessed across three SWPER domains: attitude toward violence, social independence and decision-making, categorised as low, medium or high. Multilevel mixed-effects logistic regression models were used to examine associations while accounting for individual, household, community and regional-level factors. Overall, 90.9% of women received all four ANC components. In bivariate and partially adjusted analyses, higher empowerment in the attitude toward violence and social independence domains was associated with higher odds of receiving quality ANC. However, these associations were attenuated and no longer statistically significant in the fully adjusted multilevel model. The strongest independent associations with quality ANC were health-service utilisation factors. Late ANC initiation at 4-6 months (adjusted OR (AOR)=0.75, 95% CI 0.59 to 0.97) and ≥7 months (AOR=0.28, 95% CI 0.16 to 0.49) reduced the likelihood of receiving quality ANC, whereas attending 4-8 visits (AOR=2.89, 95% CI 2.05 to 4.07) and ≥nine visits (AOR=4.25, 95% CI 2.69 to 6.71) increased the likelihood. Receiving ANC at private hospitals was associated with lower odds of quality ANC compared with public hospitals (AOR=0.43, 95% CI 0.26 to 0.74). Regular radio exposure was positively associated with quality ANC, and substantial regional disparities persisted, particularly in the Western North, Northern, Savannah, North East and Upper East regions. In Ghana, women's empowerment indirectly influences the quality of ANC through pathways of early initiation and adequate continuity of care, whereas health-system factors and regional inequities remain the dominant independent determinants. Policy efforts should prioritise timely ANC initiation, continuity of care and equitable service delivery, alongside integrated empowerment strategies within broader health-system strengthening initiatives.