BMJ Open: first published as 10.1136/bmjopen-2017-019568 on 22 March 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 29, 2021 by guest. Protected copyright. BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-019568 on 22 March 2018. Downloaded from CAN A MIDWIFERY-LED CONTINUITY MODEL IMPROVE MATERNAL SERVICES IN A LOW RESOURCE SETTING? – A NON-RANDOMIZED CLUSTER INTERVENTION STUDY IN PALESTINE ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2017-019568 Article Type: Research Date Submitted by the Author: 12-Sep-2017 Complete List of Authors: Mortensen, Berit; Oslo Universitetssykehus Intervensjonssenteret; Universitetet i Oslo Institutt for klinisk medisin Lukasse, Mirjam; Oslo and Akershus University College, Norway, Faculty of Health Sciences; Norwegian University of Science and Technology, Department of Obstetrics and Gynaecology Diep, Lien; University of Oslo, International Health; Oslo University Hospital, Unit for biostatistics and epidemiology Lieng, Marit; Oslo University Hospital, Ullevål, Department of Obstetrics Awad, Amal; Palestinian Ministry of Health Suleiman, Munjid; Palestinian Ministry of Education and Higher Education Fosse, Erik; The Intervention Centre, Oslo University Hospital Rikshospitalet, Oslo, Norway; Institute for clinical medicine, Faculty of http://bmjopen.bmj.com/ Medicine, University of Oslo, Oslo, Norway <b>Primary Subject Obstetrics and gynaecology Heading</b>: Secondary Subject Heading: Global health, Public health, Health services research, Mental health Continuity of care, Midwifery, Organisation of health services < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Quality in health care < Keywords: on September 29, 2021 by guest. Protected copyright. HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Community child health < PAEDIATRICS, Maternal care 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-2017-019568 on 22 March 2018. Downloaded from 1 2 3 CAN A MIDWIFERY-LED CONTINUITY MODEL IMPROVE MATERNAL 4 SERVICES IN A LOW RESOURCE SETTING? – A NON-RANDOMIZED CLUSTER 5 6 INTERVENTION STUDY IN PALESTINE 7 1 ,2 3,4 5 2,6 8 Berit Mortensen MCs , Mirjam Lukasse PhD , Lien My Diep MSc , Marit Lieng PhD , 9 Amal Abu Awad, PhD7, Munjid Suleiman MCs8 Erik Fosse PhD1,2 10 11 12 Corresponding author: Berit Mortensen, Wilhelm Færdens vei 4b, 0361 Oslo, 13 14 [email protected] mobile: 0047-93266113 15 Abstract 16 For peer review only 17 Objectives To improve maternal health services in rural areas the Palestinian Ministry of 18 Health launched a midwifery-led continuity model in the West Bank in 2013 in cooperation 19 20 with Norwegian Aid Committee. Midwives were weekly deployed from governmental 21 22 hospitals to provide ante- and postnatal-care in rural clinics. We studied the intervention`s 23 impact on utilization and quality indicators of maternal services after two years’ experience. 24 25 Design: A non-randomized, intervention design was chosen. The study was based on registry 26 27 data only available at cluster level, two years before (2011 & 2012) and two ears after (2014 28 & 2015) the intervention. 29 30 Setting: A total of 53 primary health care clinics in Nablus and Jericho regions were stratified 31 for inclusion. 32 http://bmjopen.bmj.com/ 33 Primary and secondary outcomes: Primary outcome was number of antenatal visits. 34 35 Important secondary outcomes were number of referrals to specialist care and number of 36 postnatal home-visits. Differences in changes within the two groups before and after the 37 38 intervention were compared by using mixed effect models. 39 Results: 14 intervention-clinics, and 25 control-clinics were included in the study. Number of 40 on September 29, 2021 by guest. Protected copyright. 41 antenatal visits increased by 1.16 per woman in the intervention-clinics while it declined by 42 43 0.39 in the control-clinics, giving a significant difference in change of 1.55 visits [95% CI 44 0.90 – 2.21]. A significant difference rate in number of referrals was observed between the 45 46 groups 3.65 [2.78 – 4.78] as number of referrals increased by a rate ratio of 3.87 in the 47 48 intervention group while in the control the change-ratio was only 1.06. 49 Home-visits increased substantially in the intervention group, but decreased in control group 50 51 giving a difference RR 97.65 (45.20 - 210.96) 52 Conclusion: The Palestinian midwifery-led continuity model improved utilization and some 53 54 quality indicators of maternal services. More research should be done to investigate if the 55 56 model had effect on individual health outcomes and satisfaction of care. 57 58 1 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 20 BMJ Open: first published as 10.1136/bmjopen-2017-019568 on 22 March 2018. Downloaded from 1 2 3 Trial registration: ClinicalTrials.gov Identifier: NCT03145571 4 5 6 Strengths and Limitations of the study 7 • The pragmatic approach strengthens the applicability to real life settings. 8 9 • The high number of clusters and the robust cluster data strengthen the study. 10 11 • A randomized allocation of clusters was not possible because the implementation of 12 the midwifery-led continuity model started before the study was planned. 13 14 • The ministry implemented the program in the clinics they found appropriate which 15 16 could leadFor to bias. peer review only 17 • The facility-based registry did not include data on individual level. 18 19 INTRODUCTION 20 1 21 As a low-middle-income country under occupation, Palestine depend largely on foreign aid. 22 The Palestinian Authority is responsible for the health services for the Palestinian people 23 24 within the occupied territories of West Bank and Gaza. In 2013, the Palestinian Ministry of 25 Health, registered 61 405 births and a fertility rate of 4.0 per woman on the West Bank.2 26 27 Maternal health services were provided by the Palestinian government and private, and non- 28 29 governmental organisations. Less than 1% of the women gave birth at home. Governmental 30 facilities covered 45.6% of antenatal-care in 2013. The Palestinian Multiple Indicator Cluster 31 32 Survey from 2014 found that 66.4% of rural women gave birth in governmental hospitals. Of http://bmjopen.bmj.com/ 33 34 them 40.7% left hospital within 6 hours postpartum and 73% did not receive any additional 35 postnatal-care.3 36 37 In 2009 the Palestinian governmental maternal services were described as of poor quality, 38 overcrowded, understaffed, including short antenatal visits lacking content, and dissatisfaction 39 40 4 5 with care. Overcrowded labour rooms prohibited women bringing a birth companion. on September 29, 2021 by guest. Protected copyright. 41 42 Midwives had restricted scope of practice and little autonomy, and few worked in antenatal- 43 care.6 The clinics were not able to implement postnatal home-visits as required by 44 45 governmental standards.6 Poor women were less likely to have postnatal-care.7 46 47 Poverty, deprived infrastructure, military checkpoints and armed Israeli settlers restricts 48 freedom of movement and reduces access to central health-facilities and legal aid in rural 49 8,9 50 areas. Rural women depend more on governmental facilities than women in urban areas, as 51 10 private services are scarce. 52 53 Several studies describe how midwifery-led continuity models improved health for mothers 54 11-16 55 and babies. Most studies were from high-income countries. World Health Organisation 56 (WHO) recommends implementation and research on midwifery-led continuity models to 57 58 2 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 20 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-019568 on 22 March 2018. Downloaded from 1 2 17 3 improve quality in low- and middle-income countries. Two main ways of organizing such 4 models are described in the literature. In the case-load model one midwife cares for up to 40 5 6 women and facilitate relational continuity, while in the team-midwifery model a group of 4-6 7 8 midwives can provide care for up to 360 women through pregnancy, birth and postnatally. 9 Ideally, in both models, women are cared for during birth by a known midwife.11,17 10 11 To improve services in rural areas, the Palestinian Ministry of Health in cooperation with the 12 non-governmental humanitarian organization Norwegian Aid Committee (NORWAC), 13 14 launched implementation of a modified midwifery-led continuity, case-load-model, in 2013, 15 16 starting in NablusFor and Jericho peer Governmental review hospitals and surrounding only villages. The 17 implementation engaged several levels in the ministry of health and the involved 18 19 communities, to overcome known barriers to quality of care.18 20 21 The aim of this study was to investigate whether the Palestinian midwifery-led continuity 22 model had impact on the utilization of services and selected quality indicators at the two 23 24 regions` clinics after two years of experience.