COMMUNITY ENGAGEMENT ACROSS THE MATERNAL CARE PATHWAY IN RURAL GHANA: A CONVERGENT MIXED-METHODS STUDY OF PREGNANCY SCHOOLS, EMERGENCY TRANSPORT AND SERVICE RESPONSIVENESS

Community education, emergency transport and social accountability are usually evaluated separately, although women meet them along one pathway to maternity care. This study examined how these three forms of community engagement operate together in two rural Ghanaian municipalities. A convergent parallel mixed-methods study was conducted in Nkwanta South (Oti Region) and Gushegu (Northern Region) in 2025. A cross-sectional survey enrolled 420 women (210 per municipality) sampled from antenatal registers of selected Community-based Health Planning and Services zones. Six focus group discussions, 20 key informant interviews and facility checklists provided qualitative and contextual data. Findings were integrated using the Three Delays Framework. Overall, 246 women (58.6%) had attended at least three pregnancy-school sessions, 316 (75.2%) reported a household contribution to a community transport fund, 302 (71.9%) reported that emergency transport was available on demand and 296 (70.5%) rated staff responsiveness as good or very good. Mean recalled decision-to-arrival time was 1.8 hours (SD 0.8): 1.6 hours in Nkwanta South and 2.0 hours in Gushegu. All reported indicators were more favourable in Nkwanta South. Participants linked Model Mother mentorship to recognising risk, regular fuel contributions and trip records to transport availability, and advocacy meetings with complaint follow-up to more responsive care. The findings describe a plausible, connected pathway from informed decisions to transport and responsive services, but the cross-sectional, register-based design does not support causal or health-outcome claims. District health teams should plan these mechanisms as one package, backed by public funding, equitable transport access and documented responses to community concerns.