Outcomes

Outcome measures that reflect the overall quality of antenatal care were selected through national stakeholder and expert group consultations (appendix 2 p 8). The clinical decision support prompts health-care providers to undertake specific activities of screening and management and these activities correspond to our outcome definitions. Among more than 500 rules in the clinical decision support rules engine, the following sentinel rules were selected: the primary process (adherence to guidelines) outcomes of screening and management of anaemia, hypertension, and diabetes during pregnancy and foetal growth monitoring (table 1). For those with a normal screening test result, screening was considered complete. For those detected with a condition, follow-up of the screening test result with correct management provided a successful primary outcome. We only included antenatal care in the clinics included in the trial; antenatal care at a referral clinic was excluded from our analysis.

Definitions of eligible antenatal contacts, screening tests, and management for the process (adherence) outcomes based on the guidelines for routine low-risk antenatal care in the West Bank, Palestine

The primary health outcomes, a composite of conditions at delivery that good-quality antenatal care aims to detect and prevent, were moderate or severe anaemia (haemoglobin at admission <10 g/dL); severe hypertension (systolic blood pressure ≥160 mm Hg or diastolic ≥110 mm Hg, or both, at admission); term large-for-gestational-age baby (≥90th percentile [birthweight of 3258 g] at 37 weeks of gestation);²⁰ term small-for-gestational-age baby (≤10th percentile [birthweight of 2394 g] at 37 weeks of gestation)²⁰ undetected during antenatal care; and malpresentation at delivery (non-cephalic presentation at or after 36 weeks of gestation) undetected during antenatal care.

The secondary outcomes were stillbirth (baby born with no signs of life at or after 28 weeks of gestation); women's antenatal care attendance from 16 weeks to 36 weeks according to guidelines; and screening and management of malpresentation (table 1). For antenatal care attendance, we calculated the proportion of women who attended each recommended antenatal care visit, among those registered for antenatal care before that visit and not sent to a referral clinic or hospital.