{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,6]],"date-time":"2026-09-06T16:10:11Z","timestamp":1788711011337,"version":"build-2803163510"},"reference-count":79,"publisher":"BMJ","issue":"6","license":[{"start":{"date-parts":[[2026,6,2]],"date-time":"2026-06-02T00:00:00Z","timestamp":1780358400000},"content-version":"unspecified","delay-in-days":1,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,5,20]]},"published-print":{"date-parts":[[2026,6]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Maternal anaemia remains a pressing global health challenge, with a notable burden in low- and middle-income countries. Existing studies in sub-Saharan Africa have largely relied on average associations, thereby concealing key variation among women and failing to account for heterogeneity.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To assess the association between completing at least eight antenatal care (ANC) contacts and maternal anaemia in Ghana and to explore heterogeneity in this association using causal machine learning.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>An institution-based cross-sectional study was conducted using a retrospective review of medical records and causal machine learning analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>Juaben Government Hospital.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>Of 2326\u2009women who delivered at the hospital, 2114 with complete data on the main exposure and outcome variables were included in the analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Main exposure<\/jats:title>\n                    <jats:p>Completion of at least eight ANC contacts. ANC contact was defined as the in-person visit to the clinic with a healthcare professional for routine ANC services and follow-up.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Main outcome<\/jats:title>\n                    <jats:p>Maternal anaemia, defined as a haemoglobin level below 11\u2009g\/dL in the last ANC before delivery.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A causal forest model was used to estimate the association between completing at least eight ANC contacts and maternal anaemia. Conditional average treatment effects were used to explore individual-level variation in these associations, providing policy-relevant insights.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Completing \u22658 ANC contacts was associated with a 6 percentage-point lower probability of maternal anaemia compared with having fewer visits (average treatment effect: -0.06, 95% CI \u22120.11 to \u22120.02). Predicted individual-level effects ranged from \u22120.21 to 0.09. Participants\u2019 age, malaria prophylaxis, marital status, parity and educational level were the five most important contributors to the observed heterogeneity.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>This study demonstrated that completing \u22658 ANC contacts is associated with a lower probability of maternal anaemia, with heterogeneity across subgroups. We recommend differentiated, context-specific ANC interventions that focus on high-impact subgroups while strengthening the effectiveness and quality of care delivered at each visit.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2026-118189","type":"journal-article","created":{"date-parts":[[2026,6,4]],"date-time":"2026-06-04T14:08:32Z","timestamp":1780582112000},"page":"e118189","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Association between completing at least eight antenatal care contacts and maternal anaemia in Ghana: a cross-sectional study using causal machine learning"],"prefix":"10.1136","volume":"16","author":[{"given":"Esther Serwah","family":"Agbedinu","sequence":"first","affiliation":[{"name":"Twedie Government Hospital, Twedie, Ghana"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frederick Osei","family":"Owusu","sequence":"additional","affiliation":[{"name":"Juaben Government Hospital, Juaben, Ghana"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kingsley","family":"Boakye","sequence":"additional","affiliation":[{"name":"School of Public Health, Department of Epidemiology and Biostatistics, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana"},{"name":"Department of Global Public Health, Julius Center for Health Sciences and Primary Care, Utrecht University, University Medical Center, Utrecht, Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Helena","family":"Addai- Manu","sequence":"additional","affiliation":[{"name":"Juaben Government Hospital, Juaben, Ghana"},{"name":"Onwe Government Hospital, Onwe, Ghana"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julius Kwabena","family":"Karikari","sequence":"additional","affiliation":[{"name":"University Hospital, Kwame Nkrumah Univeristy of Science and Technology, Kumasi, Ashanti Region, Ghana"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emmanuel","family":"Konadu","sequence":"additional","affiliation":[{"name":"University Hospital, Kwame Nkrumah Univeristy of Science and Technology, Kumasi, Ashanti Region, Ghana"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Randy Akankpabwen","family":"Akanwariwiak","sequence":"additional","affiliation":[{"name":"Komfo Anokye Teaching Hospital, Kumasi, Ashanti Region, Ghana"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lydia","family":"Asenso","sequence":"additional","affiliation":[{"name":"Juaben Government Hospital, Juaben, Ghana"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mercy","family":"Addae","sequence":"additional","affiliation":[{"name":"University Hospital, Kwame Nkrumah Univeristy of Science and Technology, Kumasi, Ashanti Region, Ghana"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mawuse","family":"Kanfra","sequence":"additional","affiliation":[{"name":"St. Dominic Catholic Hospital, Akwatia, Ghana"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2321-387X","authenticated-orcid":false,"given":"Douglas Aninng","family":"Opoku","sequence":"additional","affiliation":[{"name":"School of Public Health, Department of Epidemiology and Biostatistics, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana"},{"name":"University Hospital, Kwame Nkrumah Univeristy of Science and Technology, Kumasi, Ashanti Region, Ghana"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,6,2]]},"reference":[{"key":"2026090306260631000_16.6.e118189.1","unstructured":"World Health Organization . 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