Evaluating the impact of maternal health care policy on stillbirth and perinatal mortality in Ghana; a mixed method approach using two rounds of Ghana demographic and health survey data sets and qualitative design technique.

BACKGROUND: Stillbirth and perinatal mortality issues continue to receive inadequate policy attention in Ghana despite government efforts maternal health care policy intervention over the years. The development has raised concerns as to whether Ghana can achieve the World Health Organization target of 12 per 1000 live births by the year 2030.
PURPOSE: In this study, we compared stillbirth and perinatal mortality between two groups of women who registered and benefitted from Ghana's 'free' maternal health care policy and those who did not. We further explored the contextual factors of utilization of maternal health care under the 'free' policy to find explanation to the quantitative findings.
METHODS: The study adopted a mixed method approach, first using two rounds of Ghana Demographic and Health Survey data sets, 2008 and 2014 as baseline and end line respectively. We constructed outcome variables of stillbirth and perinatal mortality from the under 5 mortality variables (n = 487). We then analyzed for association using multiple logistics regression and checked for sensitivity and over dispersion using Poisson and negative binomial regression models, while adjusting for confounding. We also conducted 23 in-depth interviews and 8 focus group discussions for doctors, midwives and pregnant women and analyzed the contents of the transcripts thematically with verbatim quotes.
RESULTS: Stillbirth rate increased in 2014 by 2 per 1000 live births. On the other hand, perinatal mortality rate declined within the same period by 4 per 1000 live births. Newborns were 1.64 times more likely to be stillborn; aOR: 1.64; 95% [CI: 1.02, 2.65] and 2.04 times more likely to die before their 6th day of life; aOR: 2.04; 95% [CI: 1.28, 3.25] among the 'free' maternal health care policy group, compared to the no 'free' maternal health care policy group, and the differences were statistically significant, p< 0.041; p< 0.003, respectively. Routine medicines such as folic acid and multi-vitamins were intermittently in short supply forcing private purchase by pregnant women to augment their routine requirement. Also, pregnant women in labor took in local concoction as oxytocin, ostensibly to fast track the labor process and inadvertently leading to complications of uterine rapture thus, increasing the risk of stillbirths.
CONCLUSION: Even though perinatal mortality rate declined overall in 2014, the proportion of stillbirth and perinatal death is declining slowly despite the 'free' policy intervention. Shortage of medicine commodities, inadequate monitoring of labor process coupled with pregnant women intake of traditional herbs, perhaps explains the current rate of stillbirth and perinatal death.

Introduction

Stillbirth, defined as the expulsion of a fetus with no sign of life remain a global issue of public health concern [1, 2]. In practice, gestational age of 20 to 28 weeks or a birth weight of 350 to 1000g is usually required to determine stillbirth [1]. According to the World Health Organization (WHO) stillbirth is a neglected tragedy which poses economic, social and psychological effects to families, especially, the affected mother often leading to social withdrawal, loneliness and depression [3-5].

Globally, 1 in 72 babies are stillborn and this translate to nearly 2 million stillbirths annually [4, 6]. Although the current estimates represent a global reduction of 35% overall since 2000, the rate of reduction is thought to be inadequate, and hence, the World would not achieve its target of 12/1000 live births by 2030 [4, 5, 7]. Of the global estimates, 84% is accounted for by lower and middle-income countries particularly, sub-Saharan Africa and southern Asia where three of four global stillbirth estimates are reported [4, 8, 9].

In sub-Saharan Africa, stillbirth increased from 0.77 million in 2000 to 0.82 million in 2019, representing a 42 percent global stillbirths and, suggesting that the Africa region can only attain the 12 per 1000 lives birth target in 2050 [4, 10]. Averagely, 21.7 per 1000 babies were stillborn in Ghana in 2019 and although this is an improvement over previous years, it is yet high compared to the regional average [11, 12]. Stillbirths remain a critical indicator of maternal and child health care performance and reflect negatively on weak health systems, particularly in lower and middle-income countries [7, 13, 14].

Recently, the WHO launched an action plan campaign for newborn care, Every Newborn Child Action Plan (ENAP) to re-vitalize efforts toward reducing global stillbirths with emphasis on access to quality maternal health care as a necessary means to achieving country-level targets [15]. Although the ENAP is yet to receive the required attention [6, 16], the country-level programme of ’free’ maternal health care policy was introduced with the object of driving access to maternal health care, and ultimately improving newborn care outcomes [17, 18].

In line with the access to care policy, Ghana declared the ‘free’ registration of pregnant women as an exemption package of its national health insurance scheme (NHIS) in 2008 aimed at bridging the access gap to care to improve utilization of maternal health care services, thereby mitigating inequalities effect to enhance newborn care survival [19, 20].

While the ‘free’ policy targeted access to maternal health care, in particular, its broader intentions included comprehensive caregiving of newborns up to 90 days post-delivery [21, 22]. The ‘free’ maternal health care policy (FMHCP) initiative received £42.5 in funding support from the then UK and has since served over 3 million beneficiaries since its inception [22, 23]. Although the ‘free’ policy lacked an implementation framework at its inception, it nonetheless gained popularity, as pregnant women received cost ‘free’ maternal health care at a cost to the NHIS [23-25].

In this paper, we compare stillbirth outcomes between mothers who registered and benefitted from the ‘free’ maternal health care policy since its inception and mothers who did not. Given the quintessence of health system factors effect on stillbirth [26], we further explored the views of service providers and pregnant women from selected health facilities to add context to the quantitative results to inform our discussion and conclusions.

Conceptual framework

We hypothesized that certain factors undermine the successful operationalization of the ‘free’ maternal health care policy in Ghana (Fig 1) and hinder the intention of the policy and its ability to bring about a decline in not just maternal mortality, but also stillbirth and perinatal mortality in the medium to long term. The ‘free’ maternal health care policy is administered via the NHIS which in itself is bedeviled with funding constraints culminating in delays in payment of claims over the years [27, 28].

Fig 1

Conceptual framework: Multifaceted factors moderating stillbirth and perinatal mortality.

Consequently, it appears the existing challenges affect the effective management of accredited service provider facilities thereby threatening the credibility of the purchaser-provider split concept [29]. On another level, the Ghanaian society presents itself as a keeper of pregnant women with cultural demands that upset the effective implementation of the ‘free’ policy. These unintended practices seem to derail the efforts of health care professionals and policymakers and hence, frustrate their efforts of achieving reduced mortality outcomes of newborn care.

Studies have shown that maternal age, rural/urban area of residence, twin pregnancy, negative pregnancy outcome, income level, education and marital status play roles to moderate the outcome of stillbirth and perinatal mortality [30-32]. In this current study, we ask to what extent does the FMHCP intervention affect the outcome of stillbirth and perinatal mortality against the background of the policy implementation bottleneck while accounting for the moderating factors?

Contextual definition

Impact: Reduction in stillbirth and perinatal mortality over time between 2008 and 2014.

Stillbirth: The birth of a fetus after 28 weeks gestation with no signs of life.

Perinatal mortality: The death of newborns within 6 days of life.

‘Free’ maternal health care policy: Pregnant women registrants of the national health insurance scheme (NHIS).

Materials and methods

Study design

The current study employed a sequential mixed method design: first, analyzing repeated cross-section data of Ghana Demographic and Health Survey (GDHS), 2008 and 2014 as baseline and end line, respectively. The two-rounds of DHS data sets were merged, and two groups created: the ’free’ maternal health care policy group and the ‘no-free’ maternal health care policy group. We then used the NHIS registration status of women as a proxy for our exposure variable (the ‘free’ maternal health care policy) and constructed stillbirth and perinatal death as our outcome variables using the under 5 mortalities variable from the merged data sets.

The first author conducted one-on-one in-depth interviews with 5 medical doctors and 18 midwives at post to the antenatal clinics and labor units of the selected health facilities and conducted 8 focus group discussions (FGD) for pregnant women who accessed care using the ‘free’ policy in the selected hospitals, to obtain user perspective for a contextual understanding of health system factors that affect stillbirth outcomes. Given the time disparity of the secondary data and qualitative interviews, facility-level data from two regions of Ghana, obtained from the District Health Information Management Systems (DHIMS) [33] was analyzed and triangulated with those of the regression output from the GDHS to provide a current undertone to the outcomes of stillbirth and perinatal death for a meaningful inference.

Qualitative study setting

The Upper East and Northern regions (Fig 2) are among the poorest regions of Ghana. The Upper East region has a total land area of about 8,842sq km with Bolgatanga as its capital and an estimated population of approximately 1.5 million [34, 35]. The region has a national health insurance enrollment rate of 6.3% of its total population with a considerably good number of midwives compared to other regions of Ghana [21]. Between 2016 and 2020, stillbirth figures increased in trend as per the regional data from DHIMS (Fig 3).

Fig 2

Map of the Upper East and Northern regions of Ghana, showing selected districts of study.

Fig 3

Stillbirth and facility delivery output of the Upper East and Northern regions of Ghana.

On the other hand, the Northern region shared a boundary with the Upper East Region at the time of the DHS data collection (now with the North East region) with a relatively low literacy rate [36]. The Northern region has a land mass of about 70,765.2km2 with an estimated population of about 1.8m representing 9.6% of the total population of Ghana and shows a considerably stable but inconsistent decline in stillbirth proportionate to facility delivery utilization per the DHIMS record (Table 1, Fig 3).

Table 1

Facility deliveries versus Stillbirth in the Upper East and Northern Regions.

Indicator	2016	2017	2018	2019	2020	Total
Upper East Region
Facility Delivery	34,053	34,661	35,917	38,351	39,211	182,193
Fresh	219	208	188	197	212	1024
Macerated	312	246	247	233	309	1347
Stillbirth	531	454	435	430	521	2371
Northern Region
Facility Delivery	46,645	52,407	57,056	61,645	64,092	281,845
Fresh	391	463	492	496	406	2248
Macerated	473	510	486	445	531	2445
Stillbirth	664	973	978	931	937	4693

Source: DHIMS, Ghana Health Service, 2020

Study participants, sampling and variable construction

Quantitative

Stillbirth and perinatal death variables were generated from the under 5 mortality variables using STATA 15 to construct binary outcomes of ‘1’ representing ’stillbirth’, born dead or dying within day zero, and ’0’ representing ’no stillbirth’. Also, ’1’ was constructed to represent perinatal death (newborn death within 6 days of life), and ’0’ representing ’no perinatal death’.

Qualitative

The two regions (Upper East and Northern regions) were zoned into three and a hospital each selected purposively for the study. Two health centers per zone were also selected to add rural context to the data. Service providers (midwives and medical doctors) from the antenatal care clinics and labor units of the selected health facilities were then selected purposively and conveniently i.e., doctors or midwives on duty and not busy, who consented to participate and met the selection criteria, was recruited for one-on-one in-depth interview. Pregnant women in attendance to the antenatal care clinics were also recruited from the same facilities for the focus group discussions (FGDs). The use of multiple sources of data was to explore the idea of multiple realities and this added to data verification from multiple sources as argued by Creswell [37].

Data collection and analysis

Tools and pretesting

Interview guides were developed to unearth health systems challenges that confront the ’free’ policy’s successful operation and how that may have affected stillbirth outcomes as per our conceptual framework which was guided by Mosley and Chen’s analytical framework for child survival [22, 38]. The qualitative tools were pre-tested among random midwives in a random hospital in one of the regions, which was not part of the selected study sites. All the authors then revised the tools based on our observations to include the eliciting of critical community and facility level factors relevant to our study.

Inclusion criteria

Only doctors and midwives with at least 3 years of working experience in the labor units and antenatal care clinics of the selected health facilities were included in the in-depth interviews, to ensure that they have adequate experience working with the ‘free’ maternal health care policy. Also, only pregnant women registrants of the NHIS were included in the focus group discussion.

Exclusion criteria

Pregnant women whose vital signs were outside the normal range using the standard of the American Psychology Association or pregnant women who were receiving treatment for a medical condition were excluded from the study. Pregnant women who were less than 16 years, considered minors under the 1992 Constitution of the Republic of Ghana were excluded from the focus group discussions.

Sample weighting

We generated a weighted variable by dividing v005 by 1000,000 to cater for 6 decimal places, usually not reported by DHS. We then applied the weighted variable to the GDHS survey data sets in STATA using [pw = wgt], psu (v021) strata (v022) to set the data to cater for clustering and stratification. Thereafter, all Stata command prefixes ‘svy’ to take the weighting into account across the secondary data analysis. We then checked for sensitivity and overdispersion using the negative binomial regression model.

Confounding variables

Maternal age, area of residence, employment status, abortion history, caesarean section, marital status, and educational status were adjusted for as confounding as these were statistically significant (p <0.05) with the outcome variable of interest (stillbirth and perinatal) or the exposure variable (NHIS, proxy to the ‘free’ maternal health care policy).

Quality control and trustworthiness

The sample weighting catered for clustering and stratification across rural and urban areas of the complex DHS data design. The regression analysis also used the Taylor linearization technique to achieve reduced standard error. The use of purposive sampling for the qualitative data was deliberate to achieve trustworthiness through the acquisition of information from the right sources of service providers, doctors and midwives and pregnant women as policy users. This was critical, giving the ‘free’ policy is implemented by medical doctors and midwives. Also, the inclusion of an expert informant, a regional director of health services validated the field data which was useful and catered for the idea of multiple sources of information [39].

Data analysis—Quantitative

The overall stillbirth and perinatal mortality ratios were estimated between the two rounds of DHS for comparison. We then estimated the prevalence of stillbirth and perinatal mortality between the baseline (2008) and end line (2014) to compare the outcomes, pre and post the ‘free’ policy intervention. Finally, we merged the two rounds of data sets and analyzed for risk of stillbirth and perinatal mortality among the ‘free’ maternal health care policy using multiple logistic regression. We then tested for sensitivity using Poisson regression and checked for over-dispersion using negative binomial regression. All regression outputs are reported in Tables 2 and 3.

Table 2

Association between the free maternal health care policy and risk of stillbirth.

Stillbirth	Logistic regression with Linearized standard error			Poisson regression with linearized standard error			Negative binomial regression with robust std. error
	aOR	(CI: 95%)	P-Value	aPR	(CI: 95%)	P-value	aPR	(CI: 95%)	P-value
Policy intervention
No_FMHCP	1			1			1
FMHCP	1.64	(1.02–2.65)	0.041*	1.34	(1.00–1.79)	0.045*	1.34	(1.00–1.79)	0.045*
Maternal age	1.05	(1.01–1.08)	0.007*	1.02	(1.00–1.05)	0.006*	1.02	(1.00–1.05)	0.006*
Twin pregnancy
Singleton	1			1			1
1st set of twins	1.39	(0.66–2.90)	0.375	1.22	(0.83–1.77)	0.296	1.22	(0.83–1.77)	0.296
2nd set of twins	1.24	(0.43–3.56)	0.680	1.15	(0.66–2.00)	0.609	1.15	(0.66–2.00)	0.609
3rd set of twins	-	-	-	1.99	(1.20–3.20)	0.008*	1.99	(1.20–3.20)	0.008*
Caesarean section
No	1			1			1
Yes	2.10	(0.94–4.67)	0.067	1.36	(0.96–1.94)	0.084	1.36	(0.96–1.94)	0.084
Abortion history
No	1			1			1
Yes	1.04	(0.59–1.84)	0.875	1.02	(0.75–1.37)	0.906	1.02	(0.75–1.37)	0.906
Area of residence
Urban	1			1			1
Rural	1.82	(0.95–3.48)	0.067	1.37	(0.97–1.95)	0.072	1.37	(0.97–1.95)	0.072
Educational status
No education	1			1			1
Primary	1.26	(0.66–2.40)	0.472	1.14	(0.77–1.68)	0.505	1.14	(0.77–1.68)	0.505
Secondary	2.02	(1.06–3.84)	0.030*	1.47	(1.01–2.13)	0.041*	1.47	(1.01–2.13)	0.041*
Tertiary	0.25	(0.03–1.74)	0.163	0.42	(0.10–1.71)	0.229	0.42	(0.10–1.71)	0.229
Wealth index
Poorest	1			1			1
Poorer	0.95	(0.48–1.88)	0.895	0.99	(0.65–1.50)	0.966	0.99	(0.65–1.50)	0.966
Middle	1.38	(0.65–2.90)	0.394	1.22	(0.79–1.90)	0.362	1.22	(0.79–1.90)	0.362
Richer	1.26	(0.87–5.84)	0.090	1.52	(0.92–2.53)	0.101	1.52	(0.92–2.53)	0.101
Richest	1.64	(0.53–5.04)	0.383	1.33	(0.70–2.54)	0.378	1.33	(0.70–2.54)	0.378
Region
Western	1			1			1
Central	0.74	(0.31–1.78)	0.508	0.81	(0.48–1.36)	0.440	0.81	(0.48–1.36)	0.440
G. Accra	1.59	(0.50–5.04)	0.429	1.29	(0.69–2.41)	0.407	1.29	(0.69–2.41)	0.407
Volta	2.54	(0.74–8.64)	0.134	1.55	(0.86–2.79)	0.141	1.55	(0.86–2.79)	0.141
Eastern	1.42	(0.58–3.48)	0.439	1.23	(0.73–2.05)	0.436	1.23	(0.73–2.05)	0.436
Ashanti	1.15	(0.46–2.88)	0.761	1.08	(0.64–1.85)	0.749	1.08	(0.64–1.85)	0.749
Brong-Ahafo	0.92	(0.33–2.58)	0.881	0.93	(0.50–1.75)	0.837	0.93	(0.50–1.75)	0.837
Northern	1.02	(0.41–2.54)	0.959	0.96	(0.54–1.69)	0.892	0.96	(0.54–1.69)	0.892
Upper East	1.08	(0.33–3.55)	0.888	1.03	(0.47–2.22)	0.940	1.03	(0.47–2.22)	0.940
Upper West	1.15	(0.45–2.95)	0.761	1.08	(0.61–1.89)	0.785	1.08	(0.61–1.89)	0.785

Notation: 1 –reference; aOR–adjusted Odd Ratio; aPR–adjusted Prevalence Ratio

* p<0.05.

Table 3

Association between the free maternal health care policy and risk of perinatal mortality.

Perinatal Mortality	Poisson regression with Linearized std. error			Binary logistics regression with linearized std. error			Negative binomial regression with linearized std. error
	aOR	(CI: 95%)	P-Value	aPR	(CI: 95%)	P-Value	aPR	(CI: 95%)	P-Value
The Policy
No_FMHCP	1			1			1
FMHCP	2.04	(1.28–3.25)	0.003*	1.35	(1.08–1.66)	0.006*	1.35	(1.08–1.66)	0.006*
Maternal age	1.03	(0.99–1.06)	0.100	1.01	(0.99–1.03)	0.101	1.01	(0.99–1.03)	0.101
Twin pregnancy
Singleton	1			1			1
1st set of twins	1.37	(0.67–2.80)	0.377	1.14	(0.87–1.49)	0.331	1.14	(0.87–1.49)	0.331
2nd set of twins	1.82	(0.70–4.72)	0.218	1.24	(0.91–1.69)	0.166	1.24	(0.91–1.69)	0.166
3rd set of twins	1	-	-	1.43	(1.03–1.98)	0.033*	1.43	(1.03–1.98)	0.033*
Cesarean section
No	1			1			1
Yes	2.02	(0.87–4.66)	0.100	1.25	(0.97–1.60)	0.075	1.25	(0.97–1.60)	0.075
Abortion history
No	1			1			1
Yes	1.91	(1.07–3.41)	0.028*	1.25	(1.02–1.53)	0.031*	1.25	(1.02–1.53)	0.031*
Area of residence
Urban	1			1			1
Rural	1.28	(0.70–2.32)	0.407	1.11	(0.87–1.42)	0.366	1.11	(0.87–1.42)	0.366
Education
No education	1			1			1
Primary	0.93	(0.49–1.74)	0.822	1.97	(0.71–1.31)	0.863	1.97	(0.71–1.31)	0.863
Secondary	1.89	(0.98–3.63)	0.056	1.30	(0.97–1.72)	0.071	1.30	(0.97–1.72)	0.071
Tertiary	0.25	(0.04–1.44)	0.124	0.52	(0.19–1.40)	0.196	0.52	(0.19–1.40)	0.196
Wealth index
Poorest	1			1			1
Poorer	0.56	(0.26–1.23)	0.153	0.80	(0.56–1.13)	0.207	0.80	(0.56–1.13)	0.207
Middle	0.84	(0.35–1.99)	0.694	0.93	(0.66–1.31)	0.690	0.93	(0.66–1.31)	0.690
Richer	0.87	(0.32–2.35)	0.789	0.95	(0.65–1.39)	0.818	0.95	(0.65–1.39)	0.818
Richest	0.76	(0.24–2.40)	0.641	0.90	(0.58–1.38)	0.639	0.90	(0.58–1.38)	0.639
Region
Western	1			1			1
Central	0.63	(0.24–1.61)	0.340	0.79	(0.52–1.18)	0.258	0.79	(0.52–1.18)	0.258
G. Accra	1.73	(0.54–5.56)	0.353	1.20	(0.77–1.86)	0.412	1.20	(0.77–1.86)	0.412
Volta	2.79	(0.77–10.0)	0.116	1.32	(0.89–1.97)	0.159	1.32	(0.89–1.97)	0.159
Eastern	1.36	(0.51–3.62)	0.526	1.11	(0.76–1.62)	0.577	1.11	(0.76–1.62)	0.577
Ashanti	1.03	(0.38–2.78)	0.949	1.00	(0.67–1.48)	0.986	1.00	(0.67–1.48)	0.986
Brong-Ahafo	0.87	(0.30–2.50)	0.809	0.93	(0.60–1.43)	0.754	0.93	(0.60–1.43)	0.754
Northern	0.59	(0.21–1.64)	0.313	0.74	(0.47–1.17)	0.199	0.74	(0.47–1.17)	0.199
Upper East	0.45	(0.12–1.59)	0.217	0.64	(0.52–1.27)	0.200	0.64	(0.52–1.27)	0.200
Upper West	0.65	(0.23–1.85)	0.421	0.81	(0.61–1.89)	0.375	0.81	(0.61–1.89)	0.375

Notation: 1 –reference; aOR–adjusted Odds Ratio; aPR–adjusted Prevalence Ratio

*p < 0.05.

Data analysis—Qualitative

One-on-one interviews and group discussions were transcribed verbatim into Microsoft office, double-checked for accuracy, and imported into INVIVO 10 for analysis by coding the data in line with the study objectives of stillbirths and context factors of maternal health care utilization. The transcripts were read multiple times and grouped into similar and dissimilar statements with annotations. Significant statements were then categorized under constructed themes, reviewing each theme carefully for relevance.

Statements that did not align themselves to a particular theme were thoroughly examined for relevance and excluded altogether if they didn’t speak to the study objective. Constructed themes were based on common phrases and similar statement approaches. Relevant statements are quoted verbatim in reporting the qualitative results to convey participants’ impressions and aid explanatory power.

Ethical consideration

This study is part of the PhD research work of the first author and received ethical clearance from the Ghana Health Service Ethical Review Board reg. no. GHS-ERC: 002/04/19. The secondary data was obtained from Measure DHS after completing an online application process. All study participants for the primary data consented to participate in the study and completed a consent form. All interviews were conducted in private rooms, while focus group discussions were held in open spaces under chalets for aeration as part of the COVID-19 protocol. All the pregnant women had their vital signs checked by a registered nurse for normalcy prior to joining the focus group. Also, this study protocol received four double-blinded external reviewers and was published by BMC Reproductive Health Journal [22].

Results

Quantitative findings

Stillbirth and perinatal death in the Upper East and Northern regions

Antepartum stillbirth is increasing in both regions since 2019, particularly in the Upper East region of Ghana and this is reflected in the overall rise in stillbirth in the region (Fig 3) despite the increase in uptake of facility delivery (Table 1).

Distribution of maternal and population characteristics

As shows in Table 4, more women accessed the ‘free’ policy in 2014 (68%) compared to 2008 (39%). Of antenatal care uptake, 62% of the pregnant women made 4 plus visits under the free maternal health care policy group. Also, more women delivered in health facilities (65%) among the ’free’ policy group, compared to the no- ‘free’ policy group. Of the maternal and population characteristics maternal group age (p < 0.0001), area of residence (p < 0.0001), history of abortion (p = 0.0104), employment status (p = 0.0271), maternal education (p < 0.0001), wealth index (p = 0.0001), marital status (p < 0.0001) and region (p < 0.0001) were statistically significant between the two groups.

Table 4

Distribution of maternal characteristics between the ‘free’ maternal health policy and the no ‘free’ maternal health care policy groups.

Description	Observation	No FMHCP (%)	FMHCP (%)	Pearson Design-based F test (p-value)
DHS Year				0.0001**
2008	2987	1785 (61)	1202 (39)
2014	5883	1796 (32)	4087 (68)
ANC uptake				0.0001**
0–3 visits	1021	607 (63)	414 (37)
4+ visits	5335	1,921 (38)	3,414 (62)
Delivery place				0.0001**
Home	3147	1,705 (56)	1,442 (44)
Facility delivery	5672	1,853 (35)	3,819 (65)
Group Age				0.0001**
15–19	326	168 (53)	161 (47)
20–24	1592	745 (49)	847 (51)
25–29	2318	884 (40)	1434 (60)
30–34	2009	719 (37)	1290 (63)
35–39	1578	589 (38)	991 (62)
40–44	771	334 (47)	437 (53)
45–49	276	147 (59)	129 (41)
Area of residence				0.0001**
Urban	3343	1125 (36)	2218 (64)
Rural	5527	2456 (46)	3071 (54)
History of Abortion				0.0104*
No Abortion	7132	2951 (43)	4181 (57)
Abortion	1732	626 (38)	1106 (62)
Employment status				0.0271*
unemployed	1581	568 (38)	1013 (62)
Employed	7266	2996 (43)	4270 (57)
Education status				0.0001**
No Education	3169	1412 (47)	1757 (53)
Primary Education	1931	920 (52)	1011 (48)
Secondary Education	3481	1196 (36)	2285 (64)
Tertiary Education	289	53 (21)	236 (79)
Wealth quintile index				0.0001**
Poorest	2854	1253 (47)	1601 (53)
Poorer	1960	906 (50)	1054 (50)
Middle	1587	63 (43)	954 (57)
Richer	1385	491 (38)	894 (62)
Richest	1084	298 (30)	786 (70)
Marital status				0.0001**
Never married	534	261 (51)	272 (49)
Married	6126	2272 (38)	3854 (62)
Divorced	125	74 (66)	51 (34)
Widow	127	54 (49)	73 (51)
Living together	1681	781 (47)	906 (53)
Not living together	271	138 (52)	133 (48)
Region				0.0001**
Western	852	359 (40)	495 (60)
Central	830	467 (57)	363 (43)
Greater Accra	739	337 (41)	402 (59)
Volta	723	286 (40)	437 (60)
Eastern	805	310 (38)	495 (62)
Ashanti	1038	497 (46)	541 (54)
Brong-Ahafo	919	281 (31)	638 (69)
Northern	1381	607 (45)	774 (55)
Upper East	767	240 (32)	536 (68)
Upper West	807	199 (24)	608 (76)

Significant level

* p < 0.05

** p < 0.001

Prevalence of stillbirth and perinatal mortality

In total, 174 stillbirths were recorded between 2008 and 2014 rounds of DHS. Of this, 55 (28.7%) were reported in the 2008 DHS, compared to 119 (43.1%) in 2014, showing an increase in percentage points 14.4. Also, 243 perinatal deaths were reported between 2008 and 2014 of which 88 (45.6%) were reported in 2008, compared to 155 (56.4%) in 2014, representing a 10.8 percentage point increase (Table 5).

Table 5

The proportion of stillbirths and perinatal mortality in 2008 and 2014.

Variable	Obs.	2008 (%)	2014 (%)	Pearson Design-based F test (p-value)
Stillbirth				0.0067*
Not stillborn	313	143 (71.3)	170 (56.9)
Stillborn	174	55 (28.7)	119 (43.1)
Total	487	198 (100)	289 (100)
Perinatal Mortality				0.0344*
Not recorded	244	110 (54.4)	134 (43.6)
Perinatal Death	243	88 (45.6)	155 (56.4)
Total	487	198 (100)	289 (100)

Stillbirth and perinatal mortality rate

Stillbirth birth rate for 2008 was 19 per 1000 live births, compared to 21 per 1000 live births in 2014, while perinatal mortality rate was 31 per 1000 live births in 2008 and declined to 27 per 1000 lives birth in 2014 (Table 6).

Table 6

Estimated stillbirth and perinatal mortality rates.

Variable	Rate	2008	2014
Stillbirth	Per 1000 live births	19	21
Perinatal Mortality	Per 1000 live births	31	27

Risk of stillbirth in the ‘free’ maternal health care policy group

Babies were 1.64 times more likely to be stillborn in the FMHCP group, compared to the no FMHCP group; aOR: 1.64; 95% CI: 1.02 to 2.65; p = 0.041. The results are similar across the Poisson and negative binomial regressions models, aPR: 1.34; 95% CI: 1.00 to 1.79; p = 0.045 respectively as shown in Table 2.

Risk of perinatal mortality in the ‘free’ maternal health care policy group

Babies were 2.04 times likely to die within 6 days of life in the FMHCP group compared to their counterparts in the no FMHCP, aOR: 2.04; 95% CI: 1.28–3.25; p = 0.003. for the results also compare similarly for the Poisson and Negative binomial regressions, aPR: 1.34 and these were statistically significant, p = 0.006, respectively. Women with a secondary level of education were more likely to register perinatal mortality compared to women with no formal education, aOR: 1.89; 95% CI: 0.98 to 3.63. However, this was not statistically significant, p = 0.056. Women with a history of abortion were also more likely to record perinatal mortality compared to women with no history of abortion, and this was statically significant, aOR: 1.91; 95% CI: 1.07 to 3.41; p = 0.028.

Qualitative findings

Study participants

In all 67 service providers and pregnant women participated in the qualitative study (Table 7). Of the service providers, midwives were 18, and doctors/directors were 5. Of the pregnant women participants, 43 (98%) were married, 38 (86%) were employed, while 40 (81%) gave birth previously (Table 8).

Table 7

Distribution of qualitative study participant.

Method	Participant	Size
In-depth interview	Doctors/directors	5
In-depth interview	Midwives	18
Focus Group discussion	Pregnant women	8 (44)
Total		67

Table 8

Characteristics of pregnant women participants.

Description	Frequency (%)
NHIS status
Registrant	44 (100%)
Non-registrants	0 (0%)
Total	44 (100%)
Marital Status
Married	43 (98%)
Not married	2 (2%)
Total	44 (100%)
Employment Status
Employed	38 (86%)
Unemployed	6 (14%)
Total	44 (100%)
Parity
Prime parity	4 (9%)
Multiparty	40 (81%)
Total	44 (100%)

Common themes

Rising stillbirths and related causes. Stillbirth was on the rise based on the facility records and the regional data, but the service providers attributed the rise to multiple reasons, late reporting to antenatal care clinics, delayed arrival to delivery centers by pregnant women in labor and the use of local herbs as oxytocin. Service also providers argued that improved record keeping associated with increased utilization make the numbers of stillbirths look worse than it appears. In other words, pregnant women benefiting from the ‘free’ policy are more likely to report to and deliver in a health facility and have their data captured as compared to the previous data capture rate under out-of-pocket payment. A medical doctor and charge midwives explain.

"Actually, just this half–year, stillbirth numbers weren’t encouraging. It was bad. We had 22, but 13 were macerated. Then we had 9 fresh stillbirths. The numbers are going up [increased]”

“In the region, when you look at the picture, despite the so many interventions, one will say SBs [stillbirth] are still high. But when you look at it critically, it is the reporting which is also going up, so it makes you think that the policy is not helping”

“We have a high rate. This time we are getting mothers who are coming with Intra–Uterine Fetal Death (IUFD). This year we had 15 for the first 6 months. When you compare, I will say because we are taking records, that is why the numbers are high…previously there was no documentation"

Antepartum stillbirths were commonly recorded among facility deliveries, and service providers deemed this as a prove that babies died in utero before arrival to a health facility and blamed this on community and individual level factors rather care giver related. Another phenomenon reported was previous maternal health care history which appear to negatively influence the outcomes of stillbirth.

Reasons for delays bothered on two items as numerated by the service providers; some pregnant women want less of vaginal examination, explaining that the experience is uncomfortable and secondly, women with previous cesarean section (CS) avoided hospitals in order not to invite another CS. Vaginal delivery is a source of pride. Pregnant women will risk delivering per vagina as a sign of womanhood. Service providers explained further as follows.

“Few cases also dodge the hospital … maybe she had two previous cesarean sections (CS) and thinks that if she comes to the hospital, there will be another CS, so they avoid the hospital and when there are complications, then they quickly come. They want to deliver per vagina at all costs”

“…and when they come, we manage them at postnatal care…. they say they didn’t know that labor had started, some say they don’t want the examination. One woman was frank, she said when they come, they put fingers on her vagina and that one she doesn’t like it

Additionally, the cultural practice of given herbal preparations to women during labor was reported from the study sites and this seem to play a role which the midwives inferred contributed to undesirable outcome of stillbirths. Pregnant women are served locally prepared mixtures known as kaligutiem, to speed up uterine contraction during labor at the blind side of midwives and doctors. Essentially, the herbs act as oxytocin and potentiates the effect of prescribed medicines when combined, with lethal consequences of risk of excessive uterine contraction. Usually, mothers-in-law administers the potion before coming to the hospital or may secretly give a dose to the woman in labor if they judged a labor-process of having prolonged. Some communities are notorious for the use of the local herbs and this impedes the pathway to accessing health care during labor. The midwives shared their experiences.

“They also take ‘kaligutiem’ [local oxytocin to aid uterine contraction] before coming to the hospital, and when they come the contractions will be too high”

“Some also come with excessive contraction because of the ‘kalgutiem’, especially those coming from Dotoyille and Kunyevilla. The mothers–in–law. They will give it to them and follow them to hospital as well"

During the focus group discussions, pregnant women claimed knowledge of kalgutiem but denied usage of same, unsurprisingly.

“We have heard about ‘kuligutiem’, but we don’t use it. We don’t know anybody who uses it. The midwives have complained and have advised us against it.

Poor use of delivery partograph for labor monitoring. Surprisingly, it merged that labor process and progress were poorly monitored as delivery partograph, a tool recommended by the World Health Organization was sparingly used across delivery suits in the selected hospitals. A senior medical officer and director of the regional health services noted during the expert informant interviews that,

“Even though we use partograph to monitor labor we realize a substantial number are not monitored. Using a partograph to monitor will tell you the condition of that baby. So that if you realize that the baby has difficulties, that baby can be delivered [via caesarean section].”

The delivery partograph, according to experts served as an indicator for initiating advance action of cesarean operation, necessary to save the life of the unborn child. Although the use of delivery partograph is not for all pregnant women, its use during the labor management process on eligible mothers is not optional, but this was not the case at the study site. The director continued,

“Yes! A significant proportion of labor are not monitored [with delivery partograph]. Those women who are eligible, it should be 100%…”

A senior midwife with over 10 years work experience in one of the regions also shared her experience when they carried out a monitoring exercise on behalf of UNICEF. Her observation of records of partograph use was a major concern. She claimed.

“As for partograph dier! It is 0 out 100 in…hospital [a particular hospital]. We went for monitoring on behalf of UNICEF and what we saw was not good all at”

Little or no interest in ‘matters’ of stillbirth. During the one-on-one interview sessions, a medical doctor observed that somehow, little attention is given to stillbirth issues as compared to maternal mortality. Himself as a doctor, does not get to hear about stillbirth in his ward unless there was a review of a visiting team from the regional health directorate. Not even the media were interested in stillbirths as much as they were interested in maternal mortality. The doctor added thus,

"We don’t pay attention to matters of stillbirth the way we do for maternal deaths. One mother will die and the whole hospital will hear about it. I don’t even know the stillbirths in the labor ward. They don’t tell me…unless we are reporting. But when there’s maternal mortality, eeeiii! even the media is interested”

The medical doctor’s view appears to align with a seemingly common practice of midwives ignoring apparent calls of pregnant women in labor, which caught the attention of one of the pregnant women and she shared her views during the group discussions.

“Sometimes you can be crying, and they won’t mind you. One time I was suffering, and the midwives didn’t bother to check on me. I said my baby is coming….by the time they came my baby was gone. They don’t care about our babies"

Even though the reasons for their non-response were beyond the scope of this study, the descriptions during the focus group discussion suggest that there are underlying challenges that perhaps explains the poor monitoring of the labor process and the eventual outcomes of stillbirths in the study sites. Pregnant women participants added, thus,

Conversely, midwives disclosed that pregnant women had a laid-back attitude towards the survival of their unborn babies, sometimes refusing surgery as may be required and also providing inaccurate reproductive history which affects the caregiving process and hence, influencing stillbirths and perinatal deaths. Charge midwives had these to say in one of the district hospitals.

“a woman came, and the liquor was small, so the best we could do was conduct CS. When we told them, they told us that if the water is not ok, can’t you fetch water and add it. They’re opposed to cesarean section. They went home…came back some few days later and the baby was dead…"

"Taking history is key… The woman misled the midwives concerning her parity. We started inducing, and she raptured, then, we asked a relative (her daughter) and she said her mother had 6 children and 1 died. Such a person should be induced…we were misled.”

Intermittent shortage of medicine commodities. Intermittent shortages of drugs were also reported during the in-depth interviews. Pregnant women are routinely asked to purchase some medicines outside of the health facility set up to augment their required supplementary intake. Not only did this affect the economic situation of mothers and their families, but it also frustrates quality-of-care processes of the health care professionals. The medical officers shared their experiences at the antenatal clinics.

“Our environment is not good. Personal hygiene is poor. Unlike other places where they think that labor is a sterile procedure, here, we routinely put all our clients on the antibiotic cover, whether you’re on episiotomy, assisted delivery, or not."

“When you visit the facility and certain medication is not available, they are written for you in a prescription. So far as our facility is a concern, if a medication is not available…we put it on a prescription for you to find a pharmacy shop to procure…”

“The issue has to do with drugs. The challenge here is that most of the time the hospital runs out of stock. When they run out of stock, the patient must buy… because of the poverty level, most of them cannot afford the drugs…”

“We use antibiotics and pain killers for Cesarean Section. Then we also have hematinic. The better once, usually we want them to buy those outsides…. eenh! And IV fluids too. There are certain times we go virtually down, they buy virtually everything”

Midwives also bemoaned the difficulty in getting drugs at the facility level, more so as some of these drugs are considered an emergency requirement yet not in supply, and this adversely affects the effective functions of caregiving with a direct consequence on the unborn/newborn child.

"And after that, they pay for vitamin k, which we give to the child…that is when it is a normal delivery. When it is a Cesarean section, antibiotics like Cefuroxime, Amoxyclav, and Gentamycin are ordered by the doctor. If it is not there, they go to buy…”

“When the dispensary does not have hematinic (iron III), you ask them to go and buy, it is a problem…. what about if she comes for ANC and you write for her and in the end, she goes and not buy? She will come back with anemia…”

Folic acid, a dietary supplement giving during pregnancy as recommended by the World Health Organization as essential in minimizing the risk of stillbirth, is sometimes in short supply and pregnant women are told to purchase some from the open market. They shared experiences during the focus group discussion as follows.

“Whenever we come, we have been buying the drugs. Most of the time when we come, they do write for us to go and buy the drugs. The yellow and the red drugs” .

“The last time I delivered, my husband was made to buy water [intravenous fluids] for infusion…the is a drug store outside the hospital, that’s where we bought it.”

Discussion

Generally, utilization outcomes improved over time between 2008 and 2014 showing statistically significant differences between the Ghana Demographic and Health Survey data. In a similar vein, there was a corresponding increase in stillbirth and perinatal mortality and although, population growth is one plausible explanation to this, the introduction of the ’free’ maternal health care policy was also key to increasing utilization and this may put pressure on the health system capacity to deal newborn care, as previously reported [24, 40–42].

Stillbirth was accounted for mainly in 2014, with a statistically significant difference, p < 0.0344. Conversely, we found that the perinatal mortality rate declined in 2014 by 4 per 1000 live births, moving from 31 per 1000 live births in 2008 to 27 per 1000 live births in 2014. On the other hand, stillbirth rate was worse off, increasing over time by 2 per 1000 live births between 2008 and 2014.

By implication, while perinatal mortality is declining, stillbirth is rising, and this supports the views espoused by the service providers during the in-depth interviews (IDIs). The inverse relationship between stillbirth and perinatal mortality is rather surprising because perinatal mortality feed directly on stillbirth, hence, the expectation would be that as one decreases, the other should also, but this is contrary to the current findings. Nevertheless, the current findings suggests that early neonatal deaths were declining at a factor rate, perhaps outpacing the rate of stillbirth, and hence reflecting in the overall decline in perinatal mortality rate.

Secondly, home deliveries may be recording low stillbirths, compared to facility-level deliveries. This is not farfetched given the observations during the IDIs that pregnant women in labor turn to rash to the hospital after attempting and failing home delivery. Successful home deliveries will likely be those without complications and perhaps fewer mortality outcomes, yet, the rising number of stillbirths, which is consistent with the current increase in numbers of stillbirths in sub-Saharan Africa as reported by the WHO is a worrying development and a challenge for health systems and policy [4, 7].

Both stillbirth and perinatal deaths were prevalent among the ‘free’ maternal health policy group compared to the no ‘free’ maternal health care policy group. The qualitative exploration revealed that even though the ‘free’ policy may have led to increase in access to maternal health care, it was against a background of shortage of medical consumables, poor and/or inadequate monitoring of pregnancy and labor process and out-of-pocket purchasing of supplementary medicines.

Iron tablets (folic acid, and ferrous sulphate) for example, are routine drugs served at antenatal clinics as supplements to prevent anemia in pregnancy and these also aid in combating stillbirth [32, 43], yet, these medicines were consistently in short supply in the selected study sites. Indeed, findings in earlier studies show that folic acid intake during pregnancy is associated with reduced stillbirth [44, 45], and therefore, intermittent shortages perhaps poses increased risk stillbirth among pregnant women. Under the current situation, quality of care is perhaps affected by the lack of medical commodities, a key component of the WHO building blocks of health systems framework [46, 47] and perhaps also affect technical quality [48].

Despite the overall reduction in the perinatal mortality rate in 2014, perinatal mortality still increased proportionately high between 2008 and 2014 by 10.8 percentage points, moving from 45.6% to 56.4% within the DHS survey period. The results compare intriguingly with the proportion of stillbirths between 2008 and 2014 which showed a much higher increase in percentage points of 14.4 in 2014 despite the introduction of the ‘free’ maternal health care policy.

The findings imply that stillbirth failed to show a decline in 2014 both in rate and in proportion to under 5 mortalities between 2008 and 2014, while perinatal mortality declined in overall rate but increased in proportion between 2008 and 2014. Although, this is unexpected, it represents some level of gain in the face of the ‘free’ policy. Arguably, the situation could have been worse without the ‘free’ maternal health care policy.

The prevailing health systems factors of poor monitoring, delayed arrival, inadequate attention to stillbirth ’matters’ and intake of local herbs, although inconclusive probably throw some light as to why the numbers of stillbirth are high. It is imperative perhaps to consider the possibility of increased data capture and although this study did not independently explore the influence of data capture, the service providers insinuated during the IDIs that increased record keeping may have influenced the numbers of stillbirth among the ‘free’ maternal health care policy group.

Even though the gains in overall perinatal mortality could be due to increase in access to care at the neonatal period, and consequently improved immunization, perinatal death and stillbirth are twin concepts that work together and reasonably, a decline in one was expected to show a similar pattern in the other, unless early neonatal mortality was significantly declining [1, 30, 49].

Central to labor monitoring is the use of delivery partograph and although its implementation comes with striking challenges including form complication, midwifery staff shortages, and the lack of appreciation of its importance [50], perhaps it is imperative to state that in a situation where less partograph is used by midwives during labor, a rise in numbers of stillbirths may not be unexpected. The WHO recognized the challenges associated with using delivery partograph and approved its modification in Ethiopia, but the findings of the current study suggest yet another reason for further engagement of midwives on the need to use delivery partograph for labor monitoring.

Partograph use was more of a problem in the Upper East region than the Northern region, and although the reasons are unclear in the current study, a closer look at the regional data from DHIMS and those of the quantitative output shows that facility delivery was high in the Upper East region compared to the Northern region and therefore, increased workload may have played a role in affecting midwives’ ability to use the delivery partograph.

Perceived lack of care and attention also emerged from the FGDs among the pregnant women participants. The pregnant women perception somewhat lends credence to the IDI’s revelation that not much attention was paid to stillbirth ’matters’ as much as maternal mortality. This is consistent with the recent report by the WHO and UNICEF, which points out that stillbirth was receiving less attention from policy and resources, and thus, it was not surprising that stillbirth declined less in the last decade of the first century compared to maternal and under 5 mortality [4, 51].

The effect of this is that pregnant women may lose trust in facility-level delivery in the long run and turn up late and in a complicated state, thus affecting care outcomes [52, 53]. Stillbirth and perinatal mortality are sensitive indicators of health systems’ weaknesses and a test of the quality of care dimensions [54].

The use of kaligutiem to speed up contraction in labor, unaware of its adverse effect on the unborn child also emerged from the IDIs. It seems a given that women in labor will want a fast-track process of labor, yet the practice of using local herbs against medical advice demonstrates some lack of confidence in the modern health care system. The account of midwives suggests that pregnant women who take the are at risk of excessive uterine contraction with increased risk of uterine rupture and therefore stillbirth.

Strength and limitation

The use of DHS data sets was appropriate to achieve external validity and generalizability as the data was large enough and representative. Suffice to say, the ‘free’ policy primary intent was to increase utilization and access to maternal health care. This study measured stillbirth and perinatal mortality outcomes in Ghana relative to the ‘free’ maternal health care policy using a mixed method design and this added context to the study findings and discourse.

The study show limitation as well. The quantitative analysis was based on association using regression models. Although the analysis used multivariate regression models to test sensitivity, a quasi-experimental design would perhaps have measured the treatment impact with precision and give robust results. On the qualitative side, the selected regions were from the northern section Ghana, based on the quantitative findings of stillbirth outcomes, thus, excluding pregnant women’s perspective of the ‘free’ policy from the southern section of Ghana.

Conclusion

Although perinatal mortality rate declined overall in 2014, stillbirth rate increased within the period suggesting a significant decline in neonatal mortality. This is a gain in that, while the ‘free’ maternal health care policy is yet to translate to reduced stillbirths, early neonatal mortality is declining. Giving these findings are within the health systems context of poor monitoring of labor process, and intermittent shortage of drug consumables for pregnant women, the factors may have exerted negative influence on the outcomes of stillbirths. Delayed arrival during labor and the intake of local oxytocin may be compounding pregnancy outcomes and consequently, increasing stillbirth. It is recommended that health system thinking approach be adopted by the MoH and GHS to ensure regular supply of drug supplements and outright stoppage of local herb usage among pregnant women for better outcomes. There is the urgent need for leadership to monitor the use of the delivery partograph in managing eligible mother in labor.

(DOCX)

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29 Nov 2021

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RE: RESPONSE TO REVIEWERS: PONE-D-21-35524 - EVALUATING THE IMPACT OF MATERNAL HEALTH CARE POLICY ON STILLBIRTH AND PERINATAL MORTALITY IN GHANA: A MIX METHOD APPROACH USING TWO ROUNDS OF GHANA DEMOGRAPHIC AND HEALTH SURVEY DATA SETS AND QUALITATIVE DESIGN TECHNIQUE

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b. the formula for the calculation of stillbirth and perinatal mortality ratios has also been removed from the manuscript.

c. the Tables has been reduced and others merged as necessary. We now have 5 Tables instead of 7 as contained in the original submission.

4. You noted that some aspects of this manuscript appear to have been published somewhere else. This is not exactly clear to us. However;

a. the original protocol design of the study was published by BMC reproductive health journal and assigned DOI (https://doi.org/10.1186/s12978-020-01011-9) which was just the methodology of the full protocol at its design stage and did not include any results. The conceptual framework in the protocol appears similar to the one in the current manuscript, but not the same. There has been a significant modification as the study progressed which is what has been submitted in the current manuscript.

b. In preparing this manuscript, aspects of the qualitative results were presented by research gate as a pre-publication text (not peer-reviewed), usually meant to gather useful comments to enrich the manuscript (and does not constitute a publication of our current results) and thus, the wording may be similar. Accordingly, we can confirm that no part of this manuscript results has been published in any journal as a research finding and should be considered for publication in PLOS Journal as an original piece of work.

5. (We also acknowledge the cooperation and support of Ghana Health Service and the Directors who granted entrée to hospitals and health centres for this study.)

6. The above statement (item 5) was quoted to us, and intimating that we may have received funding support from Ghana Health Service or another agency. Perhaps, we did not convey the appropriate impression in the choice of words and terms such as “support of Ghana Health Service…”. However, for the avoidance of doubt, no funding support was received from Ghana Health Service or any agency of local or international in nature regarding this study. This manuscript is part of the PhD research work of the first author during his candidature in the University of Ghana School of Public Health, where the 2nd, 3rd and 4th authors are faculty and supervising committee members of the 1st author. The first author did receive tuition fee support (not research) from the Ghana Education Trust Fund (GetFUND) and this has been duly acknowledged in the manuscript. We are willing to modify our statement if the journal finds the GetFUND tuition fee as funding support for the research work.

7. Figure 2 (Fig. 2) attached in the manuscript is an original map professionally constructed for this study and about the selected study site from two regions of Ghana. The map is an original work designed for it purpose following the commencement of the study and has neither been used by anyone nor published anywhere before. To this end, we do not find the need to follow your guideline on copyright concerning third party use of a figure (the map), as this does not apply to us in this case. We are willing to remove the particular figure (Fig. 2) if there is evidence to the contrary.

8. The aspect of the ethical statement has been revised accordingly in the method section of the manuscript. The full name of the ERB, Ghana Health Service Ethical Review Board has been stated under the sub-section ‘Ethical consideration’.

9. All Tables and Figures have been duly referred to i.e. Table 7 which was cited as not referred to has been corrected. The particular Table was referenced as multiple Tables in the manuscript. However, in the revised version, Table 7 (now Table 6) is attached as a supplementary file.

10. The figures (Fig 1 and 2) have been uploaded to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic accordingly to meet PLOS requirements.

11. Humbly submitted.

Submitted filename: Response to reviewers.docx

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16 May 2022

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Reviewers' comments:

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: Thank you for a good work. Please see manuscript text for comments. The purpose of the study has to be rewritten and stated clearly as per the title of study.

Reviewer #2: the manuscripts makes an important contribution to the field but needs major revisions. the writing style is not very much scientific> the authors would benefit much by reading latest publication in the area and adjust the manuscript accordingly. the discussion and conclusion section in their current state need further revisions as they do not meet the minimum journal standards

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Reviewer #1: Yes: Emmanuel Ugwa

Reviewer #2: No

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Submitted filename: PONE-D-21-35524_reviewer.pdf

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Submitted filename: Reviewers comments_14052022.docx

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29 Jun 2022

Dear EDITOR,

RESPONSE TO REVIEWERS COMMENTS

Manuscript Title: Evaluating the impact of maternal health care policy on stillbirth and perinatal mortality in Ghana: a mix method approach using two rounds of Ghana demographic and health survey data sets and qualitative design technique

Abstract

All comments under the ABSTRACT sub-section have been addressed as follows;

1. Background: This has been revised appropriately and the WHO/UNICEF, 2020 report referenced.

2. Methods: The quantitative data was analyzed first, then the findings necessitated the qualitative study. The IDIs, especially the expert views were born out of the findings of the quantitative findings. The interview guide is attached as supplementary file.

3. Results: Although the results of the qualitative findings provide a certain perspective to the quantitative finings, this study does not seek to establish causal inferences between the results of the quantitative analysis and the qualitative interviews. Its aim was to seek understanding within what contest the ‘free’ policy was expected to produce the desire impact.

4. Conclusion: The qualitative results did not report exactly what was or what was not part of the ‘free’ maternal health care policy. It reported on what context factors affected the ‘free’ policy implementation and therefore, a consequence the stillbirth outcomes, despite the ‘free’ policy. This has been clarified in the introduction and mothed section.

5. Key works; “policy evaluation” been included accordingly.

Introduction

1. Comment: Stillbirth and perinatal mortality are part of the maternal and child health indicators which are very sensitive health system indicators reflecting negatively on the overall performance of the health systems. This needs to come out clearly.

Response: Sentence has accordingly been revised.

2. Comment: Stillbirth and perinatal mortality have received relatively good policy attention. E.g. new born health has received renewed attention and it has the potential of addressing perinatal mortality. Stillbirth too has received relative attention. The ENAP set targets for national governments to adopt towards addressing the two. You should reflect on what Ghana has done in line to achieve the ENAP targets.

Response: Although not explicitly stated, the ‘free’ maternal health care is implicitly implemented to achieve ascertain level of access to antenatal care and facility delivery utilization, which essentially feed into the purpose of ENAP. This has been explained in the opening introduction leading to stating the purpose of the study.

3. Comment: The global burden of 2.6 stillbirth is an old statistic. The current burden is 2 million annual stillbirths according to UNICEF/WHO report titled “The neglected tragedy; the global burden of stillbirth 2020. The authors need to use Up to date references.

Response: This has been revised.

4. Comment: Technically, the WHO defines stillbirth as intrauterine death after conception”. This statement is not true. The definition only applies to fetal death after 28 weeks. Revise as appropriate.

Response: Comments revised as suggested.

5. Comment: “Access to maternal health care is proven to reduce stillbirth”. It is not access to any maternal healthcare but rather “quality and timely maternal healthcare” you need to revise this to reflect the recommendation.

Response: “Quality and timely access” added to said sentence as recommended.

6. Comment: Related to the above, the authors need to highlight the global burden, regional picture and country status to bring out the problem clearly in a funnel-like approach.

Response: revised.

7. Comment: Did that policy explicitly say that it targeted to address stillbirth and perinatal mortality? You need to reflect it in the introduction.

Response: The policy included comprehensive antenatal care, facility level delivery and post-delivery care up to 10 days. During this period care, one of the gains expected by implication is reduced stillbirths and perinatal death. This is the bases for this study, to evaluate the ‘free’ policy contribution to late pregnancy outcomes and new-born care.

8. Comment: Policy components of the free maternal healthcare policy need to be highlighted for the reader. Right now it is not known.

Response: This has been revised in the introductory section.

9. Comment: Other than the social health insurance, the main maternal and child health intervention since 2000 has been the MDGs with specific goals for maternal and child health whose intervention impacts directly on the indicators you are studying in this study. This relationship needs to come out explicitly.

Response: Since MDGs were reviewed to SDGs, this is perhaps, a more appropriate reference to make which is what we made in our introduction section.

10. Comment: As early stated, other than quoting the 2015 statistics, it’s better to use recent data from the 2020 UNICEF/WHO report.

Response: The UNICEF/WHO reported has been used to update the figures and appropriated referenced.

11. Comment: Also, instead of quoting Nigerian data it would be important to quote the stillbirth burden in Ghana straight away.

Response: Ghana data used instead of Nigeria.

12. Comment: The definition of stillbirth is not clear; key issues to note are the 28 weeks’ threshold as the official position of WHO, and birth with no sign of life either fresh or macerated. This needs to come out explicitly and when using the official definition of WHO, it’s better to use their own sources.

Response: Statement revised.

13. Comment: Other definitions which stretch to less than 28 weeks of gestation are not official but rather country and study specific definitions based on period of viability.

Response: Definitions has been edited and revised.

14. Comment: There are contextual factors which need to come out clearly in the background. For example, the MDGs were a cornerstone for improvement of maternal and child health services globally. Also, the UN secretary general strategy Every Woman Every Child which was operationalized through every New Born Action Plan (ENAP) need to be highlighted when investigating stillbirth. They are the back born for the renewed interest in global stillbirth campaigns.

Response: Comments appropriately incorporated.

15. Comment: An explanation of the “free maternal health policy within the national health insurance scheme needs to be done in the introduction. Was it only aimed at improving access through addressing the healthcare costs? Or there are maternal health interventions within such as increased access to EmOC, MPDSR among others.

Response: The ‘free’ maternal health care policy explained and the national health insurance explained.

16. Comment: “Studies have shown that maternal age, rural/urban area of residence”. This paragraph ignores the important contribution of the health systems factors in addressing stillbirth risks and yet the said policy was implemented within the health systems. It would be important to strike a balance by highlighting the health systems related factors too.

Response: indeed, the policy is being implemented with certain health systems factors, which was the focus of the qualitative study. Accordingly, the sentence has been revised.

17. Comment: Contextual definitions: Stillbirth; kindly check this definition. It lacks the basics of what would constitute a stillbirth such as after the 28 weeks cut off.

Response: Definition revised.

18. Comment: Free maternal healthcare policy: This is simplistic. I suggest an elaboration of the ingredients of this policy and the aspects of maternal health that were covered. Its coverage within the Ghanaian population and any other important information.

Response: This has been revised and scope and package included in the introduction section.

19. Comment: Page 13 “local contest” did you want to mean “context”? if so change as appropriate.

Response: Yes, this refers to ‘context. Appropriately edited.

20. Comments: “we analyze the outcomes of stillbirth and perinatal deaths among mothers in2008, when the policy had just started, compared to 2014 when the policy was fully rolled out”. This should speak directly to the title of the paper and objective of the study in the introduction of your abstract.

Response: Comments revised accordingly.

Methods

1. Comment: Study design; the section is rather speaking more to the study setting other than the design. Be explicit and intentioned right away.

Response: This comment has been addressed.

2. Comment: Study setting; some information given is irrelevant to this paper, rather give information that adds value. For example, the geographical location may not be that needed, instead data on stillbirth and perinatal mortality may be more important here.

Response: Data on stillbirth for the qualitative study sites have been included.

3. Comment: The sampling procedure for the qualitative component is missing.

Response: Perhaps, this was clear enough. It has been revised accordingly.

4. Comment: Details about the qualitative tool are missing. It would be important to take the reader through the kind of information the tool elicited.

Response: A little more detail has been added on the qualitative information. Tools also attached as supplementary file.

5. Comment: Instead of attaching the ethics review letter, better quote the reference number for the protocol from the ethics committee.

Response: protocol number quoted under the section ‘ethical consideration’

6. Comment: No mention of the inclusion and exclusion criteria for FGD participants. It needs to come out.

Response: This had been revised to include inclusion and exclusion criteria of FDGs.

7. Comments: On the qualitative data analysis, how was the codebook developed, who coded the data? How many people were involved in the analysis?

Response: The first author analysed the qualitative data and supervised by the second and third authors. Coding essentially was guided by the deductive themes of stillbirth, and the context factors affecting maternal health care utilization under the ‘free’ policy and how they affect ‘stillbirth’ outcome. The emerged significant statements were grouped as inductive sub-themes and reported as the study results with verbatim quotes. Statements were reviewed thoroughly for significance through multiple reading and grouped as affecting quality of care and perhaps negatively influencing stillbirth.

8. Comment: How was saturation attained?

Response: When subsequent IDIs added no particular new information, we determined that saturation was reached, and suspended interviews. However, FGDs continued as planned and all 8 groups of FGDs were carried out and recorded views transcribed analysed in unison.

9. Comment: Attribution of the reduction to the policy

Response: This comment is not particularly clear. However, the study found that perinatal mortality rate declined between 2008 and 2014, while stillbirth rate increased within the same period. Yet, both perinatal mortality and stillbirth were more likely to occur in the ‘free’ maternal health care policy group compared to the no ‘free’ maternal health care policy group.

10. Comments: The authors need to clarify explicitly how the two methods of data collection were integrated and informed each other. They should also state if this did not happen and why.

Response: data collection and integration has been revised under the methods section

11. Comment: I would suggest that you follow the COREQ Checklist to report on your qualitative findings better.

Response: Although, the Consolidated Criteria for Reporting Qualitative research (COREQ) was not particularly used in the study, nonetheless, aspects in the manuscript have addressed issues the requirements of the COREQ checklist. The qualitative study conducted mainly by the first author, as a PhD candidate of the University of Ghana School of Public Health, under a thesis supervisory committee led by the second author, received ethical approval from the Ghana Health Service Ethical Review Committee (number quoted in main test of manuscript). Analysis was content in nature, where sub-themes were constructed to report the study results.

Results

1. Comment: “On risk of stillbirth, pregnancies in the ‘Free’ Maternal Health Policy (FMHCP) group were 1.64 times more likely to result in stillbirth compared to the no FMHCP group”. This needs to come out explicitly in the methods section how these groups were created.

Response: Group creation has been revised accordingly in the design section. Also, Table 2 has been revised to report the values of the two groups.

2. Comment: Qualitative study participants: the unit of analysis for the FGDs is the group. Therefore, when describing your study participants, its better to refer to how many FGDs were conducted other than the total number of participants within those FGDs.

Response: descriptive section of FDGs revised appropriately.

3. Comment: “The majority of pregnant women respondents had given birth previously, 41 (90.1%). Only 4 (8.9%) pregnant women participants were having children for the first time”. To me these appear to belong to the same group unless if you want to say that some were pregnant at the time of the interview and reference is being made to the index pregnancy. Revise statement to bring out clarity.

Response: Yes, we agree with your comment. The section/sentence has be revised.

4. Comment: Table 6: the column on average duration is less significant. This description should be in the narrative and refer to the average duration of each interview. In its current form it appears to be the total duration of all interviews in each category. Kindly revise as appropriate.

Response: We agree with the reviewer. The particular column has be deleted appropriately.

5. Comment: “…A few cases also dodge the hospital may they have two previous CS and knows that if they come to the hospital, there will be CS, so they avoid the hospital, when there are complications, then they quickly come...” (Doctor 1, IDI, UER). Start to use “signposts” in your write up. Whereas the introductory statement was speaking to increased number of macerated stillbirth, this statement seem to be off. Revise as appropriate.

Response: Statement/section revised appropriately.

6. Comment: “…and when they come we manage them at postnatal care…. they say they didn’t know that labour had started, some say they don’t want the examination. One woman was frank, she said when they come, they put fingers on her vagina and that one she doesn’t like it…” (Doctor 2, IDI, UER). Refer to comment above for this quotation.

Response: Also revised.

7. Comment: Service providers also observed a culture of little or no attention to stillbirth issues. Public or media lack of attention on stillbirth was cited as a principal reason compared to maternal mortality. On the other hand, pregnant women midwives’ snobbish attitude to them during labour, as a contributory factor to the rising stillbirths. The following quotes explains further. Was this part of your study objective or scope of the study? To me it appears not.

Response: Yes, these emerged from the IDIs, as some of the contextual factors that bothers on stillbirth relative the ‘free’ policy in practice.

8. Comment: “Use of local herbs for ‘rapid’ uterine contraction” this can’t be a subtheme of the study since its not part of the policy. It is rather inadequate implementation of the policy that is resulting into this. The write up should reflect that. Its either poor access to available services or poor enforcement of the policy that is resulting into this

Response: This has been revised and reported under ‘stillbirth’. Essentially, the IDIs explained the consequences of taking local herbs which was a common practice in some of the study sites. Thus, making it a relevant observation, as a factor associated with the poor outcome of stillbirth, despite the ‘free’ policy.

9. Comment: The qualitative findings only talk about the high numbers of stillbirth which have been explained to be caused by poor use of partograph for pregnancy monitoring and shortage of medicines. I highly doubt this is comprehensive and can solely explain the quantitative findings. More exploration of the qualitative data for more reasons to explain the high numbers.

Response: Indeed, poor use of partograph as found in the current study is one of the context factor which may be explaining the stillbirth outcomes in the study site. Other context factors that emerged included; late reporting/arrival, poor, shortages of folic acid/multivitamin, and lack of interest in stillbirth ‘matter’. The section has accordingly been revised.

10. Comment: “Service providers are of the view that the increase in utilization puts pressure”. Ensure to write the results section in past tense since activities and comments happened sometime back.

Response: The results section has been read and revised.

11. Comment: On the other hand, pregnant women midwives’ snobbish attitude to them during labour”. Revise sentence as appropriate.

Response: sentence has been revised.

12. Comment: Just so to confirm are these FGD quotes from mothers that experienced a stillbirth? If so it should be reported as such and if not you need to clarify in the methodology section.

Response: Not only mothers who experienced stillbirth, but mothers previous experience while giving birth at the facility level and use of using antenatal care.

13. Comment: Due to the facility level shortages, pregnant women regularly asked to purchased medicines outside of the health facility”. Revise statement as appropriate, it is not clear in its current form.

Response: Statement revised accordingly.

14. Comment: “This was not only a problem to the pregnant women, but also frustrates the quality of processes of the health care professionals” use past tense as appropriate.

Response: Manuscript read and edited accordingly.

Discussion

1. Comments: Revise the discussion section accordingly after effecting changes in the results section

Response: Discussion section revised.

2. Comment: “improvement in perinatal mortality” is it improvement in perinatal mortality or reduction in perinatal mortality?

Response: reduction in perinatal mortality. This has been revised accordingly.

Conclusion

1. Comment: Revise the discussion section accordingly after effecting changes in the results section

Response: Relevant revisions effected, including the conclusion section.

John Azaare (PhD Candidate, Thesis defended successfully)

Lead/Corresponding Author

Submitted filename: Response to Reviewers.docx

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21 Jul 2022

Submitted filename: Reviewer comments_09072022.docx

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25 Aug 2022

THE ACADEMIC EDITOR

PLOS ONE JOURNAL

Dear Editor,

RE: Evaluating the impact of maternal health care policy on stillbirth and perinatal mortality in Ghana: a mix method approach using two rounds of Ghana demographic and health survey data sets and qualitative design technique.

Thank you for reviewing this manuscript. Below are the responses to the issues raised.

General comments.

1. The definition of stillbirth should come upfront within the first paragraph of the introductory section. Referring to it as a neglected tragedy is not a definition parse but rather what it is.

Response: This has been addressed in Page 1, paragraph 1.

2. Paragraphs two and three are a repetition with one showing absolute numbers and the other showing percentages of global stillbirths. Consider deleting one.

Response: Paragraph three has been deleted, while paragraph two revised.

3. The definition of stillbirth is inadequate and its contextual. Rather use the WHO definition which restricts stillbirth to loss after 28 weeks for global comparisons. It is clear that in developed countries the definition can go as low as 20 weeks due to viability but that is not the standard definition.

Response: This has been revised in page 4, (under ‘Context definition section).

4. It may not necessarily be history of abortion “Studies have shown that maternal age, rural/urban area of residence, twin pregnancy, history of abortion” but rather negative pregnancy history. It may be pre-term delivery, miscourage, abortion or even stillbirth. You may consider revising the sentence to bring out this fact.

Response: “history of abortion” revised appropriately in paragraph four (under ‘conceptual framework’ section).

5. Under contextual definitions, you definition of stillbirth is not appropriate. The standard definition is well known and if any adjustments to the definitions were done in this study, kindly indicate so. Key to the definition is the cut off of 28 weeks and being born with no sign of life. You may need to revise or operationalise what you call “dying within day zero after birth” for which I would highly discourage you from using.

Response: This has been revised in page 6 (under context definition).

6. Study design: Are you sure the mixed methods design was in “two prongs”? To me it appears it was sequential mixed methods because you started off with the quantitative secondary data and later the qualitative. If that is the case, then revise as appropriate.

Response: This has been revised in paragraph one, page 8 (under the ‘design section’).

7. Statement not clear “who were not necessarily stillborn babies”. Did you want to say the mothers who participated in the FGDs were not necessarily “mothers” to stillborn babies? If that is the case, then revise as appropriate.

Response: This has been revised in paragraph two, page 8 (under the ‘design section’).

8. Qualitative study setting: other than giving a geographical description, I would rather you write more about the health systems characteristics especially as they relate to maternal health service access and stillbirth burden, or characteristics like to lead mothers to having a stillbirth. Still more about the policy under review would work more compared to giving geographical descriptions. The map can be retained though for visual clarity about the study location.

Response: The two regions are similar in structure and organization relative to health system characteristics, albeit with different outcomes of stillbirth and facility utilization. This has been reported in the manuscript (Table 1) and captured as Figure 3 (page 15).

9. Inclusion and exclusion criteria: in the inclusion you say you included women 15-49 years and in exclusion you indicate women below 16 years. Where does that put the ones aged 15 years you indicated under inclusion criteria? Were they included or excluded?

Response: Age “15-49’ as captured in the inclusion criteria is in reference to the age range of the secondary data sets as contained in the DHS survey data sets. However, age 16 years and below were excluded from the in-depth interview in line with the legal age limit for females to have consensual sexual decision, thus, pregnancy. To avoid any confusion for readers, the age range of ‘15-49’ in respect of the Ghana DHS survey data set has been removed under the inclusion criteria section.

10. Besides exclusion is not the direct opposite of inclusion criteria but that those respondents who met the inclusion criteria in the first place and for some reason were excluded from the sample later such as those that met the inclusion requirements but had missing data for other variables. Revise as appropriate.

Response: This has been revised under the section ‘Inclusion criteria’.

11. Data analysis-qualitative: how was the code book developed? who coded the data? how was quality control ensured? how did you choose the quote to represent others in the results section?

Response: The first author coded the data and was supervised by the second, and third author. Codes were deductive (prior to conducting in-depth interviews) based on the study objectives of stillbirth and context factors of service utilization. The second and third author checked for quality of codes, clarity and uniqueness, as supervisors of the first author. Afterwards, common themes were constructed inductively through multiple reading of the transcripts. This has been explained in paragraph on of the ‘qualitative analysis’ section.

12. Ethics statements are repeated under “tools and pre-testing” and “ethical consideration”. Consider removing one to avoid repeating yourself.

Response: The ‘ethical statement’ under the “tools and pre-testing” has been removed.

13. Results: source of data presented in table 1, how is that data from the field for you to label it as “field data”. It is clearly from the DHIMS and should be labelled as such.

Response: This has been corrected in Table (page 15).

14. Quantitative findings. Is data from table 1 not part of the quantitative findings? If so then the sub heading of quantitative findings should be shifted up to include results from table one.

Response: This comment has been addressed under the ‘Results’ section in page 14.

15. Rates of stillbirth increasing between the two timepoints this is a unique finding that needs to be explored more. Why the risk appeared to be more in the free maternal health care policy group also needs to be explored.

Response: We agree with the reviewer. The qualitative aspect of the study was aimed to address this concern, thus, the results as presented in the qualitative section. Of course, further exploration will be useful perhaps in future studies.

16. Although there was an overall decline between the two timepoints, the risk of perinatal mortality was also high in the free maternal healthcare policy compared to the control group. This phenomenon needs to be explored and discussed in relation to the national context. It calls for interrogation of the quality of secondary data used. Otherwise the conclusion would be that the free maternal healthcare policy instead led to an increase in both stillbirth and perinatal mortality.

Response: The secondary data used were two-rounds of Ghana DHS data sets (baseline and end line). DHS is a standardly collected data sets using complex design by the DHS Programme, funded by the USAID (independent of this study). The DHS data sets are nationally representative and regularly used in evaluating national programmes or project. Our analysis took clustering and stratification into consideration and applied sample weighting and also adjusted for confounding to minimise internal bias. The study findings of rising stillbirths could perhaps be attributed to increased utilization which may have affected quality of care, and this was corroborated by the qualitative study participants during the IDIs and FGDs.

17. Centrally to what is known, the education level in this study seem to disfavour the outcome variables (that the higher one’s education level the more likely they are to have negative outcomes). This needs to be interrogated too in the context of national maternal and perinatal mortality service delivery.

Response: We agree with the reviewers that education appears a disincentive as per the current findings. However, education as reported in this study is a confounding variable. Perhaps, analysing education as the main outcome variable could yield different results, but that is outside the scope of the current study.

18. Table 7: group discussion the unit is the focus group. Kindly indicate it and in bracket show the total number of participants in those FGDs which is 44. Revise as appropriate.

Response: This has been revised appropriately in Table 7.

19. “Antepartum (macerated) stillbirths” these happen before the onset of labour and any stillbirth happening after the onset of labour whether outside the health facility is fresh stillbirth. Revise the sentence as appropriate to reflect that death before arriving at the facility is not the cut off to determine macerated stillbirth.

Response: This has been revised accordingly in paragraph two, page 27.

20. “The reasons for the delay in arriving in the health facility”. What I infer from this and subsequent statements is that the pathway to seeking delivery services has a number of bottlenecks which include actors (Traditional birth attendants) and negative cultural practices (use of local herbs) this needs to come out clearly other than amplifying the “kaligutiem”

Response: Yes, cultural practices such as herbal intake affects the pathway to seeking care during labor. However, our use of the term ‘kalgutiem’ has been chosen to reflect the local context and observations by the service providers. However, this has been revised in pages 29 and 30.

21. The effects of data capture may need to be brought into the picture here. The increased number/rates of stillbirth may have been due to improvements in data capture that almost all cases are captured. Needs to be discussed if you think it may have an effect on the observed trends between the two timepoints.

Response: The effect of data capture was brought out by the service providers during the IDIs as reasons for the high figures. The current study did not independently analyse data capture impact to ascertain its influence on the totality of the stillbirth rate. Our analysis of the outcomes of stillbirth based on the secondary data obtained from the DHS programme.

22. “Both stillbirth and perinatal deaths were prevalent among” did you try to explore the role of data capture this might play on the observed outcomes? It may be that proper data capture in the free policy group will show many cases which may be the opposite in the other group.

Response: Although this study did not independently analyse the role of data capture, the service providers did mention ‘data capture’ as influencing the high figures during the IDIs, and this has been reported as part of the qualitative findings in page 27, paragraph two and also reflected in the discussion, paragraph nine (page 36).

23. “The findings imply that stillbirth failed to show a decline in 2014”. You may need to highlight the limitations of this study wherein the paper objectives were never the main aim of the policy so there is a likelihood that it may have affected the observed trends.

Response: This comment has been addressed in paragraph one under ‘strength and limitation’.

SIGNED

John AZAARE

(Corresponding Author)

Submitted filename: Response to Reviewers.docx

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31 Aug 2022

Evaluating the impact of maternal health care policy on stillbirth and perinatal mortality in Ghana: a mix method approach using two rounds of Ghana demographic and health survey data sets and qualitative design technique

PONE-D-21-35524R3

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19 Sep 2022

PONE-D-21-35524R3

Evaluating the impact of maternal health care policy on stillbirth and perinatal mortality in Ghana; a mixed method approach using two rounds of Ghana demographic and health survey data sets and qualitative design technique.

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