Effectiveness of midwife led continuity of care (MLCC) caseload model: An interventional explanatory sequential mixed methods study at Mchinji District Hospital, Malawi
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Date
2021-03-17
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Kamuzu University of Health Sciences
Abstract
Type of study: An interventional explanatory sequential mixed methods study that will utilize both quantitative
and qualitative data collection methods and analysis.
The problem: Worldwide, maternal and neonatal morbidity and mortality remain a public health concern and
improving maternal and neonatal health is a key focus in most countries. The World Health Organisation
(WHO) reports that in 2017 there were 295,000 women across the globe who died as a result of pregnancy
related complications representing a maternal mortality ratio (MMR) of 211 deaths/100,000 live births.
Similarly, 2.5 million neonates died, and the majority of these neonatal deaths were due to preterm birth (PTB)
complications. Most of the maternal (66%) and neonatal (41%) deaths occurred in sub-Saharan Africa alone.
Similar to other countries in sub-Saharan Africa, Malawi has high maternal and neonatal mortality ratios (439
deaths/100,000 live births and 27 deaths/1,000 live births respectively). In response, United Nations (UN)
developed the 2030 Sustainable Development Goals (SDGs), to work with countries across the globe to
improve development outcomes including maternal and neonatal outcomes. The SDG target 3.1 and 3.2 aim
towards reducing global maternal deaths to 70 per 100,000 live births and neonatal deaths to 12 per 1000 live
births by the year 2030. Similarly, the Malawi government developed strategies to improve maternal and
neonatal health, however, barriers to accessing, utilising, and financing maternity services poses a challenge to
improving these outcomes. To achieve these targets and end avoidable maternal and neonatal deaths, country
specific interventions are needed. The antenatal period provides a first entry point within the childbirth
continuum, to implement effective interventions aimed at improving maternal and neonatal health, through
prevention, detection, and management of obstetric complications. Timely implementation of antenatal care
(ANC) services could reduce maternal and neonatal deaths, however, statistics for sub-Saharan Africa,
including Malawi, show underutilization and low attendance for ANC services. Of the 95% women who attend
at least one ANC contact in Malawi, only 51% attend four or more ANC contacts, and only 24% attend the
initial ANC contact during the first trimester of pregnancy. The low utilization of ANC services especially in
regions with high maternal and neonatal deaths puts women at increased risk of adverse outcomes such as
preterm births. The WHO developed recommendations on antenatal care for a positive pregnancy experience to
help countries implement evidence-based interventions to improve maternal and neonatal health. One of the
recommendation relevant to this study, is the WHO’s recommendation of Midwife Led Continuity of Care
(MLCC) during pregnancy. In MLCC models women receive care from the same caregiver (caseload) or a
small group of midwives (team) during the childbirth continuum. Use of MLCC models has been associated
with improved ANC utilization and childbirth outcomes. Antenatal care in Malawi is based on a fragmented
Standard Antenatal Care (SANC) model with care provision from different midwives and doctors. Evidence
indicates that most of the current strategies, employed by Malawi in the SANC model, may not be optimal and
there is a need to adopt and evaluate strategies that have worked effectively in other countries. A new modified
service delivery model, the MLCC caseload model recommended by WHO, could be one strategy worth
implementing and evaluating in Malawi. Although the MLCC caseload model is acceptable and effective in
developed countries, no country in Africa has adopted this model to date. There is a lack of literature on the
effectiveness of caseload model in developing countries and a thorough search of the literature did not return
any study on caseload model in sub-Saharan Africa. Studies conducted in sub-Saharan Africa including Malawi
on ANC models have concentrated on ‘group’ ANC model, a model different from WHO’s recommended
caseload model. A thorough search of the literature could not find any study on caseload model in Malawi and
sub-Saharan Africa.
Aim and specific objectives: The main aim of the proposed study is to examine effectiveness of the caseload
model in improving childbirth outcomes and explore experiences of midwives working in the model. The
following specific objectives will be addressed:
1. Describe socio-demographic and obstetric characteristics of women who receive care through the
caseload model with women who receive care through SANC model. 2. Examine whether a caseload model decreases rate of PTB among women when compared with SANC
model
3. Compare women’s satisfaction with ANC in caseload model versus SANC model
4. Compare maternal outcomes (ANC attendance, admission to ANC ward, place of birth, labour onset,
mode of birth, anaemia, malaria, antepartum haemorrhage, postpartum haemorrhage, hypertensive
disorders of pregnancy, maternal death) of women who receive care in the caseload model with women
who receive care in SANC model.
5. Compare other neonatal outcomes (birth weight, fetal and neonatal loss, Apgar score, admission to
neonatal ward, initiation of breast feeding, initiation of skin-to-skin contact) among women who receive
care in the caseload model and SANC model.
6. Explore midwives’ experiences of working in a caseload model.
Methodology: An interventional explanatory sequential mixed methods study will be conducted at Mchinji
District Hospital (MDH) in Malawi in two phases. In phase one, a post-test only parallel randomised clinical
trial (RCT) will be conducted to test the intervention (caseload model). A sample of 1206 pregnant women aged
18 and above with a gestation of less than 20 weeks at initial ANC contact will be randomly allocated to
caseload or SANC model. Data will be collected on primary and secondary outcome variables and analysed
using descriptive and inferential statistical tests in Statistical Package for the Social Sciences (SPSS) version
26. Reporting of the data will follow the CONsolidated Standards of Reporting Trials (CONSORT) guidelines
for reporting of RCT’s. In phase two, a qualitative descriptive design will be used to explore midwives’
experiences of working in the caseload model. All six midwives working in the caseload model will be asked to
participate in individual in-depth interviews on completion of the study. NVivo software version 12 will be
used to organise data using thematic analysis by identifying codes and common themes emerging. Ethical
considerations such as privacy, anonymity, voluntary participation, doing no harm will be observed throughout
the study period. The first ethics approval has been obtained from Curtin Human Research Ethics Committee
(HRE2020-0752) and the second ethics approval will be obtained from Malawi College of Medicine Research
Ethics Committee (COMREC). Permission to conduct the study at MDH has been granted by the Director of
Health and Social Services, Mchinji District Health Office and the Director of Reproductive Health Services,
Ministry of Health, Malawi. The RCT has been registered with the Australian New Zealand Clinical Trials
Registry (ACTRN12621000008820p).
Expected findings and dissemination: The study will provide evidence on the effectiveness of the caseload
model in improving childbirth outcomes and experiences of midwives working in a caseload model at Mchinji
District Hospital, Malawi. Based upon the evidence around caseload model, the anticipated outcomes could
include, increased number of antenatal attendances, reduced rates of PTB, reduced prevalence of Low Birth
Weight (LBW) neonates, fewer admissions to high risk ANC ward, increased proportion of spontaneous
vaginal births, early initiation of breastfeeding within the first hour of birth, reduced admissions to neonatal
ward, reduced proportion of fetal and neonatal deaths and greater maternal satisfaction with ANC. The caseload
model in this study will provide women with more information and knowledge on pregnancy, birth and
postnatal, through antenatal appointments with a known trusted midwife. Furthermore, increased engagement
of women with a known midwife may improve the midwife-woman relationship, increasing job satisfaction for
midwives. Exploring midwives’ experiences and views could also inform policy makers in Malawi on how the
model can be adapted and expanded to other settings. Study results and findings will be disseminated through
publication in journals, research conference presentations and dissertation publication at Curtin University
online Library.
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Research Subject Categories::MEDICINE