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Research paper thumbnail of 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

Research paper thumbnail of Comparison of coverage at least one screening of ANC intervention, coverage of appropriate number of screenings prescribed for ANC interventions, and effective coverage of ANC interventions (number and timing of screening of ANC interventions)

<p>Comparison of coverage at least one screening of ANC intervention, coverage of appropria... more <p>Comparison of coverage at least one screening of ANC intervention, coverage of appropriate number of screenings prescribed for ANC interventions, and effective coverage of ANC interventions (number and timing of screening of ANC interventions).</p

Research paper thumbnail of Women with maternal conditions that were referred to health facilities that report to the RHIS, and to health facilities that do not report on antenatal care indicators to the RHIS

<p>RHIS: Routine health information system.</p

Research paper thumbnail of Routinely reported indicators of antenatal care in the RHIS selected for analysis–definitions and data needs for computation from clinical records data

<p>Routinely reported indicators of antenatal care in the RHIS selected for analysis–defini... more <p>Routinely reported indicators of antenatal care in the RHIS selected for analysis–definitions and data needs for computation from clinical records data.</p

Research paper thumbnail of Background sociodemographic characteristics of pregnant women in the sample

<p>Background sociodemographic characteristics of pregnant women in the sample.</p

Research paper thumbnail of Recommended schedule of ANC visits and ANC interventions in the West Bank

<p>Recommended schedule of ANC visits and ANC interventions in the West Bank.</p

Research paper thumbnail of Aggregate reporting in the paper-based routine health information in the West Bank, Palestine, and sources of data used for analyses in this study

<p>Aggregate reporting in the paper-based routine health information in the West Bank, Pale... more <p>Aggregate reporting in the paper-based routine health information in the West Bank, Palestine, and sources of data used for analyses in this study.</p

Research paper thumbnail of Routinely reported maternal conditions from antenatal care–comparison of indicators from all clinical records data and only referred women, and aggregate RHIS reports

<p>Routinely reported maternal conditions from antenatal care–comparison of indicators from... more <p>Routinely reported maternal conditions from antenatal care–comparison of indicators from all clinical records data and only referred women, and aggregate RHIS reports.</p

Research paper thumbnail of 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

Trials

Background This trial evaluates interventions that utilize data entered at point-of-care in the P... more 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....

Research paper thumbnail of eRegTime—Time Spent on Health Information Management in Primary Health Care Clinics Using a Digital Health Registry Versus Paper-Based Documentation: Cluster-Randomized Controlled Trial (Preprint)

BACKGROUND Digital health interventions have been shown to improve data quality and health servic... more BACKGROUND Digital health interventions have been shown to improve data quality and health services in low- and middle-income countries (LMICs). Nonetheless, in LMICs, systematic assessments of time saved with the use of digital tools are rare. We ran a set of cluster-randomized controlled trials as part of the implementation of a digital maternal and child health registry (eRegistry) in the West Bank, Palestine. OBJECTIVE In the eRegTime study, we compared time spent on health information management in clinics that use the eRegistry versus the existing paper-based documentation system. METHODS Intervention (eRegistry) and control (paper documentation) arms were defined by a stratified random subsample of primary health care clinics from the concurrent eRegQual trial. We used time-motion methodology to collect data on antenatal care service provision. Four observers used handheld tablets to record time-use data during one working day per clinic. We estimated relative time spent on h...

Research paper thumbnail of A digital health registry with clinical decision support for improving quality of antenatal care in Palestine (eRegQual): a pragmatic, cluster-randomised, controlled, superiority trial

The Lancet Digital Health

Background Health worker compliance with clinical guidelines is enhanced by digital clinical deci... more Background Health worker compliance with clinical guidelines is enhanced by digital clinical decision support at the point of care. The Palestinian public health system is implementing a digital maternal and child health eRegistry with clinical decision support. We aimed to compare the quality of antenatal care between clinics using the eRegistry and those using paper-based records. Methods The eRegQual cluster-randomised controlled trial was done in primary health-care clinics offering routine antenatal care in the West Bank, Palestine. The intervention was the eRegistry with clinical decision support for antenatal care, implemented in District Health Information Systems 2 (DHIS2) Tracker software. 133 clinics forming 120 clusters were included and randomised; clusters were randomly assigned (1:1) to either the control (paper-based documentation) or intervention (eRegistry with clinical decision support) groups. The primary process outcomes were appropriate screening and management of anaemia, hypertension, and diabetes during pregnancy and foetal growth monitoring. The primary health outcome at delivery was a composite of moderate or severe anaemia; severe hypertension; large-for-gestational-age baby; malpresentation and small-for-gestational-age baby undetected before delivery. Data were analysed with mixed-effects logistic regression, accounting for clustering within clinics and pregnancies as appropriate. This trial is registered with the ISRCTN registry (ISRCTN18008445). Findings Between Jan 15 and Sept 15, 2017, 3219 pregnant women received care in the intervention clinics (n=60 clusters) and 3148 pregnant women received care in the control primary health-care clinics (n=59 clusters). Compared with the control group, the intervention led to higher guideline adherence for screening and management of anaemia (1535 [28•9%] of 5320 vs 2297 [44•3%] of 5182; adjusted odds ratio [OR] 1•88 [95% CI 1•52-2•32]), hypertension (7555 [94•7%] of 7982 vs 7314 [96•6%] of 7569; adjusted OR 1•62 [95% CI 1•29-2•05]), and gestational diabetes (1726 (39•7%) of 4348 vs 2189 (50•7%) of 4321; adjusted OR 1•45 [95% CI 1•14-1•83]) at eligible antenatal contacts. Only 599 (9•4%) of 6367 women attended the full antenatal care schedule, and better care provision did not translate to fewer adverse health outcomes in the intervention clusters (700 cases; 21•7%) compared to the control clusters (688 cases; 21•9%; adjusted OR 0•99; 95% CI 0•87-1•12). Interpretation Clinical decision support for antenatal care in the eRegistry was superior for most process outcomes but had no effect on the adverse health outcomes. The improvements in process outcomes strengthen the evidence for the WHO guideline for digital client tracking with clinical decision support in lower-middle-income settings. Digital health interventions to address gaps in attendance might help achieve effective coverage of antenatal care.

Research paper thumbnail of Data sources used for comparative analyses and their descriptions. <sup>*</sup>

Research paper thumbnail of ANC interventions and infrastructure-related characteristics: effective coverage (%) and adjusted odds ratios from logistic regression analyses

<p>ANC interventions and infrastructure-related characteristics: effective coverage (%) and... more <p>ANC interventions and infrastructure-related characteristics: effective coverage (%) and adjusted odds ratios from logistic regression analyses.</p

Research paper thumbnail of Definitions of indicators of coverage of at least one screening, coverage of appropriate number of screenings, and effective coverage of ANC interventions

<p>Definitions of indicators of coverage of at least one screening, coverage of appropriate... more <p>Definitions of indicators of coverage of at least one screening, coverage of appropriate number of screenings, and effective coverage of ANC interventions.</p

Research paper thumbnail of Additional file 2 of 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

Additional file 2. Oral informed consent and interview guide

Research paper thumbnail of Additional file 1 of 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

Additional file 1. List of participating clinics and allocation

Research paper thumbnail of MOESM3 of Development of a targeted client communication intervention to women using an electronic maternal and child health registry: a qualitative study

Additional file 3. Quotations from the pregnant women and healthcare providers from the in-depth ... more Additional file 3. Quotations from the pregnant women and healthcare providers from the in-depth interviews, Palestine

Research paper thumbnail of MOESM2 of Development of a targeted client communication intervention to women using an electronic maternal and child health registry: a qualitative study

Additional file 2. Theories and concepts used in the design of the Targeted Client Communication ... more Additional file 2. Theories and concepts used in the design of the Targeted Client Communication (TCC) intervention

Research paper thumbnail of MOESM1 of Development of a targeted client communication intervention to women using an electronic maternal and child health registry: a qualitative study

Additional file 1. The timing and services provided according to the Palestinian national antenat... more Additional file 1. The timing and services provided according to the Palestinian national antenatal guidelines and the corresponding high-risk conditions addressed in the tailored Targeted Client Communication (TCC) intervention

Research paper thumbnail of Gestational age recorded at delivery versus estimations using antenatal care data from the Electronic Maternal and Child Health Registry in the West Bank: a comparative analysis

The Lancet, 2021

BACKGROUND Estimated dates of delivery have important consequences for clinical decisions during ... more BACKGROUND Estimated dates of delivery have important consequences for clinical decisions during pregnancy and labour. The Electronic Maternal and Child Health Registry (MCH eRegistry) in Palestine includes antenatal care data and birth data from hospitals. Our objective was to compare computed best estimates of gestational age in the MCH eRegistry with the gestational ages recorded by health-care providers in hospital delivery units. METHODS We obtained data for pregnant women in the West Bank registered in the MCH eRegistry from Jan 1, 2017 to March 31, 2017. Best estimates of gestational age in the registry are automated and based on a standard pregnancy duration of 280 days and ultrasound-based pregnancy dating before 20 weeks' gestation or the woman's last menstrual period date. Hospital recorded gestational ages are reported by care providers in delivery units and are rounded to the nearest week. We calculated proportions of gestational ages (with 95% CIs) from both so...

Research paper thumbnail of 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

Research paper thumbnail of Comparison of coverage at least one screening of ANC intervention, coverage of appropriate number of screenings prescribed for ANC interventions, and effective coverage of ANC interventions (number and timing of screening of ANC interventions)

<p>Comparison of coverage at least one screening of ANC intervention, coverage of appropria... more <p>Comparison of coverage at least one screening of ANC intervention, coverage of appropriate number of screenings prescribed for ANC interventions, and effective coverage of ANC interventions (number and timing of screening of ANC interventions).</p

Research paper thumbnail of Women with maternal conditions that were referred to health facilities that report to the RHIS, and to health facilities that do not report on antenatal care indicators to the RHIS

<p>RHIS: Routine health information system.</p

Research paper thumbnail of Routinely reported indicators of antenatal care in the RHIS selected for analysis–definitions and data needs for computation from clinical records data

<p>Routinely reported indicators of antenatal care in the RHIS selected for analysis–defini... more <p>Routinely reported indicators of antenatal care in the RHIS selected for analysis–definitions and data needs for computation from clinical records data.</p

Research paper thumbnail of Background sociodemographic characteristics of pregnant women in the sample

<p>Background sociodemographic characteristics of pregnant women in the sample.</p

Research paper thumbnail of Recommended schedule of ANC visits and ANC interventions in the West Bank

<p>Recommended schedule of ANC visits and ANC interventions in the West Bank.</p

Research paper thumbnail of Aggregate reporting in the paper-based routine health information in the West Bank, Palestine, and sources of data used for analyses in this study

<p>Aggregate reporting in the paper-based routine health information in the West Bank, Pale... more <p>Aggregate reporting in the paper-based routine health information in the West Bank, Palestine, and sources of data used for analyses in this study.</p

Research paper thumbnail of Routinely reported maternal conditions from antenatal care–comparison of indicators from all clinical records data and only referred women, and aggregate RHIS reports

<p>Routinely reported maternal conditions from antenatal care–comparison of indicators from... more <p>Routinely reported maternal conditions from antenatal care–comparison of indicators from all clinical records data and only referred women, and aggregate RHIS reports.</p

Research paper thumbnail of 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

Trials

Background This trial evaluates interventions that utilize data entered at point-of-care in the P... more 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....

Research paper thumbnail of eRegTime—Time Spent on Health Information Management in Primary Health Care Clinics Using a Digital Health Registry Versus Paper-Based Documentation: Cluster-Randomized Controlled Trial (Preprint)

BACKGROUND Digital health interventions have been shown to improve data quality and health servic... more BACKGROUND Digital health interventions have been shown to improve data quality and health services in low- and middle-income countries (LMICs). Nonetheless, in LMICs, systematic assessments of time saved with the use of digital tools are rare. We ran a set of cluster-randomized controlled trials as part of the implementation of a digital maternal and child health registry (eRegistry) in the West Bank, Palestine. OBJECTIVE In the eRegTime study, we compared time spent on health information management in clinics that use the eRegistry versus the existing paper-based documentation system. METHODS Intervention (eRegistry) and control (paper documentation) arms were defined by a stratified random subsample of primary health care clinics from the concurrent eRegQual trial. We used time-motion methodology to collect data on antenatal care service provision. Four observers used handheld tablets to record time-use data during one working day per clinic. We estimated relative time spent on h...

Research paper thumbnail of A digital health registry with clinical decision support for improving quality of antenatal care in Palestine (eRegQual): a pragmatic, cluster-randomised, controlled, superiority trial

The Lancet Digital Health

Background Health worker compliance with clinical guidelines is enhanced by digital clinical deci... more Background Health worker compliance with clinical guidelines is enhanced by digital clinical decision support at the point of care. The Palestinian public health system is implementing a digital maternal and child health eRegistry with clinical decision support. We aimed to compare the quality of antenatal care between clinics using the eRegistry and those using paper-based records. Methods The eRegQual cluster-randomised controlled trial was done in primary health-care clinics offering routine antenatal care in the West Bank, Palestine. The intervention was the eRegistry with clinical decision support for antenatal care, implemented in District Health Information Systems 2 (DHIS2) Tracker software. 133 clinics forming 120 clusters were included and randomised; clusters were randomly assigned (1:1) to either the control (paper-based documentation) or intervention (eRegistry with clinical decision support) groups. The primary process outcomes were appropriate screening and management of anaemia, hypertension, and diabetes during pregnancy and foetal growth monitoring. The primary health outcome at delivery was a composite of moderate or severe anaemia; severe hypertension; large-for-gestational-age baby; malpresentation and small-for-gestational-age baby undetected before delivery. Data were analysed with mixed-effects logistic regression, accounting for clustering within clinics and pregnancies as appropriate. This trial is registered with the ISRCTN registry (ISRCTN18008445). Findings Between Jan 15 and Sept 15, 2017, 3219 pregnant women received care in the intervention clinics (n=60 clusters) and 3148 pregnant women received care in the control primary health-care clinics (n=59 clusters). Compared with the control group, the intervention led to higher guideline adherence for screening and management of anaemia (1535 [28•9%] of 5320 vs 2297 [44•3%] of 5182; adjusted odds ratio [OR] 1•88 [95% CI 1•52-2•32]), hypertension (7555 [94•7%] of 7982 vs 7314 [96•6%] of 7569; adjusted OR 1•62 [95% CI 1•29-2•05]), and gestational diabetes (1726 (39•7%) of 4348 vs 2189 (50•7%) of 4321; adjusted OR 1•45 [95% CI 1•14-1•83]) at eligible antenatal contacts. Only 599 (9•4%) of 6367 women attended the full antenatal care schedule, and better care provision did not translate to fewer adverse health outcomes in the intervention clusters (700 cases; 21•7%) compared to the control clusters (688 cases; 21•9%; adjusted OR 0•99; 95% CI 0•87-1•12). Interpretation Clinical decision support for antenatal care in the eRegistry was superior for most process outcomes but had no effect on the adverse health outcomes. The improvements in process outcomes strengthen the evidence for the WHO guideline for digital client tracking with clinical decision support in lower-middle-income settings. Digital health interventions to address gaps in attendance might help achieve effective coverage of antenatal care.

Research paper thumbnail of Data sources used for comparative analyses and their descriptions. <sup>*</sup>

Research paper thumbnail of ANC interventions and infrastructure-related characteristics: effective coverage (%) and adjusted odds ratios from logistic regression analyses

<p>ANC interventions and infrastructure-related characteristics: effective coverage (%) and... more <p>ANC interventions and infrastructure-related characteristics: effective coverage (%) and adjusted odds ratios from logistic regression analyses.</p

Research paper thumbnail of Definitions of indicators of coverage of at least one screening, coverage of appropriate number of screenings, and effective coverage of ANC interventions

<p>Definitions of indicators of coverage of at least one screening, coverage of appropriate... more <p>Definitions of indicators of coverage of at least one screening, coverage of appropriate number of screenings, and effective coverage of ANC interventions.</p

Research paper thumbnail of Additional file 2 of 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

Additional file 2. Oral informed consent and interview guide

Research paper thumbnail of Additional file 1 of 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

Additional file 1. List of participating clinics and allocation

Research paper thumbnail of MOESM3 of Development of a targeted client communication intervention to women using an electronic maternal and child health registry: a qualitative study

Additional file 3. Quotations from the pregnant women and healthcare providers from the in-depth ... more Additional file 3. Quotations from the pregnant women and healthcare providers from the in-depth interviews, Palestine

Research paper thumbnail of MOESM2 of Development of a targeted client communication intervention to women using an electronic maternal and child health registry: a qualitative study

Additional file 2. Theories and concepts used in the design of the Targeted Client Communication ... more Additional file 2. Theories and concepts used in the design of the Targeted Client Communication (TCC) intervention

Research paper thumbnail of MOESM1 of Development of a targeted client communication intervention to women using an electronic maternal and child health registry: a qualitative study

Additional file 1. The timing and services provided according to the Palestinian national antenat... more Additional file 1. The timing and services provided according to the Palestinian national antenatal guidelines and the corresponding high-risk conditions addressed in the tailored Targeted Client Communication (TCC) intervention

Research paper thumbnail of Gestational age recorded at delivery versus estimations using antenatal care data from the Electronic Maternal and Child Health Registry in the West Bank: a comparative analysis

The Lancet, 2021

BACKGROUND Estimated dates of delivery have important consequences for clinical decisions during ... more BACKGROUND Estimated dates of delivery have important consequences for clinical decisions during pregnancy and labour. The Electronic Maternal and Child Health Registry (MCH eRegistry) in Palestine includes antenatal care data and birth data from hospitals. Our objective was to compare computed best estimates of gestational age in the MCH eRegistry with the gestational ages recorded by health-care providers in hospital delivery units. METHODS We obtained data for pregnant women in the West Bank registered in the MCH eRegistry from Jan 1, 2017 to March 31, 2017. Best estimates of gestational age in the registry are automated and based on a standard pregnancy duration of 280 days and ultrasound-based pregnancy dating before 20 weeks' gestation or the woman's last menstrual period date. Hospital recorded gestational ages are reported by care providers in delivery units and are rounded to the nearest week. We calculated proportions of gestational ages (with 95% CIs) from both so...