Enhancing the quality of maternal and neonatal care by the Safe Childbirth Project in Al Shifa Hospital, Gaza occupied Palestinian territory (oPt): a descriptive retrospective study.

BACKGROUND: The Safe Childbirth Project is a campaign, launched by WHO in 2012, to improve the quality of care for women and babies during childbirth by promoting evidence-based practice and a midwifery-led approach to care. It was intended to contribute towards achieving UN Sustainable Development Goal 3: ensure healthy lives and promote wellbeing for all at all ages. In September, 2015, the project was launched in the maternity ward of Dar Al-Shifa Hospital, Gaza City, to promote midwifery-led care for low-risk deliveries, with de-medicalisation of normal birth, early initiation of breastfeeding, and early detection of complications during the postpartum period. METHODS: Dar Al-Shifa Hospital is the largest Ministry of Health hospital in the Gaza Strip, is the referral hospital for the whole area, and includes medical, surgical, and maternity departments. Most women who attend the maternity department (70%) have high-risk pregnancies. The caesarean section rate in 2016 was 27%. 88 midwives and 82 doctors are employed on the maternity wards. We did a descriptive retrospective analysis of all women admitted in labour to the maternity hospital from the start of the Safe Childbirth Project on Sept 1, 2015, to June 30, 2018. Data were extracted from patients' files then aggregated and analysed. Six indicators of quality of care were assessed: risk assessment on admission to the labour ward; use of partograms; oxytocin augmentation of labour; babies delivered by a midwife; breastfeeding initiation within 1 h of birth; and the number of postnatal examinations. Ethics approval was obtained from the Helsinki Committee, at the Palestinian Health Research Council. FINDINGS: Of 16 400 births at Dar Al-Shifa Hospital during the study period, 11 480 (70%) were normal vaginal deliveries. The percentages of women risk assessed on admission increased from 65% at the start of the study to 100% at the end, but the proportions of pregnancies classified as being at low risk or high risk remained at roughly one-third to two-thirds (low risk 20% and high risk 45% at the start of the study vs 30% and 70%, respectively, at the end of the study). Partograms were used in all women throughout the study period. Use of oxytocin augmentation of labour decreased from 24% to 8%. Midwives delivered 53% of low-risk women at the beginning of the study and 100% at the end. The proportion of women who initiated breastfeeding within 1 h of birth increased from 45% to 81% and the percentage of women who had five or more postpartum examinations increased from 27% to 81%. INTERPRETATION: Implementation of the Safe Childbirth Project in Dar Al-Shifa Hospital improved most of our indicators of quality of care and was maintained along with regular clinical auditing. Management commitment and close clinical supervision have been the cornerstones of success. FUNDING: None.

Development of a targeted client communication intervention for pregnant and post-partum women: a descriptive study.

BACKGROUND: Targeted client communication using text messages can inform, motivate, and remind pregnant and postpartum women to use care in a timely way. The mixed results of previous studies of the effectiveness of targeted client communication highlight the importance of theory-based co-design with users. We planned, developed, and tested a theory-based intervention tailored to pregnant and postpartum women, to be automatically distributed via an electronic maternal and child health registry in occupied Palestinian territory. METHODS: We did 26 in-depth interviews with pregnant women and health-care providers in seven purposively selected public primary health-care clinics in the West Bank and Gaza to include clinics with different profiles. An interview guide was developed using the Health Belief Model to explore women's perceptions of high-risk conditions (anaemia, hypertension, diabetes, and fetal growth restriction) and timely attendance for antenatal care, as predefined by a national expert panel. We did thematic analyses of the interview data. Based on the results, we composed messages for a targeted client communication intervention, applying concepts from the Model of Actionable Feedback, social nudging, and enhanced active choice. We assessed the acceptability and understandability of the messages through unstructured interviews with local health promotion experts, health-care providers, and pregnant women. FINDINGS: The recurring themes indicated that most women were aware of the health consequences of anaemia, hypertension, and diabetes, but that they seldom associated these conditions with pregnancy. We identified knowledge gaps and low awareness of susceptibility to and severity of these complications and the benefits of timely antenatal care. The actionable messages were iteratively improved with stakeholder and end-user feedback after presenting the initial draft, and the messages deemed were understandable and acceptable based on reflections during unstructured assessment. INTERPRETATION: Following a stepwise iterative process by a theory-based approach and co-designing the intervention with users, we revealed elements critical to an efficacious targeted client communication intervention. A potential limitation of our study is that conducting in-depth interviews on several health conditions simultaneously might have reduced the depth of information we could have obtained. The strength of our study was that we assessed for, developed, and refined the intervention following recommended theoretical frameworks and best practices. The effectiveness of this intervention is under evaluation in a cluster-randomised trial (ISRCTN10520687). FUNDING: European Research Council and Research Council of Norway.

Development of a targeted client communication intervention to women using an electronic maternal and child health registry: a qualitative study.

BACKGROUND: Targeted client communication (TCC) using text messages can inform, motivate and remind pregnant and postpartum women of timely utilization of care. The mixed results of the effectiveness of TCC interventions points to the importance of theory based interventions that are co-design with users. The aim of this paper is to describe the planning, development, and evaluation of a theory led TCC intervention, tailored to pregnant and postpartum women and automated from the Palestinian electronic maternal and child health registry. METHODS: We used the Health Belief Model to develop interview guides to explore women's perceptions of antenatal care (ANC), with a focus on high-risk pregnancy conditions (anemia, hypertensive disorders in pregnancy, gestational diabetes mellitus, and fetal growth restriction), and untimely ANC attendance, issues predefined by a national expert panel as being of high interest. We performed 18 in-depth interviews with women, and eight with healthcare providers in public primary healthcare clinics in the West Bank and Gaza. Grounding on the results of the in-depth interviews, we used concepts from the Model of Actionable Feedback, social nudging and Enhanced Active Choice to compose the TCC content to be sent as text messages. We assessed the acceptability and understandability of the draft text messages through unstructured interviews with local health promotion experts, healthcare providers, and pregnant women. RESULTS: We found low awareness of the importance of timely attendance to ANC, and the benefits of ANC for pregnancy outcomes. We identified knowledge gaps and beliefs in the domains of low awareness of susceptibility to, and severity of, anemia, hypertension, and diabetes complications in pregnancy. To increase the utilization of ANC and bridge the identified gaps, we iteratively composed actionable text messages with users, using recommended message framing models. We developed algorithms to trigger tailored text messages with higher intensity for women with a higher risk profile documented in the electronic health registry. CONCLUSIONS: We developed an optimized TCC intervention underpinned by behavior change theory and concepts, and co-designed with users following an iterative process. The electronic maternal and child health registry can serve as a unique platform for TCC interventions using text messages.

The effect of a digital targeted client communication intervention on pregnant women's worries and satisfaction with antenatal care in Palestine-A cluster randomized controlled trial.

BACKGROUND: The eRegCom cluster randomized controlled trial assesses the effectiveness of targeted client communication (TCC) via short message service (SMS) to pregnant women, from a digital maternal and child health registry (eRegistry) in Palestine, on improving attendance and quality of care. In this paper, we assess whether this TCC intervention could also have unintended consequences on pregnant women's worries, and their satisfaction with antenatal care (ANC). METHODS: We interviewed a sub-sample of Arabic-speaking women attending ANC at public primary healthcare clinics, randomized to either the TCC intervention or no TCC (control) in the eRegCom trial, who were in 38 weeks of gestation and had a phone number registered in the eRegistry. Trained female data collectors interviewed women by phone from 67 intervention and 64 control clusters, after securing informed oral consent. The Arabic interview guide, pilot-tested prior to the data collection, included close-ended questions to capture the woman's socio-demographic status, agreement questions about their satisfaction with ANC services, and the 13-item Cambridge Worry Scale (CWS). We employed a non-inferiority study design and an intention-to-treat analysis approach. RESULTS: A total of 454 women, 239 from the TCC intervention and 215 from the control arm participated in this sub-study. The mean and standard deviation of the CWS were 1.8 (1.9) for the intervention and 2.0 (1.9) for the control arm. The difference in mean between the intervention and control arms was -0.16 (95% CI: -0.31 to -0.01) after adjusting for clustering, which was below the predefined non-inferiority margin of 0.3. Women in both groups were equally satisfied with the ANC services they received. CONCLUSION: The TCC intervention via SMS did not increase pregnancy-related worries among recipients. There was no difference in women's satisfaction with the ANC services between intervention and control arms.

eRegCom-Quality Improvement Dashboard for healthcare providers and Targeted Client Communication to pregnant women using data from an electronic health registry to improve attendance and quality of antenatal care: study protocol for a multi-arm cluster randomized trial.

BACKGROUND: This trial evaluates interventions that utilize data entered at point-of-care in the Palestinian maternal and child eRegistry to generate Quality Improvement Dashboards (QID) for healthcare providers and Targeted Client Communication (TCC) via short message service (SMS) to clients. The aim is to assess the effectiveness of the automated communication strategies from the eRegistry on improving attendance and quality of care for pregnant women. METHODS: This four-arm cluster randomized controlled trial will be conducted in the West Bank and the Gaza Strip, Palestine, and includes 138 clusters (primary healthcare clinics) enrolling from 45 to 3000 pregnancies per year. The intervention tools are the QID and the TCC via SMS, automated from the eRegistry built on the District Health Information Software 2 (DHIS2) Tracker. The primary outcomes are appropriate screening and management of anemia, hypertension, and diabetes during pregnancy and timely attendance to antenatal care. Primary analysis, at the individual level taking the design effect of the clustering into account, will be done as intention-to-treat. DISCUSSION: This trial, embedded in the implementation of the eRegistry in Palestine, will inform the use of digital health interventions as a health systems strengthening approach. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN10520687 . Registered on 18 October 2018.