Background: Anaemia in women of reproductive age is a persistent contributor to maternal morbidity and adverse birth outcomes in sub-Saharan Africa. Ghanaian surveys have repeatedly placed national anaemia prevalence in the World Health Organization’s severe public health problem range, yet the geographical distribution of this burden, and
the socioeconomic factors that may account for it after geographical adjustment, remain insufficiently elucidated.
Methods: This cross-sectional study analysed the women’s and cluster GPS files of the 2022 Ghana Demographic and Health Survey. Anaemia was defined as altitude- and smoking-adjusted haemoglobin below World Health Organization thresholds among 7,557 women aged 15–49 years with a valid measurement. Survey-weighted multivariable logistic regression, accounting for clustering, stratification, and sampling weights, was used to elucidate socioeconomic and demographic correlates. Cluster-level prevalence was tested for spatial clustering with global Moran’s I and local Getis-Ord Gi* statistics (k-nearest neighbour weights, k = 8). The four-level severity outcome was also modelled with surveyweighted proportional-odds (ordinal) logistic regression. Robustness of the hotspots was examined with k = 4, k = 12 and distance-band weights, empirical Bayes smoothing, Benjamini–Hochberg false discovery rate (FDR) correction
and a Bernoulli spatial scan statistic.

Results: Weighted anaemia prevalence was estimated at 41.1% (mild: 22.6%, moderate: 17.3%, and severe: 1.1%). Pregnant women appeared to have higher adjusted odds of anaemia than non-pregnant women (adjusted odds ratio [AOR] 1.71, 95% CI 1.38–2.12), as did women in the Oti (AOR 1.54, 95% CI 1.16–2.06) and Northern (AOR 1.35, 95% CI 1.04–1.76) regions relative to Greater Accra, while the Bono region showed lower odds (AOR 0.64, 95% CI 0.43–0.94). Associations with rural residence, education, and wealth that were significant in crude analysis appeared substantially attenuated after adjustment. In the ordinal model, pregnancy (odds ratio [OR] 1.63, 95% CI 1.35–1.97) and residence in Oti (OR 1.44, 95% CI 1.11–1.87) were associated with more severe anaemia, and wealth showed no gradient (OR per quintile 0.97, 95% CI 0.90–1.04). Moran’s I suggested significant positive spatial autocorrelation (I = 0.156, p = 0.001); Getis-Ord Gi* identified 109 hotspot and 117 cold spot clusters among 618 clusters, with hotspots concentrated in the north and cold spots in the mid-southern forest belt. Global clustering and the broad pattern were stable across specifications and were confirmed by the scan statistic (northern high-risk window, relative risk 1.25; forest-belt low-risk window, relative risk 0.76), but only 12 hotspots (mainly on the Western region coast and in Volta and Oti) and 10 cold spots (mainly in Bono) remained significant after FDR correction.

Conclusion: Two in five women of reproductive age in Ghana were estimated to have been anaemic in 2022. Risk appeared to be shaped more by region and pregnancy status than by household wealth or education once geography was accounted for. Anaemia-control programming may benefit from prioritising the northern high-risk zone alongside routine antenatal supplementation, with the smaller coastal Western and Volta hotspots investigated further; individual cluster-level hotspots should be treated as exploratory.
Keywords: Anaemia; Women of reproductive age; Socioeconomic factors; Spatial analysis; Getis-Ord Gi*; Demographic and Health Survey; Ghana; Cross-sectional study