Jahn Frederik Frøen

• Uwera, Thaoussi; Sandøy, Ingvild Fossgard; Frøen, Jahn Frederik; Papadopoulou, Eleni; Sibomana, Hassan & Muhire, Andrew [Show all 8 contributors for this article] (2026). Implementation strategies to promote e-Tracker use in the childhood immunization program in Rwanda – a mixed methods study. Frontiers in Health Services. 6. doi: 10.3389/frhs.2026.1816682. Full text in Research Archive Show summary

  Background: In Rwanda, the introduction of a digital immunization registry based in the District Health Information Software 2 (DHIS2), the e-Tracker, has encountered several implementation challenges. This study aimed to design, implement, and evaluate targeted implementation strategies to enhance the adoption and sustained use of the e-Tracker within the National Immunization Program. Method: We used an implementation research design with a mixed methods approach. We conducted focus group discussions with immunization nurses and co-designed facilitation-based implementation strategies with health workers and implemented them in 12 purposively selected intervention facilities from 48 health facilities that were under-performing on the e-Tracker. The remaining 36 under-performing facilities served as a control group. Evaluations were conducted three months post-implementation with one immunization nurse per facility as respondents, using a process evaluation questionnaire assessing three implementation outcomes: acceptability, appropriateness, and feasibility. We assessed data consistency for the BCG, Penta3 and MR1 vaccines with routine reports before and after implementation of the co-designed strategies. Results: The co-designed strategies included educational videos, establishment of a collaborative group of immunization health workers to facilitate regular learning, and provision of support from champion users. The intervention group indicated higher acceptability ((Mdn=23 vs. Mdn=20.5, p = .026) and feasibility (Mdn=18 vs. Mdn=15, p = .002) of using the e-Tracker than the control group. Intervention and control groups had similar scores on appropriateness (Mdn = 22 vs. Mdn=23, p = .84). Data consistency for all indicators was nearly 100% in both groups before and after the introduction of implementation strategies. Discussion: The co-designed strategies improved the acceptability and feasibility of the e-Tracker among immunization health workers, while there was no difference in data consistency. These findings suggest an association between participatory, facilitation-based approaches and nurses’ commitment which in turn may support sustainable use of digital tools.

• Uwera, Thaoussi; Frøen, Jahn Frederik; Papadopoulou, Eleni; Rukundo, Enock; Sibomana, Hassan & Muhire, Andrew [Show all 8 contributors for this article] (2025). Child immunization data quality in Rwanda: an assessment of routine health information system data. Archives of Public Health. ISSN 0778-7367. 83. doi: 10.1186/s13690-025-01583-7. Full text in Research Archive Show summary

  Background: Documentation and reporting of routine data by health workers is the backbone of the childhood immunization program. Immunization data from health management information systems (HMIS) in low-and middle-income countries (LMICs) are often incomplete and unreliable. In Rwanda, the immunization e-Tracker, an individual-level health management information system (HMIS) built on DHIS2 open-source software, has been implemented and scaled nationwide since 2019. The aim of this study was to assess the quality of the routine HMIS immunization data over time. Method: Data were derived from four HMIS sources for January to December 2020 from 24 health facilities from four districts: health facility registers (paper-based), district aggregated reports (paper-based), national HMIS reports (electronic), and e-Tracker reports (electronic). We then obtained e-Tracker reports and national HMIS reports from 2022 for the same facilities and assessed changes over time. Data quality assessments were conducted for four selected childhood immunization indicators: Bacille Calmette-Guérin (BCG), Pentavalent 3 (Penta 3) and Measles & Rubella 1 (MR1). We calculated frequencies and percentage differences. Accuracy ratios were computed for HMIS reports against facility registers for 2020 and e-Tracker for 2022. Results: In 2020, varying degrees of inconsistencies between facility registers and HMIS reports were observed, ranging from − 2.57 to 0.67% for BCG, -13.85% to -1.45% for Penta3, and − 8.30–2.00% for MR1. Only BCG data were entered in the e-Tracker in 2020. By 2022, e-Tracker completeness of Penta3 and MR1 had also increased substantially. Conclusions: Data quality in the paper based HMIS was variable across districts and health facilities. Improvements in quality of e-Tracker data over time demonstrate increased uptake of e-Tracker use by health workers, possibly explained by the removal of paper documentation and reporting. Further improvements in data quality can be achieved by purposefully designed implementation strategies to support health workers with digital data entry.

• Bhutada, Kiran; Venkateswaran, Mahima; Atim, Maureen; Munabi-Babigumira, Susan Kyomuhendo; Nankabirwa, Victoria & Namagembe, Flavia [Show all 8 contributors for this article] (2024). Factors influencing the uptake of antenatal care in Uganda: a mixed methods systematic review. BMC Pregnancy and Childbirth. 24(1). doi: 10.1186/s12884-024-06938-6. Full text in Research Archive Show summary

  Background In 2016, the World Health Organization (WHO) recommended increasing antenatal care (ANC) visits from four to eight to reduce maternal morbidity and mortality. However, many low-middle income countries (LMICs), including Uganda, struggle to achieve even the basic four ANC visits. To further improve ANC attendance, understanding the perceptions and beliefs of end users is crucial. This systematic review explores the perceptions, experiences, and behavior of pregnant or previously pregnant women, their families and healthcare workers on ANC attendance in Uganda. Methods The review includes qualitative and quantitative studies published from January 2012 to September 2022. Outcomes include early initiation of ANC visits and any attendance or utilization of routine ANC services. The Critical Appraisal Skills Programme (CASP) checklist was used to assess the quality of included studies. Results We searched 7 databases, identified 725 references and assessed 107 in full text for eligibility based on selected inclusion criteria. Forty-seven studies were eligible and are included in this review. Quantitative findings highlight socioeconomic factors like occupation, wealth index, and marital status as key determinants of ANC uptake and timely uptake of care, favoring higher wealth, younger age, marriage, and media access. Qualitative evidence reveals challenges to ANC attendance including financial constraints, cultural beliefs, gendered decision-making, and geographical distance from healthcare facilities. Potential solutions involve financially empowering women, providing reliable ANC equipment and medication, and community engagement and education. Conclusions This review offers valuable insights for policymakers and healthcare providers seeking to tailor interventions that address the unique needs and challenges faced by pregnant women, their families, and healthcare workers in Uganda. By doing so, it may enhance ANC accessibility and quality, ultimately aligning with the WHO’s recommendation of eight ANC contacts (ANC8) and contributing to reducing maternal morbidity and mortality rates.

• Venkateswaran, Mahima; Pervin, Jesmin; Dolphyne, Akuba; Friberg, Ingrid Kristina; Fjeldheim, Ingvild & Frøen, J. Frederik [Show all 14 contributors for this article] (2024). eRegMat – a digital registry for improved quality of antenatal care: a cluster-randomized trial in a rural area in Bangladesh. BMC Digital Health. 2(5). doi: 10.1186/s44247-023-00059-4. Full text in Research Archive Show summary

  Introduction Longitudinal client tracking systems with digital health interventions are recommended for implementation in resource-limited settings but lack evidence of benefits, harms, and implementation. In the eRegMat cluster-randomized controlled trial, we aimed to assess the effectiveness of an eRegistry versus an unshared digital client record. Methods Fifty-nine primary health care facilities in Matlab, Bangladesh were randomized with a 1:1 allocation ratio to receive an eRegistry (intervention, 30 health facilities) with decision support, feedback dashboards and targeted client communication, or an unshared digital client record without digital health interventions (control, 29 health facilities). We assessed timely antenatal care attendance, quality of care, and health outcomes. Outcome data were captured in the eRegistry, or unshared digital client record used by health workers, and through a postpartum household survey. We estimated adjusted relative risks (ARRs) following the intention-to-treat principle and adjusted for cluster randomization. Results From October 2018 to June 2020, 3023 pregnant women were enrolled in the intervention and 2746 in the control groups through community and facility registrations. Intervention and control groups did not differ for the primary outcomes: timely attendance at eligible antenatal care visits (42.5% vs. 40.3%, ARR 0.96, 95% CI 0.89–1.05, p-value 0.4) and hypertension screening and management (95.1% vs. 94.7%, ARR 1.00, 95% CI 0.96–1.03, p-value 0.8). The secondary outcome of perinatal mortality and severe perinatal morbidities was lower in the intervention (14.6%) compared to the control group (15%) (ARR 0.74, 95% CI 0.58–0.96, p-value 0.02), with the change mostly attributed to morbidity outcomes. Conclusion Due to technical and implementation challenges we were unable to estimate the effect of the intervention with sufficient precision. Challenges included delays in rollout of the digital health interventions and outcome data collection, existence of parallel documentation systems on paper and digital and the COVID-19 pandemic. Given these methodological constraints, we are unable to draw definitive interpretations of trial results.

• Uwera, Thaoussi; Venkateswaran, Mahima; Bhutada, Kiran; Papadopoulou, Eleni; Rukundo, Enock & Tumusiime, David K. [Show all 7 contributors for this article] (2024). Electronic Immunization Registry in Rwanda: Qualitative Study of Health Worker Experiences. JMIR Human Factors. 11. doi: 10.2196/53071. Full text in Research Archive Show summary

  Background: Monitoring childhood immunization programs is essential for health systems. Despite the introduction of an electronic immunization registry called e-Tracker in Rwanda, challenges such as lacking population denominators persist, leading to implausible reports of coverage rates of more than 100%. Objective: This study aimed to assess the extent to which the immunization e-Tracker responds to stakeholders’ needs and identify key areas for improvement. Methods: In-depth interviews were conducted with all levels of e-Tracker users including immunization nurses, data managers, and supervisors from health facilities in 5 districts of Rwanda. We used an interview guide based on the constructs of the Human, Organization, and Technology–Fit (HOT-Fit) framework, and we analyzed and summarized our findings using the framework. Results: Immunization nurses reported using the e-Tracker as a secondary data entry tool in addition to paper-based forms, which resulted in considerable dissatisfaction among nurses. While users acknowledged the potential of a digital tool compared to paper-based systems, they also reported the need for improvement of functionalities to support their work, such as digital client appointment lists, lists of defaulters, search and register functions, automated monthly reports, and linkages to birth notifications and the national identity system. Conclusions: Reducing dual documentation for users can improve e-Tracker use and user satisfaction. Our findings can help identify additional digital health interventions to support and strengthen the health information system for the immunization program.

• Blom-Bakke, Kjersti Mørkrid; Ghanem, Buthaina; Abbas, Eatimad; Khader, Khadija Abu; Ward, Itimad Abu & Ataallah, Amjad [Show all 21 contributors for this article] (2023). Quality improvement dashboard for healthcare providers and targeted client communication to pregnant women to improve timely attendance and quality of antenatal care: A multi-arm cluster randomized trial (the eRegCom trial). Oxford Open Digital Health. 1(1), p. 1–10. doi: 10.1093/oodh/oqad010. Full text in Research Archive Show summary

  Background: Digital health interventions can strengthen coverage and quality of care. Our aim was to assess the effectiveness of targeted client communication (TCC) to pregnant women via text messages, health care provider communication via a quality improvement dashboard (QID) and the combination of TCC and QID—generated and delivered from a digital maternal and child health registry (MCH eRegistry), running on the District Health Information Software 2 (DHIS2) platform in West Bank and Gaza. The control was the regular MCH eRegistry. Methods: We included 137 clusters in a four-arm cluster randomized controlled trial. Primary outcomes were appropriate screening and management of anemia, hypertension and diabetes during pregnancy, and timely attendance to routine antenatal care (ANC). Results: The COVID-19 pandemic interrupted the trial, which failed to achieve the estimated sample size. Between 1 December 2019 and 23 March 2020, 4138 women attended ANC in the TCC, 3553 in the QID, 4223 in the TCC & QID and 3324 in the control arm. In the TCC arm, 76.5% of the visits were attended timely versus 73.4% in the control arm, (adjusted odds ratio, 1.2; 95% confidence interval, 0.90–1.61). We found no difference between QID and control, or between TCC & QID control in the proportion of visits where anemia, hypertension and diabetes were appropriately screened and managed. Conclusion: The routine individual-level data of the MCH eRegistry enabled the implementation of theory-driven TCC and QID. However, the COVID-19 pandemic interrupted this trial of TCC and QID, and we were unable to observe any significant effect.

• Venkateswaran, Mahima; Ghanem, Buthaina; Abbas, Eatimad; Khader, Khadija Abu; Ward, Itimad Abu & Awwad, Tamara [Show all 13 contributors for this article] (2022). A digital health registry with clinical decision support for improving quality of antenatal care in Palestine (eRegQual): a pragmatic, cluster-randomised, controlled, superiority trial. The Lancet Digital Health. 4(2), p. e126–e136. doi: 10.1016/S2589-7500(21)00269-7. Full text in Research Archive Show summary

  Background Health worker compliance with clinical guidelines is enhanced by digital clinical decision support at the point of care. The Palestinian public health system is implementing a digital maternal and child health eRegistry with clinical decision support. We aimed to compare the quality of antenatal care between clinics using the eRegistry and those using paper-based records. Methods The eRegQual cluster-randomised controlled trial was done in primary health-care clinics offering routine antenatal care in the West Bank, Palestine. The intervention was the eRegistry with clinical decision support for antenatal care, implemented in District Health Information Systems 2 (DHIS2) Tracker software. 133 clinics forming 120 clusters were included and randomised; clusters were randomly assigned (1:1) to either the control (paper-based documentation) or intervention (eRegistry with clinical decision support) groups. The primary process outcomes were appropriate screening and management of anaemia, hypertension, and diabetes during pregnancy and foetal growth monitoring. The primary health outcome at delivery was a composite of moderate or severe anaemia; severe hypertension; large-for-gestational-age baby; malpresentation and small-for-gestational-age baby undetected before delivery. Data were analysed with mixed-effects logistic regression, accounting for clustering within clinics and pregnancies as appropriate. This trial is registered with the ISRCTN registry (ISRCTN18008445). Findings Between Jan 15 and Sept 15, 2017, 3219 pregnant women received care in the intervention clinics (n=60 clusters) and 3148 pregnant women received care in the control primary health-care clinics (n=59 clusters). Compared with the control group, the intervention led to higher guideline adherence for screening and management of anaemia (1535 [28·9%] of 5320 vs 2297 [44·3%] of 5182; adjusted odds ratio [OR] 1·88 [95% CI 1·52–2·32]), hypertension (7555 [94·7%] of 7982 vs 7314 [96·6%] of 7569; adjusted OR 1·62 [95% CI 1·29–2·05]), and gestational diabetes (1726 (39·7%) of 4348 vs 2189 (50·7%) of 4321; adjusted OR 1·45 [95% CI 1·14–1·83]) at eligible antenatal contacts. Only 599 (9·4%) of 6367 women attended the full antenatal care schedule, and better care provision did not translate to fewer adverse health outcomes in the intervention clusters (700 cases; 21·7%) compared to the control clusters (688 cases; 21·9%; adjusted OR 0·99; 95% CI 0·87–1·12). Interpretation Clinical decision support for antenatal care in the eRegistry was superior for most process outcomes but had no effect on the adverse health outcomes. The improvements in process outcomes strengthen the evidence for the WHO guideline for digital client tracking with clinical decision support in lower-middle-income settings. Digital health interventions to address gaps in attendance might help achieve effective coverage of antenatal care.

• Venkateswaran, Mahima; Nazzal, Zaher; Ghanem, Buthaina; Khraiwesh, Reham; Abbas, Eatimad & Khader, Khadija Abu [Show all 12 contributors for this article] (2022). eRegTime—Time Spent on Health Information Management in Primary Health Care Clinics Using a Digital Health Registry Versus Paper-Based Documentation: Cluster-Randomized Controlled Trial. JMIR Formative Research. 6(5). doi: 10.2196/34021. Full text in Research Archive Show summary

  Background: Digital health interventions have been shown to improve data quality and health services in low- and middle-income countries (LMICs). Nonetheless, in LMICs, systematic assessments of time saved with the use of digital tools are rare. We ran a set of cluster-randomized controlled trials as part of the implementation of a digital maternal and child health registry (eRegistry) in the West Bank, Palestine. Objective: In the eRegTime study, we compared time spent on health information management in clinics that use the eRegistry versus the existing paper-based documentation system. Methods: Intervention (eRegistry) and control (paper documentation) arms were defined by a stratified random subsample of primary health care clinics from the concurrent eRegQual trial. We used time-motion methodology to collect data on antenatal care service provision. Four observers used handheld tablets to record time-use data during one working day per clinic. We estimated relative time spent on health information management for booking and follow-up visits and on client care using mixed-effects linear regression. Results: In total, 22 of the 24 included clinics (12 intervention, 10 control) contributed data; no antenatal care visits occurred in the other two clinics during the study period. A total of 123 and 118 consultations of new pregnancy registrations and follow-up antenatal care visits were observed in the intervention and control groups, respectively. Average time spent on health information management for follow-up antenatal care visits in eRegistry clinics was 5.72 minutes versus 8.10 minutes in control clinics (adjusted relative time 0.69, 95% CI 0.60-0.79; P<.001), and 15.26 minutes versus 18.91 minutes (adjusted relative time 0.96, 95% CI 0.61-1.50; P=.85) for booking visits. The average time spent on documentation, a subcategory of health information management, was 5.50 minutes in eRegistry clinics versus 8.48 minutes in control clinics (adjusted relative time 0.68, 95% CI 0.56-0.83; P<.001). While the average time spent on client care was 5.01 minutes in eRegistry clinics versus 4.91 minutes in control clinics, some uncertainty remains, and the CI was consistent with eRegistry clinics using less, the same, or more time on client care compared to those that use paper (adjusted relative time 0.85, 95% CI 0.64-1.13; P=.27). Conclusions: The eRegistry captures digital data at point of care during client consultations and generates automated routine reports based on the clinical data entered. Markedly less time (plausibly a saving of at least 18%) was spent on health information management in eRegistry clinics compared to those that use paper-based documentation. This is likely explained by the fact that the eRegistry requires lesser repetitive documentation work than paper-based systems. Adoption of eRegistry-like systems in comparable settings may save valuable and scarce health care resources.

• Khatun, Fatema; Distler, Rebecca; Rahman, Monjur; O'Donnell, Brian; Gachuhi, Noni & Alwani, Manoj [Show all 10 contributors for this article] (2022). Comparison of a palm-based biometric solution with a name-based identification system in rural Bangladesh. Global health action. ISSN 1654-9716. 15(1). doi: 10.1080/16549716.2022.2045769. Full text in Research Archive Show summary

  Background Unique identifiers are not universal in low- and middle-income countries. Biometric solutions have the potential to augment existing name-based searches used for identification in these settings. This paper describes a comparison of the searching accuracy of a palm-based biometric solution with a name-based database. Objective To compare the identification of individuals between a palm-based biometric solution to a name-based District Health Information Software 2 (DHIS2) Android application, in a low-resource setting. Methods The study was conducted in Chandpur district, Bangladesh. Trained data collectors enrolled 150 women of reproductive age into two android applications – i) a name-based DHIS2 application, and ii) a palm-based biometric solution – both run on tablets. One week after enrollment, a different research team member attempted to re-identify each enrolled woman using both systems. A single image or text-based name was used for searching at the time of re-identification. We interviewed data collectors at the end of the study. Results Significantly more women were successfully identified on the first attempt with a palm-based biometric application (84%) compared with the name-based DHIS2 application (61%). The proportion of identifications that required three or more attempts was similar between name-based (7%, CI 3.7–12.3) and palm-based biometric system (5%, CI: 1.9–9.4). However, the total number of attempts needed was significantly lower with the palm-based solution (mean 1.2 vs. 1.5, p < 0.001). In a group discussion, data collectors reported that the palm-based biometric identification system was both accurate and easy to use. Conclusion A palm-based biometric identification system on mobile devices was found to be an easy-to-use and accurate technology for the unique identification of individuals compared to an existing name-based application. Our findings imply that palm-based biometrics on mobile devices may be the next step in establishing unique identifiers in remote and rural settings where they are currently absent.

• Frøen, Jahn Frederik Alexander Claude; Bianchi, Ana; Moller, Ann-Beth & Jacobsson, Bo (2021). FIGO good practice recommendations on the importance of registry data for monitoring rates and health systems performance in prevention and management of preterm birth. International Journal of Gynecology & Obstetrics. ISSN 0020-7292. 155(1), p. 5–7. doi: 10.1002/ijgo.13847. Full text in Research Archive
• Pervin, Jesmin; Venkateswaran, Mahima; Nu, U. Tin; Rahman, Monjur; O’Donnell, Brian F. & Friberg, Ingrid Kristina [Show all 8 contributors for this article] (2021). Determinants of utilization of antenatal and delivery care at the community level in rural Bangladesh. PLOS ONE. 16(9). doi: 10.1371/journal.pone.0257782. Full text in Research Archive Show summary

  Background: Timely utilization of antenatal care and delivery services supports the health of mothers and babies. Few studies exist on the utilization and determinants of timely ANC and use of different types of health facilities at the community level in Bangladesh. This study aims to assess the utilization, timeliness of, and socio-demographic determinants of antenatal and delivery care services in two sub-districts in Bangladesh. Methods: This cross-sectional study used data collected through a structured questionnaire in the eRegMat cluster-randomized controlled trial, which enrolled pregnant women between October 2018-June 2020. We undertook univariate and multivariate logistic regression analysis to determine the associations of socio-demographic variables with timely first ANC, four timely ANC visits, and facility delivery. We considered the associations in the multivariate logistic regression as statistically significant if the p-value was found to be <0.05. Results are presented as adjusted odds ratios (AOR) with 95% confidence intervals (CI). Results: Data were available on 3293 pregnant women. Attendance at a timely first antenatal care visit was 59%. Uptake of four timely antenatal care visits was 4.2%. About three-fourths of the women delivered in a health facility. Women from all socio-economic groups gradually shifted from using public health facilities to private hospitals as the pregnancy advanced. Timely first antenatal care visit was associated with: women over 30 years of age (AOR: 1.52, 95% CI: 1.05–2.19); nulliparity (AOR: 1.30, 95% CI: 1.04–1.62); husbands with >10 years of education (AOR: 1.40, 95% CI: 1.09–1.81) and being in the highest wealth quintile (AOR: 1.49, 95% CI: 1.18–1.89). Facility deliveries were associated with woman’s age; parity; education; the husband’s education, and wealth index. None of the available socio-demographic factors were associated with four timely antenatal care visits. Conclusions: The study observed socio-demographic inequalities associated with increased utilization of timely first antenatal care visit and facility delivery. The pregnant women, irrespective of wealth shifted from public to private facilities for their antenatal care visits and delivery. To increase the health service utilization and promote good health, maternal health care programs should pay particular attention to young, multiparous women, of low socio-economic status, or with poorly educated husbands.

• Blom-Bakke, Kjersti Mørkrid; Bungudo, Binyam; Abbas, Eatimad; Khader, Khadija Abu; Ward, Itimad Abu & Attalh, Amjad [Show all 20 contributors for this article] (2021). 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. Trials. 22, p. 1–13. doi: 10.1186/s13063-020-04980-1. Full text in Research Archive Show summary

  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.

• Pervin, Jesmin; Sarker, Bidhan Krishna; Nu, U. Tin; Khatun, Fatema; Rahman, A. M. Quaiyum & Venkateswaran, Mahima [Show all 9 contributors for this article] (2021). Developing targeted client communication messages to pregnant women in Bangladesh: a qualitative study. BMC Public Health. 21(1). doi: 10.1186/s12889-021-10811-y. Full text in Research Archive Show summary

  Abstract Background:Timely and appropriate evidence-based practices during antenatal care improve maternal and neonatal health. There is a lack of information on how pregnant women and families perceive antenatal care in Bangladesh. The aim of our study was to develop targeted client communication via text messages for increasing antenatal care utilization, as part of an implementation of an electronic registry for maternal and child health. Methods:Using a phenomenological approach, we conducted this qualitative study from May to June 2017 in two sub-districts of Chandpur district, Bangladesh. We selected study participants by purposive sampling. A total of 24 in-depth interviews were conducted with pregnant women(n= 10), lactating women (n=5), husbands(n= 5), and mothers-in-law(n= 4). The Health Belief Model (HBM) was used to guide the data collection. Thematic analysis was carried out manually according to the HBM constructs. We used behavior change techniques to inform the development of targeted client communication based on the thematic results. Results:Almost no respondents mentioned antenatal care as a preventive form of care, and only perceived it as necessary if any complications developed during pregnancy. Knowledge of the content of antenatal care (ANC) and pregnancy complications was low. Women reported a variety of reasons for not attending ANC, including the lack of information on the timing of ANC; lack of decision-making power; long-distance to access care; being busy with household chores, and not being satisfied with the treatment by health care providers. Study participants recommended phone calls as their preferred communication strategy when asked to choose between the phone call and text message, but saw text messages as a feasible option. Based on the findings, we developed a library of 43 automatically customizable text messages to increase ANC utilization. Conclusions:Pregnant women and family members had limited knowledge about antenatal care and pregnancy complications. Effective health information through text messages could increase awareness of antenatal care among the pregnant women in Bangladesh. This study presents an example of designing targeted client communication to increase antenatal care utilization within formal scientific frameworks, including a taxonomy of behavior change techniques.

• Bungudo, Binyam Bogale; Blom-Bakke, Kjersti Mørkrid; O'Donnell, Brian; Ghanem, Buthaina; Ward, Itimad Abu & Khader, Khadija Abu [Show all 13 contributors for this article] (2021). Development of a targeted client communication intervention for pregnant and post-partum women: a descriptive study. The Lancet. ISSN 0140-6736. 398, p. S18–S18. doi: 10.1016/S0140-6736(21)01504-X. Full text in Research Archive
• Isbeih, Mervett; Venkateswaran, Mahima; Abbas, Eatimad; Khader, Khadija Abu; Awwad, Tamara & Baniode, Mohammad [Show all 12 contributors for this article] (2021). Gestational age recorded at delivery versus estimations using antenatal care data from the Electronic Maternal and Child Health Registry in the West Bank: a comparative analysis. The Lancet. ISSN 0140-6736. 398(1S), p. S31–S31. doi: 10.1016/S0140-6736(21)01517-8. Full text in Research Archive
• Rahman, Anisur; Friberg, Ingrid Kristina; Dolphyne, Akuba Kwansima; Fjeldheim, Ingvild; Khatun, Fatema & O’Donnell, Brian [Show all 13 contributors for this article] (2021). An Electronic Registry for Improving the Quality of Antenatal Care in Rural Bangladesh (eRegMat): Protocol for a Cluster Randomized Controlled Trial. JMIR Research Protocols. 10(7). doi: 10.2196/26918. Full text in Research Archive Show summary

  Background: Digital health interventions (DHIs) can alleviate several barriers to achieving better maternal and child health. The World Health Organization’s guideline recommendations for DHIs emphasize the need to integrate multiple DHIs for maximizing impact. The complex health system of Bangladesh provides a unique setting for evaluating and understanding the role of an electronic registry (eRegistry) for antenatal care, with multiple integrated DHIs for strengthening the health system as well as improving the quality and utilization of the public health care system. Objective: The aim of this study is to assess the effect of an eRegistry with DHIs compared with a simple digital data entry tool without DHIs in the community and frontline health facilities. Methods: The eRegMat is a cluster-randomized controlled trial conducted in the Matlab North and Matlab South subdistricts in the Chandpur district, Bangladesh, where health facilities are currently using the eRegistry for digital tracking of the health status of pregnant women longitudinally. The intervention arm received 3 superimposed data-driven DHIs: health worker clinical decision support, health worker feedback dashboards with action items, and targeted client communication to pregnant women. The primary outcomes are appropriate screening as well as management of hypertension during pregnancy and timely antenatal care attendance. The secondary outcomes include morbidity and mortality in the perinatal period as well as timely first antenatal care visit; successful referrals for anemia, diabetes, or hypertension during pregnancy; and facility delivery. Results: The eRegistry and DHIs were co-designed with end users between 2016 and 2018. The eRegistry was implemented in the study area in July 2018. Recruitment for the trial started in October 2018 and ended in June 2020, followed by an 8-month follow-up period to capture outcome data until February 2021. Trial results will be available for publication in June 2021. Conclusions: This trial allows the simultaneous assessment of multiple integrated DHIs for strengthening the health system and aims to provide evidence for its implementation. The study design and outcomes are geared toward informing the living review process of the guidelines for implementing DHIs.

• Bungudo, Binyam; Blom-Bakke, Kjersti Mørkrid; Abbas, Eatimad; Ward, Itimad Abu; Anaya, Firas & Ghanem, Buthaina [Show all 12 contributors for this article] (2021). The effect of a digital targeted client communication intervention on pregnant women's worries and satisfaction with antenatal care in Palestine-A cluster randomized controlled trial. PLOS ONE. 16(4), p. 1–13. doi: 10.1371/journal.pone.0249713. Full text in Research Archive Show summary

  Background: The eRegCom cluster randomized controlled trial assesses the effectiveness of targeted client communication (TCC) via short message service (SMS) to pregnant women, from a digital maternal and child health registry (eRegistry) in Palestine, on improving attendance and quality of care. In this paper, we assess whether this TCC intervention could also have unintended consequences on pregnant women’s worries, and their satisfaction with antenatal care (ANC). Methods: We interviewed a sub-sample of Arabic-speaking women attending ANC at public primary healthcare clinics, randomized to either the TCC intervention or no TCC (control) in the eRegCom trial, who were in 38 weeks of gestation and had a phone number registered in the eRegistry. Trained female data collectors interviewed women by phone from 67 intervention and 64 control clusters, after securing informed oral consent. The Arabic interview guide, pilot-tested prior to the data collection, included close-ended questions to capture the woman’s socio-demographic status, agreement questions about their satisfaction with ANC services, and the 13-item Cambridge Worry Scale (CWS). We employed a non-inferiority study design and an intention-to-treat analysis approach. Results: A total of 454 women, 239 from the TCC intervention and 215 from the control arm participated in this sub-study. The mean and standard deviation of the CWS were 1.8 (1.9) for the intervention and 2.0 (1.9) for the control arm. The difference in mean between the intervention and control arms was -0.16 (95% CI: -0.31 to -0.01) after adjusting for clustering, which was below the predefined non-inferiority margin of 0.3. Women in both groups were equally satisfied with the ANC services they received. Conclusion: The TCC intervention via SMS did not increase pregnancy-related worries among recipients. There was no difference in women’s satisfaction with the ANC services between intervention and control arms.

• Mohan, Sanjana Brahmawar; Sommerfelt, Halvor; Frøen, Jahn Frederik; Taneja, Sunita; Kumar, Tivendra & Bhatia, Kiran [Show all 11 contributors for this article] (2020). Antenatal uterotonics as a risk factor for intrapartum stillbirth and first-day death in Haryana, India: A nested case-control study. Epidemiology. ISSN 1044-3983. 31(5), p. 668–676. doi: 10.1097/EDE.0000000000001224. Full text in Research Archive
• Bungudo, Binyam; Blom-Bakke, Kjersti Mørkrid; O'Donnell, Brian; Ghanem, Buthaina; Ward, Itimad Abu & Khader, Khadija Abu [Show all 13 contributors for this article] (2020). Development of a targeted client communication intervention to women using an electronic maternal and child health registry: a qualitative study. BMC Medical Informatics and Decision Making. 20(1). doi: 10.1186/s12911-019-1002-x. Full text in Research Archive Show summary

  Background Targeted client communication (TCC) using text messages can inform, motivate and remind pregnant and postpartum women of timely utilization of care. The mixed results of the effectiveness of TCC interventions points to the importance of theory based interventions that are co-design with users. The aim of this paper is to describe the planning, development, and evaluation of a theory led TCC intervention, tailored to pregnant and postpartum women and automated from the Palestinian electronic maternal and child health registry. Methods We used the Health Belief Model to develop interview guides to explore women’s perceptions of antenatal care (ANC), with a focus on high-risk pregnancy conditions (anemia, hypertensive disorders in pregnancy, gestational diabetes mellitus, and fetal growth restriction), and untimely ANC attendance, issues predefined by a national expert panel as being of high interest. We performed 18 in-depth interviews with women, and eight with healthcare providers in public primary healthcare clinics in the West Bank and Gaza. Grounding on the results of the in-depth interviews, we used concepts from the Model of Actionable Feedback, social nudging and Enhanced Active Choice to compose the TCC content to be sent as text messages. We assessed the acceptability and understandability of the draft text messages through unstructured interviews with local health promotion experts, healthcare providers, and pregnant women. Results We found low awareness of the importance of timely attendance to ANC, and the benefits of ANC for pregnancy outcomes. We identified knowledge gaps and beliefs in the domains of low awareness of susceptibility to, and severity of, anemia, hypertension, and diabetes complications in pregnancy. To increase the utilization of ANC and bridge the identified gaps, we iteratively composed actionable text messages with users, using recommended message framing models. We developed algorithms to trigger tailored text messages with higher intensity for women with a higher risk profile documented in the electronic health registry. Conclusions We developed an optimized TCC intervention underpinned by behavior change theory and concepts, and co-designed with users following an iterative process. The electronic maternal and child health registry can serve as a unique platform for TCC interventions using text messages.

• Blom-Bakke, Kjersti Mørkrid; Bungudo, Binyam; Ward, Itimad Abu; Abbas, Eatimad; Attalh, Amjad & Khader, Khadija Abu [Show all 20 contributors for this article] (2020). 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. Trials. doi: 10.21203/rs.3.rs-25173/v2. Full text in Research Archive
• Barlinn, Regine; Trogstad, Lill; Rollag, Halvor; Frøen, Jahn Frederik; Magnus, Per & Dudman, Susanne Gjeruldsen (2020). Parvovirus B19 DNAemia in pregnant women in relation to perinatal death: A nested case‐control study within a large population‐based pregnancy cohort. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. 99(7), p. 856–864. doi: 10.1111/aogs.13801. Full text in Research Archive Show summary

  Introduction: Parvovirus B19 (B19V) is the infectious cause of exanthema infectiosum. In Europe around 40% of pregnant women are susceptible to infection. Having small children at home is the main risk factor for contracting an infection during pregnancy. The association between B19V‐infection and perinatal death is not yet settled. The aims of the study were to estimate the association between maternal parvovirus B19 infection in pregnancy and perinatal death, and to assess the significance of a positive B19V PCR in pregnancy. Material and methods: The study population consists of women included in the Norwegian Mother and Child Cohort Study, a prospective population‐based pregnancy cohort of nearly 100 000 women. Blood samples were obtained during weeks 17‐18 in pregnancy (M1), at birth, and in umbilical cord blood. Within participants in the pregnancy cohort, 138 cases of perinatal death and 1350 controls with live‐born children were included in a nested case‐control study. Samples were analyzed with B19V serology and B19V PCR according to a predefined test algorithm. For cases, medical records and laboratory results from hospitals were combined with the results of B19V serology and PCR. The reported causes of perinatal death were categorized using the classification system: Causes Of Death and Associated Conditions (CODAC). Results: The B19V seroconversion rates were 9.8% for cases and 6.8% for control mothers. The odds ratio for maternal B19V infection in cases compared with controls was 1.28 (95% CI 0.35‐4.70), adjusted for age, parity, body mass index and tobacco use. B19V‐PCR‐positive samples were detected at weeks 17‐18 of gestation in both cases and controls. The proportion of positive samples was similar in cases and controls, 24% and 28.2%, respectively. Mothers with PCR‐positive M1 samples transmitted B19V vertically in 9.1% of cases and in 11.9% of the controls. Of all perinatal deaths, 53% were attributed to placental pathology or unknown causes. Conclusions: B19V PCR positivity was high and similar in both cases and controls. In our study B19V DNAemia was not seen to be associated with fatal outcome of pregnancy. The clinical significance of B19V DNA detection during pregnancy is uncertain. Caution is needed when diagnosing a B19V infection based only on B19V DNAemia.

• Lindberg, Marie Hella; Venkateswaran, Mahima; Khader, Khadija Abu; Awwad, Tamara; Ghanem, Buthaina & Hijaz, Taghreed [Show all 8 contributors for this article] (2019). eRegTime, Efficiency of Health Information Management Using an Electronic Registry for Maternal and Child Health: Protocol for a Time-Motion Study in a Cluster Randomized Trial. JMIR Research Protocols. 8(8). doi: 10.2196/13653. Full text in Research Archive Show summary

  <i>Background</i>: Paper-based routine health information systems often require repetitive data entry. In the West Bank, the primary health care system for maternal and child health was entirely paper-based, with care providers spending considerable amounts of time maintaining multiple files and client registers. As part of the phased national implementation of an electronic health information system, some of the primary health care clinics are now using an electronic registry (eRegistry) for maternal and child health. The eRegistry consists of client-level data entered by care providers at the point-of-care and supports several digital health interventions that are triggered by the documented clinical data, including guideline-based clinical decision support and automated public health reports.<p> <p><i>Objective</i>: The aim of the eRegTime study is to investigate whether the use of the eRegistry leads to changes in time-efficiency in health information management by the care providers, compared with the paper-based systems.<p> <p><i>Methods</i>: This is a substudy in a cluster randomized controlled trial (the eRegQual study) and uses the time-motion observational study design. The primary outcome is the time spent on health information management for antenatal care, informed and defined by workflow mapping in the clinics. We performed sample size estimations to enable the detection of a 25% change in time-efficiency with a 90% power using an intracluster correlation coefficient of 0.1 and an alpha of .05. We observed care providers for full workdays in 24 randomly selected primary health care clinics—12 using the eRegistry and 12 still using paper. Linear mixed effects models will be used to compare the time spent on health information management per client per care provider.<p> <p><i>Results</i>: Although the objective of the eRegQual study is to assess the effectiveness of the eRegistry in improving quality of antenatal care, the results of the eRegTime study will contribute to process evaluation, supplementing the findings of the larger trial.<p> <p><i>Conclusions</i>: Electronic health tools are expected to reduce workload for the care providers and thus improve efficiency of clinical work. To achieve these benefits, the implementation of such systems requires both integration with existing workflows and the creation of new workflows. Studies assessing the time-efficiency of electronic health information systems can inform policy decisions for implementations in resource-limited low- and middle-income settings.

• Friberg, Ingrid Kristina; Venkateswaran, Mahima; Ghanem, Buthaina & Frøen, Frederik (2019). Antenatal care data sources and their policy and planning implications: a Palestinian example using the Lives Saved Tool. BMC Public Health. 19:124, p. 1–11. doi: 10.1186/s12889-019-6427-8. Full text in Research Archive
• Venkateswaran, Mahima; Bungudo, Binyam; Khader, Khadija Abu; Awwad, Tamara; Friberg, Ingrid Kristina & Ghanem, Buthaina [Show all 9 contributors for this article] (2019). Effective coverage of essential antenatal care interventions: A cross-sectional study of public primary healthcare clinics in the West Bank. PLOS ONE. 14:e0212635(2), p. 1–15. doi: 10.1371/journal.pone.0212635. Full text in Research Archive
• Chong, Hsu Phern; Frøen, Frederik; Richardson, Sylvia; Liquet, Benoit; Charnock-Jones, D. Stephen & Smith, Gordon C.S. (2018). Age at menarche and the risk of operative delivery. Journal of Maternal-Fetal & Neonatal Medicine. ISSN 1476-7058. 32(3), p. 411–418. doi: 10.1080/14767058.2017.1381823. Full text in Research Archive Show summary

  Objectives: We sought to evaluate the impact of later menarche on the risk of operative delivery. Population: We studied 38,069 eligible women (first labors at term with a singleton infant in a cephalic presentation) from the Norwegian Mothers and Child Cohort Study. The main exposures were the age at menarche and the duration of the interval between menarche and the first birth. Methods: Poisson's regression with a robust variance estimator. Main outcome measures: Operative delivery, defined as emergency cesarean or assisted vaginal delivery (ventouse extraction or forceps). Results: A 5 year increase in age at menarche was associated with a reduced risk of operative delivery (risk ratio [RR] 0.84, 95%CI 0.78, 0.89; p < .001). Adjustment for the age at first birth slightly strengthened the association (RR 0.79, 95%CI 0.74, 0.84; p < .001). However, the association was lost following adjustment for the menarche to birth interval (RR 0.99, 95%CI 0.93, 1.06; p = .81). A 5 years increase in menarche to birth interval was associated with an increased risk of operative delivery (RR 1.26, 95%CI 1.23, 1.28; p < .001). This was not materially affected by adjustment for an extensive series of maternal characteristics (RR 1.23, 95%CI 1.20, 1.25; p < .001). Conclusions: Later menarche reduces the risk of an operative first birth through shortening the menarche to birth interval. This observation is consistent with the hypothesis that the pattern and/or duration of prepregnancy exposure of the uterus to estrogen and progesterone contributes to uterine aging.

• Norman, Jane E.; Heazell, Alex E.P.; Rodriguez, Aryelly; Weir, Christopher J.; Stock, Sarah J.E. & Calderwood, Catherine J. [Show all 17 contributors for this article] (2018). Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM): a stepped wedge, cluster-randomised trial. The Lancet. ISSN 0140-6736. 392(10158), p. 1629–1638. doi: 10.1016/S0140-6736(18)31543-5. Full text in Research Archive
• Daly, Lisa M.; Gardener, Glenn; Bowring, Victoria; Burton, Wendy; Chadha, Yogesh & Ellwood, David [Show all 14 contributors for this article] (2018). Care of pregnant women with decreased fetal movements: Update of a clinical practice guideline for Australia and New Zealand. Australian and New Zealand Journal of Obstetrics and Gynaecology (ANZJOG). ISSN 0004-8666. 58(4), p. 463–468. doi: 10.1111/ajo.12762. Full text in Research Archive
• Venkateswaran, Mahima; Blom-Bakke, Kjersti Mørkrid; Khader, Khadija Abu; Awwad, Tamara; Friberg, Ingrid Kristina & Ghanem, Buthaina [Show all 8 contributors for this article] (2018). Comparing individual-level clinical data from antenatal records with routine health information systems indicators for antenatal care in the West Bank: A cross-sectional study. PLOS ONE. 13(11). doi: 10.1371/journal.pone.0207813. Full text in Research Archive
• Venkateswaran, Mahima; Blom-Bakke, Kjersti Mørkrid; Ghanem, Buthaina; Abbas, Eatimad; Abuward, Itimad & Baniode, Mohammad [Show all 8 contributors for this article] (2018). 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. Trials. 19:54, p. 1–12. doi: 10.1186/s13063-017-2386-5. Full text in Research Archive
• Flenady, Vicki; Wojcieszek, Aleena M; Ellwood, David; Leisher, Susannah Hopkins; Erwich, Jan Jaap H.M. & Draper, Elizabeth S. [Show all 27 contributors for this article] (2017). Classification of causes and associated conditions for stillbirths and neonatal deaths. Seminars in Fetal & Neonatal Medicine. ISSN 1744-165X. 22(3), p. 176–185. doi: 10.1016/j.siny.2017.02.009. Full text in Research Archive
• Reinebrant, H E; Leisher, S H; Coory, M; Henry, S; Wojcieszek, A M & Gardener, G [Show all 31 contributors for this article] (2017). Making stillbirths visible: a systematic review of globally reported causes of stillbirth. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 125(2), p. 212–224. doi: 10.1111/1471-0528.14971. Full text in Research Archive
• Pay, Aase Serine Devold; Frøen, Frederik; Staff, Anne Cathrine; Jacobsson, Bo & Gjessing, Håkon K. (2017). Symfyse-fundus-mål – prediktiv verdi av ny referansekurve. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 137(10), p. 717–720. doi: 10.4045/tidsskr.16.1022. Full text in Research Archive
• Heazell, Alexander E. P.; Weir, Christopher J.; Stock, Sarah J. E.; Burley, Sarah Cunningham; Frøen, Frederik & Geary, Michael J. [Show all 15 contributors for this article] (2017). Can promoting awareness of fetal movements and focusing interventions reduce fetal mortality? A stepped-wedge cluster randomised trial (AFFIRM). BMJ Open. 7(8). doi: 10.1136/bmjopen-2016-014813. Full text in Research Archive Show summary

  Background In 2013, the stillbirth rate in the UK was 4.2 per 1000 live births, ranking 24th out of 49 high-income countries, with an annual rate of reduction of only 1.4% per year. The majority of stillbirths occur in normally formed infants, with (retrospective) evidence of placental insufficiency the most common clinical finding. Maternal perception of reduced fetal movements (RFM) is associated with placental insufficiency and increased risk of subsequent stillbirth. This study will test the hypothesis that the introduction of a package of care to increase women's awareness of the need for prompt reporting of RFM and standardised management to identify fetal compromise with timely delivery in confirmed cases, will reduce the rate of stillbirth. Following the introduction of a similar intervention in Norway the odds of stillbirth fell by 30%, but the efficacy of this intervention (and possible adverse effects and implications for service delivery) has not been tested in a randomised trial. Methods We describe a stepped-wedge cluster trial design, in which participating hospitals in the UK and Ireland will be randomised to the timing of introduction of the care package. Outcomes (including the primary outcome of stillbirth) will be derived from detailed routinely collected maternity data, allowing us to robustly test our hypothesis. The degree of implementation of the intervention will be assessed in each site. A nested qualitative study will examine the acceptability of the intervention to women and healthcare providers and identify process issues including barriers to implementation. Ethics and dissemination Ethical approval was obtained from the Scotland A Research Ethics Committee (Ref 13/SS/0001) and from Research and Development offices in participating maternity units. The study started in February 2014 and delivery of the intervention completed in December 2016. Results of the study will be submitted for publication in peer-reviewed journals and disseminated to local investigating sites to inform education and care of women presenting with RFM.

• Flenady, Vicki J.; Wojcieszek, Aleena M.; Middleton, Philippa; Ellwood, David; Erwich, Jan Jaap H.M. & Coory, Michael [Show all 35 contributors for this article] (2016). Stillbirths: recall to action in high-income countries. The Lancet. ISSN 0140-6736. 387(10019), p. 691–702. doi: 10.1016/S0140-6736(15)01020-X. Full text in Research Archive
• Frøen, Frederik; Myhre, Sonja; Frost, Michael James; Chou, Doris; Mehl, Garrett & Say, Lale [Show all 22 contributors for this article] (2016). eRegistries: Electronic registries for maternal and child health. BMC Pregnancy and Childbirth. 16(11). doi: 10.1186/s12884-016-0801-7. Full text in Research Archive Show summary

  Background The Global Roadmap for Health Measurement and Accountability sees integrated systems for health information as key to obtaining seamless, sustainable, and secure information exchanges at all levels of health systems. The Global Strategy for Women’s, Children’s and Adolescent’s Health aims to achieve a continuum of quality of care with effective coverage of interventions. The WHO and World Bank recommend that countries focus on intervention coverage to monitor programs and progress for universal health coverage. Electronic health registries - eRegistries - represent integrated systems that secure a triple return on investments: First, effective single data collection for health workers to seamlessly follow individuals along the continuum of care and across disconnected cadres of care providers. Second, real-time public health surveillance and monitoring of intervention coverage, and third, feedback of information to individuals, care providers and the public for transparent accountability. This series on eRegistries presents frameworks and tools to facilitate the development and secure operation of eRegistries for maternal and child health. Methods In this first paper of the eRegistries Series we have used WHO frameworks and taxonomy to map how eRegistries can support commonly used electronic and mobile applications to alleviate health systems constraints in maternal and child health. A web-based survey of public health officials in 64 low- and middle-income countries, and a systematic search of literature from 2005–2015, aimed to assess country capacities by the current status, quality and use of data in reproductive health registries. Results eRegistries can offer support for the 12 most commonly used electronic and mobile applications for health. Countries are implementing health registries in various forms, the majority in transition from paper-based data collection to electronic systems, but very few have eRegistries that can act as an integrating backbone for health information. More mature country capacity reflected by published health registry based research is emerging in settings reaching regional or national scale, increasingly with electronic solutions. 66 scientific publications were identified based on 32 registry systems in 23 countries over a period of 10 years; this reflects a challenging experience and capacity gap for delivering sustainable high quality registries. Conclusions Registries are being developed and used in many high burden countries, but their potential benefits are far from realized as few countries have fully transitioned from paper-based health information to integrated electronic backbone systems. Free tools and frameworks exist to facilitate progress in health information for women and children.

• Pay, Aase Serine Devold; Frøen, Frederik; Staff, Anne Cathrine; Jacobsson, Bo & Gjessing, Håkon K. (2016). Prediction of small-for-gestational-age status by symphysis–fundus height: a registry-based population cohort study. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 123(7), p. 1167–1173. doi: 10.1111/1471-0528.13727. Full text in Research Archive
• Leisher, Susannah Hopkins; Teoh, Zheyi; Reinebrant, Hanna; Allanson, Emma; Blencowe, Hannah & Erwich, Jan Jaap [Show all 19 contributors for this article] (2016). Seeking order amidst chaos: a systematic review of classification systems for causes of stillbirth and neonatal death, 2009-2014. BMC Pregnancy and Childbirth. 16. doi: 10.1186/s12884-016-1071-0. Full text in Research Archive
• Agarwal, Smisha; LeFevre, Amnesty E.; Lee, Jaime; L'Engle, Kelly; Mehl, Garrett & Sinha, Chaitali [Show all 8 contributors for this article] (2016). Guidelines for reporting of health interventions using mobile phones: Mobile health (mHealth) Evidence reporting and assessment (mERA) checklist. The BMJ. 352. doi: 10.1136/bmj.i1174. Full text in Research Archive
• Wojcieszek, Aleena M; Reinebrant, Hanna E; Leisher, Susannah Hopkins; Allanson, Emma; Coory, Michael & Erwich, Jan Jaap H.M. [Show all 19 contributors for this article] (2016). Characteristics of a global classification system for perinatal deaths: a Delphi consensus study. BMC Pregnancy and Childbirth. 16. doi: 10.1186/s12884-016-0993-x. Full text in Research Archive
• Allanson, Emma R.; Vogel, Joshua Peter; Tunçalp, Özge; Gardosi, Jason O.; Pattinson, Robert Clive & Francis, André [Show all 15 contributors for this article] (2016). Application of ICD-PM to preterm-related neonatal deaths in South Africa and United Kingdom. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 123(12), p. 2029–2036. doi: 10.1111/1471-0528.14245. Full text in Research Archive
• Allanson, Emma R.; Tunçalp, Özge; Gardosi, Jason; Pattinson, Robert Clive; Francis, André & Vogel, Joshua Peter [Show all 15 contributors for this article] (2016). The WHO application of ICD-10 to deaths during the perinatal period (ICD-PM): results from pilot database testing in South Africa and United Kingdom. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 123(12), p. 2019–2028. doi: 10.1111/1471-0528.14244. Full text in Research Archive
• Allanson, Emma R.; Tunçalp, Özge; Gardosi, Jason O.; Pattinson, Robert Clive; Francis, André & Vogel, Joshua Peter [Show all 15 contributors for this article] (2016). Optimising the International Classification of Diseases to identify the maternal condition in the case of perinatal death. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 123(12), p. 2037–2046. doi: 10.1111/1471-0528.14246. Full text in Research Archive
• Winje, Brita Askeland; Wojcieszek, A M; González-Angulo, Licé Yulieth; Teoh, Z; Norman, J & Frøen, Frederik [Show all 7 contributors for this article] (2016). Interventions to enhance maternal awareness of decreased fetal movement: a systematic review. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 123(6), p. 886–898. doi: 10.1111/1471-0528.13802. Full text in Research Archive
• Myhre, Sonja; Kaye, Jane; Bygrave, Lee Andrew; Aanestad, Margunn; Ghanem, Buthaina & Mechael, Patricia [Show all 7 contributors for this article] (2016). eRegistries: governance for electronic maternal and child health registries. BMC Pregnancy and Childbirth. 16. doi: 10.1186/s12884-016-1063-0. Full text in Research Archive Show summary

  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.

• Leisher, Susannah Hopkins; Teoh, Zheyi; Reinebrant, Hanna E.; Allanson, Emma R.; Blencowe, Hannah & Erwich, Jan Jaap [Show all 19 contributors for this article] (2016). Classification systems for causes of stillbirth and neonatal death, 2009-2014: an assessment of alignment with characteristics for an effective global system. BMC Pregnancy and Childbirth. 16. doi: 10.1186/s12884-016-1040-7. Full text in Research Archive
• Lawn, Joy E.; Blencowe, Hannah; Waiswa, Peter; Amouzou, Agbessi; Mathers, Colin D. & Hogan, Dan [Show all 16 contributors for this article] (2016). Stillbirths: rates, risk factors, and acceleration towards 2030. The Lancet. ISSN 0140-6736. 387(10018), p. 587–603. doi: 10.1016/S0140-6736(15)00837-5. Full text in Research Archive
• Frøen, Frederik; Friberg, Ingrid; Lawn, Joy E; Bhutta, Zulfiqar A.; Pattinson, Robert C. & Allanson, Emma R. [Show all 19 contributors for this article] (2016). Stillbirths: progress and unfinished business. The Lancet. ISSN 0140-6736. 387(10018), p. 574–586. doi: 10.1016/S0140-6736(15)00818-1. Full text in Research Archive
• Flenady, Vicki; Wojcieszek, Aleena M.; Fjeldheim, Ingvild; Friberg, Ingrid; Nankabirwa, Victoria & Jani-Bølstad, Jagrati [Show all 20 contributors for this article] (2016). eRegistries: indicators for the WHO Essential Interventions for reproductive, maternal, newborn and child health. BMC Pregnancy and Childbirth. 16. doi: 10.1186/s12884-016-1049-y. Full text in Research Archive Show summary

  Background: Electronic health registries - eRegistries - can systematically collect relevant information at the point of care for reproductive, maternal, newborn and child health (RMNCH). However, a suite of process and outcome indicators is needed for RMNCH to monitor care and to ensure comparability between settings. Here we report on the assessment of current global indicators and the development of a suite of indicators for the WHO Essential Interventions for use at various levels of health care systems nationally and globally. Methods: Currently available indicators from both household and facility surveys were collated through publicly available global databases and respective survey instruments. We then developed a suite of potential indicators and associated data points for the 45 WHO Essential Interventions spanning preconception to newborn care. Four types of performance indicators were identified (where applicable): process (i.e. coverage) and outcome (i.e. impact) indicators for both screening and treatment/prevention. Indicators were evaluated by an international expert panel against the eRegistries indicator evaluation criteria and further refined based on feedback by the eRegistries technical team. Results: Of the 45 WHO Essential Interventions, only 16 were addressed in any of the household survey data available. A set of 216 potential indicators was developed. These indicators were generally evaluated favourably by the panel, but difficulties in data ascertainment, including for outcome measures of cause-specific morbidity and mortality, were frequently reported as barriers to the feasibility of indicators. Indicators were refined based on feedback, culminating in the final list of 193 total unique indicators: 93 for preconception and antenatal care; 53 for childbirth and postpartum care; and 47 for newborn and small and ill baby care. Conclusions: Large gaps exist in the availability of information currently collected to support the implementation of the WHO Essential Interventions. The development of this suite of indicators can be used to support the implementation of eRegistries and other data platforms, to ensure that data are utilised to support evidence-based practice, facilitate measurement and accountability, and improve maternal and child health outcomes.

• Leitao, Jordana; Chandramohan, Daniel; Byass, Peter; Jakob, Robert; Bundhamcharoen, Kanitta & Choprapawon, Chanpen [Show all 39 contributors for this article] (2013). Revising the WHO verbal autopsy instrument to facilitate routine cause-of-death monitoring. Global health action. ISSN 1654-9716. 6. doi: 10.3402/gha.v6i0.21518. Full text in Research Archive
• Pay, Aase Serine Devold; Frøen, Frederik; Staff, Anne Cathrine; Jacobsson, Bo & Gjessing, Håkon K. (2013). A new population-based reference curve for symphysis-fundus height. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. 92(8), p. 925–933. doi: 10.1111/aogs.12157. Full text in Research Archive
• Winje, Brita Askeland; Røislien, Jo; Saastad, Eli; Eide, Jorid; Riley, Christopher Finne & Stray-Pedersen, Babill [Show all 7 contributors for this article] (2013). Wavelet principal component analysis of fetal movement counting data preceding hospital examinations due to decreased fetal movement: a prospective cohort study. BMC Pregnancy and Childbirth. 13. doi: 10.1186/1471-2393-13-172. Full text in Research Archive Show summary

  Background Fetal movement (FM) counting is a simple and widely used method of assessing fetal well-being. However, little is known about what women perceive as decreased fetal movement (DFM) and how maternally perceived DFM is reflected in FM charts. Methods We analyzed FM counting data from 148 DFM events occurring in 137 pregnancies. The women counted FM daily from pregnancy week 24 until birth using a modified count-to-ten procedure. Common temporal patterns for the two weeks preceding hospital examination due to DFM were extracted from the FM charts using wavelet principal component analysis; a statistical methodology particularly developed for modeling temporal data with sudden changes, i.e. spikes that are frequently found in FM data. The association of the extracted temporal patterns with fetal complications was assessed by including the individuals’ scores on the wavelet principal components as explanatory variables in multivariable logistic regression analyses for two outcome measures: (i) complications identified during DFM-related consultations (n = 148) and (ii) fetal compromise at the time of consultation (including relevant information about birth outcome and placental pathology). The latter outcome variable was restricted to the DFM events occurring within 21 days before birth (n = 76). Results Analyzing the 148 and 76 DFM events, the first three main temporal FM counting patterns explained 87.2% and 87.4%, respectively, of all temporal variation in the FM charts. These three temporal patterns represented overall counting times, sudden spikes around the time of DFM events, and an inverted U-shaped pattern, explaining 75.3%, 8.6%, and 3.3% and 72.5%, 9.6%, and 5.3% of variation in the total cohort and subsample, respectively. Neither of the temporal patterns was significantly associated with the two outcome measures. Conclusions Acknowledging that sudden, large changes in fetal activity may be underreported in FM charts, our study showed that the temporal FM counting patterns in the two weeks preceding DFM-related consultation contributed little to identify clinically important changes in perceived FM. It thus provides insufficient information for giving detailed advice to women on when to contact health care providers. The importance of qualitative features of maternally perceived DFM should be further explored.

• Heazell, Alexander E.P.; Leisher, Susannah; Cregan, Mairie; Flenady, Vicki; Frøen, Frederik & Gravensteen, Ida Kathrine [Show all 13 contributors for this article] (2013). Sharing experiences to improve bereavement support and clinical care after stillbirth: report of the 7th annual meeting of the international stillbirth alliance. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. 92(3), p. 352–361. doi: 10.1111/aogs.12042. Full text in Research Archive
• Saastad, Eli; Winje, Brita Askeland; Winje, Brita A; Israel, Pravin & Frøen, Jahn Frederik (2012). Birth Fetal Movement Counting—Maternal Concern and Experiences: A Multicenter, Randomized, Controlled Trial. Birth. ISSN 0730-7659. doi: 10.1111/j.1523-536X.2011.00508.x. Full text in Research Archive
• Saastad, Eli; Winje, Brita Askeland; Israel, Pravin & Frøen, Frederik (2012). Fetal Movement Counting-Maternal Concern and Experiences: A Multicenter, Randomized, Controlled Trial. Birth. ISSN 0730-7659. 39(1), p. 10–20. doi: 10.1111/j.1523-536X.2011.00508.x. Full text in Research Archive
• Dutton, Philip J.; Warrander, Lynne K.; Roberts, Stephen A.; Bernatavicius, Giovanna; Byrd, Louise M. & Gaze, David [Show all 11 contributors for this article] (2012). Predictors of Poor Perinatal Outcome following Maternal Perception of Reduced Fetal Movements - A Prospective Cohort Study. PLOS ONE. 7(7). doi: 10.1371/journal.pone.0039784. Full text in Research Archive
• Winje, Brita Askeland; Roald, Borghild; Kristensen, Nina Petrov & Frøen, Frederik (2012). Placental Pathology in Pregnancies with Maternally Perceived Decreased Fetal Movement - A Population-Based Nested Case-Cohort Study. PLOS ONE. 7(6). doi: 10.1371/journal.pone.0039259. Full text in Research Archive
• Winje, Brita Askeland; Røislien, Jo & Frøen, Frederik (2012). Temporal patterns in count-to-ten fetal movement charts and their associations with pregnancy characteristics: a prospective cohort study. BMC Pregnancy and Childbirth. 12(124). doi: 10.1186/1471-2393-12-124. Full text in Research Archive
• Frøen, Jahn Frederik A.; Cacciatore, Joanne; McClure, Elizabeth M; Kuti, Oluwafemi; Jokhio, Abdul Hakeem & Islam, Monir [Show all 7 contributors for this article] (2011). Stillbirths 1 Stillbirths: why they matter. The Lancet. ISSN 0140-6736. 377(9774), p. 1353–1366. doi: 10.1016/S0140-6736(10)62232-5. Full text in Research Archive
• Saastad, Eli; Israel, Pravin; Ahlborg, Tone; Gunnes, Nina & Frøen, Frederik (2011). Fetal movement counting - effects on maternal-fetal attachment: a multicenter randomized controlled trial. Birth. ISSN 0730-7659. 38(4), p. 282–293. doi: 10.1111/j.1523-536X.2011.00489.x. Full text in Research Archive
• Saastad, Eli; Winje, Brita Askeland; Stray-Pedersen, Babill & Frøen, Jahn Frederik A. (2011). Fetal movement counting improved identification of fetal growth restriction and perinatal outcomes - a multi-centre, randomized, controlled trial. PLOS ONE. 6(12). doi: 10.1371/journal.pone.0028482. Full text in Research Archive
• Flenady, Vicki; Koopmans, Laura; Middleton, Philippa; Frøen, Jahn Frederik A.; Smith, Gordon C & Gibbons, Kristen [Show all 12 contributors for this article] (2011). Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis. The Lancet. ISSN 0140-6736. 377(9774), p. 1331–1340. doi: 10.1016/S0140-6736(10)62233-7. Full text in Research Archive
• Goldenberg, Robert L; McClure, Elizabeth M; Bhutta, Zulfiqar A; Bélizan, José; Reddy, Uma M & Rubens, Craig E [Show all 13 contributors for this article] (2011). Stillbirths: the vision for 2020. The Lancet. ISSN 0140-6736. 377(9779), p. 1798–1805. doi: 10.1016/S0140-6736(10)62235-0. Full text in Research Archive
• Winje, Brita Askeland; Saastad, Eli; Gunnes, Nina; Tveit, Julie Victoria Holm; Stray-Pedersen, Babill & Flenady, V [Show all 7 contributors for this article] (2011). Analysis of 'count-to-ten' fetal movement charts: a prospective cohort study. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 118(10), p. 1229–1238. doi: 10.1111/j.1471-0528.2011.02993.x. Full text in Research Archive
• Flenady, Vicki; Middleton, Philippa; Smith, Gordon CS; Duke, Wes; Erwich, Jan Jaap & Khong, T Yee [Show all 12 contributors for this article] (2011). Stillbirths 5 Stillbirths: the way forward in high-income countries. The Lancet. ISSN 0140-6736. 377(9778), p. 1703–1717. doi: 10.1016/S0140-6736(11)60064-0. Full text in Research Archive
• Pattinson, Robert; Kerber, Kate; Buchmann, Eckhart; Friberg, Ingrid K; Belizan, Maria & Lansky, Sonia [Show all 16 contributors for this article] (2011). Stillbirths: how can health systems deliver for mothers and babies? The Lancet. ISSN 0140-6736. 377(9777), p. 1610–1623. doi: 10.1016/S0140-6736(10)62306-9. Full text in Research Archive
• Bhutta, Zulfiqar A; Yakoob, Mohammad Yawar; Lawn, Joy E; Rizvi, Arjumand; Friberg, Ingrid K & Weissman, Eva [Show all 12 contributors for this article] (2011). Stillbirths: what difference can we make and at what cost? The Lancet. ISSN 0140-6736. 377(9766), p. 1523–1538. doi: 10.1016/S0140-6736(10)62269-6. Full text in Research Archive
• Lawn, Joy E; Blencowe, Hannah; Pattinson, Robert; Cousens, Simon; Kumar, Rajesh & Ibiebele, Ibinablo [Show all 14 contributors for this article] (2011). Stillbirths: Where? When? Why? How to make the data count? The Lancet. ISSN 0140-6736. 377(9775), p. 1448–1463. doi: 10.1016/S0140-6736(10)62187-3. Full text in Research Archive
• Frøen, J. Frederik; Fretts, Ruth C & Flenady, Vicki (2010). Definition and epidemiology of stilbirths. In Facchinetti, Fabio; Dekker, Gustaaf A; Baronciani, Dante & Saade, George (Ed.), Stillbirth - Understanding and management. Informa Healthcare. ISSN 9780415473903. p. 1–15. Full text in Research Archive
• Fretts, Ruth C; Frøen, J. Frederik & Flenady, Vicki (2010). Stillbirths and prevention strategies in developing and developed countries. In Facchinetti, Fabio; Dekker, Gustaaf A; Baronciani, Dante & Saade, George (Ed.), Stillbirth - Understanding and management. Informa Healthcare. ISSN 9780415473903. p. 65–70. Full text in Research Archive
• Flenady, Vicki; Silver, Robert M; Incerpi, Marc; Fretts, Ruth C; Pattinson, Robert & Erwick, Jan Jaap [Show all 9 contributors for this article] (2010). Essential diagnostic workup of stillbirths. In Facchinetti, Fabio; Dekker, Gustaaf A; Baronciani, Dante & Saade, George (Ed.), Stillbirth - Understanding and management. Informa Healthcare. ISSN 9780415473903. p. 71–90. Full text in Research Archive
• Saastad, Eli; Tveit, Julie Victoria Holm; Flenady, Vicki; Stray-Pedersen, Babill; Fretts, Ruth C & Børdahl, Per E [Show all 7 contributors for this article] (2010). Implementation of uniform information on fetal movement in a Norwegian population reduced delayed reporting of decreased fetal movement and stillbirths in primiparous women - a clinical quality improvement. BMC Research Notes. 3. doi: 10.1186/1756-0500-3-2. Full text in Research Archive Show summary

  Background: Delayed maternal reporting of decreased fetal movement (DFM) is associated with adverse pregnancy outcomes. Inconsistent information on fetal activity to women during the antenatal period may result in delayed reporting of DFM. We aimed to evaluate an intervention of implementation of uniform information on fetal activity to women during the antenatal period. Methods: In a prospective before-and-after study, singleton women presenting DFM in the third trimester across 14 hospitals in Norway were registered. Outcome measures were maternal behavior regarding reporting of DFM, concerns and stillbirth. In addition, cross-sectional studies of all women giving birth were undertaken to assess maternal concerns about fetal activity, and population-based data were obtained from the Medical Birth Registry Norway. Results: Pre- and post-intervention cohorts included 19 407 and 46 143 births with 1 215 and 3 038 women with DFM respectively. Among primiparous women with DFM, a reduction in delayed reporting of DFM (≥48 hrs) OR 0.61 (95% CI 0.47-0.81) and stillbirths OR 0.36 (95% CI 0.19-0.69) was shown in the post-intervention period. No difference was shown in rates of consultations for DFM or maternal concerns. Stillbirth rates and maternal behavior among women who were of non-Western origin, smokers, overweight or >34 years old were unchanged. Conclusions: Uniform information on fetal activity provided to pregnant women was associated with a reduction in the number of primiparous women who delayed reporting of DFM and a reduction of the stillbirth rates for primiparous women reporting DFM. The information did not appear to increase maternal concerns or rate of consultation. Due to different imperfections in different clinical settings, further studies in other populations replicating these findings are required.

• Tveit, Julie Victoria Holm; Saastad, Eli; Stray-Pedersen, Babill; Børdahl, Per E & Frøen, J. Frederik (2010). Concerns for decreased foetal movements in uncomplicated pregnancies - Increased risk of foetal growth restriction and stillbirth among women being overweight, advanced age or smoking. Journal of Maternal-Fetal & Neonatal Medicine. ISSN 1476-7058. 23(10), p. 1129–1135. doi: 10.3109/14767050903511578. Full text in Research Archive
• Frøen, J. Frederik; Gordjin, Sanne J; Abdel-Aleem, Hany; Bergsjø, Per; Betran, Ana & Duke, Charles W [Show all 16 contributors for this article] (2009). Making stillbirths count, making numbers talk - Issues in data collection for stillbirths. BMC Pregnancy and Childbirth. 9. doi: 10.1186/1471-2393-9-58. Full text in Research Archive Show summary

  Background: Stillbirths need to count. They constitute the majority of the world's perinatal deaths and yet, they are largely invisible. Simply counting stillbirths is only the first step in analysis and prevention. From a public health perspective, there is a need for information on timing and circumstances of death, associated conditions and underlying causes, and availability and quality of care. This information will guide efforts to prevent stillbirths and improve quality of care. Discussion: In this report, we assess how different definitions and limits in registration affect data capture, and we discuss the specific challenges of stillbirth registration, with emphasis on implementation. We identify what data need to be captured, we suggest a dataset to cover core needs in registration and analysis of the different categories of stillbirths with causes and quality indicators, and we illustrate the experience in stillbirth registration from different cultural settings. Finally, we point out gaps that need attention in the International Classification of Diseases and review the qualities of alternative systems that have been tested in low- and middle-income settings. Summary: Obtaining high-quality data will require consistent definitions for stillbirths, systematic population-based registration, better tools for surveys and verbal autopsies, capacity building and training in procedures to identify causes of death, locally adapted quality indicators, improved classification systems, and effective registration and reporting systems.

• Flenady, Vicki; Frøen, J. Frederik; Pinar, Halit; Torabi, Rozbeh; Saastad, Eli & Guyon, Grace [Show all 18 contributors for this article] (2009). An evaluation of classification systems for stillbirth. BMC Pregnancy and Childbirth. 9. doi: 10.1186/1471-2393-9-24. Full text in Research Archive
• Flenady, Vicki; MacPhail, Julie; Gardener, Glenn; Chada, Yogesh; Mahomed, Kassam & Heazell, Alexsander [Show all 8 contributors for this article] (2009). Detection and management of decreased fetal movements in Australia and New Zealand: A survey of obstetric practice. Australian and New Zealand Journal of Obstetrics and Gynaecology (ANZJOG). ISSN 0004-8666. 49(4), p. 358–363. doi: 10.1111/j.1479-828X.2009.01026.x. Full text in Research Archive

View all works in NVA

• Tikkanen, Roosa Sofia; Venkateswaran, Mahima; Papadopoulou, Eleni; Tessema, Mashresha; Denu, Zewditu & Gashu, Kassahun Dessie [Show all 9 contributors for this article] (2026). Implementing Digital Antenatal Care Registries at Public Health Care Facilities in Ethiopia and Uganda: A Comparative Study of Barriers and Enablers. Full text in Research Archive Show summary

  Background: Digital registries can support clinical decision-making, longitudinal tracking of patient care and resource allocation decisions. Yet, questions around how to implement registries remain unsolved. We identified barriers, enablers and implementation strategies for digital antenatal care registries (ANC eRegistry) in public primary health facilities in Ethiopia and Uganda. Methods: We utilized data from research projects on ANC eRegistries in sub/urban Ethiopia (Addis Ababa, Adama, Harar, Jimma) and Uganda (Mukono). Interviews (n=35) and focus groups (n=18, 90 persons) with ANC providers, health facility managers, and sub-national and national leaders, identified through purposive sampling were English-translated and coded (NVivo) through deductive thematic analysis mapped onto Consolidated Framework for Implementation Research domains, identifying barriers and enablers in common and unique to each country. CFIR-ERIC (Expert Recommendations for Implementing Change) tool matched barriers and enablers to implementation strategies. Results: Among common barriers were financial constraints exacerbating infrastructure insufficiencies (computers, servers, unreliable networks), and heavy provider workloads constraining time towards meticulous data entry. Enablers in both settings were high motivation to switch to digital records, perceived ease of use of the eRegistry, simplified tasks and improved workflows, and existing peer-learning networks. Unique barriers in Ethiopia were lack of interoperability with existing health information systems and providers prioritizing clinical care over data entry: strong leadership commitment to digitalization was an enabler. In Uganda, limited proactive leadership and difficulties learning new systems were unique barriers; computer-literate young providers was an enabler. Six common implementation strategies were: Conducting ongoing training, preparing champions, formal implementation blueprints, provider performance data, coalition building, and conducting cyclical small change tests. Conclusions: Despite different contexts, identifying implementation determinants and strategies in common and unique to different contexts can facilitate adoption of digital registries. Health systems should capitalize on provider motivation to digitalize while ensuring training, resources and leadership.

• Bhutada, Kiran; Venkateswaran, Mahima; Atim, Maureen; Munabi-Babigumira, Susan Kyomuhendo; Nankabirwa, Victoria & Namagembe, Flavia [Show all 8 contributors for this article] (2024). Erratum: Correction: Factors influencing the uptake of antenatal care in Uganda: a mixed methods systematic review (BMC pregnancy and childbirth (2024) 24 1 DOI: 10.1186/s12884-024-06938-6). BMC Pregnancy and Childbirth. 24(1), p. 793–793. doi: 10.1186/s12884-024-07001-0. Full text in Research Archive
• Frøen, Jahn Frederik (2022). Kvalitet i forskerutdanningen – perspektiver fra en arbeidsgiver. Full text in Research Archive
• Awwad, Tamara; Venkateswaran, Mahima; Lindberg, Marie Hella; Khader, Khadija Abu; Hijaz, Taghreed & Ghanem, Buthaina [Show all 10 contributors for this article] (2019). Use of the national electronic maternal and child health registry (MCH eRegistry) in primary care clinics in occupied Palestinian territory: a pilot time-motion study. The Lancet. ISSN 0140-6736. 393(Special Issue 1), p. 18–18. doi: 10.1016/S0140-6736(19)30604-X. Full text in Research Archive
• Khatun, Fatema; Sarker, Bidhan Krishna; O’Donnell, Brian; Rahman, Anisur; Frøen, Jahn Frederik Alexander Claude & Friberg, Ingrid Kristina (2019). Evaluation of palm-based biometric identification among women in rural Bangladesh. Full text in Research Archive
• Friberg, Ingrid Kristina; Sarker, Bidhan Krishna; Fjeldheim, Ingvild; Frøen, Jahn Frederik Alexander Claude; Khatun, Fatema & Pervin, Jesmin [Show all 9 contributors for this article] (2019). Primary care readiness for digital interventions in the public system in rural Bangladesh. Full text in Research Archive
• Bungudo, Binyam; Blom-Bakke, Kjersti Mørkrid; Frost, Kimberly; Frost, Michael James; Venkateswaran, Mahima & Buthaina, Ghanem [Show all 14 contributors for this article] (2018). eRegCom: Communication strategies from the maternal and child health eRegistry to health care providers and women: A cluster randomized controlled trial protocol. Full text in Research Archive
• Awwad, Tamara; Venkateswaran, Mahima; Lindberg, Marie Hella; Khader, Khadija Abu; Hijaz, Taghreed & Ghanem, Buthaina [Show all 10 contributors for this article] (2018). Use of the national electronic maternal and child health registry (MCH eRegistry) in primary care clinics in Palestine: a pilot time-motion study. Full text in Research Archive
• Frøen, Frederik (2018). eRegistries: Digital health solutions for universal health coverage in reproductive, maternal, newborn and child Health - eRegistries Initiative. Full text in Research Archive
• Isbeih, Mervett; Venkateswaran, Mahima; Awwad, Tamara; Ghanem, Buthaina; Khader, Khadija Abu & Hijaz, Taghreed [Show all 12 contributors for this article] (2018). Maternal and child health and care provision in Palestine: data from the national electronic maternal and child health registry (MCH eRegistry). Full text in Research Archive
• Friberg, Ingrid Kristina; Frost, Michael James; Ghanem, Buthaina; Blom-Bakke, Kjersti Mørkrid; Rahman, Anisur & Frøen, Frederik (2017). eRegistries: clinical registries to support women's and children's health. Full text in Research Archive
• Allanson, Emma; Tuncalp, Özge; Gardosi, Jason O.; Pattinson, Robert Clive; Erwich, Jan Jaap H.M. & Flenady, Vicki J. [Show all 12 contributors for this article] (2016). Classifying the causes of perinatal death. Bulletin of the World Health Organization. ISSN 0042-9686. 94(2), p. 79–79A. doi: 10.2471/BLT.15.168047. Full text in Research Archive
• Jani-Bølstad, Jagrati; Venkateswaran, Mahima; Fjeldheim, Ingvild; Myhre, Sonja & Frøen, Frederik (2016). eRegistries: A Framework for Electronic Registries for Maternal and Child Health. Full text in Research Archive
• Nyanchoka, Linda; Stone, Hollie; Myhre, Sonja; Jani-Bølstad, Jagrati & Frøen, Frederik (2015). Status of Maternal and Child Health Registries in Low and Middle Income Countries: A Systematic Review of Literature. Full text in Research Archive
• Pay, Aase Serine Devold; Gjessing, Håkon K.; Staff, Anne Cathrine; Jacobsson, Bo & Frøen, Frederik (2012). A population-based reference chart for fundal height measures. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. 91, p. 117–118. Full text in Research Archive
• Flenady, Vicki; Smith, Gordon; Ellwood, David; Erwich, Jan Jaap; Frøen, Frederik & Khong, T Yee (2011). Stillbirth in high-income countries Reply. The Lancet. ISSN 0140-6736. 378(9794), p. 875–875. Full text in Research Archive
• Flenady, Vicki; Koopmans, L; Middleton, P; Frøen, Jahn Frederik A.; Smith, GC & Gibbons, K [Show all 12 contributors for this article] (2011). Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis EDITORIAL COMMENT. Obstetrical and Gynecological Survey. ISSN 0029-7828. 66(8), p. 483–485. doi: 10.1097/OGX.0b013e318235215c. Full text in Research Archive
• Frøen, Frederik (2010). Svangerskap - tryggest på overtid? Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 130(23), p. 2341–2341. Full text in Research Archive
• Tveit, Julie Victoria Holm; Saastad, Eli; Stray-Pedersen, Babill; Børdahl, Per E; Flenady, Vicki & Fretts, Ruth C [Show all 7 contributors for this article] (2010). Correction: Reduction of late stillbirth with the introduction of fetal movement information and guidelines - a clinical quality improvement. BMC Pregnancy and Childbirth. 10(49). doi: 10.1186/1471-2393-10-49. Full text in Research Archive Show summary

  We have performed a full cross-validation of this clinical Femina data collection against the routinely collected data of the Medical Birth Registry of Norway to validate the estimates of reduced mortality in the total population. The original estimate of fewer deaths during the intervention with OR 0.7 remains virtually unchanged for the original data collection. The validation procedures revealed inaccuracies in data from the Medical Birth Registry of Norway for a partial comparison with mortality outside the study area, and we here correct this comparison. We present new, corrected and cross-validated data. Despite comparability issues, the most robust and cross-validated estimates confirm similar estimates of reduced mortality during the quality improvement intervention. The online version of the original article can be found at 10.1186/1471-2393-9-32

• Tveit, JVH; Saastad, Eli; Stray-Pedersen, B; Børdahl, Per E; Flenady, V & Fretts, R [Show all 7 contributors for this article] (2010). Reduction of Late Stillbirth With the Introduction of Fetal Movement Information and Guidelines A Clinical Quality Improvement COMMENT. Obstetrical and Gynecological Survey. ISSN 0029-7828. 65(1), p. 8–9. Full text in Research Archive
• HELGADOTTIR, LINDA BJØRK; Helgadottir, LB; Skjeldestad, FE; Jacobsen, AF; Turowski, G & Roald, B [Show all 9 contributors for this article] (2009). Incidence and classification of intrauterine fetal death (IUFD) in the Oslo area 1990-2003. Thrombosis Research. ISSN 0049-3848. 123, p. S137–S137. Full text in Research Archive
• Frøen, Jahn Frederik A.; Myhre, Jo-Inge; Gran, Sarah Frandsen & Frich, Jan C (2009). Implementing a quality improvement curriculum for medical students. Full text in Research Archive
• Venkateswaran, Mahima; Frøen, Jahn Frederik & Blom-Bakke, Kjersti Mørkrid (2019). Attributes and consequences of health information systems data for antenatal care : Health status, health system performance and policy. Universitetet i Bergen. ISSN 9788230850015. Full text in Research Archive Show summary

  Background: A routine health information system (RHIS) serves as an important source of data for monitoring health of clients and health system performance. All countries use RHIS data for some form of priority setting; the extent of use varies across settings depending on the nature and availability of data. In the West Bank, Palestine, the paper-based routine health information system consisting of manually aggregated data is currently undergoing a transformation to an electronic health registry (eRegistry) consisting of individual-level data collected at the point-of-care for antenatal care services in primary healthcare. Aim: The overall aim of the present study was to examine the consequences of the transformation from the existing RHIS based on manual aggregation, to an RHIS based on clinical records data for calculations of routine indicators and health system performance indicators. Various aspects of anticipated data-related changes were examined in the three papers constituting this PhD dissertation. In paper I, we calculated the routinely reported indicators from individual-level clinical data from antenatal paper records, and compared the values to the existing aggregate RHIS reports. In paper II, we calculated the coverage of at least one screening, coverage of appropriate number of screenings, and effective coverage of timely and appropriate screening of antenatal care interventions in public primary healthcare clinics, and explored selected infrastructure-related and maternal sociodemographic factors potentially associated with effective coverage. In paper III, we assessed the implications of using different available data sources in the health data ecosystem for modeling the scale up of antenatal care interventions in the Lives Saved Tool. Materials and methods: Four data sources were used. First, manually aggregated RHIS reports submitted by care providers for primary healthcare clinics were retrieved (2015). Second, a cross-sectional study was conducted, where data were extracted from paper-based clinical records of women attending antenatal care (2015) from a random sample of public primary healthcare clinics. Third, secondary data were exported from the eRegistry electronic clinical records (2017). Fourth, data were obtained from the Palestinian multiple indicator cluster survey (2014). Using the paper-based clinical records data, routinely reported indicators were calculated and compared to the aggregate RHIS reports (paper I). Data from paper-based clinical records were also used to generate coverage of clinical antenatal care interventions (paper II). All four sources of data were used to calculate distinct sets of values of input indicators in the Lives Saved Tool, and the mortality and morbidity averted through the scale-up of antenatal care interventions was modeled (paper III). Results: Paper I: The values of the routinely reported indicators were significantly different when computed with clinical records data, compared to aggregate RHIS reports. The magnitude of the difference varied across indicators. There was divergence in the coverage of anemia screening between the clinical records data and aggregate RHIS reports. Paper II: Effective coverage of antenatal care interventions was considerably lower than the coverage of at least one screening and coverage of the appropriate number of screenings for antenatal care interventions. Timely attendance at antenatal care in the clinics was low. Effective coverage of antenatal care interventions was higher in clinics with laboratory and ultrasound. Paper III: All indicators required for input in the Lives Saved Tool could be calculated directly from the clinical records. The various sources of data yielded notably different results for the number of deaths averted. With clinical records data, the number of maternal deaths, stillbirths, and anemia cases that could be averted with the scale-up of health interventions were higher compared to the RHIS aggregate reports and the multiple indicator cluster survey. Each of the data sources also yielded varying compositions of antenatal care interventions averting deaths. Conclusions: The transition from an RHIS based on manual aggregations to an RHIS based on individual-level clinical records data will lead to significant changes in the values of routinely-reported indicators, and the understanding of health system performance of antenatal care. Health systems managers should be aware of the underlying mechanisms of data-related changes. Paper I: Reliable and complete routine indicators can be generated when clinical records data are directly used for automated computations. In such a system, transcription errors involved in diagnosis and referral, and manual counting and application of indicator definitions are minimized, and the existing complex reporting structure can be circumvented. Paper II: The metric used to quantify antenatal care service provision has consequences for the understanding of health system performance. Effective coverage of antenatal care interventions in public clinics can be increased by improving the provision of care according to recommended guidelines, including timely ANC attendance. Paper III: The demonstrated variability in the Lives Saved Tool model output from using the various data sources highlights the importance of understanding the characteristics of data available in a health information system by program managers that use such planning tools for decision-making.

• Winje, Brita Askeland; Frøen, Frederik; Røislien, Jo & Stray-Pedersen, Babill (2013). Fetal movement counts and fetal health. Universitetet i Oslo. ISSN 9788282647595. Full text in Research Archive
• Tveit, Julie Victoria Holm; Frøen, Jahn Frederik A. & Stray-Pedersen, Babill (2011). Decreased fetal movements in late pregnancy - importance today? Universitetet i Oslo. Full text in Research Archive Show summary

  Concerns for decreased fetal movements (DFM) is a frequent cause of unplanned health consultations throughout the third trimester ranging between 4 % - 16 % in various populations. In the present thesis, women in the third trimester who reported a concern for DFM were registered prospectively at fourteen delivery units from April 2004 to March 2007. The routine provision of information about FM, and guidelines for management of DFM, were implemented in November 2005. A perception of DFM was associated with adverse pregnancy outcomes. Women were often poorly informed about the significance of FM and no evidence based guidelines for management existed. Maternal characteristics and the duration of the perceived decrease of FM were characteristics that helped in identifying pregnancies that could be targeted for intensified management. Improved management of DFM and provision of uniform information to women was associated with improved perinatal outcome. The findings suggest that women experiencing DFM in late pregnancy are at risk for adverse pregnancy outcome. Information may increase maternal awareness toward fetal activity and help the expectant mother to identify significant changes. Time matters and knowledge-based information to women are needed. Improved definitions of DFM and randomized controlled trials are needed to identify the optimal management of pregnancies with DFM.

View all works in NVA