Ethics statement
The study aims and design were developed in collaboration with community members of the research team. The study was approved by the Ethical Review Committee of the Ghana Health Service and the University of Michigan Institutional Review Board (HUM00161464).With IRB approval, oral consent was obtained from participants due high rates of illiteracy among Ghanaian women. The informed consent document was read aloud individually to all potential participants in their local language by Ghanaian research assistants. Using a teach-back method to confirm comprehension, the RAs then asked potential participants questions to ensure understanding of the research process and informed consent document, inviting questions until the information was clear. A health facility staff member signed that they were present while the benefits, risks, and procedures were read to the participant, that all questions were answered, and that women voluntarily agreed to take part in the research. For the midwives participating in the interviews, written consent was obtained in English.