“If there is no data, how do we improve?” Exploring health workers’ perspective on stillbirth recording in the Ashanti Region of Ghana

Health workers play a critical role in documenting the estimated 2 million stillbirths that occur annually. From the moment a stillbirth occurs, a health worker is responsible for recording the birth outcome. The reliability of stillbirth data for informing global and national-level strategies on stillbirths depends on the information recorded by the health worker at the point of care. This study aimed to gain insights into the health worker practices and challenges related to stillbirth recording and reporting. The qualitative study explored three objectives using an a priori framework: 1) experiences, perceptions, and attitudes; 2) barriers; and 3) support mechanisms available to health workers for stillbirth recording and reporting. Semi-structured interviews were conducted with 28 health workers, including midwives, medical officers, physician assistants, and health information officers. The study was conducted across four secondary and four primary care facilities in the Ashanti Region of Ghana. All health facilities are government owned. Thematic analysis was performed. Under experiences, perceptions, and attitudes, inconsistent definitions were used to describe stillbirths. Health workers described stillbirths using various gestational age thresholds, including 24-,28-,36-, and 38-weeks. Some health workers did not reference gestational age when describing stillbirths. Pre-service education shaped knowledge on stillbirths and its recording, with limited opportunities for in-service training. The motivation to record stillbirths was influenced by both intrinsic, driven by the moral imperative to do what is right, and extrinsic factors, influenced by district-level standards. Misclassifications and omissions of stillbirths occurred due to a higher workload, a large volume of forms requiring completion, limited knowledge and experience, and a deliberate effort to minimize facility mortality rates, especially in cases of macerated stillbirths. For barriers to stillbirth recording, midwives reported that blame was evident at three levels: blame from the broader health system, blame within the organizational facility-level, and individual-level blame. The failure to implement audit recommendations was identified as a bottleneck perpetuating negative attitudes toward collecting stillbirth data. The engagement of clinical staff in audit reviews and training was identified as support available to health workers. We need to understand the health worker experiences, perceptions, and attitudes that underpin stillbirth data to reduce the stillbirth burden. The study suggests several recommendations, including socializing the national stillbirth definition, and reviewing audit protocols.