Effectiveness of midwife led continuity of care (MLCC) caseload model: An interventional explanatory sequential mixed methods study at Mchinji District Hospital, Malawi
| dc.contributor.author | Zileni, Barbara Debra | |
| dc.date.accessioned | 2021-11-24T10:41:37Z | |
| dc.date.available | 2021-11-24T10:41:37Z | |
| dc.date.issued | 2021-03-17 | |
| dc.description.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. | en_US |
| dc.description.sponsorship | Curtin University, School of Nursing, Midwifery and Paramedicine; Kamuzu University of Health Sciences. | en_US |
| dc.identifier.uri | http://rscarchive.kuhes.ac.mw/handle/20.500.12988/359 | |
| dc.language.iso | en | en_US |
| dc.publisher | Kamuzu University of Health Sciences | en_US |
| dc.relation.ispartofseries | Ethics Protocol;P.01/21/3243 | |
| dc.subject | Research Subject Categories::MEDICINE | en_US |
| dc.title | Effectiveness of midwife led continuity of care (MLCC) caseload model: An interventional explanatory sequential mixed methods study at Mchinji District Hospital, Malawi | en_US |
| dc.type | Plan or blueprint | en_US |