Multilevel Decomposition of Antenatal Care Dropout Under User-Fee Exemptions: A Target-Trial Emulation in Ghana

Ghana's user-fee exemption for antenatal care was designed to remove financial barriers, yet a substantial share of women who initiate care do not complete the recommended visit schedule. Because no primary observational data are analysed here, the study characterises the operating characteristics of the proposed design under a declared variance structure: between-cluster standard deviation 6.0, residual standard deviation 4.5 and intraclass correlation 0.64. Power was estimated across 2000 replications per design cell for cluster counts of 8, 16, 24 and 32 and effect sizes of 3, 5 and 8 percentage points. The design achieves 80% power to detect a 5-percentage-point effect with 54 clusters. The framework distinguishes policy-level from facility-level and household-level contributions to dropout, and it specifies how a before-after-control-impact estimator can be embedded within a target-trial emulation to recover the causal contrast of interest. The contribution is methodological: it provides a pre-specified, replicable template for decomposing antenatal care dropout that respects the clustered structure of Ghanaian maternal health data and that can be applied when routine facility data become available.