Reducing unmeasured confounding from non-compliance with randomization in surgical RCTs: a simulation study.

Maternal mortality (MM) is a major public health concern. The World Health Organization (WHO defined maternal mortality as “deaths occurring in women, while pregnant or within 42 days of termination of pregnancy irrespective of the duration and site of the pregnancy from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes” []. Pregnancy-related complications continue to pose a major threat to maternal health, but beyond the clinical consequences, they also impose substantial financial burdens on households. An estimated 810 women die from preventable pregnancy-related complications every day globally []. Women living in developing countries are 300 times more likely to die as a result of childbirth or pregnancy-related complications than those in developed countries []. The WHO also recommends that all pregnant women should have antenatal care (ANC) with a skilled provider, utilize the service of a skilled birth attendant (SBA) at birth, and obtain first postnatal care (PNC) within the first 24 h after birth as part of the measures to reduce MMR [, ]. Over the years, Ghana has made progress by reducing its maternal mortality rate (MMR) from 740 to 319/100,000 live births between 1990 and 2015 (Adu et al., 2021). Even though there is recent evidence of a reduction in maternal mortality worldwide, most developing countries like Ghana still lag in achieving Sustainable Development Goal (SDG) target 3.1, which seeks to reduce maternal mortality to 70 per 100,000 live births by 2030 [, ]. Reducing MM remains a priority for the government of Ghana and it’s donor agencies []. The Ghana government implemented policies which include free maternal health care policy in 2008 through the National Health Insurance Scheme to reduce the financial burden on pregnant women and their families and improve access to skilled and comprehensive maternal health care [–]. Although Ghana has implemented the free maternal health care policy under the NHIS, to reduce financial barriers to skilled maternal care, significant gaps remain. While the policy covers selected direct medical services such as antenatal care, routine laboratory tests, and treatment for delivery-related complications, households still incur considerable out-of-pocket payments. These payments include admission fees, diagnostics and drugs not covered under the scheme, and all direct non-medical costs such as transportation, feeding, and accommodation for caregivers.