Effectiveness of a Midwife Led Continuity of Antenatal care caseload model on preterm birth and maternal satisfaction among women in Malawi

MIDWIFE LED CONTINUITY OF ANTENATAL CARE CASELOAD MODEL (INTERVENTION) The study intervention is midwife led continuity of antenatal care caseload model. Pregnant women allocated to the midwife led continuity of antenatal care caseload model will receive antenatal care from a known primary midwife from their first antenatal care contact to their last antenatal care contact. The women will have a minimum of eight scheduled individual antenatal care contacts with their primary midwife, who will provide 30-minute appointments for each scheduled contact. The antenatal care (assessments, care and health information) will be provided using the current Malawi antenatal care guidelines and matrix, which stipulate that each woman should attend a minimum of eight antenatal care contacts as follows: 1st contact up to 12 weeks; 2nd contact at 20 weeks; 3rd contact at 26 weeks; 4th contact at 30 weeks; 5th contact at 34 weeks; 6th contact at 36 weeks, 7th contact at 38 weeks and 8th contact at 40 weeks gestation. Within each antenatal care contact the primary midwife will conduct maternal and fetal assessments, provide care on prevention of malaria, anaemia and infection, and health information on diet, exercise, contraception, birth preparedness, breastfeeding and danger sign to each woman, which will provide women with increased information and knowledge through longer antenatal appointments with a known primary midwife. If a woman develops any complication, she will be referred to a medical doctor for further management and the primary midwife will continue to provide antenatal care in addition to the medical or obstetric care. Women allocated to the caseload model will be encouraged to contact their primary midwife by mobile phone when they have questions, concerns or need further clarification. STAFFING OF MIDWIVES TO MIDWIFE LED CONTINUITY OF ANTENATAL CARE CASELOAD MODEL In order to staff the study intervention, a total of six primary midwives will be employed to provide antenatal care to approximately 603 women allocated to the caseload model, 100 women each, and they will work up to 40 hours per week, Monday to Friday on shifts as previously arranged in accordance with the schedule of his/her individual woman. The primary midwives will be paired to provide backup should the other midwife be absent, and the backup midwife will be introduced to women of the other midwife within the first three antenatal care contacts. To be eligible to work in the caseload model, the midwife must be registered with Nurses and Midwives Council of Malawi, have a minimum of one-year work experience in a maternity setting and demonstrate interest in caseload model. The midwives will continue to work under the professional supervision of the hospital matrons and the District Nursing and Midwifery Officer of Mchinji District Hospital, Malawi. ADHERENCE TO STUDY PROTOCOLS AND INTERVENTION EVALUATION Two weeks before commencement of the study, all midwives working at the antenatal clinic of Mchinji District Hospital, Malawi will undergo a one-day training where they will be re-oriented to Malawi guidelines for providing antenatal care and the study protocols. The primary midwives will have an additional one-day training where they will be oriented to principles behind caseload model. Three facilitators, the researcher (BDZ), matron of the antenatal clinic and an officer from Quality Assurance Directorate of Malawi will train the midwives using study specific training material and current Malawi antenatal care guidelines. Adherence to guidelines for the caseload model will be ascertained through monthly meetings between the research team, hospital matrons, primary midwives and officers from Quality Assurance Directorate of Malawi who conduct monthly supervision of government hospitals in Malawi. At the final monthly meeting, questions on compliance to study interventions will be asked to primary midwives to ascertain whether study implementation guidelines were adhered to. In addition, there will be weekly checks of data entered in the electronic database to assess adherence to data entry guidelines. Women’s exposure to the caseload model will be measured by checking quality and quantity of data on care provision captured in the maternity record books. In addition, a survey with women at the last antenatal care contact will include questions on model of care to check if they had a known primary midwife and the number of antenatal care contacts they had with the midwife/midwives.