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Obstetrics and gynaecology
Research
Can a midwife-led continuity model improve maternal services in a low-resource setting? A non-randomised cluster intervention study in Palestine
  1. Berit Mortensen1,2,
  2. Mirjam Lukasse3,4,
  3. Lien My Diep5,
  4. Marit Lieng2,6,
  5. Amal Abu-Awad7,
  6. Munjid Suleiman8,
  7. Erik Fosse1,2
  1. 1 The Intervention Centre, Oslo University Hospital, Oslo, Norway
  2. 2 Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
  3. 3 Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
  4. 4 Faculty of Health and Social Sciences, University College of Southeast Norway, Oslo, Norway
  5. 5 Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
  6. 6 Department of Gynaecology, Oslo University Hospital, Oslo, Norway
  7. 7 Department of Education in Health, Palestinian Ministry of Health, Nablus, Palestine
  8. 8 Department of Statistics, Palestinian Ministry of Education and Higher Education, Ramallah, Palestine
  1. Correspondence to Berit Mortensen; beritmor{at}me.com

Abstract

Objectives To improve maternal health services in rural areas, the Palestinian Ministry of Health launched a midwife-led continuity model in the West Bank in 2013. Midwives were deployed weekly from governmental hospitals to provide antenatal and postnatal care in rural clinics. We studied the intervention’s impact on use and quality indicators of maternal services after 2 years’ experience.

Design A non-randomised intervention design was chosen. The study was based on registry data only available at cluster level, 2 years before (2011and2012) and 2 years after (2014and2015) the intervention.

Setting All 53 primary healthcare clinics in Nablus and Jericho regions were stratified for inclusion.

Primary and secondary outcomes Primary outcome was number of antenatal visits. Important secondary outcomes were number of referrals to specialist care and number of postnatal home visits. Differences in changes within the two groups before and after the intervention were compared by using mixed effect models.

Results 14 intervention clinics and 25 control clinics were included. Number of antenatal visits increased by 1.16 per woman in the intervention clinics, while declined by 0.39 in the control clinics, giving a statistically significant difference in change of 1.55 visits (95% CI 0.90 to 2.21). A statistically significant difference in number of referrals was observed between the groups, giving a ratio of rate ratios of 3.65 (2.78–4.78) as number of referrals increased by a rate ratio of 3.87 in the intervention group, while in the control the rate ratio was only 1.06.

Home visits increased substantially in the intervention group but decreased in the control group, giving a ratio of RR 97.65 (45.20 - 210.96)

Conclusion The Palestinian midwife-led continuity model improved use and some quality indicators of maternal services. More research should be done to investigate if the model influenced individual health outcomes and satisfaction with care.

Trial registration number NCT03145571; Results.

  • continuity of care
  • midwifery
  • organisation of health services
  • quality in health care
  • maternal care
  • low- middle income country

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjopen-2017-019568

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    Footnotes

    • Contributors BM was involved in the implementation, study design, datacollection, data analysis, data interpretation and writing and drafted the article, figures and tables. MiL was involved in study design, datainterpretation and writing. LMD was involved with study design, data analysisand writing. MaL was involved in study design, data interpretation and writing. AAA with the implementation, data interpretation and writing. MS conducted collection and systematisation of data. EF was involved in study design, datacollection, data analysis, data interpretation and writing. All authors have reviewed and approved the final manuscript.

    • Funding This work was partly supported by the Research Council of Norway through the Global Health and Vaccination Program (GLOBVAC), project number 243706 and partly by public funding through Norwegian Aid Committee(NORWAC). Three of the authors were partly employed by NORWAC and were involved in the implementation and interpretation of data. The analysis was performed by a statistician at Oslo University Hospital. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

    • Competing interests None declared.

    • Patient consent Not required.

    • Ethics approval The study was approved by the Norwegian Regional Committee for Medical Health Research Ethics South East (REK) id number: 2015/1235. It was also approved by the Palestinian Ministry of Health.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement The data file is available upon request to the corresponding author after receiving approval from the Palestinian Ministry of Health.