1.&n= bsp; INTRODUCTION

Reproductive health is a concern at any age throughout the life of women and represents more than 80% of health issues globally (Elizabeth et al., 2020). Antenatal care is the care provi= ded by skilled healthcare professionals to women throughout their pregnancy and= it includes risk identification and screening, prevention, and management of pregnancy-related diseases (Ali, 2020). Antenatal care prevents and redu= ces pregnancy and delivery-related complications such as postpartum haemorrhage, hypertension, pre-eclampsia, eclampsia, sepsis, spontaneous abortion, and obstetric fistula which are the leading causes of maternal morbidity and mortality globally (Kotoh & Boah, 2019). Therefore, pregnant women with l= ate initiation of antenatal care are more likely to attain poor health outcomes= during pregnancy (Aung, 2016). The goal of antenatal care is to reduce maternal and child morbidity and mortality, as such timely antenatal care initiation is crucial for the safety of the pregnant mother and the un= born child through early identification, management and prevention of pregnancy-= related problems by giving supplementation of micronutrients like iron and folic ac= id and screening of infection (Tola, = 2021). Evidence has established that pregnant women who can initiate early antenatal care do not suffer from pre= gnancy-related complications because such complications are detected at the onset of the e= arly visit, and appropriate medications and attention are given to such women. A= lso, there are safe maternal health, safe childbirth, and a reduction in pregnancy-related mortalities (Yah & Tambo, 2018).

Late antenatal booking and infrequent antenatal care are common. However, they are avoidable patient-related risk factors for maternal deaths (Muhwava, 2016). Women accessing prenatal care ea= rly receives the full benefits of treating medical conditions, identifying and reducing potential risks, and addressing behavioural and environmental fact= ors that contribute to poor pregnancy outcomes (Barder et al., 2020). Globally, a pregnant woman dies every minute from complications related to childbirth and about half a mill= ion women die each year due to maternal causes with 99% of the deaths taking pl= ace in developing countries (Ochako et al., 2011). Moreover, approximately 830 women die from preventable causes related to pregnancy and childbirth-related complications every day and countr= ies with low-resource settings account for almost all of these deaths ADDIN CSL_CITAT= ION {"citationItems":[{"id":"ITEM-1","itemDa= ta":{"DOI":"10.1136/bmjopen-2021-052886","ISS= N":"20446055","PMID":"34949621","ab= stract":"Objective This paper explored the factors that influence the timely initiation of antenatal care (ANC) in Bangladesh. Design This was a cross-sectional surve= y. Setting This study conducted in two rural subdistricts and one urban area f= rom three Northern districts of Bangladesh from August to November 2016. Participants Women who had a live birth in the last 1 year prior to data collection were enrolled for this study. In each study area, around 900 wom= en were interviewed, and finally, we completed 2731 interviews. Primary outcome measures The primary outcome was timely first ANC from a Medically Trained Provider (MTP). Results About 43% of pregnancies were detected at their earliest time. The majority of participants (82%) received at least one ANC from an MTP. Only 11% received timely first ANC from an MTP as per the WHO = FANC model. The women who detected pregnancy earlier were more likely (adj.OR 1.= 99, 95% CI 1.31 to 3.01) to receive the timely first ANC. The urban women were = more likely (adj.OR 1.78, 95% CI 1.13 to 2.80) to receive the timely first ANC f= rom an MTP than those of the rural women. Besides, their husbands' educational status (adj.OR 1.61, 95% CI 1.0 to 2.60) was significantly associated with = the timely first ANC. Conclusion Apart from sociodemographic factors, early pregnancy detection was strongly associated with the timely first ANC visit. Timely initiation of ANC is an opportunity to adhere to all the WHO recomme= nded timely ANC visits for a pregnant woman. The findings suggest maternal, neonatal, and child health programmes to focus on the early detection of pregnancy to ensure universal ANC coverage and its timeliness.","author":[{"dropping-particle":"= ","family":"Sarker","given":"Bidhan Krishna","non-dropping-particle":"","parse-na= mes":false,"suffix":""},{"dropping-particle&q= uot;:"","family":"Rahman","given":&= quot;Tawhidur","non-dropping-particle":"","pa= rse-names":false,"suffix":""},{"dropping-part= icle":"","family":"Rahman","given&q= uot;:"Tanjina","non-dropping-particle":"",&qu= ot;parse-names":false,"suffix":""},{"dropping= -particle":"","family":"Rahman","gi= ven":"Musfikur","non-dropping-particle":"&quo= t;,"parse-names":false,"suffix":""}],"co= ntainer-title":"BMJ Open","id":"ITEM-1","issue":"12&quo= t;,"issued":{"date-parts":[["2021"]]},"p= age":"1-10","title":"Factors associated with the timely initiation of antenatal care: Findings from a cross-sectional study in Northern Bangladesh","type":"article-journal","volume&= quot;:"11"},"uris":["http://www.mendeley.com/docum= ents/?uuid=3D9901036b-f0ea-447b-813b-96080f3f223a"]}],"mendeley&q= uot;:{"formattedCitation":"(Sarker, Rahman, Rahman, & Rahman, 2021)","manualFormatting":"(Rahman, 2021)","plainTextFormattedCitation":"(Sarker, Rahman, Rahman, & Rahman, 2021)"},"properties":{"noteIndex":0},"schema&= quot;:"https://github.com/citation-style-language/schema/raw/master/cs= l-citation.json"}(Rahman, 2021). Evidence shows that many women especially in sub-Saharan Africa do not access antenatal services in their first trimester of pregnancy with others attending only once which has contributed to most maternal-related complications such as severe bleeding leading to anaemia (Kotoh & Boah, 2019). In Ghana, the maternal mortality ratio is estimated at 310/100,000 live births, while neonatal and infant mortality rates were 25/1,000 and 37/1,000 pregnancies, which is partly due= to most pregnant women initiating antenatal= care late (Appiah et al., 2020). This study, therefore, determined the prevalence and associated factors to late initiation of antenatal care among pregnant women in the Dormaa Central Municipality.<= /p>

2. = MATERIALS AND METHODS:<= /b>

Stud= y area

The study was conducted in Dormaa Central Municipal. Dormaa Municipal is one of the most populous districts in the Bono Region. It covers an area of 599km^{2.
It is located in the forest belt of Ghana and shares a boundary on the North
with Dormaa East, South with Dormaa West, and West with Cote d’Ivoire. The
Municipal capital town is Dormaa Ahenkro and it is located 80km from Sunyani
the Regional capital and 8km from the Cote D'Ivoire Ghana border.}

Table 1. Socio-demographic characteristics of respondents

Variable(s)=		Category	Frequency	Percentage = (%)
=				Age ( years)	=	27.0±6.5 (16-43) years	=	=
		16-19	53	13.2
	=	20-25<= /o:p>	122	30.5
		26-30	106	26.5
	=	31-36<= /o:p>	80	20.0
		37-49	39	9.8

Marital status		Married	160	40.0
	=	Single=	99	24.8
		Co-habiting	141	35.2

Educational level		Non-Formal Education	37	9.2
	=	Basic educa= tion	239	59.8
		Secondary education	98	24.5
	=	Tertiary education	26	6.5

Religion	=	=	=	=
		Christian	313	78.2
	=	Islam<= /o:p>	85	21.3
		Traditional	2	0.5
	=	=	=	=
Residency
	=	Rural<= /o:p>	325	81.2
		Urban	75	18.8
	=	=	=	=
Ethnicity
	=	Akan	289	72.2
		Ewe	8	2.0
	=	Northerner<= o:p>	85	21.3
		Others	18	4.5
	=	=	=	=
Occupation
	=	Farming	103	25.7
		Trading	117	29.2
	=	Housewife	60	15.0
		Civil service	21	5.2
	=	Others=	99	24.8

Gravidity and Parity of Respondents

<= /span>

Figure 2. Gravity of Respondents

Most= 256 (64.0%) of the respondents were multigravida whilst 144 (36.0%) were Primigravida during the period of the study (Fig. 2).

<= /span>

Figure 3. Parity of Respondents<= b>

Abou= t 242(60.5%) of the respondents were multiparous, 110 (27.5%) were primiparous and 48 (1= 2.0%) were nulliparous (Fig. 3).

Trimester = of pregnancy

About 231 (57.7%) of the respondents were = in their first trimester, 139 (34.8%) were in their second trimester whilst 30 (7.5%) were in their third trimester (Fig. 4).

<= /span>

Figure 4= . Trimester of pregnancy

Initiation= of ante-natal care

Figure 5 shows that, about 170 (42.5%) o= f the pregnant women initiated antenatal care late while 230 (57.5%) initiated antenatal care early.

Figure 5. Initiation of antenatal care

Socioeconomic factors influencing initiation of antenatal visit

Table 2. Socioecon= omic factors influencing antenatal care initiation

Variable	Ca= tegory	Fr= equency	Pe= rcentage (%)

The right time to initiate ANC
	Ye= s	297	74.3
	No	103	25.7

Husband influence on ANC initiation=
	Ye= s	214	53.5
	No	186	46.5

Visit ANC whenever pregnant
	Ye= s	346	86.5
	No	54	13.5

Reasons for ANC initiation
	Ti= me to start	194	48.5
	Risk factor	126	31.5
	Si= ckness	80	20.0

Proximity to a health facility
	Near	288	72.0
	Di= stant	112	28.0

Transport system to a health facility
	Frequent	331	82.8
	In= frequent	69	17.2

Time is taken to reach the ANC centre	&l= t;30 minutes	294	73.5
	30-60 minutes	68	17.0
	&g= t;60 minutes	35	9.5

Transport cost to ANC =
	Cheap (<10GHS)	309	77.3
	Ex= pensive(>10GHS)	91	22.7

Association between socio-demographic factors and initiation o= f antenatal = care

The Pearson chi-square test set at a 95% confidence interval was used to determine the strength of association betwe= en socio-demographic factors and initiation of ante-natal care. Respondent's l= evel of education was 11.24 times more to initiate antenatal care late during pregnancy [X²=3D11.24, P=3D0.010] (Table 3).<= /p>

Table 3. Associati= on between socio-demographic factors and initiation of antenatal = care

Variable	Late initiation n (%)<= /b>	Early initiation n (%)=	X²(p-value)


Age (years)			10.8(0.054)
16= -19	21(12.3)	32(13.9)
20= -25	49= (28.8)	73(31.7)
26= -30	48(28.2)	58(25.3)
31= -36	44= (25.8)	36(15.6)
37= -49	8(4.7)	31(13.5)
Marital status			3.74(0.154)
Ma= rried	61(35.8)	99(43.0)
Si= ngle	41= (24.1)	58(25.3)
Co= -habiting	68(37.6)	73(31.7)

Education			11.24(0.010)*
No= n-formal education	24= (14.1)	13(5.6)
Ba= sic education	97(57.0)	142(61.7)
Se= condary education	44= (25.8)	54(23.4)
Te= rtiary education	5(2.9)	21(9.1)

Religion			2.69(0.259)
Ch= ristian	13= 2(77.7)	181(78.7)
Is= lam	36(21.1)	49(21.3)
Tr= aditional	2(= 1.2)	0(0.0)

Residency			0.1(0.75)
Ru= ral	141(82.9)	184 (80.0)
Ur= ban	29= (17.1)	46 (20.0)

Ethnicity			4.14(0.24)
Ak= an	116(68.2)	173(75.2)
Ew= e	3 = (1.8)	5 (2.2)
No= rtherner	45 (26.4)	40 (17.4)
ot= hers	6 = (3.5)	12 (5.2)

Occupation			8.80 (0.06)
Fa= rming	57(33.5)	46 (20.0)
Tr= ading	47= (27.6)	70(30.5)
Ho= usewife	31(18.2)	29(12.6)
Ci= vil service	5(= 2.9)	16(6.9)
ot= hers	30(17.6)	69(30.0)

Association between gravidity, parity and initiation of antenatal care

The Pearson chi-square test set at 95%confidnece interval was employed to deter= mine the relationship between the gravidity, and parity of pregnant women and th= eir initiation of antenatal care. The study found that pregnant women with one = or more pregnancies were 7.85 times to initiate antenatal care late [X^{2 <=
/sup>=3D7.85,
p=3D0.005]. In addition, it was revealed that pregnant women with one or mo=
re
children were 6.27 times to initiate antenatal care late [X²=3D=
6.27,
p=3D0.043] (Table 4).}

Table 4. Association between gravidity and parity,= and initiation of antenatal care

Variable	Late initiation n (%)<= /b>	Early initiation n (%)=	X²(p-value)


Gravidity			7.85(0.005)*
Pr= imigravida	49(28.5)	94(42.2)
Mu= ltigravida	12= 3(71.5)	12= 9(57.8)

Parity			6.27(0.043)*
Nu= lliparous	15(8.7)	33(14.8)
Pr= imiparous	42= (24.4)	67= (30.0)
Mu= ltiparous	115(66.9)	123(55.2)

Association between socioeconomic factors and initiation of antenatal = care

Table 5. Association between socioeconomic factors= and initiation of antenatal care

Variable	Late initiation n (%)<= /b>	Early initiation n (%)=	X²(p-value)

The right time to initiate ANC			16.4(.0001)*
Ye= s	11= 0(64.7)	60(35.3)
No=	182(79.1)	48(20.9)

Husband influence on ANC			5.7(0.017)*
Ye= s	80 (37.6)	92(49.5)
No=	133(62.4)	94(50.5)

= Visit ANC when pregnant			3.0(0.08)
Ye= s	14= 3(83.1)	29(16.9)
No=	198(89.2)	24(10.8)

Reasons for ANC			3.11(0.21)
Ti= me to start	83= (48.8)	106(47.7)
Kn= own risk factor	48(28.2)	78(35.1)
si= ckness	39= (22.9)	38(17.1)

Proximity to a health facility			0.28(0.59)
Ne= ar	122(71.3)	78(28.7)
Di= stant	16= 3(73.8)	58(26.2)

Tr= ansport system			2.36(0.124)
Fr= equent	137(80.6)	33(19.4)
in= frequent	19= 0(86.4)	30(13.6)

Ti= me is taken to reach ANC			4.47(0.107)
&l= t;30 minutes	121(70.8)	121(77.4)
30= -60 minutes	30= (17.5)	37(16.7)
>60 minutes	20(11.7)	13(5.9)

Tr= ansport cost			0.37(0.54)
Ch= eap (<GHS 10 )	40= (23.4)	131(76.6)
Expensive(>GHS 10)	46(20.8)	175(79.2)

4.&n= bsp; DISCUSSION

This current study revealed that socio-demographic factors such as the education of pregnant women had an association with pregnant women's late commencement of antenatal care. For example, 59.8% of the respondents had basic education and this influenced t= heir late initiation of antenatal care. The outcome of a quantitative cross-sectional study conducted in Nigeria indicated that the educational l= evel of pregnant women had a relationship with their commencement of antenatal c= are. The study further revealed that pregnant women who had attained basic educa= tion were more likely to report to antenatal care late (Ochako et al., 2011) and this finding a= grees well with the outcome of this recent study. A similar quantitative cross-section= al study was conducted to determine the factors associated with pregnant women= 's late commencement of antenatal care and it was revealed that, most of the pregna= nt women who had a basic form of education had a higher odds of attending antenatal care late (Wolde et al., 2019). Moreover, in the United Arab Emirates, it is established that the late commencement of antenatal care by pregnant women are ascribed to socio-demographic factors such as education.= The study indicated that pregnant women's education plays a vital role in their initiation of antenatal care (Ali et al. 2020) and this is also in line with the outcome of this study. What could have accounted for the similarities of study findings could be that these studies were conducted among pregnant wo= men with a low level of education, particularly those in rural areas where thei= r level of education might not be high compared to pregnant women residing in urban= areas with some form of formal education. However, a study conducted by Gebresila= ssie et al., (2019) has argued that the level of pregnant women's education had = no association with late antenatal care but rather an early initiation. The st= udy further revealed that pregnant women with higher education attend early antenatal care in contrast to our current findings. The implications of pregnant women being influenced by their level of education to initiate antenatal care late may result in late detection of the onset of pregnancy-= related complications which healthcare providers may find it challenging to averting such pregnancy-related complications. For example, pregnant women who have developed an early onset of complication such as high blood pressure or diabetes may worsen their state of health when such health challenge is not addressed earlier. This affects the health of the mother, and the developing foetus, thereby increasing maternal and infant-related morbidities during pregnancy (Ali et al., 2020). In addition, delayed initiation of antenatal = care due to absence of maternal education deprives the pregnant mother and the developing foetus from all the benefits they would have received from anten= nal service. The pregnant mother who is well educated on how to take care of her pregnancy and to report any pregnancy-related danger signs that can affect = her health, pregnancy and the foetus to health professionals for immediate interventions. In addition, they a= re educated on their nutrition which is the kind of food that will help the mo= ther to grow strong and the baby as well. The delayed initiation of ANC by the pregnant woman may lead to her forfeiting some vital information that would= be necessary to keep them fit. This results in poor feeding practices, thereby= predisposing the unborn babies to low birth weight and poor health outcomes (Kante’ et a= l., 2013; Appiah- Kubi et al., 2020). When the pregnant mother delays in initia= ting antenatal care early, she misses the full benefits of iron, folic acids and other essential drugs necessary to keep her strong and for good foetal development. Iron and Folic intake during early pregnancy help the mother to maintain a steady haemoglobin concentration during and after birth. However, her delayed initiation could result in low haemoglobin concentration which affects the baby as well during pregnancy. The baby can be born anaemic and sometimes suffer from poor mental development due to decreased iron and fol= ic acid supply for brain cell and spinal cord development ( Wana, 2020). Babies suffer from poor structural development, which affects their growth rate wh= ilst mothers sometimes suffer from anaemia before and after delivery, with subsequent blood transfusion (Wana, 2020).

<= /span>

This current study has established that the parity and gravidity of pregnant women associate well with their late initiation of antenatal care. For example, in this study about (60.50%) and (64.0%) of the respondents were multiparous and multigravida, respectively. That is most of the respondents had given birth to two or more and had also conceived two or more pregnancies, respectively. In the United State of America, the report of a cross-sectional study has demonstrated that multiparous women delay in attending to antenatal care and this supports the outcome of this study (Barder et al., 2020). Moreover, a study conducted by Wolde et al., (2019) to determine the obstetric history of pregnant women a= nd how it influenced the initiation of antenatal care found that multiparous w= omen had adequate knowledge and as such begins to initiate care after the first trimester. These findings are also consistent with the outcome of this curr= ent study. Moreover, in a cross-sectional study conducted in Myanmar, it was revealed that the parity and gravidity of pregnant women influenced the initiation of antenatal care. The study highlighted that pregnant women who= had more than one birth pregnancy had an increased odds of delaying antenatal c= are when they conceived a baby (Aung et al., 2016). In contrast to the above support= ive studies, a descriptive cross-sectional study aimed at establishing a correlation between multiparous and initiation of antenatal care revealed t= hat multiparous pregnant women have a higher odds of starting antenatal care on time compared to nulliparous and primiparous women.(Gidey et al., 2017). In addition, Fobelets et al., (2015), in their qualitative enquiry demonstrated that multiparity women had no relationship to delay timing in antenatal care. Moreover, Jihad et al., (2022), found in a quantitative cross-sectional survey that, pregnant women who were multi-parous and multi-gravid have no association to delay initiation of the antenatal study= . Similarly, Ewunetie et al., (2018), had demonstrated in their study that, no significant association existed between the parity of a pregnant w= oman and the late start of antenatal. The odds of a pregnant woman being multipa= rous are less likely to affect her delayed initiation of antenatal care. The stu= dy found that there was no statistically significant difference between parity and l= ate commencement of antenatal care among pregnant women and this finding also disagrees with the outcome of this current study (Tesfu et al., 2022). Furthermore, a related cross-sectional survey conducted to determine the predictors of delayed ant= enatal study initiation among pregnant women found that parity and gravidity of pregnant women had no relationship to late initiation of ANC. (Tadele et al., 2022).

What could have accounted for the differences in study findings could be ascribed to the differences in knowledge acquisition among multipa= rous and multigravida women about antenatal care. The complications associated w= ith multi-gravid and multiparous pregnant women delaying in initiating early antenatal care could increase their preference for patronizing the services= of a local birth attendant who may not be skilled enough to attend to all her = pregnancy needs. This usually happens when such multiparous or multigravida pregnant woman resides at a long distance to access the services of a health facilit= y. She may adopt the traditional methods of keeping pregnancy which may expose= her to several risks that can endanger her health and that of the unborn child.= Her increased preference for seeing a traditional birth attendant who may have = not all the necessary skills may increase her odds of pre and post-partum complications such as loss of blood leading to anaemia with subsequent poor= and decrease in the supply of oxygen which can necessitate foetal death whilst = in the womb. There is also an increased risk in the contraction of infections which become difficult to detect whilst relying on the services of local bi= rth attendance without seeking services early and from skilled professionals. T= he undetected infections can migrate through the birth canal to affect the unb= orn child. For example, pregnant women infected with sexually transmitted infections such as Syphilis can affect the eye of the baby if left undetect= ed and treated during the early phase of initiating ANC (Sarker et al., 2021).

The study also found that, among the socioeconomic factors that influence late initiation of antenatal care among pregnant women in the municipality, husbands' influence has a role to play. The role husbands pla= y in decisions concerning pregnant women's initiation of pregnancy influences the woman commencing antenatal care early or late. Husbands in the context of Ghanaian culture are the head of the nuclear family that takes most of the decisions of the family and must also work to provide finances for the upke= ep of the family. Situations, whereby the husband does not provide the needed financial assistance to the pregnant wife on time, may contribute to her la= te initiation of antenatal care. Moreover, women who are married do not have c= omplete autonomy in making decisions for them but have to seek the support or conse= nt of their husbands. In this regard, when the husband is not in support of the decision the wife is suggesting concerning her early initiation of antenatal care may cause her delay in starting antenatal care (Tesfaye et al., 2017). According to the outcome of a cross-sectional study conducted to determine husband non-involvement in antenatal care, initiation may cause late initiation of their wives starting late and this relates well with the outcome of this study (Konje et al., 2018; Dorji et al., 2019)<= /span>. When husbands involve themselves= in their pregnant women's attendance to seeking services, they will ensure that their pregnant wives attend early antenatal services and also will do everything in their capacity to provide the necessary support that may be needed for her to successfully take care of their pregnancy. This means that the influence of husband on their pregnant women's early initiation of antenatal care promote the good health of the woman and the unborn child (Mamo et al., 2021).

In Tanzania, the report of an exploratory qualitative enquiry indicated that husbands influence the cause of their pregnant women's late initiation by n= ot providing the needed financial assistance to the pregnant woman. As a resul= t, pregnant women may encounter both economic and psychological barriers that = may hinder them from beginning early visits (Mgata & Maluka, 2019), and this finding agrees well with the outcome of this study In Kenya, it is indicated that the infl= uence of husbands plays a key role in determining when a woman should initiate pregnancy care. The study revealed that, pregnant women who consult their husbands on when to initiate services sometimes start late (Ochako et al., 2011). This is consistent= with the outcome of this current study. According to the findings of a study conducted to ascertain how husbands influence pregnancy antenatal care initiation, it was revealed that pregnant women whose husbands accompany th= em to health care facility has a positive influence on their wife's early initiation. This means that husbands have an influence on pregnant women's early initiation of care (Teklesilasie & Deressa, 2018)= , which contrasts with the findings of this current study. Husbands' influence on pregnant women's delayed initiation of care may lead to poor discussion and joint decisions making on how to take care of the pregnancy and the unborn baby. For example, the husband must plan with the pregnant wife the type of facility to seek services and deliver the baby when due, the required items= for delivery, among other essential activities that require the support of the = man. This current study also indicated that the right time for a pregnant woman = to initiate care contributes to pregnant women's delay in initiating care. This means that, when pregnant women are not well informed or do not have adequa= te knowledge of the required time for them to begin antenatal services, they m= ay likely initiate it late. This finding is supported by a study that found th= at pregnant mothers with poor knowledge of antenatal care especially the right time for booking commence late in seeking health care services (Jihad et al., 2022). Similar= ly, in a study conducted by Gebresilassie et al., (2019), found t= hat pregnant women who are uninformed of the need for antenatal services and the appropriate timing are always delayed in seeking antenatal services. In addition, the report of a quantitative cross-sectional study conducted on w= hy pregnant women initiate care late found that most pregnant women did not recognise the right time to initiate services (Tola et al., 2021), and thi= s is consistent with the findings of this recent study. Furthermore, it was esta= blished in the report of a quantitative study conducted on pregnant women's initiat= ion of antenatal care that the lack of knowledge on the right time for pregnant women to commence antenatal care was a strong predictor of their late initiation (Appiah et al., 2020; Tola et al., 2021).

&nbs= p;

5. = CONCLUSION

Most of the pregna= nt women who delayed in commencing antenatal care had basic education and also= resided in rural areas. This implies that most pregnant women in the municipality w= hen they delay in antenatal care may suffer pregnancy-related complications suc= h as anaemia, and eclampsia which have the potential of causing maternal deaths = or foetal-related structural defects. The study also concluded that obstetric factors such as the number of births and pregnancies of pregnant women in t= he municipality influence their late attendance to seek healthcare. That is mo= st pregnant women who have given birth to two or more and are pregnant for the second or third time rely on their previous knowledge to determine when to = seek or initiate antenatal care. This behaviour exposes the pregnant woman to multiple risk factors for the development of conditions and diseases that m= ay be difficult for healthcare providers to detect at the onset when the visit= is delayed. This may lead to health related complications of the mother and the baby with a subsequent increase in maternal morbidities and mortalities as = well as an increase in the occurrences of neonatal diseases and sometimes death. Furthermore, the unawareness of the right time for pregnant women and the influence of husbands contribute to the delayed initiation of antenatal care among pregnant women in the municipality. This contributes to psychological, emotional and sometimes economic depression that collectively can affect the health of the mother and the unborn child with the subsequent inability of = the pregnant mother to cooperate with her pregnancy and the immediate family members. The study recommends that the policymakers in the health sector such a= s the Ministry of Health through its agencies including the Ghana Health Service, Christian Health Association, and Teaching Hospitals among others should initiate policies that promote and intensify public health education continuously on the need for pregnant women to initiate antenatal care earl= y on local radio stations and community durbars, These programmes will increase = the awareness of pregnant women on the importance of early visit particularly t= hose in the rural communities. Health authorities in the Municipality should intensify health promotion programs aimed at educating pregnant women on the right time to begin a visit to a health facility whilst incorporating in th= eir activities strategies to involve husbands to support and encourage their pregnant wives to visit antenatal care facilities early. There is the need = for future qualitative enquiry into cultural, community-level and healthcare providers’ related factors that influence pregnant women's late visits to the antenata= l facilities in the Municipality.

ACKN= OWLEDGEMENT

We are forever grateful to the management = of the Dormaa Municipal Health Directorate and the staff at the Public Health = and antenatal department of the Directorate for their assistance in diverse way= s.

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REFERENCES=

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