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BMJ Open Is Committed to Open Peer Review. As Part of This Commitment We Make the Peer Review History of Every Article We Publish Publicly Available BMJ Open: first published as 10.1136/bmjopen-2018-022614 on 8 November 2018. Downloaded from BMJ Open is committed to open peer review. As part of this commitment we make the peer review history of every article we publish publicly available. When an article is published we post the peer reviewers’ comments and the authors’ responses online. We also post the versions of the paper that were used during peer review. These are the versions that the peer review comments apply to. The versions of the paper that follow are the versions that were submitted during the peer review process. They are not the versions of record or the final published versions. They should not be cited or distributed as the published version of this manuscript. BMJ Open is an open access journal and the full, final, typeset and author-corrected version of record of the manuscript is available on our site with no access controls, subscription charges or pay-per-view fees (http://bmjopen.bmj.com). If you have any questions on BMJ Open’s open peer review process please email [email protected] http://bmjopen.bmj.com/ on September 27, 2021 by guest. Protected copyright. BMJ Open BMJ Open: first published as 10.1136/bmjopen-2018-022614 on 8 November 2018. Downloaded from Effectiveness of a Free Maternal Healthcare Programme under National Health Insurance Scheme on Skilled Care: Evidence from a Cross Sectional Study in Two Districts in Ghana ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2018-022614 Article Type: Research Date Submitted by the Author: 05-Mar-2018 Complete List of Authors: Twum, Peter; Shandong University, Department of Social Medicine Qi, Ling ; Weifang Medical University, School of Public Health and Management Aurelie , Kasangye ; shandong university, Social medicine and Health Services Management Xu, Lingzhong; Shandong University, Social medicine and Health Services Management Effect, Maternal health Insurance, Programme, facility-based delivery, Keywords: Ghana http://bmjopen.bmj.com/ on September 27, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 20 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2018-022614 on 8 November 2018. Downloaded from 1 2 3 Effectiveness of a Free Maternal Healthcare Programme 4 5 under National Health Insurance Scheme on Skilled 6 Care: Evidence from a Cross Sectional Study in Two 7 8 Districts in Ghana 9 10 Peter Twum 1, Jing Qi 2, Kasangye Kangoy Aurelie 3 and Lingzhong Xu 4,* 11 1 Peter Twum; email: [email protected]; School of Public Health, Department of Social Medicine 12 and Health Services Management, Shandong University, P.O. Box 110, 44 Wenhuaxi Road, Lixia District, 13 250012, Jinan, China; (P.T.); 14 2 Jing Qi; [email protected] ;Weifang Medical University, School of Public Health and Management 15 Baotongxi road 7166 Weicheng District Weifang city Weifang, Shandong, CN 261053 16 3 , Kasangye KangoyFor Aurelie peer ; email: [email protected] review; School only of Public Health, Department of 17 Social Medicine and Health Services Management, Shandong University, P.O. Box 110, 44 Wenhuaxi Road, 18 Lixia District, 250012, Jinan, China 19 4 Lingzhong Xu; email; [email protected]: School of Public Health, Department of Social Medicine and 20 Health Services Management, Shandong University, P.O. Box 110, 44 Wenhuaxi Road, Lixia District, 21 250012, Jinan, China 22 * Correspondence: [email protected]; Tel.: +86-531-88382648 23 24 Abstract 25 26 Objectives: Ghana in her quest to reduce maternal mortality, introduced a free maternal healthcare 27 programme under the national health insurance scheme. We conducted this study to find out if 28 women registered with the insurance stand better chance of having access to maternal healthcare 29 services in the two districts. 30 31 Setting: We conducted a cross-sectional quantitative study involving household interview 32 among all women of reproductive age group (15- 49 years) residing in Kintampo North 33 Municipality alongside Kintampo South District from May to July 2015. Logistics Regression http://bmjopen.bmj.com/ 34 analysis at 95% confidence interval was used to determine the independent associations between 35 maternal health insurance and use of antenatal care, facility-based delivery and postnatal care 36 services. 37 38 Participants: Women who had children aged three (3) to twelve (12) months were selected to take 39 part in the study. 40 41 on September 27, 2021 by guest. Protected copyright. Results: We observed that women with insurance are 39.5 times more likely to have a maximum 42 of six (6) antenatal care visits and 2.6 times more likely to have average of four (4) antenatal care 43 visits than those without insurance. Also, they are 5.3 times more likely to have facility-based 44 45 delivery than those without insurance. More so there is an association between post-natal care use 46 and insurance as women who don’t have insurance are 12.0(1/0.083) times more likely to receive 47 post-natal care than those with insurance. Conclusions: Pregnant women who registered with 48 health insurance had at least four antenatal care visits and delivered in a health facility. However 49 majority of them did not go for postnatal care. 50 Key words: Effect; Maternal health Insurance; Programme; facility-based delivery; Ghana 51 52 Strengths and limitations of the study 53 54 the use of district representative primary data 55 56 It assessed all aspects of maternal healthcare services 57 1 58 59 it uses robust sampling technique 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml memory bias as the data are from cross-sectional study It does not include health facility data on service use and insurance BMJ Open Page 2 of 20 BMJ Open: first published as 10.1136/bmjopen-2018-022614 on 8 November 2018. Downloaded from 1 2 3 4 5 6 7 8 9 10 1. Background 11 The Millennium Development Goal (MDG5A) called for 75% reduction in the global Maternal 12 Mortality Ratio (MMR) between the year 1990 and 2015 [1].Within 300 months after this call, MMR 13 dropped by almost 44% to an estimated 216, with 80% uncertainty interval (UI) of 207 and 249, 14 maternal deaths per 100,000 live births in 2015 compared to 1990 MMR of 385 per 100,000 live birth 15 with UI 359 to 427. The global lifetime risk of maternal death also dropped considerably from 1 in 73 16 to 1 in 180 [1]. NoFor country peerin the MDGs regionsreview was able to make only 75% reduction in MMR target. 17 18 However, each of them made some effort after United Nations (UN) announced MDGs in the year 19 2000. An estimated annual global MMR reduction rate between 2000 and 2015 was 3%. This was 20 higher than the reduction rate of 1.2% of 1990–2000. This acceleration of progress reflects a 21 widespread escalation of efforts to cut maternal mortality, stimulated by MDG5[2] 22 Building on the momentum generated by the MDG5, the Sustainable Development Goals 23 (SDGs) is also calling for acceleration of present improvement to meet a universal MMR of 70 24 maternal deaths per 100,000 live births, or less, by the year 2030, to end all preventable maternal 25 mortalities [3-5]. Achieving this universal aim will need countries to cut their MMR by at least 7.5% 26 each year between 2016 and 2030. The effective strategy for meeting this ambitious goal required the 27 right interventions including access to and use of skilled care during pregnancy and an appropriate 28 plan for financing universal access to this intervention [4]. However financial constraint is one of the 29 major barriers to healthcare for marginalised sections of society, including parturient in many 30 developing countries. Hence several countries in the sub-Saharan Africa started rolling out policies 31 in their quest to make deliveries or healthcare for mothers and children free or almost free to meet 32 the MDGs [6-9]. 33 http://bmjopen.bmj.com/ Preliminary data of the Ghana Maternal Health Survey (GMHS) which became available at the 34 start of 2008 show that the country was off-track to meet the maternal health targets of MDGs due to 35 the low coverage of facility-based deliveries with its associated high institutional maternal mortality 36 37 rate. It was then declared a national emergency that called for action [10]. In the same year 2008, 38 Ghana introduced a Free Maternal Healthcare Program (FMHCP) under the National Health 39 Insurance Scheme (NHIS). The policy exempted pregnant women from paying premium for fresh 40 registration or renewal of membership and processing fees. They also have access to general medical 41 benefits covered by the scheme, and a comprehensive maternal benefit package covering antenatal, on September 27, 2021 by guest. Protected copyright. 42 delivery and post-natal care as well as neonatal care for infants for three months [10-13]. A total of 43 774,009 pregnant women have registered with the programme as at the end of 2013. We conducted 44 this study to ascertain the effectiveness of registration with the programme on access to maternal 45 healthcare services. We hypothesise that pregnant women who are registered with health insurance 46 have more access to antenatal care (ANC) facility-based delivery and postnatal care (PNC). 47 48 49 50 2. Materials and Methods 51 52 2.1. Study Design 53 54 We conducted a cross-sectional quantitative study from May to July 2015. Household 55 questionnaires were administered to 343 women of reproductive age group 15–49.
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