Abstract
SummaryBackgroundHealth 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.MethodsThe 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).FindingsBetween 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).InterpretationClinical 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.FundingEuropean Research Council and Research Council of Norway.TranslationFor the Arabic translation of the abstract see Supplementary Materials section.
Highlights
Universal effective coverage of antenatal care is key to fulfil the promises of the UN’s Global Strategy for Women’s, Children’s, and Adolescents’ Health, and to achieve the UN Sustainable Development Goal (SDG) targets for maternal and child health
In the eRegQual trial, we developed and tested the effectiveness of a clinical decision support system based on guidelines of care in the public health system
Between Jan 15 and Sept 15, 2017, 3219 pregnant women presented themselves for antenatal care in the intervention group (n=60 clusters, mean cluster size 78·4 pregnancies per cluster) as did 3148 pregnant women in the control group (n=59 clusters, mean cluster size 74·8; figure 1)
Summary
Universal effective coverage of antenatal care is key to fulfil the promises of the UN’s Global Strategy for Women’s, Children’s, and Adolescents’ Health, and to achieve the UN Sustainable Development Goal (SDG) targets for maternal and child health. The Lancet Global Health Commission on high-quality health systems in the SDG era asserted that “providing health services without guaranteeing a minimum level of quality is ineffective, wasteful, and unethical”.1. This remains a challenge in low-income and middle-income countries (LMICs).[1,2]. WHO underlines that, despite the promise of digital health interventions, evidence of their effectiveness is scarce, and there are multiple contextual implementation challenges.[4] www.thelancet.com/digital-health Vol 4 February 2022
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