In most low- and middle-income settings, national aggregate health data is the most consistently available source for policy-making and international comparisons. In the West Bank, the paper-based health information system with manual aggregations is transitioning to an individual-level data eRegistry for maternal and child health at the point-of-care.

The aim of this study was to explore beforehand how routine health information systems indicators for antenatal care can change with the introduction of the eRegistry.

Data were collected from clinical antenatal paper records of pregnancy enrollments for 2015 from 17 primary healthcare clinics, selected by probability sampling from five districts in the West Bank.

They used the individual-level data from clinical records to generate routinely reported health systems indicators. We weighted the data to produce population-level estimates and compared these indicators with aggregate routine health information systems reports.

Antenatal anemia screening at 36 weeks was 20% per the clinical records data, compared to 52% in the routine reports. The clinical records data showed considerably higher incidences of key maternal conditions compared to the routine reports, including fundal height discrepancy (20% vs. 0.01%); Rh-negative blood group (6.8% vs. 1.4%); anemia with hemoglobin<9.5 g/dl (6% vs. 0.6%); and malpresentation at term (1.3% vs. 0.03%). Only about a sixth of cases with these conditions were referred per guidelines to designated referral clinics.

Clinical records data

Differences between indicators from the clinical records data and routine health information systems reports can be attributed to human error, inconsistent denominators, and complexities of data processes. Key health systems indicators were prone to underestimations since their registration was dependent on the referral of pregnant women.

With a transition to individual-level data, as in the eRegistry under implementation, the public health authorities will be able to generate reliable health systems indicators reflective of the population's health status.

A strength of this study was its ability to identify issues beyond the quality of RHIS data and processes, such as variations in adherence to guidelines for referrals as well as selective reporting of indicators in the health system.

The quality of healthcare services may be improved by understanding and addressing issues related to referrals. The public health authorities may need to revisit the value of certain guidelines for referral, particularly for non-critical conditions during pregnancy.

The eRegistry for maternal and child health aims to eliminate sources of errors that impact the quality of health systems data, by using individual-level clinical data to directly produce RHIS reports at the individual, clinic, sub-national and national levels.

As the health system in the West Bank shifts from manually aggregated data to the eRegistry, it will be possible to generate more reliable and complete health systems indicators.