Maternal and child health in the occupied Palestinian territory

The epidemiology of gestational diabetes, gestation hypertension, and anemia in North Palestine from 2018 to 2020: A retrospective study

BACKGROUND

In Palestine, women face a challenging environment and a demanding lifestyle, which puts them at a higher risk of experiencing complications during pregnancy. This study aimed to examine the risk factors linked with abnormal hemoglobin (Hb) levels, gestational diabetes (GD), and gestational hypertension (GH) among pregnant women. The results was compared between women residing in cities or villages areas and those in refugee camps.

METHODS

Medical records (N = 7889) for pregnant women at primary healthcare centers in the North West Bank were reviewed for sociodemographic and medical data along with the reported fasting blood sugar, hemoglobin, and blood pressure in the first and second trimesters from July 2018 to July 2020. However, only 6640 were included in the analysis as 1249 were excluded for having multiple pregnancy or lost to follow up. Complications and risk factors were defined according to the available global guidelines. Then, descriptive analysis was used to show the percentages of different risk factors and complications among them. The correlation between the several characteristics and variables with these complications was assessed by calculating the odds ratios (OR) using logistic regression. P-values of <0.05 were considered significant.

RESULTS

The prevalence of adolescent pregnancy was the highest among women living in rural areas (9.8%) and grand multigravidity among refugee women (22%). The overall prevalence of anemia was higher in the second-trimester (16.2%) than in the first-trimester (11.2%), with anemic women in the first-trimester being more likely to be anemic in the second-trimester (OR = 8.223, P-value<0.001). Although anemia was less common in the first-trimester among refugees than among women living in urban areas (OR = 0.768, P-value = 0.006), it was more prevalent in the second-trimester (OR = 1.352, P-value<0.001). Moreover, refugee women were at lower risk than women living in urban areas of having GD (OR = 0.687, P-value<0.001) and diabetes mellitus (OR = 0.472, P-value<0.001) in the second-trimester. GH was associated with GD (OR = 1.401, P-value = 0.003) and DM (OR = 1.966, P-value<0.001).

CONCLUSION

The findings of this study provide evidence-based data on the considerable prevalence of pregnancy complications, anemia, GD, and GH among Palestinian pregnant women living in the north of the West Bank. Multi gravida, gestational age, Hb levels, and the type of settings were strong predictors of pregnancy complications. Therefore, a national plan is needed to ensure adequate maternal care for all, especially disadvantaged women, those in rural areas and refugee camps.

The Effect of the COVID-19 Pandemic on Palestinian Patients Attending Selected Governmental Hospitals: An Analysis of Hospital Records

INTRODUCTION

Confronting the COVID-19 epidemic forced the closure or relocation of the majority of health facilities. It is likely that non-COVID-19 patients suffered collateral effects.

METHODS

The clinic and operating room records were analyzed at selected Palestinian government hospitals in the West Bank region.

RESULTS

The reduction in patient clinic visits varied from 49% to 90%, with Ear-Nose-Throat (ENT), urology, and pediatric clinics being the most affected. The reduction in operation numbers in the center (which had independent decision-making) ranged from 7.1% to 23.4%, but in the north and south (which followed centralized choices), the reduction ranged from 19.6% to 91.8%.

CONCLUSIONS

COVID-19 affected outpatient visits. The pandemic affected some services, but West Bank hospitals were able to provide normal obstetric and gynecological treatments and help patients who needed primary or intermediate surgery.

Understanding coverage of antenatal care in Palestine: Cross-sectional analysis of Palestinian Multiple Indicator Cluster Survey, 2019-2020

INTRODUCTION

Antenatal care is an essential component of primary healthcare, providing opportunities to screen, prevent, and treat morbidity to preserve the health of mothers and offspring. The World Health Organization now recommends a minimum of eight antenatal care contacts, instead of four, which is challenging in countries exposed to political violence and structural disparities in access to social, economic and healthcare resources as exist in Palestine. This study examines the compliance of the recommend standard of antenatal care in Palestine.

METHODS

We analyzed data from the UNICEF's Palestinian Multiple Indicator Cluster Survey (MICS) 2019-2020. The eligible sample consisted of 2,028 women, 15-49 years of age, living in Palestine, on whom data were available on reported antenatal care services received during the most recent pregnancy within the last two years. Outcome variables of interest were the reported frequencies of antenatal care visits, gestational timing of 1st visit, and services received. Potential risk factors were assessed in women attending less than eight versus eight or more antenatal contacts, as recommended by WHO, by estimating prevalence ratios with 95% Confidence Intervals.

RESULTS

Overall, 28% of women did not meet the WHO's recommendation of eight or more antenatal contacts, varying from 18% in Central West Bank to 33% in South West Bank across the four areas of Palestine (North, Central, and South West Bank and Gaza Strip). Twelve percent of women reported having had no antenatal contacts in the 1st trimester, and these women were two- to three-folds more unlikely to meet WHO recommendation of antenatal contacts than mothers who initiated the antenatal contact in the 1st trimester. Women who had less than eight antenatal contacts were generally poorer, higher in parity, lived in North and South West Bank, sought ANC from either doctor or nurse/midwife only, and initiated antenatal contact in 2nd-to-3rd trimesters.

CONCLUSION

There were considerable socioeconomic and geographic inequalities in the prevalence of not meeting WHO recommended number of antenatal contacts in Palestine, offering the opportunity to inform, improve and continuously reassess coverage of antenatal care.

Exploring women's experiences during childbirth in health facilities during COVID-19 pandemic in occupied palestinian territory: a cross-sectional community survey

INTRODUCTION

This study aims to assess the prevalence of mistreatment during childbirth in the occupied Palestinian territory and to explore factors associated with mistreatment.

METHODS

A cross-sectional study of women who gave birth in the West Bank and Gaza Strip health facilities. The survey was administered over the phone to women up to 8 weeks post-partum. Data collection took place between July 2020 and March 2021.

RESULTS

A total of 745 women participated in the study, 36·25% were from the Gaza Strip and 63·75% from the West Bank. The prevalence of mistreatment was 18·8% in which women reported any verbal abuse, physical abuse, or stigma or discrimination during childbirth, with verbal abuse as the most common form of mistreatment reported. Physical abuse was more likely to be reported by women with no labour companion with them (OR: 3·11, 95%CI: 1·24 - 7·99). Verbal abuse was more likely to be reported by women with less than three live births (OR: 1·71, 95%CI: 1·06 - 2·76, women with no birth companion (OR: 2·72, 95%CI: 1·36 - 3·80) and more likely to be reported if curtains wre not used (OR: 2·55, 95%CI: 1·33 - 4·88). Women with less education were more likely to report long waiting times or delays in receiving services compared to women with higher education (OR: 1·40, 95%CI: 1·06 - 2·10).

CONCLUSION

For the first time using the World Health Organisation (WHO) tool in the Eastern Mediterranean region, the study findings, show the occurrence of mistreatment and identify areas to be strengthened to ensure that all women have a respectful childbirth experience within health facilities.

Mistreatment of Women during Childbirth and Associated Factors in Northern West Bank, Palestine

Mistreatment of women during childbirth is a clear breach of women's rights during childbirth. This study aimed to determine the prevalence and associated factors of mistreatment of women during childbirth in the north of West Bank, Palestine. A cross-sectional study was conducted among 269 women within the first 16 weeks of their last vaginal childbirth to understand the childbirth events by using proportionate stratified random sampling. An Arabic valid questionnaire was used as a study instrument. Simple and multiple logistic regression analyses were conducted to determine the factors associated with each type of mistreatment. The mean age of the women was 26.5 (SD 4.77) years. The overall prevalence of mistreatment was 97.8%. There were six types of mistreatment. Nine factors were significantly associated with the occurrence of one or more types of mistreatment. Delivery at a public childbirth facility was associated with all of the six types (aAdjOR: 2.17-16.77; p-values < 0.001-0.013). Women who lived in villages (aAdjOR 2.33; p-value = 0.047), had low education (aAdjOR 5.09; p-value = 0.004), underwent induction of labour (aAdjOR 3.03; p-value = 0.001), had a long duration of labour (aAdjOR 1.10; p-value = 0.011), did not receive pain killers (aAdjOR: 2.18-3.63; p-values = 0.010-0.020), or had an episiotomy or tear (aAdjOR 5.98; p-value < 0.001) were more likely to experience one or more types of mistreatment. With every one-hour increase in the duration of labor, women were 1.099 times more likely to experience a failure to meet the professional standard of care. Women were less likely to experience mistreatment with increasing age. Women with increasing age (aAdjOR: 0.91-0.92; p-values = 0.003-0.014) and parity (aAdjOR 0.72; p-value = 0.010) were less likely to experience mistreatment. Awareness of women's fundamental rights during childbirth, making the childbirth process as normal as possible, and improving the childbirth facilities' conditions, policies, practices and working environment may decrease mistreatment occurrence.

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

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. Primary analysis, at the individual level taking the design effect of the clustering into account, will be done as intention-to-treat.

DISCUSSION

This trial, embedded in the implementation of the eRegistry in Palestine, will inform the use of digital health interventions as a health systems strengthening approach.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN10520687 . Registered on 18 October 2018.

Women's satisfaction with midwife-led continuity of care: an observational study in Palestine

OBJECTIVES

A midwife-led continuity model of care had been implemented in the Palestinian governmental health system to improve maternal services in several rural areas. This study investigated if the model influenced women's satisfaction with care, during antenatal, intrapartum and postnatal period.

DESIGN

An observational case-control design was used to compare the midwife-led continuity model of care with regular maternity care.

PARTICIPANTS AND SETTING

Women with singleton pregnancies, who had registered for antenatal care at a rural governmental clinic in the West Bank, were between 1 to 6 months after birth invited to answer a questionnaire rating satisfaction with care in 7-point Likert scales.

PRIMARY OUTCOME

The mean sum-score of satisfaction with care through the continuum of antenatal, intrapartum and postnatal period, where mean sum-scores range from 1 (lowest) to 7 (highest).

SECONDARY OUTCOME

Exclusive breastfeeding.

RESULTS

Two hundred women answered the questionnaire, 100 who received the midwife-led model and 100 who received regular care. The median time point of interview were 16 weeks postpartum in both groups. The midwife-led model was associated with a statistically significant higher satisfaction with care during antenatal, intrapartum and postnatal period, with a mean sum-score of 5.2 versus 4.8 in the group receiving regular care. The adjusted mean difference between the groups' sum-score of satisfaction with care was 0.6 (95% CI 0.35 to 0.85), p<0.0001. A statistically significant higher proportion of women who received the midwife-led continuity model of care were still exclusively breastfeeding at the time point of interview, 67% versus 46% in the group receiving regular care, an adjusted OR of 2.56 (1.35 to 4.88) p=0.004.

CONCLUSIONS

There is an association between receiving midwife-led continuity of care and increased satisfaction with care through the continuum of pregnancy, intrapartum and postpartum period, and an increased duration of exclusive breastfeeding.

TRIAL REGISTRATION NUMBER

NCT03863600.

Maternal and child access to care and intensity of conflict in the occupied Palestinian territory: a pseudo longitudinal analysis (2000-2014)

Background

In the occupied Palestinian territory (oPt), access to maternal and child healthcare (MCH) services are constrained due to the prolonged Israeli military occupation, the Separation Wall, army checkpoints, and restrictions on the movement of people and goods. This study assesses the relationship between conflict intensity and access to Maternal and Child Health care in occupied Palestinian territory (oPt). To the best of our knowledge, the impact of conflict on access to health care has not been measured due to the lack of data.

Methods

We analyse pooled data from household surveys covering a fifteen-year period (2000–2014) of children (n = 16,793) and women (n = 8477) in five regions of the oPt. Conflict intensity was used as a continuous variable defined as the square root of non-combatant conflict mortality taken from monthly death rates of non-combatants by region. We use multilevel logistic models to explain four outputs: child vaccination schedules, antenatal care, caesarean sections, and complications during pregnancy.

Results

Locality is important with results showing the negative impact of conflict intensity on access to care, especially in the South West Bank for maternal health services and Central West Bank for vaccination (B − 0.161 p = 0.000 for DPT). Wealth is only significant for DPT vaccinations with poorest (B − 0.098 p = 0.005) and poor (B − 0.148 p = 0.002) individuals less likely to access services. Otherwise conflict does not show a differential effect across socio-economic conditions.

Conclusions

This study shows how locality is the strongest factor when looking at the impact of conflict in the oPt. Preventative services (ANC and vaccinations) are the most affected by conflict. We recommend a greater use of community health care to improve access to maternal and child care when barriers impede access to health facilities during times of conflict.

Improving Maternal and Neonatal Health by a Midwife-led Continuity Model of Care - An Observational Study in One Governmental Hospital in Palestine

BACKGROUND

From 2013 a midwife-led continuity model of care was implemented in the Nablus region in occupied Palestine, involving a governmental hospital and ten rural villages. This study analysed the relation between the midwife-led model and maternal and neonatal health outcomes.

METHOD

A register-based, retrospective cohort design was used, involving 2201 singleton births between January 2016 and June 2017 at Nablus governmental hospital. Data from rural women, with singleton pregnancies and mixed risk status, who either lived in villages that offered the midwife-led continuity model and had registered at the governmental clinic, or who lived in villages without the midwife-led model and received regular care, were compared. Primary outcome was unplanned caesarean section. Secondary outcomes were other modes of birth, postpartum anaemia, preterm birth, birth weight, and admission to neonatal intensive care unit.

FINDINGS

Statistically significant less women receiving the midwife-led model had unplanned caesarean sections, 12·8% vs 15·9%, adjusted risk ratio (aRR) 0·80 (95% CI 0·64-0·99) and postpartum anaemia,19·8% vs 28·6%, aRR 0·72 (0·60-0·85). There was also a statistically significant lower rate of preterm births within the exposed group, 13·1% vs 16·8, aRR 0·79 (0·63-0·98), admission to neonatal intensive care unit, 7·0% vs 9·9%, aRR 0·71 (0·52-0·98) and newborn with birth weight 1500 g and less, 0·1% vs 1·1%, aRR 0·13 (0·02-0·97).

INTERPRETATION

Receiving the midwife-led continuity model of care in Palestine was associated with several improved maternal and neonatal health outcomes. The findings support further implementation of the model. Implementation research, including randomised studies, would be useful to further investigate the effect and feasibility of the model in a low resource setting.

FUNDING

This study was partly funded by the Research Council of Norway through the Global Health and Vaccination Program (GLOBVAC), project number 243706. The implementation received public funding through Norwegian Aid Committee (NORWAC).

Introducing rotavirus vaccine to the Palestinian territories: the role of public-private partnerships

BACKGROUND

Introducing childhood immunization poses challenges in environments of societal fragility. The Palestinian territories (Pt) are considered 'fragile' because of their lack of political, economic and territorial sovereignty. Poverty is rife, infant mortality high, and diseases associated with overcrowding widespread. Under these circumstances the Rostropovich Vishneskaya Foundation (RVF) has assembled a network of public and private stakeholders to introduce a country-wide rotavirus immunization program.

METHODS

The incidence of diarrhea was determined for 18 months before and 18 months after the introduction of rotavirus vaccine among all children younger than 5 years presenting to outpatient clinics in Gaza with three or more loose stools per day. Simultaneously the prevalence of rotavirus was established by rotavirus antigen detection in stool samples collected from children younger than 3 years at Caritas Baby Hospital in Bethlehem during the corresponding time periods.

RESULTS

Within 12 months 97.4% immunization coverage was achieved. The incidence of diarrhea dropped by 32.2%, while the prevalence of rotavirus in stool samples decreased by 64.6% throughout the following year.

CONCLUSION

In environments of economic or political instability private-public partnerships for the introduction of comprehensive vaccination programs can work based on close collaboration, shared vision, flexibility and inter-organizational trust.

Effective coverage of essential antenatal care interventions: A cross-sectional study of public primary healthcare clinics in the West Bank

BACKGROUND

The proportion of women attending four or more antenatal care (ANC) visits is widely used for monitoring, but provides limited information on quality of care. Effective coverage metrics, assessing if ANC interventions are completely delivered, can identify critical gaps in healthcare service delivery. We aimed to measure coverage of at least one screening and effective coverage of ANC interventions in the public health system in the West Bank, Palestine, and to explore associations between infrastructure-related and maternal sociodemographic variables and effective coverage.

METHODS

We used data from paper-based clinical records of 1369 pregnant women attending ANC in 17 primary healthcare clinics. Infrastructure-related variables were derived from a 2014 national inventory assessment of clinics. Sample size calculations were made to detect effective coverage ranging 40-60% with a 2-3% margin of error, clinics were selected by probability sampling. We calculated inverse probability weighted percentages of: effective coverage of appropriate number and timing of screenings of ANC interventions; and coverage of at least one screening.

RESULTS

Coverage of one screening and effective coverage of ANC interventions were notably different for screening for: hypertension (98% vs. 10%); fetal growth abnormalities (66% vs. 6%); anemia (93% vs. 14%); gestational diabetes (93% vs. 34%), and antenatal ultrasound (74% vs. 24%). Clinics with a laboratory and ultrasound generally performed better in terms of effective coverage, and maternal sociodemographic factors had no associations with effective coverage estimates. Only 13% of the women attended ANC visits according to the recommended national schedule, driving effective coverage down.

CONCLUSION

Indicators for ANC monitoring and their definitions can have important consequences for quantifying health system performance and identifying issues with care provision. To achieve more effective coverage in public primary care clinics in the West Bank, efforts should be made to improve care provision according to prescribed guidelines.

The role and scope of practice of midwives in humanitarian settings: a systematic review and content analysis

BACKGROUND

Midwives have an essential role to play in preparing for and providing sexual and reproductive health (SRH) services in humanitarian settings due to their unique knowledge and skills, position as frontline providers and geographic and social proximity to the communities they serve. There are considerable gaps in the international guidance that defines the scope of practice of midwives in crises, particularly for the mitigation and preparedness, and recovery phases. We undertook a systematic review to provide further clarification of this scope of practice and insights to optimise midwifery performance. The review aimed to determine what SRH services midwives are involved in delivering across the emergency management cycle in humanitarian contexts, and how they are working with other professionals to deliver health care.

METHODS

Four electronic databases and the websites of 33 organisations were searched between January and March 2017. Papers were eligible for inclusion if they were published in English between 2007 and 2017 and reported primary research pertaining to the role of midwives in delivering and performing any component of sexual and/or reproductive health in humanitarian settings. Content analysis was used to map the study findings to the Minimum Initial Service Package (MISP) for SRH across the three phases of the disaster management cycle and identify how midwives work with other members of the health care team.

RESULTS

Fourteen studies from ten countries were included. Twelve studies were undertaken in conflict settings, and two were conducted in the context of the aftermath of natural disasters. We found a paucity of evidence from the research literature that examines the activities and roles undertaken by midwives across the disaster management cycle. This lack of evidence was more apparent during the mitigation and preparedness, and recovery phases than the response phase of the disaster management cycle.

CONCLUSION

Research-informed guidelines and strategies are required to better align the scope of practice of midwives with the objectives of multi-agency guidelines and agreements, as well as the activities of the MISP, to ensure that the potential of midwives can be acknowledged and optimised across the disaster management cycle.

Maternal mortality in the Gaza strip: a look at causes and solutions

BACKGROUND

Maternal mortality is an important health indicator for the overall health of a population. This study assessed the causes and contributing factors to maternal mortality that occurred in the Gaza-Strip between July 2014 and June 2015.

METHODS

This is a retrospective study that used both quantitative and qualitative data. The data were collected from available medical records, investigation reports, death certificates, and field interviews with healthcare professionals as well as families.

RESULTS

A total of 18 maternal mortalities occurred in Gaza between 1st July 2014 and June 30th 2015. Age at time of death ranged from 18 to 44 years, with 44.4% occurring before the age of 35 years. About 22.2% were primiparous, while 55.6% were grand multiparous women. The most common causes of death were sepsis, postpartum haemorrhage, and pulmonary embolism. The most striking deficiency was very poor medical documentation which was observed in 17 cases (94%). In addition, poor communication between doctors and women and their families or among healthcare teams was noticed in nine cases (50%). These were repeatedly described by families during interviews. Further aspects surfacing in many interviews were distrust by families towards clinicians and poor understanding of health conditions by women. Other factors included socioeconomic conditions, poor antenatal attendance and the impact of the 2014 war. Low morale among medical staff was expressed by most interviewed clinicians, as well as the fear of being blamed by families and management in case of adverse events. Substandard care and lack of appropriate supervision were also found in some cases.

CONCLUSIONS

This study revealed deficiencies in maternity care, some of which were linked to the socioeconomic situation and the 2014 war. Others show poor implementation of clinical guidelines and lack of professional skills in communication and teamwork. Specialised training should be offered for clinicians in order to improve these aspects. However, the most striking deficiency was the extremely poor documentation, reflecting a lack of awareness among clinicians regarding its importance. Local policymakers should focus on systematic application of quality improvement strategies in order to achieve greater patient safety and further reductions in the maternal mortality rate.

Stalled decline in infant mortality among Palestine refugees in the Gaza Strip since 2006

BACKGROUND

The United Nations Relief and Works Agency for Palestine refugees in the Near East (UNRWA) has periodically estimated infant mortality rates (IMR) among Palestine refugees in the Gaza Strip (Gaza). These surveys have recorded a decline from 127 per 1000 live births in 1960 to 20.2 in 2006. Thereafter, a survey revealed an IMR of 22.4 in 2011. Alerted by these findings, a follow up survey was conducted in 2015 to further assess the trend of IMR.

METHODS

We used the same preceding-birth technique as in previous surveys to estimate IMR and neonatal mortality rate (NMR) per 1000 live births. All multiparous mothers who came to the 22 UNRWA health centers to register their last-born child for immunization were asked if their preceding child was alive or dead. We based our target sample size on the previous IMR of 22.4 and we interviewed 3126 mothers from September to November 2015.

FINDINGS

The third survey estimated mortality rates in 2013. The IMR was 22.7 (95% CI 17.2-28.1) per 1000 live births. IMR did not decline since the estimated IMR of 20.2 (15.3-25.1) per 1000 live births in 2006 and 22.4 (16.4-28.3) per 1000 live births in 2011. NMR was 16.1 (11.6-20.7) per 1000 live births, which was not statistically significantly different from 2006 (12.1 (8.7-16.4)), and was lower than in 2011 (20.3 (15.3-26.2)).

CONCLUSION

The estimated mortality rate in infants of Palestine refugees in Gaza has not declined since 2006. The stagnation of infant mortality rates indicates that further efforts are needed to investigate causes for this stagnation and ways of addressing the potentially preventable causes among Palestine refugee children in Gaza.

Association Between Maternal and Child Health Handbook and Quality of Antenatal Care Services in Palestine

Objectives The Maternal and Child Health (MCH) handbook is an integrated home-based record allowing clients to keep records on the continuum of care for mothers and children. This study aimed to assess associations between MCH handbook ownership and receipt of selected content of antenatal care services in Palestine. Methods Distribution of the MCH handbook in Palestine was launched in 2008. We used an anonymous data set of the Palestinian Family Survey 2010 and analyzed the data of 2026 women who had live births within the past 12 months. Descriptive statistical analysis was conducted to assess differences between MCH handbook holders and non-holders. Multivariable logistic regression models were used to estimate adjusted odds ratios of the effects of MCH handbook use according to proxy indicators of antenatal care quality. Results Accounting for about 60% (n = 1202) of study participants, handbook holders were more likely to be primipara, live in the Gaza Strip, live in refugee camps, and live within a 30-min distance to antenatal care facilities; however, household wealth levels for handbook holders were lower compared with non-holders. Handbook users had significantly higher odds of receiving all three kinds of medical tests and receiving information on five or more health education topics as part of antenatal care. The higher odds remained after adjusting for possible confounding variables, such as household wealth, region, residential area, birth order of the child, frequency of antenatal care, and time required to reach antenatal care facilities. Conclusions for Practice Use of the handbook as a portable checklist possibly promoted providers' higher adherence to the national guideline.

Can a midwife-led continuity model improve maternal services in a low-resource setting? A non-randomised cluster intervention study in Palestine

OBJECTIVES

To improve maternal health services in rural areas, the Palestinian Ministry of Health launched a midwife-led continuity model in the West Bank in 2013. Midwives were deployed weekly from governmental hospitals to provide antenatal and postnatal care in rural clinics. We studied the intervention's impact on use and quality indicators of maternal services after 2 years' experience.

DESIGN

A non-randomised intervention design was chosen. The study was based on registry data only available at cluster level, 2 years before (2011and2012) and 2 years after (2014and2015) the intervention.

SETTING

All 53 primary healthcare clinics in Nablus and Jericho regions were stratified for inclusion.

PRIMARY AND SECONDARY OUTCOMES

Primary outcome was number of antenatal visits. Important secondary outcomes were number of referrals to specialist care and number of postnatal home visits. Differences in changes within the two groups before and after the intervention were compared by using mixed effect models.

RESULTS

14 intervention clinics and 25 control clinics were included. Number of antenatal visits increased by 1.16 per woman in the intervention clinics, while declined by 0.39 in the control clinics, giving a statistically significant difference in change of 1.55 visits (95% CI 0.90 to 2.21). A statistically significant difference in number of referrals was observed between the groups, giving a ratio of rate ratios of 3.65 (2.78-4.78) as number of referrals increased by a rate ratio of 3.87 in the intervention group, while in the control the rate ratio was only 1.06.Home visits increased substantially in the intervention group but decreased in the control group, giving a ratio of RR 97.65 (45.20 - 210.96) CONCLUSION: The Palestinian midwife-led continuity model improved use and some quality indicators of maternal services. More research should be done to investigate if the model influenced individual health outcomes and satisfaction with care.

TRIAL REGISTRATION NUMBER

NCT03145571; Results.

Research priority-setting: reproductive health in the occupied Palestinian territory

BACKGROUND

Occupied Palestinian territory (oPt) is an authority with limited resources. Therefore, research conducted in such a setting should be prioritized and coordinated to follow a national research agenda. This study aims to produce a research agenda for reproductive health in the oPt that can be utilized by reproductive health stakeholders and contribute to the development of policy-based evidence to guide health practice.

METHODS

In the current study, we followed research prioritization methods developed by the World Health Organization-Child Health and Nutrition Research Initiative. Research questions were obtained from reproductive health experts in the oPt. The questions were then grouped into thematic areas which were prioritized by the reproductive health experts. Scores were calculated and sorted to define the top priority research areas.

RESULTS

A total of 232 research questions were prioritized by 30 reproductive health experts. Health system issues were the most addressed in the top 50 research questions. They included questions on the quality of services and health professionals' knowledge and continuous professional training. Adolescents' sexual and reproductive health and gender-based violence were rarely mentioned in the top 50 questions. The number of questions related to safe motherhood was around 50% followed by questions related to health system. Questions related to elderly women and menopause as well as reproductive system cancers were also within the top 50 ranked questions.

CONCLUSIONS

Priority research areas in reproductive health were identified for the oPt, which should be utilized by researchers with a focus on the high priority areas. Policy makers and funders should coordinate their efforts to ensure the production of research with value to the Palestinian context, in the most efficient way possible.

eRegQual-an electronic health registry with interactive checklists and clinical decision support for improving quality of antenatal care: study protocol for a cluster randomized trial

Background

Health worker compliance with established best-practice clinical and public health guidelines may be enhanced by customized checklists of care and clinical decision support driven by point-of-care data entry into an electronic health registry. The public health system of Palestine is currently implementing a national electronic registry (eRegistry) for maternal and child health. This trial is embedded in the national implementation and aims to assess the effectiveness of the eRegistry’s interactive checklists and clinical decision support, compared with the existing paper based records, on improving the quality of care for pregnant women.

Methods

This two-arm cluster randomized controlled trial is conducted in the West Bank, Palestine, and includes 120 clusters (primary healthcare clinics) with an average annual enrollment of 60 pregnancies. The intervention tool is the eRegistry’s interactive checklists and clinical decision support implemented within the District Health Information System 2 (DHIS2) Tracker software, developed and customized for the Palestinian context. The primary outcomes reflect the processes of essential interventions, namely timely and appropriate screening and management of: 1) anemia in pregnancy; 2) hypertension in pregnancy; 3) abnormal fetal growth; 4) and diabetes mellitus in pregnancy. The composite primary health outcome encompasses five conditions representing risk for the mother or baby that could have been detected or prevented by high-quality antenatal care: moderate or severe anemia at admission for labor; severe hypertension at admission for labor; malpresentation at delivery undetected during pregnancy; small for gestational age baby at delivery undetected during pregnancy; and large for gestational age baby at delivery. Primary analysis at the individual level taking the design effect of the clustering into account will be performed as intention-to-treat.

Discussion

This trial, embedded in the national implementation of the eRegistry in Palestine, allows the assessment of process and health outcomes in a large-scale pragmatic setting. Findings will inform the use of interactive checklists and clinical decision support driven by point-of-care data entry into an eRegistry as a health systems-strengthening approach.

Trial registration

ISRCTN trial registration number, ISRCTN18008445. Registered on 6 April 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2386-5) contains supplementary material, which is available to authorized users.

Women's health in the occupied Palestinian territories: Contextual influences on subjective and objective health measures

The links between two commonly used measures of health-self-rated health (SRH) and self-reported illness (SRI)-and socio-economic and contextual factors are poorly understood in Low and Middle Income Countries (LMICs) and more specifically among women in conflict areas. This study assesses the socioeconomic determinants of three self-reported measures of health among women in the occupied Palestinian territories; self-reported self-rated health (SRH) and two self-reported illness indicators (acute and chronic diseases). Data were obtained from the 2010 Palestinian Family Health Survey (PFHS), providing a sample of 14,819 women aged 15-54. Data were used to construct three binary dependent variable-SRH (poor or otherwise), and reporting two SRI indicators-general illness and chronic illness (yes or otherwise). Multilevel logistic regression models for each dependent variable were estimated, with individual level socioeconomic and sociodemographic predictors and random intercepts at the governorate and community level included, to explore the determinants of inequalities in health. Consistent socioeconomic inequalities in women's reports of both SRH and SRI are found. Better educated, wealthier women are significantly less likely to report an SRI and poor SRH. However, intra-oPt regional disparities are not consistent across SRH and SRI. Women from the Gaza Strip are less likely to report poor SRH compared to women from all other regions in the West Bank. Geographic and residential factors, together with socioeconomic status, are key to understanding differences between women's reports of SRI and SRH in the oPt. More evidence is needed on the health of women in the oPt beyond the ages currently included in surveys. The results for SRH show discrepancies which can often occur in conflict affected settings where a combination of ill-health and poor access to health services impact on women's health. These results indicate that future policies should be developed in a holistic manner by targeting physical and mental health and well-being in programmes addressing the health needs of women, especially those in conflict affected zones.

Age of despair or age of hope? Palestinian women's perspectives on midlife health

There is limited evidence about women's experiences of the midlife, beyond a narrow - frequently biomedical - focus on the menopause. The broader (physical, social, cultural, political) dimensions of women's midlife health are poorly understood, particularly in low and middle-income countries. Our study seeks to understand how women in the West Bank (occupied Palestinian territories) conceptualise, experience and manage their health in the midlife. We generated qualitative evidence using in-depth life history interviews in 2015 with women (n = 35) living in the West Bank, analysed thematically. Women's understandings of good health draw on indigenous and biomedical knowledge and include a calm psychological state, ease of movement, as well as physical appearance and complexion. Exposure to political violence was understood as impacting mental and physical well-being. Most women articulated a positive view about midlife and ageing as a natural process. A range of terms and expressions were suggested by women experiencing this transition, internalised differently according to marital and motherhood status. For many women, the menopause was merely one - often relatively unimportant - aspect of changes associated with ageing. In dealing with midlife health issues women used multiple strategies, or health pluralism, sequentially or simultaneously; drawing on multiple sets of accrued resources. For never-married or childless women, formal healthcare services represented a site of social exclusion. Our evidence highlights the importance of considering the broader dimensions related to midlife health for understanding women's health maintaining and care-seeking behaviours as they age.

From Feeling Broken to Looking Beyond Broken: Palestinian Mothers' Experiences of Having a Child With Spina Bifida

Spina bifida (SB) is the second most common birth defect worldwide. Mothers of children with SB face extraordinary challenges due to the complicated conditions and disability of their children. Little is known about the impact of these challenges on the mothers' well-being, particularly in Middle Eastern culture, where chronic illness and disability are perceived as a stigma, and care of disabled children has traditionally been the responsibility of the mother. The aim of this study was to illuminate mothers' lived experience of having a child with SB in Palestine. Twenty Arab-Muslim mothers living in Palestine were purposefully recruited from several rehabilitation centers in Palestine and were interviewed in 2014. The transcribed interviews were analyzed according to phenomenological hermeneutics. The mothers' experiences were described in the main theme: From feeling broken to looking beyond broken. Four themes were interwoven: living with constant anxiety, living with uncertainty, living with a burden, and living with a difficult life situation. These findings highlight the burden and resilience of the Arab-Muslim Palestinian mothers while striving to maintain the well-being of the whole family as well as facilitating the child's welfare.

Building a research registry for studying birth complications and outcomes in six Palestinian governmental hospitals

Background

Electronic-health (e-health) provides opportunities for quality improvement of healthcare, but implementation in low and middle income countries is still limited. Our aim was to describe the implementation of a registration (case record form; CRF) for obstetric interventions and childbirth events using e-health in a prospective birth cohort study in Palestine. We also report the completeness and the reliability of the data.

Methods

Data on maternal and fetal health was collected prospectively for all women admitted to give birth during the period from 1st March 2015 to 31st December 2015 in three governmental hospitals in Gaza and three in the West Bank. Essential indicators were noted in a case registration form (CRF) and subsequently entered into the District Health Information Software 2 (DHIS 2) system. Completeness of registered cases was checked against the monthly hospital birth registries. Reliability (correct information) of DHIS2 registration and entry were checked for 22 selected variables, collected during the first 10 months. In the West Bank, a comparison between our data registration and entry and data obtained from the Ministry of Health patient electronic records was conducted in the three hospitals.

Results

According to the hospital birth registries, a total of 34,482 births occurred in the six hospitals during the study period. Data on the mothers and children registered on CRF was almost complete in two hospitals (100% and 99.9%); in the other hospitals the completeness ranged from 72.1% to 98.7%. Eighty birth events were audited for 22 variables in the three hospitals in the West Bank. Out of 1760 registrations in each hospital, the rates of correct data registration ranged from 81% to 93.2% and data entry ranged from 84.5% to 93.1%.

Conclusions

The registered and entered data on birth events in six hospitals was almost complete in five out of six hospitals. The collected data is considered reliable for research purposes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1296-6) contains supplementary material, which is available to authorized users.

Access to healthcare for children in Palestine

Currently, 5 million Palestinian refugees live in Palestine, Jordan, Syria and Lebanon and around 40% of these are children. Mortality rates for Palestinian children are comparable to neighbouring Arab countries but the speed of reduction has faltered in recent years. Morbidity is greatly affected by the occupation which has increased violence towards children, mental health problems and poor nutrition, particularly in Gaza which is experiencing a health crisis. Access to healthcare for children in Palestine is constrained as a result of the requirement for visas to travel into Jerusalem where specialist hospitals are sited, by difficulties with ambulance transfers, by shortages of equipment in hospitals and by lack of trained staff. Palestinian health workers are developing new initiatives in healthcare and show a high level of resilience, despite the very considerable stress affecting most citizens.

Postpartum depression in the Occupied Palestinian Territory: a longitudinal study in Bethlehem

Background

Postpartum depression (PPD) affects women from different cultures around the world. No previous studies have investigated PPD among women in Palestine. Fertility rates in Palestine are among the highest in the world, hence even low rates of PPD could have considerable national impact. The aim of this study was to determine the prevalence of, and risk factors for, PPD among Palestinian mothers.

Methods

101 mothers were recruited during the registration of their child’s birth (within 1 week) at the Bethlehem branch of the Ministry of Interior. Participants were assessed via a face to face interview, and were followed up 1 week, 2 weeks, 6 weeks, 3 months, and 6 months later by telephone interview. Interviews included the Arabic Edinburgh Postnatal Depression Scale (EPDS), with PPD indicated by depressive symptoms (EPDS score ≥11) at ≥2 follow-up time points. Pearson’s correlation was calculated between repeated EPDS scores, and multivariable logistic regression was used to investigate risk factors for PPD.

Results

The prevalence of depressive symptoms was fairly constant (14–19%) over the follow-up period. Most depressive symptoms developed within 1 month of delivery; mothers with depressive symptoms at 3 months postpartum were highly likely to still have symptoms at 6 months. 27.7% (28/101) of women met our criteria for PPD. High parity (odds ratio (OR) 4.52 (95% CI 0.90, 22.8) parity 3+ versus primiparous), unplanned pregnancy (OR 2.44 (0.99, 6.01)) and sex of child not being the one desired (OR 5.07 (1.12, 22.9)) were associated with PPD, but these associations were attenuated in multivariable analysis.

Conclusions

The prevalence of PPD in Palestine appears to be higher than in high income countries, but similar to the prevalence in other Middle Eastern countries. High parity and unplanned pregnancy were identified as risk factors for PPD, suggesting that fully meeting the need for family planning could reduce the incidence of PPD in the Palestinian population.

eRegistries: governance for electronic maternal and child health registries

BACKGROUND

The limited availability of maternal and child health data has limited progress in reducing mortality and morbidity among pregnant women and children. Global health agencies, leaders, and funders are prioritizing strategies that focus on acquiring high quality health data. Electronic maternal and child health registries (eRegistries) offer a systematic data collection and management approach that can serve as an entry point for preventive, curative and promotive health services. Due to the highly sensitive nature of reproductive health information, careful consideration must be accorded to privacy, access, and data security. In the third paper of the eRegistries Series, we report on the current landscape of ethical and legal governance for maternal and child health registries in developing countries.

METHODS

This research utilizes findings from two web-based surveys, completed in 2015 that targeted public health officials and health care providers in 76 countries with high global maternal and child mortality burden. A sample of 298 public health officials from 64 countries and 490 health care providers from 59 countries completed the online survey. Based on formative research in the development of the eRegistries Governance Guidance Toolkit, the surveys were designed to investigate topics related to maternal and child health registries including ethical and legal issues.

RESULTS

According to survey respondents, the prevailing legal landscape is characterized by inadequate data security safeguards and weak support for core privacy principles. Respondents from the majority of countries indicated that health information from medical records is typically protected by legislation although legislation dealing specifically or comprehensively with data privacy may not be in place. Health care provider trust in the privacy of health data at their own facilities is associated with the presence of security safeguards.

CONCLUSION

Addressing legal requirements and ensuring that privacy and data security of women's and children's health information is protected is an ethical responsibility that must not be ignored or postponed, particularly where the need is greatest. Not only are the potential harm and unintended consequences of inaction serious for individuals, but they could impact public trust in health registries leading to decreased participation and compromised data integrity.

Contrasting cardiovascular mortality trends in Eastern Mediterranean populations: Contributions from risk factor changes and treatments

BACKGROUND

Middle income countries are facing an epidemic of non-communicable diseases, especially coronary heart disease (CHD). We used a validated CHD mortality model (IMPACT) to explain recent trends in Tunisia, Syria, the occupied Palestinian territory (oPt) and Turkey.

METHODS

Data on populations, mortality, patient numbers, treatments and risk factor trends from national and local surveys in each country were collated over two time points (1995-97; 2006-09); integrated and analysed using the IMPACT model.

RESULTS

Risk factor trends: Smoking prevalence was high in men, persisting in Syria but decreasing in Tunisia, oPt and Turkey. BMI rose by 1-2 kg/m(2) and diabetes prevalence increased by 40%-50%. Mean systolic blood pressure and cholesterol levels increased in Tunisia and Syria. Mortality trends: Age-standardised CHD mortality rates rose by 20% in Tunisia and 62% in Syria. Much of this increase (79% and 72% respectively) was attributed to adverse trends in major risk factors, occurring despite some improvements in treatment uptake. CHD mortality rates fell by 17% in oPt and by 25% in Turkey, with risk factor changes accounting for around 46% and 30% of this reduction respectively. Increased uptake of community treatments (drug treatments for chronic angina, heart failure, hypertension and secondary prevention after a cardiac event) accounted for most of the remainder.

DISCUSSION

CHD death rates are rising in Tunisia and Syria, whilst oPt and Turkey demonstrate clear falls, reflecting improvements in major risk factors with contributions from medical treatments. However, smoking prevalence remains very high in men; obesity and diabetes levels are rising dramatically.

A glance into the hidden burden of maternal morbidity and patterns of management in a Palestinian governmental referral hospital

BACKGROUND

Little is known about the burden and patterns of maternal morbidity during childbirth, particularly in the Middle East Region. Investigating the patterns of maternal morbidity can be useful in guiding improvement in the quality of maternal services, and informing policy debates on women's health.

OBJECTIVE

To examine the incidence, types and patterns of management of severe and non-severe maternal morbidities of Palestinian women during pregnancy, labour, delivery and up to seven days postpartum in one Palestinian hospital.

METHODS

A prospective hospital-based study was conducted for a 3-month period in 2011-2012, reviewing hospital records for all pregnant women (1.583) admitted to the governmental hospital in Ramallah, Palestine.

FINDINGS

Of all pregnant women included in this analysis (1.558), 419 (26.9%) women experienced one or more maternal morbidities and 15 (0.96%) women survived a life-threatening complication (near miss). Of all women who suffered morbidities, 69 (16.5%) had vaginal deliveries, 61 (14.6%) had cesarean sections, 179 (42.7%) had abortions/miscarriage, and 110 (26.3%) experienced complications during pregnancy or the post-partum. Hemorrhage during pregnancy, birth or postpartum was the most common morbidity. Of those who gave birth, women who gave birth by cesarean sections were three times more likely to suffer from morbidities than those who had vaginal delivery.

CONCLUSIONS

The burden of maternal morbidity for Palestinian women between the ages of 16 and 48 is high. In Palestine, maternal morbidity can be prevented by promoting a rational use of cesarean section, avoiding unnecessary medicalization, reducing unwanted pregnancies and updating practices of providers related to abortion/miscarriage care.

Increasing Neonatal Mortality among Palestine Refugees in the Gaza Strip

Background

The United Nations Relief and Works Agency for Palestine refugees in the Near East (UNRWA) has periodically estimated infant mortality rates among Palestine refugees in Gaza. These surveys have recorded a decline from 127 per 1000 live births in 1960 to 20.2 in 2008.

Methods

We used the same preceding-birth technique as in previous surveys. All multiparous mothers who came to the 22 UNRWA health centres to register their last-born child for immunization were asked if their preceding child was alive or dead. We based our target sample size on the infant mortality rate in 2008 and included 3128 mothers from August until October 2013. We used multiple logistic regression analyses to identify predictors of infant mortality.

Findings

Infant mortality in 2013 was 22.4 per 1000 live births compared with 20.2 in 2008 (p = 0.61), and this change reflected a statistically significant increase in neonatal mortality (from 12.0 to 20.3 per 1000 live births, p = 0.01). The main causes of the 65 infant deaths were preterm birth (n = 25, 39%), congenital anomalies (n = 19, 29%), and infections (n = 12, 19%). Risk factors for infant death were preterm birth (OR 9.88, 3.98–24.85), consanguinity (2.41, 1.35–4.30) and high-risk pregnancies (3.09, 1.46–6.53).

Conclusion

For the first time in five decades, mortality rates have increased among Palestine refugee newborns in Gaza. The possible causes of this trend may include inadequate neonatal care. We will estimate infant and neonatal mortality rates again in 2015 to see if this trend continues and, if so, to assess how it can be reversed.

Public, environmental, and occupational health research activity in Arab countries: bibliometric, citation, and collaboration analysis

BACKGROUND

The objective of this study was to analyze quantity, assess quality, and investigate international collaboration in research from Arab countries in the field of public, environmental and occupational health.

METHODS

Original scientific articles and reviews published from the 22 Arab countries in the category "public, environmental & occupational health" during the study period (1900 - 2012) were screened using the ISI Web of Science database.

RESULTS

The total number of original and review research articles published in the category of "public, environmental & occupational health" from Arab countries was 4673. Main area of research was tropical medicine (1862; 39.85%). Egypt with 1200 documents (25.86%) ranked first in quantity and ranked first in quality of publications (h-index = 51). The study identified 2036 (43.57%) documents with international collaboration. Arab countries actively collaborated with authors in Western Europe (22.91%) and North America (21.04%). Most of the documents (79.9%) were published in public health related journals while 21% of the documents were published in journals pertaining to prevention medicine, environmental, occupational health and epidemiology.

CONCLUSION

Research in public, environmental and occupational health in Arab countries is in the rise. Public health research was dominant while environmental and occupation health research was relatively low. International collaboration was a good tool for increasing research quantity and quality.

Stillbirths at a hospital in Nablus, 2010: a cohort study

BACKGROUND

Stillbirths are insufficiently reported in many countries. In Nablus, reporting has recently started; little is published in Palestine on the stillbirth rate and its risk factors.

OBJECTIVE

To study the rate of stillbirths at Rafidia Hospital in 2010 and some of its risk factors.

DESIGN

A retrospective cohort design.

METHODS

Data were collected from the delivery registry for all births and we analysed those with a gestation of 28 weeks or more at Rafidia Hospital. Stillbirth rates were estimated for available determinants.

RESULTS

In 2010, a total of 5,644 women gave birth to 5,782 babies, of whom 41 were stillbirths, that is, a stillbirth rate of 7.1/1,000 births (95% confidence interval 5.2-9.5). Premature babies had a higher risk of being a stillbirth. For small babies, the lower the birth weight the higher was the probability of being a stillbirth, and for babies weighing 4,500 g or more there was a higher risk of being stillborn. The risk of stillbirth was also higher among babies from mothers with high haemoglobin concentration, but low maternal haemoglobin was not associated with stillbirths.

CONCLUSIONS

The stillbirth rates at Rafidia hospital assessed in this study compares favourably with the reported national numbers, indicating a good reliability of the on-going registration. The rates were highest among premature births. Stillbirth was linked to low birth weight, foetal macrosomia, and maternal haemoconcentration. We believe the findings identify areas to address when designing antenatal care with the aim of improving perinatal mortality in the country.

Assessing the Scientific Research Productivity of the Palestinian Higher Education Institutions

An-Najah National University (ANNU) is a Palestinian university that was established more than 35 years ago. The objective of this study was to do a bibliometric assessment of research output, which describes the growth, contribution, and impact of research carried out by the faculty members, researchers, or students of ANNU in the past 35 years. The data used for this study were retrieved from Scopus database. Bibliometric analysis was used to identify the pattern of publication, relative growth rate, authorship pattern, collaborative measures, author’s productivity, most prolific authors, and most prolific journals. A total of 791 published documents were retrieved for ANNU. Seventeen documents (2.1%) were published in Acta Crystallographica Section E Structure Reports Online, whereas 16 (2.0%) were published in Journal of Environmental Science and Health, Part A: Environmental Science and Engineering, and 10 (1.3%) were published in International Journal of Clinical Pharmacology and Therapeutics. Six hundred one (76%) documents were published in journals listed in Web of Knowledge. The total number of citations for documents published from ANNU, at the time of data analysis (November 19, 2013), was 4,553, with an average of 5.8 citations per document. The study identified 384 (25.8%) documents with 59 countries as ANNU–foreign collaborators. Research output from ANNU showed steady growth over the past 35 years. Research output was high from certain scientific disciplines, whereas was lagging from others. Future emphasis on joint research, international collaboration, and publishing in indexed journals is needed.

No safe place for childbirth: women and midwives bearing witness, Gaza 2008-09

Women seek to give birth in a place where they feel safe, protected and secure. However, in conflict settings, many are forced to give birth in dangerous and frightening situations, where even the most rudimentary help and protection is unavailable. This study, based on interviews with women who gave birth and midwives during the 22-day Israeli attack on Gaza in December 2008 - January 2009, illustrates the vulnerability and trauma women experience when there is no safe place for childbirth. They recounted their overwhelming fear of not knowing when they would go into labour, not reaching a hospital or skilled attendant during the bombing, complications in labour without emergency care, and fear for the safety of their families and being separated from them. Most of the midwives were unprepared both materially and psychologically to attend births outside a hospital setting, while physicians were overwhelmed with severely injured patients. The capacity of midwifery care to keep birth normal whenever possible is particularly crucial in situations of political instability, conflict, poverty and disaster. Planning for emergency care by mapping the location of midwives, supplying them with basic equipment and medications, and legitimizing their profession with an appropriate scope of practice, licensing, back-up, and incentives would facilitate their ability to respond to birthing women's needs.

"It's not easy to acknowledge that I'm ill": a qualitative investigation into the health seeking behavior of rural Palestinian women

BACKGROUND

This qualitative study sets to fill a gap in knowledge by exploring the health seeking behaviour of rural women living in the occupied Palestinian territories (oPt). The existing literature on the oPt has so far focused on unravelling the country's epidemiological and health system profile, but has largely neglected the assessment of factors shaping people's decisions on health care use.

METHODS

Based on a conceptual framework rooted in the Anderson behavioural model, we conducted 30 semi-structured interviews with purposely selected women and seven key informant interviews in three purposely selected villages in Ramallah district.

RESULTS

Our findings indicate that women delay seeking professional care, use self-prescribed medications and home treatment, and do not use preventive and educational health services. Their health seeking behaviour is the result of the interplay of several factors: their gendered socio-cultural role; their health beliefs; financial affordability and geographical accessibility; their perceptions of the quality of care; and their perceived health needs.

CONCLUSIONS

Findings are discussed in the light of their policy implications, suggesting that adequate health policy planning ought to take into considerations socio-cultural dimensions beyond those directly pertinent to the health care system.

The impact of occupation on child health in a Palestinian refugee camp

This article focuses on child health in the Palestinian refugee camp of Dheisheh in the West Bank region of the Occupied Palestinian Territories. Thirty in-depth interviews were carried out with parents to determine their perceptions of their children's health. The questions related to physical, mental and social well-being, access to health facilities, factors that were likely to hinder health and measures that could be implemented to improve child health. The study was carried out prior to and during the Gaza War in December 2008 that resulted in the deaths of 1380 Palestinians including 431 children and 112 women [1]. The effects of occupation, conflict and being a refugee had a detrimental impact on perceptions of health. Interviewees revealed that their perceptions of their children's health were determined by the camp's conditions, the current economic climate, past and current political conflict and financial and social restrictions. The understanding of being healthy incorporated physical and mental health as well as social well-being. As a result, 70% of interviewees deemed that their children were not in good health. This finding accelerated to 100% after the Gaza War, showing the negative effect war has on health perceptions. Findings showed that perceptions of physical health are very much interlinked with mental well-being and parents' perceptions of their children's health, and are closely related to their state of mental health. Consequently, a clear correlation can be discerned between the ongoing occupation and its detrimental effects on mental health. Therapeutic and preventive health programmes such as child therapy and stress management that have already been implemented by the Gaza Community Mental Health Programme would be highly beneficial to both children and adults in Dheisheh refugee camp.

Assessing the silent epidemic of malnutrition in Palestinian preschool children

BACKGROUND

The nutritional status of children living under conflict is an important issue. The aim of the present study is to review all available data on malnutrition in preschool Palestinian children and provide objective results concerning the epidemic of malnutrition.

METHODS

The literature for all research on the prevalence of malnutrition on Palestinian children with data collected during the period 1998-2007 was reviewed. Der Simonian-Laird Random effects model for meta-analysis was applied and cumulative analyses were performed to determine time-trends for each outcome measure (iron deficiency anemia [IDA], wasting, underweight and stunting).

FINDINGS

The results showed that 39.5% of the children suffered from IDA, 2.9% from wasting, 4.7% were underweight and 10.9% stunted. The cumulative analyses showed a peak in the prevalence of IDA during 1999, followed by an irregular decrease afterward. The proportion of wasted and underweight children peaked during 2002 and 2004, respectively, both showing a gradual decline afterward. Chronic malnutrition appears to be almost similar during the decade 1998-2007, by demonstrating small, irregular oscillations.

CONCLUSIONS

Although the prevalence of malnutrition among Palestinian preschool children has been improved during the studied period, it still remains high. Additionally, the results show that interventions/aid have acute effects on the health of children.

FUNDING

None.

Is the Maternal and Child Health (MCH) handbook effective in improving health-related behavior? Evidence from Palestine

OBJECTIVE

This study examines the effect of the Maternal and Child Health (MCH) handbook--a home-based health record--on women's knowledge and behavior in the Jericho and Ramallah Governorates of Palestine.

METHODS

This study uses a repeated, cross-sectional data set in which pre- and post-intervention situations are incorporated on two groups: those exposed and those not exposed to the MCH handbook. We employed a difference-in-difference regression analysis utilizing a pre-tested knowledge, attitude, and practice survey of women at 24 MCH 'treatment' centers (N=260, 270, pre-/post-) in comparison with the women at 6 MCH centers (N=70, 70, pre-/post-) where the MCH handbook was not released. A trained facilitator conducted a series of focus group discussions with 42 women who were the clients of MCH services and 25 health providers, both from the intervention area, to confirm the results obtained from the quantitative study.

FINDINGS

Knowledge related to MCH such as the importance of exclusive breastfeeding and how to cope with the risks of rupture of membranes during pregnancy increased among MCH handbook users, especially among less-educated women. The MCH handbook may be an effective tool for communication with health providers and husbands, for both highly educated and less-educated women during their first pregnancy. Our results suggest that although less-educated women rarely read the handbook themselves at home, they became familiar with health information and options related to MCH through personalized guidance that was provided by health providers at health facilities utilizing MCH handbook.

CONCLUSION

The MCH handbook may be an effective tool to improve (i) communication between the client and the health provider and (ii) women's knowledge- and health-seeking behaviors related to maternal, newborn, and child health.

Is self-rated health a valid measure to use in social inequities and health research? Evidence from the PAPFAM women's data in six Arab countries

INTRODUCTION

Some evidence from high-income countries suggests that self-rated health (SRH) is not a consistent predictor of objective health across social groups, and that its use may lead to inaccurate estimates of the effects of inequities on health. Given increased interest in studying and monitoring social inequities in health worldwide, the aim of the present study was to evaluate the validity of SRH as a consistent measure of health across socioeconomic categories in six Arab countries.

METHODS

We employed the PAPFAM population-based survey data on women from Morocco, Algeria, Tunisia, Lebanon, Syria, and the Occupied Palestinian Territories (OPT). Multivariate logistic regression analyses were performed to assess the strength of the association between fair/poor SRH and objective health (reporting at least one chronic condition), adjusting for available socio-demographic and health-related variables. Analyses were then stratified by two socioeconomic indicators: education and household economic status.

RESULTS

The association between SRH and objective health is strong in Algeria, Tunisia, Lebanon, Syria, and OPT, but weak in Morocco. The strength of the association between reporting fair/poor health and objective health was not moderated by education or household economic status in any of the six countries.

CONCLUSION

As the SRH-objective health association does not vary across social categories, the use of the measure in social inequities in health research is justified. These results should not preclude the need to carry out other validation studies using longitudinal data on men and women, or the need to advocate for improving the quality of morbidity and mortality data in the Arab region.

Breastfeeding patterns among Palestinian infants in the first 6 months in Nablus refugee camps: a cross-sectional study

BACKGROUND

Several studies in Palestine, including some performed in refugee camps, showed that breastfeeding is a common practice, however, exclusive breastfeeding was practiced less frequently. The social and cultural patterns in relation to different types of infant feeding were not studied.

OBJECTIVES

This study aimed to evaluate the association between mothers' and infants' sociodemographic factors and breastfeeding patterns during the first 6 months of infant life.

METHODS

This cross-sectional study evaluated data of 690 clinic files from 3 refugee camps in Nablus, Palestine in 2007. Maternal age, age at marriage, parity, mother's and father's education, type of delivery and infant's gender were studied in relation to 3 types of breastfeeding: exclusive breastfeeding, partial breastfeeding, and exclusive formula feeding in the first 6 months of life. Bivariate analysis and logistic regression were applied for data analysis.

RESULTS

A total of 69.7% of infants aged 0-6 months were exclusively breastfed and only 14.3% were exclusively formula fed. Older mothers at marriage (risk ratio [RR], 0.13; 95% confidence interval [CI], 0.06-0.28), and cesarean birth (RR, 0.59; 95% CI, 0.41-0.81) were negatively associated with EBF.

CONCLUSION

Breastfeeding educational and health promotion program and policy for EBF implemented by UNRWA (United Nations Relief and Works Agency for Palestine Refugees in the Near East) should continue with special attention to older mothers at marriage, and to babies born by cesarean section.

Health expectancy in the occupied Palestinian territory: estimates from the Gaza Strip and the West Bank: based on surveys from 2006 to 2010

OBJECTIVES

The purpose of the study was to estimate health expectancy for the Palestinian population and to evaluate changes that have taken place over the past 5 years.

DESIGN

Mortality data and population-based health surveys.

SETTING

The Israeli-occupied Palestinian territory of the Gaza Strip and the West Bank.

PARTICIPANTS

17 034 and 38 071 adults aged 20 or over participating the Palestinian Family Health Surveys of 2006 and 2010. Death rates for 2007 and 2010 covered the entire population.

OUTCOME MEASURES

Life expectancy and expected lifetime with and without chronic disease were estimated using the Sullivan method on the basis of mortality data and data on the prevalence of chronic disease.

RESULTS

Life expectancy at the age of 20 increased from 52.8 years in 2006 to 53.3 years in 2010 for men and from 55.1 years to 55.7 years for women. In 2006, expected lifetime without a chronic disease was 37.7 (95% CI 37.0 to 38.3) years and 32.5 (95% CI 31.9 to 33.2) years for 20-year-old men and women, respectively. By 2010, this had decreased by 1.6 years for men and increased by 1.3 years for women. The health status of men has worsened. In particular, lifetime with hypertension and diabetes has increased. For women, the gain in life expectancy consisted partly of years with and partly of years without the most prevalent diseases.

CONCLUSIONS

Health expectancy for men and women diverged, which could to some extent be due to gender-specific exposures related to lifestyle factors and the impact of military occupation.

Natural Disaster and Crisis: Lessons Learned about Cleft and Craniofacial Care from Hurricane Katrina and the West Bank

Cleft care is generally characterized by staged, carefully timed surgeries and long-term, team-centered follow-up. Acute and chronic crises can wreak havoc on the comprehensive team care required by children with craniofacial anomalies. In addition, there is evidence that crises, including natural disasters and chronic disruptions, such as political turmoil and poverty, can lead to an increased incidence of craniofacial anomalies. The purpose of this article is to delineate the impact of acute and chronic crises on cleft care. Hurricane Katrina in New Orleans, Louisiana, in 2005, resulted in an acute crisis that temporarily disrupted the infrastructure necessary to deliver cleft care; chronic turmoil in the West Bank/Palestine has resulted in an absence of infrastructure to deliver cleft care. Through these central examples, this article will illustrate—through the prism of cleft care—the need for (1) disaster preparedness for acute crises, (2) changing needs following acute crises that may lead to persistent chronic disruption, and (3) baseline and long-term monitoring of population changes after a disaster has disrupted a health care delivery system.

Low infant mortality among Palestine refugees despite the odds

OBJECTIVE

To present data from a 2008 infant mortality survey conducted in Jordan, Lebanon, the Syrian Arab Republic, the Gaza Strip and the West Bank and analyse infant mortality trends among Palestine refugees in 1995-2005.

METHODS

Following the preceding birth technique, mothers who were registering a new birth were asked if the preceding child was alive or dead, the day the child was born and the date of birth of the neonate whose birth was being registered. From this information, neonatal, infant and early child mortality rates were estimated. The age at death for early child mortality was determined by the mean interval between successive births and the mean age of neonates at registration.

FINDINGS

In 2005-2006, infant mortality among Palestine refugees ranged from 28 deaths per 100 000 live births in the Syrian Arab Republic to 19 in Lebanon. Thus, infant mortality in Palestine refugees is among the lowest in the Near East. However, infant mortality has stopped decreasing in recent years, although it remains at a level compatible with the attainment of Millennium Development Goal 4.

CONCLUSION

Largely owing to the primary health care provided by the United Nations Relief and Works Agency (UNRWA) for Palestine Refugees in the Near East and other entities, infant mortality among Palestine refugees had consistently decreased. However, it is no longer dropping. Measures to address the most likely reasons - early marriage and childbearing, poor socioeconomic conditions and limited access to good perinatal care - are needed.