Healthcare providers' perceptions of maternal and newborn care quality in the West Bank, Palestine: a qualitative study

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This study aimed to explore healthcare providers' perceptions of maternal and newborn care quality in the West Bank, occupied Palestinian territories, where the healthcare system faces systemic and political challenges. Methods This qualitative study was undertaken in government hospitals and primary healthcare clinics operating under the Palestinian Ministry of Health across the north, central, and south regions of the West Bank. Between May and October 2023, sixteen in-depth, semi-structured interviews were conducted with healthcare providers, comprising 12 midwives and four physicians. The interviews were guided by the Quality Maternal and Newborn Care Framework, which focuses on practice, organization, values, philosophy, and care providers. Data were analyzed using the reflexive thematic analysis approach. Results Two main themes were developed. The first, "navigating high demands in an unpredictable system," highlights the toll of professional burnout and systemic challenges, including resource shortages, administrative inefficiencies, and the impact of the Israeli occupation. The second, "opportunities for enhancing care quality," identifies pathways for improvement, including expanding the role of midwives in decision-making, encouraging respectful and person-centered care, increasing access to evidence-based clinical training, and strengthening care coordination and continuity. Conclusions The findings highlight critical challenges and key opportunities for improving maternal and newborn care quality in the West Bank. Addressing these issues holistically through the lens of the Quality Maternal and Newborn Care Framework aligns with global priorities and offers a pathway to strengthen quality of care in conflict-affected settings. Maternal care quality Newborn care quality Healthcare in conflict settings Midwifery Reflexive thematic analysis Qualitative research methods Palestine Figures Figure 1 Background Improving maternal and newborn care quality is central to global maternal health strategies, aligning with Sustainable Development Goal 3 (SDG3) to reduce preventable maternal and neonatal deaths and promote well-being by 2030 [ 1 ]. Achieving this requires an integrated approach that strengthens the continuum of maternal and newborn care, from antenatal to postnatal services, ensuring equity, accessibility, and a resilient healthcare system [ 2 ]. The Quality Maternal and Newborn Care (QMNC) Framework, established in the 2014 Lancet Series on Midwifery, serves as a globally recognized, evidence-based model for optimizing maternal and newborn care. It defines essential dimensions, including clinical practice, care organization, values, philosophy, and healthcare providers [ 3 ]. Its application has been reinforced through evaluation studies, which developed interview guides for qualitative assessments and quality-of-care evaluations [ 4 , 5 ]. Further empirical validation led to the QMNC Framework Index, a standardized instrument for global quality-of-care assessments [ 6 ]. Global and regional studies emphasize that high-quality, evidence-based care throughout pregnancy, childbirth, and the postpartum period is essential in reducing maternal and neonatal deaths, particularly in low-resource, conflict-affected settings [ 7 , 8 ]. The healthcare system in the occupied Palestinian territories (oPt) is deeply fragmented, shaped by political instability, economic constraints, and occupation-related challenges. These barriers have resulted in unequal healthcare access across regions, with significant disparities between Gaza, the West Bank (WB), and East Jerusalem [ 9 , 10 ]. This study focused on the WB, home to about 3.2 million people, constituting 59.5% of the Palestinian population [ 11 ]. The WB's healthcare system is multisectoral, involving governmental institutions, non-governmental organizations (NGOs), the United Nations Relief and Works Agency (UNRWA), and private providers [ 11 , 12 ]. It includes 608 primary healthcare centers (PHCs), 18 government-run hospitals, and 17 non-governmental hospitals, all providing maternal and newborn care services despite ongoing challenges [ 11 ]. Despite efforts to strengthen midwifery-led care and professional training, healthcare providers continue to face systemic challenges [ 12 , 13 ]. The ongoing Israeli occupation exacerbates these issues by restricting access to essential medical resources, obstructing emergency referrals due to military checkpoints, and creating logistical barriers for both healthcare providers and women [ 9 ]. Research indicates that rural women are disproportionately affected, experiencing delays in maternity care access, which heightens the risks of maternal and neonatal complications [ 14 , 15 ]. Midwifery-led continuity models (MLCMs) have proven effective in improving maternal health outcomes, particularly in resource-limited and conflict-affected settings [ 16 , 17 ]. MLCMs have been associated with increased antenatal visits, improved birth preparedness, reduced maternal complications, and higher maternal satisfaction [ 12 , 18 ]. However, the long-term sustainability of implemented MLCMs in the WB remains uncertain due to political instability, economic fragility, and disruptions from the COVID-19 pandemic [ 12 ]. Additionally, healthcare fragmentation across the Palestinian Ministry of Health (MoH), NGOs, UNRWA, and private providers leads to inefficiencies, service delivery gaps, and resource duplication, hindering care coordination effectiveness [ 11 ]. While prior research has explored maternal health policies and system-level challenges in the oPt, limited qualitative studies have investigated healthcare providers’ perspectives on barriers and opportunities to enhance maternal and newborn care [ 12 , 19 ]. This study investigated providers' experiences in the WB. It identifies systemic gaps and potential interventions to strengthen maternal and newborn care in a conflict-affected setting. Methods Study Site The study was conducted across all governorates in the WB, including government hospitals and PHCs under the Palestinian MoH. The selection included both urban and rural settings in the north, central, and south regions to ensure a comprehensive understanding of maternal and newborn care providers’ experiences. Design A qualitative research design was applied, using in-depth individual interviews to explore healthcare providers' perceptions of maternal and newborn care services within the Palestinian context. Recruitment and Data Generation A purposive sampling strategy was used to ensure representation across different healthcare facility types. Eligible participants included Palestinian midwives and physicians with at least one year of maternal care experience to ensure sufficient clinical expertise and firsthand insight. After obtaining ethics approval, the lead researcher (KZ) conducted preliminary visits to introduce the study and distribute an Arabic-translated QMNC Framework. Potential participants received information sheets detailing the study purpose. In-depth interviews were guided by a contextually adapted tool, developed based on QMNC components and reviewed by a panel of experts, including maternal health specialists, healthcare users, and researchers, to ensure cultural and contextual relevance [ 20 ] (see Additional File 1). Interviews were conducted in Arabic. Eight in-person interviews took place at participants’ workplaces, lasting between 30 and 68 minutes (mean: 43.5 minutes). Due to the deteriorating security situation, the remaining interviews were conducted digitally via Zoom videoconferencing from participants’ homes, lasting between 60 and 120 minutes (mean: 98 minutes) [ 21 , 22 ]. The first author, an experienced midwife trained in qualitative research, conducted the interviews, supervised by senior researchers to ensure procedural consistency. Each interview was audio-recorded using the encrypted “nettskjema dictaphone” application [ 23 ], with secure storage at the University of Oslo database Services for Sensitive Data (TSD) [ 24 ]. Data analysis Data were analyzed using reflexive thematic analysis, following Braun and Clarke’s six-phase approach [ 25 ]. A professional translator translated the Arabic transcripts into English, and the first and last authors validated them by comparing translations with the original texts to ensure accuracy. Field notes further supported the transcription process. The analysis began with data familiarization, where three researchers (KZ, AM, & BM) immersed themselves in the transcripts, repeatedly reading and discussing the data to generate preliminary themes. Visual mind maps were created to summarize key concepts. The first author conducted systematic coding and engaged in regular consultations with senior researchers to identify broader patterns and maintain coding consistency. Initial themes were collaboratively developed by the core research team and later refined through discussions with the full research team to ensure a comprehensive and objective analysis. Final theme development was reached through iterative discussions to confirm alignment with the research objectives and participant narratives. Throughout the process, the research team engaged in reflexive practice, critically examining contextual influences to deepen thematic understanding [ 26 ]. Results Participants Sixteen participants engaged in individual in-depth interviews conducted between May and October 2023. Of these, 15 were female and one was male. Participants included 12 midwives, three obstetricians, and one general practitioner (GP), each offering insights shaped by their professional experiences in maternal and newborn care. Their clinical experience ranged from 5 to 33 years, with all working full-time in healthcare facilities across the WB (see Table 1). Findings Through reflexive thematic analysis, we developed two main themes: Navigating high demands in an unpredictable system and Opportunities for enhancing care quality . Each theme includes three subthemes, as illustrated in Fig. 1 . Theme 1: Navigating high demands in an unpredictable system This theme explores the immense pressures faced by healthcare providers in government hospitals and PHCs operating in resource-limited and politically unstable environments. Providers described systemic limitations, including understaffing, resource shortages, outdated infrastructure, and unpredictable patient loads, all exacerbated by economic instability and the Israeli occupation. These constraints not only affected the delivery of maternal and newborn care but also deepened structural inequities, particularly for rural populations. The findings illustrate how cultural norms, institutional policies, and systemic deficiencies intersect to shape care quality and provider experiences. Subtheme 1: Trapped between system constraints and women’s needs Healthcare providers in public maternity wards and PHCs often struggled to balance institutional constraints with women's needs, particularly concerning labor support, privacy, and family expectations. Chronic understaffing, insufficient resources, and restrictive institutional policies frequently led to tensions between providers and families. In government hospitals, overcrowded labor wards, where only curtains separated birthing women, severely compromised privacy and restricted the presence of support persons during labor. While institutional policies prohibited family members from remaining in the labor ward, cultural norms strongly emphasized companionship and emotional support during childbirth. One physician described the frequent disputes this policy provoked: “There are numerous instances when conflicts arise between the medical staff and the companions.” (P8, physician) The absence of dedicated family spaces made it difficult for midwives to accommodate support persons during labor, despite recognizing the emotional and cultural importance of family presence. As institutional gatekeepers, midwives were responsible for enforcing hospital policies that restricted companion presence, often leading to conflict and, in some cases, physical abuse of staff. “Once a midwife colleague had to tell the family companions to leave the labor ward ... the family replied that she had no right to expel them and beat the midwife.” (P9, midwife). Confronted with these tensions, midwives adopted varied communication strategies, ranging from authoritative enforcement to conciliatory approaches aimed at mitigating conflict and restoring trust. In some cases, midwives sought to de-escalate tensions by acknowledging women's frustrations and negotiating their roles within institutional constraints, one midwife explained: “Sometimes, you have to raise your voice... but immediately, we apologized... explaining it was for her good.” (P14, midwife) Similarly, many providers in public maternity wards and PHCs described how cultural preferences for female doctors posed additional challenges, particularly in rural areas. Women frequently refused male doctors, complicating care provision in facilities with few female physicians: “Women often refuse male doctors, but if no female doctor is available, we ensure she is covered and accompanied by a midwife during the examination.” (P11, midwife) Despite systemic constraints, some midwives adapted their approaches when workload pressures were lower. One midwife described how, in less crowded labor wards, she was able to offer small gestures of flexibility, which she perceived positively influenced women's childbirth experiences: “If only one woman was in the labor ward, I might allow a family member to help dress the baby... this made women happier and more responsive.” (P7, midwife) However, such flexibility was rarely possible due to severe understaffing and excessive workload pressures. Subtheme 2: Burned-out professional passion Despite their dedication to maternal health, providers in government hospitals and PHCs described increasing emotional exhaustion driven by excessive workloads, chronic understaffing, and minimal systemic support. They described juggling multiple responsibilities under relentless pressure, leaving little time for compassionate care. These constraints forced providers to prioritize efficiency over patient-centered care, leading to detachment and burnout. “This is the system in .... hospital. They have only one delivery room with two beds, and five or six post-labor rooms; this was also the situation five years ago….” (P6, midwife) In government hospitals, midwives described how fast-paced labor environments limited their ability to form meaningful connections with birthing women, as they were often required to manage multiple births simultaneously: “I assisted in three birthing women... I had to make sure that the babies had the correct identification bracelets before I ran to help the next birthing woman.” (P9, midwife) Similarly, midwives in PHCs expressed frustration over medication shortages and economic instability, which made it impossible to meet women’s medical needs, particularly in low-income areas: “You feel embarrassed when the medication isn’t available because people are poor and miserable.” (P7, midwife) Both midwives and physicians emphasized systemic understaffing as a root cause of burnout, with workloads intended for multiple providers frequently falling onto a single healthcare provider. “The service that should be managed by two or three physicians often falls to one, which affects the quality of care provided.” (P15, physician) Over time, grueling conditions in labor wards contributed to chronic exhaustion, health issues, and high attrition rates. Many midwives sought less demanding roles, further exacerbating workforce retention challenges in high-stress environments. Chronic stress, sleep deprivation, and deteriorating health were frequently cited as key factors influencing their decisions to leave labor wards. “I worked in the labor ward for eight years... but it became hard to continue in this job. Therefore, I requested to join primary care... Work in primary care means a healthy heart, quality life, and job stability.” (P7, midwife) “With time, my health deteriorated... Sleeplessness is the most challenging aspect.” (P12, midwife) The emotional and physical toll of burnout extended beyond professional responsibilities, negatively affecting providers' motivation and well-being. Some providers in government healthcare facilities described how overcrowding with women receiving maternity care created a sense of futility among staff: “I need motivation; my director should give me a thank-you letter as spiritual encouragement means a lot to us; it affects us more than materialistic motivation. The one who does a good job will continue to do so, whether appreciated or not.” (P5, physician) Beyond systemic constraints and emotional exhaustion, healthcare providers also identified external factors, including economic instability and the Israeli occupation, as significant barriers to maternal healthcare delivery. Subtheme 3: External quality barriers Providers in government hospitals and PHCs described the impact of the Israeli occupation, economic instability, and persistent medical supply shortages on maternal healthcare delivery, particularly in rural and conflict-affected regions. One of the most critical barriers was the impact of Israeli military checkpoints and settler violence, which frequently delayed or prevented women in labor from accessing care, leading to avoidable maternal and neonatal complications: “We noticed cases that took place in a region with conflict... The ambulance would go back because they prevented the ambulance from taking the woman, or when they were sure that the woman was dead, they would allow the ambulance to take the casualties.” (P14, midwife) Providers also reported economic instability as a major barrier, noting that the withholding of Palestinian tax revenues by Israel leads to financial instability. Healthcare workers frequently went unpaid or received partial salaries, worsening financial hardships. “Our debts increased, and I just wanted my full salary.” (P4, midwife) In addition, shortages of essential medications, particularly oxytocin, a critical drug for managing labor complications, and outdated medical equipment, further compromised maternal care. “We don’t have enough basic medicines for emergencies. For example, oxytocin is not always available, and this delays necessary care during labor.” (P6, midwife) Similarly, many providers emphasized that outdated and insufficient medical equipment significantly hindered their ability to deliver high-quality maternal care. Items such as blood pressure monitors, scissors, cardiotocography (CTG) machines, and sterilization tools were often outdated, in disrepair, or insufficient. “I requested maintenance for the ultrasound equipment two months ago... nothing has been done.” (P8, physician) “Our equipment is old and worn out; I feel that our ward is in need of repair, everything, everything. For example, the scissors are worn out. I don’t know if the new items we receive are really new, or because of frequent use, they wear out quickly.” (P11, midwife) Theme 2: Opportunities for enhancing care quality Amid systemic challenges, providers identified key opportunities to improve maternal care, including expanding midwives’ autonomy, promoting respectful care, enhancing training, and strengthening care coordination. These insights highlighted the resilience and adaptability of healthcare workers and their commitment to maternal and newborn health. Subtheme 1: Navigating autonomy and respectful care Midwives in both government hospitals and PHCs frequently reported feeling constrained by restrictive protocols that limited their professional autonomy, particularly in the absence of physicians. They expressed frustration over their inability to perform tasks they were trained for, such as suturing after delivery, without facing reprimands. A physician highlighted the systemic barriers preventing midwives from acting independently, even in emergencies. “A midwife isn’t supposed to do something without referring to the doctor. However, if the midwife decided to do a procedure without referring to the doctor, she is punished.” (P8, physician) This lack of autonomy was further compounded by cultural and gender preferences, as many Palestinian women preferred female providers for sensitive procedures such as vaginal examinations. However, in public hospitals, male physicians were often the only available option, creating tensions between women’s preferences and staffing limitations. “If there is a male physician on duty, we tell her that there is no female physician on duty, and if the woman refuses, she signs and is discharged against medical advice... In case we have a female physician on duty, she examines her, but we don’t force any woman to allow a male doctor to examine her.” (P9, midwife) Despite these constraints, midwives reflected on how continuity of care programs helped address systemic limitations by fostering autonomy and enabling more personalized, respectful care. These programs facilitated repeated interactions, building trust and culturally sensitive care for women and their families. Midwives shared positive experiences of how continuity programs strengthened communication and individualized support, particularly in nutrition and breastfeeding counseling, improving maternal and newborn health outcomes. “We followed up with the pregnant woman and used to see her seven, eight, nine, ten times... I began to get to know people and understand how to deal with them.” (P9, midwife) However, providers emphasized that the benefits of these programs were hindered by outdated training approaches, which often failed to align with evidence-based clinical practices. Subtheme 2: Improving training and evidence-based practices Healthcare providers across government hospitals and PHCs identified critical gaps in training programs, describing them as overly theoretical and lacking practical, evidence-based approaches. A physician emphasized the need for a well-equipped workforce capable of addressing the dynamic challenges of maternal healthcare: “We need well-trained young individuals who are adequately equipped to address the dynamic needs of healthcare delivery.” (P2, physician) Midwives shared similar concerns, noting that training programs focused on protocols rather than real-world clinical practice: “The last training course was two years back... Most are about protocols, not about real-world challenges.” (P9, midwife) This gap between training content and clinical practice perpetuated outdated and, at times, harmful methods, adversely affecting maternal outcomes. One midwife recounted witnessing a procedure explicitly prohibited by modern medical national guidelines but still performed due to inadequate training. “I saw another midwife applying pressure to the uterus, which is illegal, but it happened due to lack of training.” (P10, midwife) Providers emphasized that bridging these training gaps requires a shift toward competency driven, evidence-based education. Such an approach would enable healthcare workers to eliminate outdated practices and adapt to the evolving needs of maternal and newborn care. Subtheme 3: Strengthening care coordination and continuity Providers highlighted that rural areas face significant challenges in managing high-risk pregnancies due to fragmented referral systems and limited access to specialists at primary care centers. Women in these regions often struggle with financial and logistical barriers when traveling to urban centers for follow-ups, leading to delays or missed appointments that negatively impact maternal and neonatal health: “In remote villages, a woman may face a problem visiting the primary care center in the city... because there is no specialist available except in the center in the city.” (P15, physician) Additionally, providers noted that the disconnect between private and public healthcare systems exacerbates these challenges. Incomplete referral information from private hospitals often resulted in delayed interventions and increased complications: “We received referrals from private hospitals like bombs (unpredictable cases without referral).” (P12, midwife) Midwives reflected on the negative impact of discontinuing the continuity of care program, which had previously integrated hospital-based and community-based services through antenatal care and postnatal home visits. Those who participated in the program emphasized its effectiveness in bridging the gap between hospital and community-based care, fostering trust, education, and maternal support. The program’s suspension during the COVID-19 pandemic introduced significant disruptions in care coordination, reducing opportunities for women to receive holistic maternity care. Midwives highlighted how continuity of care models strengthened relationships between women and healthcare providers, allowing women to voice their concerns and receive more personalized, culturally sensitive care: “When women knew I would assist with their delivery and follow up with them postnatally, they were happier and more open to discussing their concerns.” (P9, midwife) Discussion This study explored healthcare providers' perspectives on maternal and neonatal healthcare quality in the WB, highlighting key barriers and opportunities for improvement. Through reflexive thematic analysis, two overarching themes were developed: navigating high demands in an unpredictable system and identifying strategies to enhance care quality. The analysis was informed by the QMNC Framework, which provided a structured approach to understanding systemic challenges and potential improvements. Healthcare providers in oPt operate within a system marked by inadequate staffing, fragmented healthcare structures, and resource limitations, which collectively hinder the provision of person-centered care. These barriers are particularly severe in rural and underserved regions, where women struggle with logistical and financial obstacles in accessing essential maternal services [ 27 – 29 ]. Addressing these systemic deficiencies through targeted reforms is necessary to enhance both clinical efficiency and equity in care delivery [ 30 ]. Respect, effective communication, and culturally sensitive care are critical to improving maternal experiences. However, restrictive hospital policies and outdated infrastructure often limit the extent to which these practices can be implemented [ 29 ]. For instance, limitations on family involvement during labor leave many women feeling unsupported, despite strong evidence indicating that labor companionship improves maternal outcomes [ 31 ]. Addressing these institutional barriers is necessary to foster a more person-centered approach. Family-centered care, especially labor companionship, has been widely recognized for its benefits in improving maternal experiences and birth outcomes [ 30 , 32 ] However, many hospitals continue to prohibit family presence during labor due to concerns about overcrowding and limited space [ 33 ]. Family companions, compared to unfamiliar ones, are more effective in alleviating childbirth fears and fostering a positive birth experience [ 34 ]. Ensuring companions are well-informed and engaged further strengthens their support role, improving maternal well-being [ 35 ]. Expanding structured labor companionship programs could help bridge this gap, fostering maternal confidence and trust in healthcare providers [ 36 , 37 ]. Cultural norms and preferences for female providers present another critical challenge, particularly in prenatal, labor, and postpartum care [ 19 , 38 , 39 ]. Workforce shortages and rigid scheduling disproportionately impact rural areas, limiting women's access to female providers. This disparity highlights the need for gender-sensitive policies that ensure equitable access to care [ 3 , 40 ]. This reinforces inequities in access and highlights the urgent need for policies supporting gender-sensitive services. Burnout among healthcare providers was a recurring concern in this study. Participants described excessive workloads, inadequate staffing, and limited resources as major stressors. Many reported progressive emotional exhaustion, which negatively affected their ability to provide high-quality care. These findings underscore the urgent need for workforce policies focused on retention, stress management, and burnout mitigation strategies to ensure a sustainable maternal healthcare system [ 41 , 42 ]. Maternal healthcare in oPt is heavily shaped by economic constraints and political instability. Delayed salaries, restricted access to medical supplies, and transportation challenges disproportionately affect rural populations, further exacerbating healthcare inequities [ 28 , 38 ]. Geographic fragmentation and occupation imposed restrictions disproportionately impact marginalized communities, further limiting access to equitable and effective care [ 38 ]. Addressing these barriers requires targeted interventions that improve healthcare accessibility and reduce disparities [ 10 ]. This study identified three key areas for improving maternal and newborn care in oPt: navigating autonomy and respectful care, improving training and evidence-based practices, and strengthening care coordination and continuity. Addressing these gaps would enable healthcare providers to deliver more effective, person-centered care while overcoming systemic challenges to better meet the needs of women and newborns. Enhancing midwifery autonomy is essential for strengthening maternal healthcare in oPt [ 38 ]. Participants described restrictive protocols and hierarchical systems that limited their ability to perform key clinical tasks, such as suturing and leading care for low-risk pregnancies. Many midwives expressed frustration over the dominance of physician-led models, which restricted their professional scope [ 28 ]. Policy reforms that expand midwives' roles and decision-making authority could improve maternal healthcare delivery while alleviating burdens on overstretched healthcare systems [ 38 ]. Promoting respectful and culturally appropriate care is essential for improving maternal experiences and outcomes [ 30 ]. However, restrictive policies, such as limiting family involvement during labor, and inadequate gender-sensitive services prevent providers from fully addressing women's cultural preferences and needs. A local study by Dwekat et al. (2021) linked these systemic constraints to mistreatment during childbirth, highlighting the need for dignity-focused reforms [ 32 ]. Implementing policies that empower midwives and expand family-centered approaches could help improve maternal care experiences, as suggested by Mortensen et al. (2018) [ 12 ]. This study underscores the inadequacy of existing training programs, which remain heavily focused on theoretical protocols while neglecting practical, evidence-based approaches. As a result, providers reported a persistent gap between training and clinical practice, contributing to the continued use of outdated or harmful techniques. Continuous professional development is essential for bridging this gap [ 38 ]. Evidence-based, competency-driven education is a key strategy in improving maternal and newborn care, enhancing provider confidence, and reducing medical errors [ 1 ]. Continuous quality improvement initiatives in maternal and reproductive health services play a crucial role in strengthening care quality and outcomes [ 2 ].Strengthening competency training programs with hands-on, evidence-based learning opportunities could significantly improve maternal healthcare delivery [ 43 ].Care coordination remains a critical area for improvement, particularly in rural regions where fragmented referral systems and logistical barriers delay access to specialists and emergency services. Providers in this study highlighted how incomplete referrals from private hospitals and poor communication between public and private systems contribute to inefficiencies, increase complications, and exacerbate disparities. Strengthening integration across facility and community levels is essential to ensuring continuity and accessibility in maternal healthcare [ 3 ]. MLCMs offer a viable solution. A study by Mortensen et al. (2018) found that MLCMs enhanced antenatal care utilization, facilitated timely referrals, and improved maternal health outcomes [ 12 ]. The World Health Organization (WHO) recognizes MLCMs as a cost-effective intervention, particularly in resource-constrained settings like oPt [ 30 ]. Research on the QMNC Framework further supports this by evaluating antenatal care models and their effectiveness in improving maternal health outcomes [ 19 ]. Reintroducing and scaling MLCMs could address systemic inefficiencies while empowering midwives to provide culturally sensitive, person-centered care. Despite their proven benefits, the expansion of MLCMs faces significant barriers, including financial constraints, inadequate infrastructure, and political instability. Targeted investments, strategic policy reforms, and enhanced inter-sectoral coordination are necessary to overcome these obstacles [ 16 , 17 , 44 ]. Aligning Palestinian maternal healthcare systems with global best practices through these interventions would help ensure equitable, high-quality care for all women and newborns [ 45 ]. Strengths and limitations This study provides rich qualitative insights, offering an in-depth exploration of maternal and newborn care practices from the perspectives of frontline providers. Purposive sampling and semi-structured interviews ensured representation across diverse rural and urban settings in the WB. Conducting interviews in both physical and digital formats enhanced flexibility and accessibility. Notably, digital interviews created a safer and more private space, particularly in a politically unstable context, allowing participants to discuss systemic challenges more openly. Conducting research in conflict-affected settings presents unique methodological and ethical challenges. However, this study successfully navigated these complexities by employing adaptive strategies. The use of digital interviews mitigated security risks and enabled participation from geographically dispersed providers, ensuring diverse perspectives. Additionally, the study highlights how institutional policies, security risks, and resource constraints shape maternal care in fragile settings, offering insights that are often underrepresented in global maternal health research. Despite these strengths, this study has certain limitations. The limited representation of physicians may have narrowed the diversity of perspectives, particularly regarding the management of high-risk pregnancies and referral-based care. This limitation may have affected the study’s ability to fully capture interdisciplinary collaboration challenges. Additionally, workplace-based interviews, even when conducted digitally, may have constrained participants from fully expressing their views due to time pressures, power hierarchies, or fear of reprisal when discussing institutional policies and systemic barriers. Although digital interviews allowed for more extended discussions, they were occasionally disrupted by environmental interruptions, affecting conversational flow. These disruptions may have influenced participants' ability to elaborate on complex issues, potentially impacting the depth of some responses. Despite these limitations, the findings are transferable to other conflict-affected, low-resource settings facing similar systemic healthcare constraints. This study provides valuable lessons on improving maternal and newborn care quality, offering policy and practice insights for contexts with comparable structural challenges. Conclusions This study provides critical insights into the complex challenges affecting maternal healthcare in the WB, Palestine, particularly the compounded impact of political instability, systemic fragmentation, and resource limitations on the delivery and quality of care. The findings highlight the urgent need for structural reforms to strengthen care coordination, implement midwifery-led continuity of care models, and foster culturally sensitive, evidence-based clinical practices. Applying the QMNC Framework underscored the necessity for systemic, multi-level interventions that enhance provider competence, clinical practices, and organizational care models to achieve sustainable improvements in maternal and newborn health outcomes. Future research should incorporate women's lived experiences and perspectives to develop a holistic understanding of maternal care challenges, supporting the design of person-centered policies and interventions. Additionally, addressing regional disparities and developing tailored strategies for conflict-affected populations are essential steps toward building adaptive, resilient, and sustainable healthcare models in fragile settings. Abbreviations SDG3 Sustainable Development Goal 3 QMNC Quality Maternal and Newborn Care oPt Occupied Palestinian Territories WB West Bank UNRWA United Nations Relief and Works Agency PHCs Primary Healthcare Centers MLCMs Midwifery-Led Continuity Models MoH Palestinian Ministry of Health NGOs Non-Governmental Organizations TSD Service for Sensitive Data COVID-19 Coronavirus Disease 2019 GP General Practitioner CTG Cardiotocography REK Regional Ethics Committee for South-East Norway WHO World Health Organization Declarations Ethics approval and consent to participate We followed ethical guidelines throughout the research involving human participants. Informed consent was obtained from all participants, ensuring they understood their rights and the study's purpose. To protect confidentiality, no identifying information, such as names, current workplace, or phone numbers were collected. Instead, transcripts were assigned serial numbers to maintain anonymity. The transcripts were stored securely, and all data handling followed strict protocols to ensure privacy. The study received multiple layers of ethical clearance. The Regional Ethics Committee for South-East Norway (REK) determined that ethics approval from them was not required, as the study focused on health services rather than personal health data (ref. no. 491275). The Norwegian Data Inspectorate approved the study (ref no 791638). Oslo Metropolitan (OsloMet) University’s data protection officer approved the study’s ethical framework and data management protocols (approval no. 22/08280). Additionally, ethical approval was granted by the Ethical Research Committee at the Faculty of Pharmacy, Nursing, and Health Professions, Birzeit University, WB (approval no. BZUPNH2139). Data management agreement between Birzeit and OsloMet university (approval no.EU2021/9/4). The Palestinian Ministry of Health also approved the study and ensured the permission to conduct the interviews (approval no. 162/1255/2022). Consent for publication Not applicable. Data availability The data supporting the findings of this study are included within the manuscript and its supplementary information files. The dataset used and analyzed in this study is not publicly accessible; however, it can be made available upon reasonable request, contingent on obtaining the necessary ethical approvals Competing interests The authors declare no competing interests. Funding This study was funded by NORWAY, under the NORHEDII project, Midwifery Research and Education Development (MIDRED), reference number 70320. The funders were not involved in any aspect of the research, including data interpretation, publication decisions, or manuscript writing. Authors' contributions Study conception and design: KZ, AM, SH, EB, HM, BM; Supervision of data collection: BM, SH, HM; Data collection: KZ; Analysis: KZ, BM, AM; Interpretation of results: KZ, AM, SH, EB, HM, BM; Draft manuscript preparation: KZ, AM, SH, EB, HM, BM. All authors reviewed the results and approved the final version of the manuscript. Acknowledgement The authors express their gratitude to all healthcare providers, including physicians and midwives, whose participation and insights were critical to this study. Their contributions were invaluable in enhancing the understanding of maternal and newborn care in the region. This research was conducted using the Service for Sensitive Data (TSD) facilities, owned by the University of Oslo and operated by the TSD service group at the University of Oslo IT Department (USIT). For further information, contact [email protected] . Author information Khadeja Zaza¹, Alison McFadden², Sahar Hassan³, Hadil Ali-Masri³⁴, Ellen Blix¹, Berit Mortensen¹ Authors and Affiliations 1 Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway. 2 Mother and Infant Research unit, School of Nursing and Health Sciences, University of Dundee, Dundee, United Kingdom. 3 Department of Nursing and Master program of Women’s Health, Faculty of Pharmacy, Nursing and Health professions, Birzeit University, Birzeit, Palestine. 4 Women’s Health and Development Unit, Ministry of Health, Ramallah, Palestine References UNFPA WHO. Improving maternal and newborn health and survival and reducing stillbirth - Progress report 2023. In. Geneva, Switzerland; Progress report2023. Karp C, Edwards EM, Tappis H. Quality improvement in maternal and reproductive health services. BMC Pregnancy Childbirth. 2024;24(1):21. Renfrew MJ, McFadden A, Bastos MH, Campbell J, Channon AA, Cheung NF, Silva DR, Downe S, Kennedy HP, Malata A, et al. Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet. 2014;384(9948):1129–45. Cummins A, Coddington R, Fox D, Symon A. Exploring the qualities of midwifery-led continuity of care in Australia (MiLCCA) using the quality maternal and newborn care framework. Women Birth. 2020;33(2):125–34. Symon A, McFadden A, White M, Fraser K, Cummins A. Using a quality care framework to evaluate user and provider experiences of maternity care: A comparative study. Midwifery. 2019;73:17–25. Symon A, Mortensen B, Pripp AH, Chhugani M, Adjorlolo S, Badzi C, Kharb R, Prussing E, McFadden A, Gray NM et al. Validating the Quality Maternal and Newborn Care Framework Index: A Global Tool for Quality-of-Care Evaluations. Birth 2024. Zelka MA, Yalew AW, Debelew GT. Effectiveness of a continuum of care in maternal health services on the reduction of maternal and neonatal mortality: Systematic review and meta-analysis. Heliyon. 2023;9(6):e17559. Fikre R, Gubbels J, Teklesilasie W, Gerards S. Effectiveness of midwifery-led care on pregnancy outcomes in low- and middle-income countries: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2023;23(1):386. Kearney JE, Thiel N, El-Taher A, Akhter S, Townes DA, Trehan I, Pottinger PS. Conflicts in Gaza and around the world create a perfect storm for infectious disease outbreaks. PLOS Glob Public Health. 2024;4(2):e0002927. Mortensen B, Lukasse M, Diep LM, Lieng M, Abu-Awad A, Suleiman M, Fosse E. Can a midwife-led continuity model improve maternal services in a low-resource setting? A non-randomised cluster intervention study in Palestine. BMJ Open. 2018;8(3):e019568. (MOH) PMoH. Annual Health Report: Maternal and Child Health Statistics in the West Bank and Gaza Strip. Palestine; 2022. Mortensen B, Lieng M, Diep LM, Lukasse M, Atieh K, Fosse E. Improving Maternal and Neonatal Health by a Midwife-led Continuity Model of Care - An Observational Study in One Governmental Hospital in Palestine. EClinicalMedicine 2019, 10:84–91. Ali-Masri H, Hassan S, Fosse E, Zimmo KM, Zimmo M, Ismail KMK, Vikanes Å, Laine K. Impact of electronic and blended learning programs for manual perineal support on incidence of obstetric anal sphincter injuries: a prospective interventional study. BMC Med Educ. 2018;18(1):258. Horino M, Massad S, Ahmed S, Abu Khalid K, Abed Y. Understanding coverage of antenatal care in Palestine: Cross-sectional analysis of Palestinian Multiple Indicator Cluster Survey, 2019–2020. PLoS ONE. 2024;19(2):e0297956. Leone T, Alburez-Gutierrez D, Ghandour R, Coast E, Giacaman R. Maternal and child access to care and intensity of conflict in the occupied Palestinian territory: a pseudo longitudinal analysis (2000–2014). Confl Health. 2019;13:36. Hailemeskel S, Alemu K, Christensson K, Tesfahun E, Lindgren H. Health care providers' perceptions and experiences related to Midwife-led continuity of care-A qualitative study. PLoS ONE. 2021;16(10):e0258248. Podder L, Bhardwaj G, Siddiqui A, Agrawal R, Halder A, Rani M. Utilizing Midwifery-Led Care Units (MLCU) for Enhanced Maternal and Newborn Health in India: An Evidence-Based Review. Cureus. 2023;15(8):e43214. Mortensen B, Diep LM, Lukasse M, Lieng M, Dwekat I, Elias D, Fosse E. Women's satisfaction with midwife-led continuity of care: an observational study in Palestine. BMJ Open. 2019;9(11):e030324. Dwekat IMM, Tengku Ismail TA, Ibrahim MI, Ghrayeb F. Exploring factors contributing to mistreatment of women during childbirth in West Bank, Palestine. Women Birth. 2021;34(4):344–51. Symon A, McFadden A, White M, Fraser K, Cummins A. Adapting the Quality Maternal and Newborn Care (QMNC) Framework to evaluate models of antenatal care: A pilot study. PLoS ONE. 2018;13(8):e0200640. Archibald MM, Ambagtsheer RC, Casey MG, Lawless M. Using Zoom Videoconferencing for Qualitative Data Collection: Perceptions and Experiences of Researchers and Participants. Int J Qualitative Methods. 2019;18:1609406919874596. Video Conferencing with Zoom API. [ https://wordpress.org/plugins/video-conferencing-with-zoom-api/] Nettskjema Dictaphone. [ https://www.uio.no/english/services/it/adm-services/nettskjema/help/nettskjema-dictaphone.html] Cite TSD. [ https://www.uio.no/tjenester/it/forskning/sensitiv/mer-om/cite-tsd.html] Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101. Berger R. Now I see it, now I don’t: researcher’s position and reflexivity in qualitative research. Qualitative Res. 2013;15(2):219–34. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, Aguiar C, Saraiva Coneglian F, Diniz AL, Tunçalp Ö, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12(6):e1001847. discussion e1001847. Dickson KE, Kinney MV, Moxon SG, Ashton J, Zaka N, Simen-Kapeu A, Sharma G, Kerber KJ, Daelmans B, Gülmezoglu A, et al. Scaling up quality care for mothers and newborns around the time of birth: an overview of methods and analyses of intervention-specific bottlenecks and solutions. BMC Pregnancy Childbirth. 2015;15(Suppl 2):S1. Mortensen B. Making Midwifery Matter: The Introduction of a Midwife-led Continuity Model of Care in Occupied Palestine. PhD Dissertation. University of Oslo; 2020. (WHO) WHO. Transitioning to Midwifery Models of Care: Global Position Paper. In. Geneva, Switzerland; 2024. World Health O. WHO recommendations: optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting. Geneva: World Health Organization; 2012. Filby A, McConville F, Portela A. What Prevents Quality Midwifery Care? A Systematic Mapping of Barriers in Low and Middle Income Countries from the Provider Perspective. PLoS ONE. 2016;11(5):e0153391. Hofmann PB. Stress Among Healthcare Professionals Calls Out for Attention. J Healthc Manag. 2018;63(5):294–7. Jayasundara D, Jayawardane IA, Weliange SDS, Jayasingha T, Madugalle T. Impact of continuous labor companion- who is the best: A systematic review and meta-analysis of randomized controlled trials. PLoS ONE. 2024;19(7):e0298852. Evans K, Pallotti P, Spiby H, Evans C, Eldridge J. Supporting birth companions for women in labor, the views and experiences of birth companions, women and midwives: A mixed methods systematic review. Birth. 2023;50(4):689–710. Hassan-Bitar S, Wick L. Evoking the guardian angel: childbirth care in a Palestinian hospital. Reprod Health Matters. 2007;15(30):103–13. Mother-baby. friendly birthing facilities. Int J Gynaecol Obstet. 2015;128(2):95–9. Hassan-Bitar S, Narrainen S. Shedding light' on the challenges faced by Palestinian maternal health-care providers. Midwifery. 2011;27(2):154–9. Giacaman R, Wick L, Abdul-Rahim H, Wick L. The politics of childbirth in the context of conflict: policies or de facto practices? Health Policy. 2005;72 2:129–39. Majaj L, Nassar M, De Allegri M. It's not easy to acknowledge that I'm ill: a qualitative investigation into the health seeking behavior of rural Palestinian women. BMC Womens Health. 2013;13:26. Kumar S. Burnout and Doctors: Prevalence, Prevention and Intervention. Healthc (Basel) 2016, 4(3). Wahdan Y, Abu-Rmeileh NME. The association between labor companionship and obstetric violence during childbirth in health facilities in five facilities in the occupied Palestinian territory. BMC Pregnancy Childbirth. 2023;23(1):566. Zapata T, Buchan J, De Silva D. Improving retention of health workers in rural and remote areas. Case studies from WHO South-East Asia Region; 2020. Bradford BF, Wilson AN, Portela A, McConville F, Fernandez Turienzo C, Homer CSE. Midwifery continuity of care: A scoping review of where, how, by whom and for whom? PLOS Glob Public Health. 2022;2(10):e0000935. Homer CS, Turkmani S, Wilson AN, Vogel JP, Shah MG, Fogstad H, Langlois EV. Enhancing quality midwifery care in humanitarian and fragile settings: a systematic review of interventions, support systems and enabling environments. BMJ Glob Health 2022, 7(1). Tables Table 1. Characteristics of Healthcare Providers Participating in the Study This table presents the demographic and professional characteristics of healthcare providers, including gender, profession, healthcare setting, years of experience, type of interview, and location of work in the West Bank. Category N (%) Gender Female 15 (93.75%) Male 1 (6.25%) Profession Registered Midwife 12 (75.00%) Physician 4 (25.00%) Healthcare Setting Primary Health Care 8 (50.00%) Government Hospital 8 (50.00%) Years of Experience Mean (Range) 15.2 (3–34) 1–5 years 1 (6.25%) 6–10 years 5 (31.25%) 11–20 years 5 (31.25%) >20 years 5 (31.25%) Type of Interview Face-to-Face 8 (50.00%) Online (Zoom) 8 (50.00%) Place of Current Work Single Facility 7 (43.75%) Multiple Facilities 9 (56.25%) Previous Work Experience Same Facility 1 (6.25%) Different Facilities 15 (93.75%) Location of Current Work North West Bank 6 (37.50%) Central West Bank 5 (31.25%) South West Bank 5 (31.25%) Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5989286","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":436379609,"identity":"366dbcc7-2bb6-4b33-a2d9-525dffee395a","order_by":0,"name":"Khadeja Zaza¹","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIie3PMQrCMBSA4VeETpGuL6R4hkChIIi9SqFgl2yOggqCXXqAiqdw6RwptIsH6NjeQBdRELTq4pTWTTA/vCHwPsgD0Ol+MMRmgABYAIb8jtAlwJNgR9LEZVdCt6u6PNpjzymiSp7EaA5spf4gs3NnmJCg5x4OfL9JJwh27ivJAH2XEdIz3VJA1k8zBBS8hYRndiML4iRh1ZB7O2EoXAYkQ44+b4hsJzQR02FMCo7vWwK6xon6FizDXXmNZ54VRXV1SseWhYFUkldG/PEw2/efXbqt6XQ63Z/2AJhbQjTo86s1AAAAAElFTkSuQmCC","orcid":"","institution":"Oslo Metropolitan University","correspondingAuthor":true,"prefix":"","firstName":"Khadeja","middleName":"","lastName":"Zaza¹","suffix":""},{"id":436379610,"identity":"57bbefb0-5334-444b-ae7f-76ac433ada4a","order_by":1,"name":"Alison McFadden²","email":"","orcid":"","institution":"University of Dundee","correspondingAuthor":false,"prefix":"","firstName":"Alison","middleName":"","lastName":"McFadden²","suffix":""},{"id":436379611,"identity":"c62d2873-ad1a-4fe3-bb10-919cc38b3fed","order_by":2,"name":"Sahar Hassan³","email":"","orcid":"","institution":"Birzeit University","correspondingAuthor":false,"prefix":"","firstName":"Sahar","middleName":"","lastName":"Hassan³","suffix":""},{"id":436379612,"identity":"dac225cc-7502-4850-b44c-ae2f18241858","order_by":3,"name":"Hadil Ali-Masri³,⁴","email":"","orcid":"","institution":"Birzeit University","correspondingAuthor":false,"prefix":"","firstName":"⁴","middleName":"Hadil","lastName":"Ali-Masri³","suffix":""},{"id":436379613,"identity":"43fb4487-7c4b-4473-ae74-5ae27e2b1865","order_by":4,"name":"Ellen Blix¹","email":"","orcid":"","institution":"Oslo Metropolitan University","correspondingAuthor":false,"prefix":"","firstName":"Ellen","middleName":"","lastName":"Blix¹","suffix":""},{"id":436379614,"identity":"a79fc548-b62b-45f5-a326-a7b66ce0bc89","order_by":5,"name":"Berit Mortensen¹","email":"","orcid":"","institution":"Oslo Metropolitan University","correspondingAuthor":false,"prefix":"","firstName":"Berit","middleName":"","lastName":"Mortensen¹","suffix":""}],"badges":[],"createdAt":"2025-02-08 18:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5989286/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5989286/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88974055,"identity":"b880b253-e630-4547-a2ba-17633420f1de","added_by":"auto","created_at":"2025-08-13 10:04:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":40246,"visible":true,"origin":"","legend":"\u003cp\u003eThemes and subthemes\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5989286/v1/aaf24aefb5eb09e7447f6b60.png"},{"id":105564493,"identity":"fdf7b794-752d-4fd0-8e9e-b52c72edb25b","added_by":"auto","created_at":"2026-03-27 12:49:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":968184,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5989286/v1/c5df19ff-0c37-4f74-8d48-57bee08040e7.pdf"},{"id":88975390,"identity":"aa0b106d-1583-457a-b512-ec12413b9045","added_by":"auto","created_at":"2025-08-13 10:20:15","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":35070,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-5989286/v1/d4b6ca4537b8b77678774175.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Healthcare providers' perceptions of maternal and newborn care quality in the West Bank, Palestine: a qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003eImproving maternal and newborn care quality is central to global maternal health strategies, aligning with Sustainable Development Goal 3 (SDG3) to reduce preventable maternal and neonatal deaths and promote well-being by 2030 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Achieving this requires an integrated approach that strengthens the continuum of maternal and newborn care, from antenatal to postnatal services, ensuring equity, accessibility, and a resilient healthcare system [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The Quality Maternal and Newborn Care (QMNC) Framework, established in the 2014 Lancet Series on Midwifery, serves as a globally recognized, evidence-based model for optimizing maternal and newborn care. It defines essential dimensions, including clinical practice, care organization, values, philosophy, and healthcare providers [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Its application has been reinforced through evaluation studies, which developed interview guides for qualitative assessments and quality-of-care evaluations [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Further empirical validation led to the QMNC Framework Index, a standardized instrument for global quality-of-care assessments [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eGlobal and regional studies emphasize that high-quality, evidence-based care throughout pregnancy, childbirth, and the postpartum period is essential in reducing maternal and neonatal deaths, particularly in low-resource, conflict-affected settings [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The healthcare system in the occupied Palestinian territories (oPt) is deeply fragmented, shaped by political instability, economic constraints, and occupation-related challenges. These barriers have resulted in unequal healthcare access across regions, with significant disparities between Gaza, the West Bank (WB), and East Jerusalem [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This study focused on the WB, home to about 3.2\u0026nbsp;million people, constituting 59.5% of the Palestinian population [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The WB's healthcare system is multisectoral, involving governmental institutions, non-governmental organizations (NGOs), the United Nations Relief and Works Agency (UNRWA), and private providers [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. It includes 608 primary healthcare centers (PHCs), 18 government-run hospitals, and 17 non-governmental hospitals, all providing maternal and newborn care services despite ongoing challenges [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite efforts to strengthen midwifery-led care and professional training, healthcare providers continue to face systemic challenges [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The ongoing Israeli occupation exacerbates these issues by restricting access to essential medical resources, obstructing emergency referrals due to military checkpoints, and creating logistical barriers for both healthcare providers and women [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Research indicates that rural women are disproportionately affected, experiencing delays in maternity care access, which heightens the risks of maternal and neonatal complications [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Midwifery-led continuity models (MLCMs) have proven effective in improving maternal health outcomes, particularly in resource-limited and conflict-affected settings [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. MLCMs have been associated with increased antenatal visits, improved birth preparedness, reduced maternal complications, and higher maternal satisfaction [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, the long-term sustainability of implemented MLCMs in the WB remains uncertain due to political instability, economic fragility, and disruptions from the COVID-19 pandemic [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Additionally, healthcare fragmentation across the Palestinian Ministry of Health (MoH), NGOs, UNRWA, and private providers leads to inefficiencies, service delivery gaps, and resource duplication, hindering care coordination effectiveness [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile prior research has explored maternal health policies and system-level challenges in the oPt, limited qualitative studies have investigated healthcare providers\u0026rsquo; perspectives on barriers and opportunities to enhance maternal and newborn care [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This study investigated providers' experiences in the WB. It identifies systemic gaps and potential interventions to strengthen maternal and newborn care in a conflict-affected setting.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Site\u003c/h2\u003e\u003cp\u003eThe study was conducted across all governorates in the WB, including government hospitals and PHCs under the Palestinian MoH. The selection included both urban and rural settings in the north, central, and south regions to ensure a comprehensive understanding of maternal and newborn care providers\u0026rsquo; experiences.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eDesign\u003c/h3\u003e\n\u003cp\u003eA qualitative research design was applied, using in-depth individual interviews to explore healthcare providers' perceptions of maternal and newborn care services within the Palestinian context.\u003c/p\u003e\n\u003ch3\u003eRecruitment and Data Generation\u003c/h3\u003e\n\u003cp\u003eA purposive sampling strategy was used to ensure representation across different healthcare facility types. Eligible participants included Palestinian midwives and physicians with at least one year of maternal care experience to ensure sufficient clinical expertise and firsthand insight.\u003c/p\u003e\u003cp\u003eAfter obtaining ethics approval, the lead researcher (KZ) conducted preliminary visits to introduce the study and distribute an Arabic-translated QMNC Framework. Potential participants received information sheets detailing the study purpose.\u003c/p\u003e\u003cp\u003eIn-depth interviews were guided by a contextually adapted tool, developed based on QMNC components and reviewed by a panel of experts, including maternal health specialists, healthcare users, and researchers, to ensure cultural and contextual relevance [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] (see Additional File 1).\u003c/p\u003e\u003cp\u003eInterviews were conducted in Arabic. Eight in-person interviews took place at participants\u0026rsquo; workplaces, lasting between 30 and 68 minutes (mean: 43.5 minutes). Due to the deteriorating security situation, the remaining interviews were conducted digitally via Zoom videoconferencing from participants\u0026rsquo; homes, lasting between 60 and 120 minutes (mean: 98 minutes) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The first author, an experienced midwife trained in qualitative research, conducted the interviews, supervised by senior researchers to ensure procedural consistency. Each interview was audio-recorded using the encrypted \u0026ldquo;nettskjema dictaphone\u0026rdquo; application [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], with secure storage at the University of Oslo database Services for Sensitive Data (TSD) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eData were analyzed using reflexive thematic analysis, following Braun and Clarke\u0026rsquo;s six-phase approach [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. A professional translator translated the Arabic transcripts into English, and the first and last authors validated them by comparing translations with the original texts to ensure accuracy. Field notes further supported the transcription process.\u003c/p\u003e\u003cp\u003eThe analysis began with data familiarization, where three researchers (KZ, AM, \u0026amp; BM) immersed themselves in the transcripts, repeatedly reading and discussing the data to generate preliminary themes. Visual mind maps were created to summarize key concepts.\u003c/p\u003e\u003cp\u003eThe first author conducted systematic coding and engaged in regular consultations with senior researchers to identify broader patterns and maintain coding consistency. Initial themes were collaboratively developed by the core research team and later refined through discussions with the full research team to ensure a comprehensive and objective analysis.\u003c/p\u003e\u003cp\u003e Final theme development was reached through iterative discussions to confirm alignment with the research objectives and participant narratives. Throughout the process, the research team engaged in reflexive practice, critically examining contextual influences to deepen thematic understanding [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eSixteen participants engaged in individual in-depth interviews conducted between May and October 2023. Of these, 15 were female and one was male. Participants included 12 midwives, three obstetricians, and one general practitioner (GP), each offering insights shaped by their professional experiences in maternal and newborn care. Their clinical experience ranged from 5 to 33 years, with all working full-time in healthcare facilities across the WB (see Table\u0026nbsp;1).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eFindings\u003c/h3\u003e\n\u003cp\u003eThrough reflexive thematic analysis, we developed two main themes: \u003cem\u003eNavigating high demands in an unpredictable system\u003c/em\u003e and \u003cem\u003eOpportunities for enhancing care quality\u003c/em\u003e. Each theme includes three subthemes, as illustrated in \u003cb\u003eFig.\u0026nbsp;1\u003c/b\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eTheme 1: Navigating high demands in an unpredictable system\u003c/h3\u003e\n\u003cp\u003eThis theme explores the immense pressures faced by healthcare providers in government hospitals and PHCs operating in resource-limited and politically unstable environments. Providers described systemic limitations, including understaffing, resource shortages, outdated infrastructure, and unpredictable patient loads, all exacerbated by economic instability and the Israeli occupation. These constraints not only affected the delivery of maternal and newborn care but also deepened structural inequities, particularly for rural populations. The findings illustrate how cultural norms, institutional policies, and systemic deficiencies intersect to shape care quality and provider experiences.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eSubtheme 1: Trapped between system constraints and women\u0026rsquo;s needs\u003c/h2\u003e\u003cp\u003eHealthcare providers in public maternity wards and PHCs often struggled to balance institutional constraints with women's needs, particularly concerning labor support, privacy, and family expectations. Chronic understaffing, insufficient resources, and restrictive institutional policies frequently led to tensions between providers and families.\u003c/p\u003e\u003cp\u003eIn government hospitals, overcrowded labor wards, where only curtains separated birthing women, severely compromised privacy and restricted the presence of support persons during labor. While institutional policies prohibited family members from remaining in the labor ward, cultural norms strongly emphasized companionship and emotional support during childbirth. One physician described the frequent disputes this policy provoked:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There are numerous instances when conflicts arise between the medical staff and the companions.\u0026rdquo;\u003c/em\u003e (P8, physician)\u003c/p\u003e\u003cp\u003eThe absence of dedicated family spaces made it difficult for midwives to accommodate support persons during labor, despite recognizing the emotional and cultural importance of family presence. As institutional gatekeepers, midwives were responsible for enforcing hospital policies that restricted companion presence, often leading to conflict and, in some cases, physical abuse of staff.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Once a midwife colleague had to tell the family companions to leave the labor ward ... the family replied that she had no right to expel them and beat the midwife.\u0026rdquo;\u003c/em\u003e (P9, midwife).\u003c/p\u003e\u003cp\u003eConfronted with these tensions, midwives adopted varied communication strategies, ranging from authoritative enforcement to conciliatory approaches aimed at mitigating conflict and restoring trust. In some cases, midwives sought to de-escalate tensions by acknowledging women's frustrations and negotiating their roles within institutional constraints, one midwife explained:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes, you have to raise your voice... but immediately, we apologized... explaining it was for her good.\u0026rdquo;\u003c/em\u003e (P14, midwife)\u003c/p\u003e\u003cp\u003eSimilarly, many providers in public maternity wards and PHCs described how cultural preferences for female doctors posed additional challenges, particularly in rural areas. Women frequently refused male doctors, complicating care provision in facilities with few female physicians:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Women often refuse male doctors, but if no female doctor is available, we ensure she is covered and accompanied by a midwife during the examination.\u0026rdquo;\u003c/em\u003e (P11, midwife)\u003c/p\u003e\u003cp\u003eDespite systemic constraints, some midwives adapted their approaches when workload pressures were lower. One midwife described how, in less crowded labor wards, she was able to offer small gestures of flexibility, which she perceived positively influenced women's childbirth experiences:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If only one woman was in the labor ward, I might allow a family member to help dress the baby... this made women happier and more responsive.\u0026rdquo;\u003c/em\u003e (P7, midwife)\u003c/p\u003e\u003cp\u003eHowever, such flexibility was rarely possible due to severe understaffing and excessive workload pressures.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eSubtheme 2: Burned-out professional passion\u003c/h2\u003e\u003cp\u003eDespite their dedication to maternal health, providers in government hospitals and PHCs described increasing emotional exhaustion driven by excessive workloads, chronic understaffing, and minimal systemic support. They described juggling multiple responsibilities under relentless pressure, leaving little time for compassionate care. These constraints forced providers to prioritize efficiency over patient-centered care, leading to detachment and burnout.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;This is the system in .... hospital. They have only one delivery room with two beds, and five or six post-labor rooms; this was also the situation five years ago\u0026hellip;.\u0026rdquo;\u003c/em\u003e (P6, midwife)\u003c/p\u003e\u003cp\u003eIn government hospitals, midwives described how fast-paced labor environments limited their ability to form meaningful connections with birthing women, as they were often required to manage multiple births simultaneously:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I assisted in three birthing women... I had to make sure that the babies had the correct identification bracelets before I ran to help the next birthing woman.\u0026rdquo;\u003c/em\u003e (P9, midwife)\u003c/p\u003e\u003cp\u003eSimilarly, midwives in PHCs expressed frustration over medication shortages and economic instability, which made it impossible to meet women\u0026rsquo;s medical needs, particularly in low-income areas:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You feel embarrassed when the medication isn\u0026rsquo;t available because people are poor and miserable.\u0026rdquo;\u003c/em\u003e (P7, midwife)\u003c/p\u003e\u003cp\u003eBoth midwives and physicians emphasized systemic understaffing as a root cause of burnout, with workloads intended for multiple providers frequently falling onto a single healthcare provider.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The service that should be managed by two or three physicians often falls to one, which affects the quality of care provided.\u0026rdquo;\u003c/em\u003e (P15, physician)\u003c/p\u003e\u003cp\u003eOver time, grueling conditions in labor wards contributed to chronic exhaustion, health issues, and high attrition rates. Many midwives sought less demanding roles, further exacerbating workforce retention challenges in high-stress environments. Chronic stress, sleep deprivation, and deteriorating health were frequently cited as key factors influencing their decisions to leave labor wards.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I worked in the labor ward for eight years... but it became hard to continue in this job. Therefore, I requested to join primary care... Work in primary care means a healthy heart, quality life, and job stability.\u0026rdquo;\u003c/em\u003e (P7, midwife)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;With time, my health deteriorated... Sleeplessness is the most challenging aspect.\u0026rdquo;\u003c/em\u003e (P12, midwife)\u003c/p\u003e\u003cp\u003eThe emotional and physical toll of burnout extended beyond professional responsibilities, negatively affecting providers' motivation and well-being. Some providers in government healthcare facilities described how overcrowding with women receiving maternity care created a sense of futility among staff:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I need motivation; my director should give me a thank-you letter as spiritual encouragement means a lot to us; it affects us more than materialistic motivation. The one who does a good job will continue to do so, whether appreciated or not.\u0026rdquo;\u003c/em\u003e (P5, physician)\u003c/p\u003e\u003cp\u003eBeyond systemic constraints and emotional exhaustion, healthcare providers also identified external factors, including economic instability and the Israeli occupation, as significant barriers to maternal healthcare delivery.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eSubtheme 3: External quality barriers\u003c/h2\u003e\u003cp\u003eProviders in government hospitals and PHCs described the impact of the Israeli occupation, economic instability, and persistent medical supply shortages on maternal healthcare delivery, particularly in rural and conflict-affected regions.\u003c/p\u003e\u003cp\u003eOne of the most critical barriers was the impact of Israeli military checkpoints and settler violence, which frequently delayed or prevented women in labor from accessing care, leading to avoidable maternal and neonatal complications:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We noticed cases that took place in a region with conflict... The ambulance would go back because they prevented the ambulance from taking the woman, or when they were sure that the woman was dead, they would allow the ambulance to take the casualties.\u0026rdquo;\u003c/em\u003e (P14, midwife)\u003c/p\u003e\u003cp\u003eProviders also reported economic instability as a major barrier, noting that the withholding of Palestinian tax revenues by Israel leads to financial instability. Healthcare workers frequently went unpaid or received partial salaries, worsening financial hardships.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Our debts increased, and I just wanted my full salary.\u0026rdquo;\u003c/em\u003e (P4, midwife)\u003c/p\u003e\u003cp\u003eIn addition, shortages of essential medications, particularly oxytocin, a critical drug for managing labor complications, and outdated medical equipment, further compromised maternal care.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We don\u0026rsquo;t have enough basic medicines for emergencies. For example, oxytocin is not always available, and this delays necessary care during labor.\u0026rdquo;\u003c/em\u003e (P6, midwife)\u003c/p\u003e\u003cp\u003eSimilarly, many providers emphasized that outdated and insufficient medical equipment significantly hindered their ability to deliver high-quality maternal care. Items such as blood pressure monitors, scissors, cardiotocography (CTG) machines, and sterilization tools were often outdated, in disrepair, or insufficient.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I requested maintenance for the ultrasound equipment two months ago... nothing has been done.\u0026rdquo;\u003c/em\u003e (P8, physician)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Our equipment is old and worn out; I feel that our ward is in need of repair, everything, everything. For example, the scissors are worn out. I don\u0026rsquo;t know if the new items we receive are really new, or because of frequent use, they wear out quickly.\u0026rdquo;\u003c/em\u003e (P11, midwife)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eTheme 2: Opportunities for enhancing care quality\u003c/h2\u003e\u003cp\u003eAmid systemic challenges, providers identified key opportunities to improve maternal care, including expanding midwives\u0026rsquo; autonomy, promoting respectful care, enhancing training, and strengthening care coordination. These insights highlighted the resilience and adaptability of healthcare workers and their commitment to maternal and newborn health.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eSubtheme 1: Navigating autonomy and respectful care\u003c/h2\u003e\u003cp\u003eMidwives in both government hospitals and PHCs frequently reported feeling constrained by restrictive protocols that limited their professional autonomy, particularly in the absence of physicians. They expressed frustration over their inability to perform tasks they were trained for, such as suturing after delivery, without facing reprimands. A physician highlighted the systemic barriers preventing midwives from acting independently, even in emergencies.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;A midwife isn\u0026rsquo;t supposed to do something without referring to the doctor. However, if the midwife decided to do a procedure without referring to the doctor, she is punished.\u0026rdquo;\u003c/em\u003e (P8, physician)\u003c/p\u003e\u003cp\u003eThis lack of autonomy was further compounded by cultural and gender preferences, as many Palestinian women preferred female providers for sensitive procedures such as vaginal examinations. However, in public hospitals, male physicians were often the only available option, creating tensions between women\u0026rsquo;s preferences and staffing limitations.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If there is a male physician on duty, we tell her that there is no female physician on duty, and if the woman refuses, she signs and is discharged against medical advice... In case we have a female physician on duty, she examines her, but we don\u0026rsquo;t force any woman to allow a male doctor to examine her.\u0026rdquo;\u003c/em\u003e (P9, midwife)\u003c/p\u003e\u003cp\u003eDespite these constraints, midwives reflected on how continuity of care programs helped address systemic limitations by fostering autonomy and enabling more personalized, respectful care. These programs facilitated repeated interactions, building trust and culturally sensitive care for women and their families. Midwives shared positive experiences of how continuity programs strengthened communication and individualized support, particularly in nutrition and breastfeeding counseling, improving maternal and newborn health outcomes.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We followed up with the pregnant woman and used to see her seven, eight, nine, ten times... I began to get to know people and understand how to deal with them.\u0026rdquo;\u003c/em\u003e (P9, midwife)\u003c/p\u003e\u003cp\u003eHowever, providers emphasized that the benefits of these programs were hindered by outdated training approaches, which often failed to align with evidence-based clinical practices.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eSubtheme 2: Improving training and evidence-based practices\u003c/h2\u003e\u003cp\u003eHealthcare providers across government hospitals and PHCs identified critical gaps in training programs, describing them as overly theoretical and lacking practical, evidence-based approaches. A physician emphasized the need for a well-equipped workforce capable of addressing the dynamic challenges of maternal healthcare:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We need well-trained young individuals who are adequately equipped to address the dynamic needs of healthcare delivery.\u0026rdquo;\u003c/em\u003e (P2, physician)\u003c/p\u003e\u003cp\u003eMidwives shared similar concerns, noting that training programs focused on protocols rather than real-world clinical practice:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The last training course was two years back... Most are about protocols, not about real-world challenges.\u0026rdquo;\u003c/em\u003e (P9, midwife)\u003c/p\u003e\u003cp\u003eThis gap between training content and clinical practice perpetuated outdated and, at times, harmful methods, adversely affecting maternal outcomes. One midwife recounted witnessing a procedure explicitly prohibited by modern medical national guidelines but still performed due to inadequate training.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I saw another midwife applying pressure to the uterus, which is illegal, but it happened due to lack of training.\u0026rdquo;\u003c/em\u003e (P10, midwife)\u003c/p\u003e\u003cp\u003eProviders emphasized that bridging these training gaps requires a shift toward competency driven, evidence-based education. Such an approach would enable healthcare workers to eliminate outdated practices and adapt to the evolving needs of maternal and newborn care.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eSubtheme 3: Strengthening care coordination and continuity\u003c/h2\u003e\u003cp\u003eProviders highlighted that rural areas face significant challenges in managing high-risk pregnancies due to fragmented referral systems and limited access to specialists at primary care centers. Women in these regions often struggle with financial and logistical barriers when traveling to urban centers for follow-ups, leading to delays or missed appointments that negatively impact maternal and neonatal health:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;In remote villages, a woman may face a problem visiting the primary care center in the city... because there is no specialist available except in the center in the city.\u0026rdquo;\u003c/em\u003e (P15, physician)\u003c/p\u003e\u003cp\u003eAdditionally, providers noted that the disconnect between private and public healthcare systems exacerbates these challenges. Incomplete referral information from private hospitals often resulted in delayed interventions and increased complications:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We received referrals from private hospitals like bombs (unpredictable cases without referral).\u0026rdquo;\u003c/em\u003e (P12, midwife)\u003c/p\u003e\u003cp\u003eMidwives reflected on the negative impact of discontinuing the continuity of care program, which had previously integrated hospital-based and community-based services through antenatal care and postnatal home visits. Those who participated in the program emphasized its effectiveness in bridging the gap between hospital and community-based care, fostering trust, education, and maternal support. The program\u0026rsquo;s suspension during the COVID-19 pandemic introduced significant disruptions in care coordination, reducing opportunities for women to receive holistic maternity care. Midwives highlighted how continuity of care models strengthened relationships between women and healthcare providers, allowing women to voice their concerns and receive more personalized, culturally sensitive care:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When women knew I would assist with their delivery and follow up with them postnatally, they were happier and more open to discussing their concerns.\u0026rdquo;\u003c/em\u003e (P9, midwife)\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored healthcare providers' perspectives on maternal and neonatal healthcare quality in the WB, highlighting key barriers and opportunities for improvement. Through reflexive thematic analysis, two overarching themes were developed: navigating high demands in an unpredictable system and identifying strategies to enhance care quality. The analysis was informed by the QMNC Framework, which provided a structured approach to understanding systemic challenges and potential improvements.\u003c/p\u003e\u003cp\u003eHealthcare providers in oPt operate within a system marked by inadequate staffing, fragmented healthcare structures, and resource limitations, which collectively hinder the provision of person-centered care. These barriers are particularly severe in rural and underserved regions, where women struggle with logistical and financial obstacles in accessing essential maternal services [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Addressing these systemic deficiencies through targeted reforms is necessary to enhance both clinical efficiency and equity in care delivery [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRespect, effective communication, and culturally sensitive care are critical to improving maternal experiences. However, restrictive hospital policies and outdated infrastructure often limit the extent to which these practices can be implemented [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. For instance, limitations on family involvement during labor leave many women feeling unsupported, despite strong evidence indicating that labor companionship improves maternal outcomes [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Addressing these institutional barriers is necessary to foster a more person-centered approach.\u003c/p\u003e\u003cp\u003eFamily-centered care, especially labor companionship, has been widely recognized for its benefits in improving maternal experiences and birth outcomes [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] However, many hospitals continue to prohibit family presence during labor due to concerns about overcrowding and limited space [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Family companions, compared to unfamiliar ones, are more effective in alleviating childbirth fears and fostering a positive birth experience [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Ensuring companions are well-informed and engaged further strengthens their support role, improving maternal well-being [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Expanding structured labor companionship programs could help bridge this gap, fostering maternal confidence and trust in healthcare providers [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCultural norms and preferences for female providers present another critical challenge, particularly in prenatal, labor, and postpartum care [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Workforce shortages and rigid scheduling disproportionately impact rural areas, limiting women's access to female providers. This disparity highlights the need for gender-sensitive policies that ensure equitable access to care [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. This reinforces inequities in access and highlights the urgent need for policies supporting gender-sensitive services.\u003c/p\u003e\u003cp\u003eBurnout among healthcare providers was a recurring concern in this study. Participants described excessive workloads, inadequate staffing, and limited resources as major stressors. Many reported progressive emotional exhaustion, which negatively affected their ability to provide high-quality care. These findings underscore the urgent need for workforce policies focused on retention, stress management, and burnout mitigation strategies to ensure a sustainable maternal healthcare system [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMaternal healthcare in oPt is heavily shaped by economic constraints and political instability. Delayed salaries, restricted access to medical supplies, and transportation challenges disproportionately affect rural populations, further exacerbating healthcare inequities [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Geographic fragmentation and occupation imposed restrictions disproportionately impact marginalized communities, further limiting access to equitable and effective care [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Addressing these barriers requires targeted interventions that improve healthcare accessibility and reduce disparities [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study identified three key areas for improving maternal and newborn care in oPt: navigating autonomy and respectful care, improving training and evidence-based practices, and strengthening care coordination and continuity. Addressing these gaps would enable healthcare providers to deliver more effective, person-centered care while overcoming systemic challenges to better meet the needs of women and newborns.\u003c/p\u003e\u003cp\u003eEnhancing midwifery autonomy is essential for strengthening maternal healthcare in oPt [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Participants described restrictive protocols and hierarchical systems that limited their ability to perform key clinical tasks, such as suturing and leading care for low-risk pregnancies. Many midwives expressed frustration over the dominance of physician-led models, which restricted their professional scope [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Policy reforms that expand midwives' roles and decision-making authority could improve maternal healthcare delivery while alleviating burdens on overstretched healthcare systems [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePromoting respectful and culturally appropriate care is essential for improving maternal experiences and outcomes [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. However, restrictive policies, such as limiting family involvement during labor, and inadequate gender-sensitive services prevent providers from fully addressing women's cultural preferences and needs. A local study by Dwekat et al. (2021) linked these systemic constraints to mistreatment during childbirth, highlighting the need for dignity-focused reforms [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Implementing policies that empower midwives and expand family-centered approaches could help improve maternal care experiences, as suggested by Mortensen et al. (2018) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study underscores the inadequacy of existing training programs, which remain heavily focused on theoretical protocols while neglecting practical, evidence-based approaches. As a result, providers reported a persistent gap between training and clinical practice, contributing to the continued use of outdated or harmful techniques. Continuous professional development is essential for bridging this gap [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Evidence-based, competency-driven education is a key strategy in improving maternal and newborn care, enhancing provider confidence, and reducing medical errors [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Continuous quality improvement initiatives in maternal and reproductive health services play a crucial role in strengthening care quality and outcomes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].Strengthening competency training programs with hands-on, evidence-based learning opportunities could significantly improve maternal healthcare delivery [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].Care coordination remains a critical area for improvement, particularly in rural regions where fragmented referral systems and logistical barriers delay access to specialists and emergency services. Providers in this study highlighted how incomplete referrals from private hospitals and poor communication between public and private systems contribute to inefficiencies, increase complications, and exacerbate disparities. Strengthening integration across facility and community levels is essential to ensuring continuity and accessibility in maternal healthcare [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMLCMs offer a viable solution. A study by Mortensen et al. (2018) found that MLCMs enhanced antenatal care utilization, facilitated timely referrals, and improved maternal health outcomes [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The World Health Organization (WHO) recognizes MLCMs as a cost-effective intervention, particularly in resource-constrained settings like oPt [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Research on the QMNC Framework further supports this by evaluating antenatal care models and their effectiveness in improving maternal health outcomes [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Reintroducing and scaling MLCMs could address systemic inefficiencies while empowering midwives to provide culturally sensitive, person-centered care.\u003c/p\u003e\u003cp\u003eDespite their proven benefits, the expansion of MLCMs faces significant barriers, including financial constraints, inadequate infrastructure, and political instability. Targeted investments, strategic policy reforms, and enhanced inter-sectoral coordination are necessary to overcome these obstacles [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Aligning Palestinian maternal healthcare systems with global best practices through these interventions would help ensure equitable, high-quality care for all women and newborns [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003eThis study provides rich qualitative insights, offering an in-depth exploration of maternal and newborn care practices from the perspectives of frontline providers. Purposive sampling and semi-structured interviews ensured representation across diverse rural and urban settings in the WB. Conducting interviews in both physical and digital formats enhanced flexibility and accessibility. Notably, digital interviews created a safer and more private space, particularly in a politically unstable context, allowing participants to discuss systemic challenges more openly.\u003c/p\u003e\u003cp\u003eConducting research in conflict-affected settings presents unique methodological and ethical challenges. However, this study successfully navigated these complexities by employing adaptive strategies. The use of digital interviews mitigated security risks and enabled participation from geographically dispersed providers, ensuring diverse perspectives. Additionally, the study highlights how institutional policies, security risks, and resource constraints shape maternal care in fragile settings, offering insights that are often underrepresented in global maternal health research.\u003c/p\u003e\u003cp\u003eDespite these strengths, this study has certain limitations. The limited representation of physicians may have narrowed the diversity of perspectives, particularly regarding the management of high-risk pregnancies and referral-based care. This limitation may have affected the study\u0026rsquo;s ability to fully capture interdisciplinary collaboration challenges.\u003c/p\u003e\u003cp\u003eAdditionally, workplace-based interviews, even when conducted digitally, may have constrained participants from fully expressing their views due to time pressures, power hierarchies, or fear of reprisal when discussing institutional policies and systemic barriers. Although digital interviews allowed for more extended discussions, they were occasionally disrupted by environmental interruptions, affecting conversational flow. These disruptions may have influenced participants' ability to elaborate on complex issues, potentially impacting the depth of some responses.\u003c/p\u003e\u003cp\u003eDespite these limitations, the findings are transferable to other conflict-affected, low-resource settings facing similar systemic healthcare constraints. This study provides valuable lessons on improving maternal and newborn care quality, offering policy and practice insights for contexts with comparable structural challenges.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003e This study provides critical insights into the complex challenges affecting maternal healthcare in the WB, Palestine, particularly the compounded impact of political instability, systemic fragmentation, and resource limitations on the delivery and quality of care. The findings highlight the urgent need for structural reforms to strengthen care coordination, implement midwifery-led continuity of care models, and foster culturally sensitive, evidence-based clinical practices. Applying the QMNC Framework underscored the necessity for systemic, multi-level interventions that enhance provider competence, clinical practices, and organizational care models to achieve sustainable improvements in maternal and newborn health outcomes.\u003c/p\u003e\u003cp\u003eFuture research should incorporate women's lived experiences and perspectives to develop a holistic understanding of maternal care challenges, supporting the design of person-centered policies and interventions. Additionally, addressing regional disparities and developing tailored strategies for conflict-affected populations are essential steps toward building adaptive, resilient, and sustainable healthcare models in fragile settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSDG3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSustainable Development Goal 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eQMNC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eQuality Maternal and Newborn Care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eoPt\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOccupied Palestinian Territories\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWest Bank\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUNRWA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUnited Nations Relief and Works Agency\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePHCs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePrimary Healthcare Centers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMLCMs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMidwifery-Led Continuity Models\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMoH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePalestinian Ministry of Health\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNGOs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNon-Governmental Organizations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eService for Sensitive Data\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCoronavirus Disease 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGeneral Practitioner\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCTG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCardiotocography\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eREK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRegional Ethics Committee for South-East Norway\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWHO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWorld Health Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe followed ethical guidelines throughout the research involving human participants. Informed consent was obtained from all participants, ensuring they understood their rights and the study's purpose. To protect confidentiality, no identifying information, such as names, current workplace, or phone numbers were collected. Instead, transcripts were assigned serial numbers to maintain anonymity. The transcripts were stored securely, and all data handling followed strict protocols to ensure privacy. The study received multiple layers of ethical clearance. The Regional Ethics Committee for South-East Norway (REK) determined that ethics approval from them was not required, as the study focused on health services rather than personal health data (ref. no. 491275). The Norwegian Data Inspectorate approved the study (ref no 791638). Oslo Metropolitan (OsloMet) University’s data protection officer approved the study’s ethical framework and data management protocols (approval no. 22/08280). Additionally, ethical approval was granted by the Ethical Research Committee at the Faculty of Pharmacy, Nursing, and Health Professions, Birzeit University, WB (approval no. BZUPNH2139). Data management agreement between Birzeit and OsloMet university (approval no.EU2021/9/4). The Palestinian Ministry of Health also approved the study and ensured the permission to conduct the interviews (approval no. 162/1255/2022).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The data supporting the findings of this study are included within the manuscript and its supplementary information files. The dataset used and analyzed in this study is not publicly accessible; however, it can be made available upon reasonable request, contingent on obtaining the necessary ethical approvals\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by NORWAY, under the NORHEDII project, Midwifery Research and Education Development (MIDRED), reference number 70320. The funders were not involved in any aspect of the research, including data interpretation, publication decisions, or manuscript writing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy conception and design: KZ, AM, SH, EB, HM, BM; Supervision of data collection: BM, SH, HM; Data collection: KZ; Analysis: KZ, BM, AM; Interpretation of results: KZ, AM, SH, EB, HM, BM; Draft manuscript preparation: KZ, AM, SH, EB, HM, BM. All authors reviewed the results and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors express their gratitude to all healthcare providers, including physicians and midwives, whose participation and insights were critical to this study. Their contributions were invaluable in enhancing the understanding of maternal and newborn care in the region. This research was conducted using the Service for Sensitive Data (TSD) facilities, owned by the University of Oslo and operated by the TSD service group at the University of Oslo IT Department (USIT). For further information, contact\u0026nbsp;[email protected].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKhadeja Zaza¹, Alison McFadden², Sahar Hassan³, Hadil Ali-Masri³⁴, Ellen Blix¹, Berit Mortensen¹\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and Affiliations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003eMother and Infant Research unit, School of Nursing and Health Sciences, University of Dundee, Dundee, United Kingdom.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003e Department of Nursing and Master program of Women’s Health, Faculty of Pharmacy, Nursing and Health professions, Birzeit University, Birzeit, Palestine.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003e Women’s Health and Development Unit, Ministry of Health, Ramallah, Palestine\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUNFPA WHO. 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Qualitative Res Psychol. 2006;3(2):77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBerger R. Now I see it, now I don\u0026rsquo;t: researcher\u0026rsquo;s position and reflexivity in qualitative research. Qualitative Res. 2013;15(2):219\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, Aguiar C, Saraiva Coneglian F, Diniz AL, Tun\u0026ccedil;alp \u0026Ouml;, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12(6):e1001847. discussion e1001847.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDickson KE, Kinney MV, Moxon SG, Ashton J, Zaka N, Simen-Kapeu A, Sharma G, Kerber KJ, Daelmans B, G\u0026uuml;lmezoglu A, et al. Scaling up quality care for mothers and newborns around the time of birth: an overview of methods and analyses of intervention-specific bottlenecks and solutions. BMC Pregnancy Childbirth. 2015;15(Suppl 2):S1.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMortensen B. Making Midwifery Matter: The Introduction of a Midwife-led Continuity Model of Care in Occupied Palestine. \u003cem\u003ePhD Dissertation.\u003c/em\u003e University of Oslo; 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e(WHO) WHO. Transitioning to Midwifery Models of Care: Global Position Paper. In. Geneva, Switzerland; 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health O. WHO recommendations: optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting. Geneva: World Health Organization; 2012.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFilby A, McConville F, Portela A. What Prevents Quality Midwifery Care? A Systematic Mapping of Barriers in Low and Middle Income Countries from the Provider Perspective. PLoS ONE. 2016;11(5):e0153391.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHofmann PB. Stress Among Healthcare Professionals Calls Out for Attention. J Healthc Manag. 2018;63(5):294\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJayasundara D, Jayawardane IA, Weliange SDS, Jayasingha T, Madugalle T. Impact of continuous labor companion- who is the best: A systematic review and meta-analysis of randomized controlled trials. PLoS ONE. 2024;19(7):e0298852.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEvans K, Pallotti P, Spiby H, Evans C, Eldridge J. Supporting birth companions for women in labor, the views and experiences of birth companions, women and midwives: A mixed methods systematic review. Birth. 2023;50(4):689\u0026ndash;710.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHassan-Bitar S, Wick L. Evoking the guardian angel: childbirth care in a Palestinian hospital. Reprod Health Matters. 2007;15(30):103\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMother-baby. friendly birthing facilities. Int J Gynaecol Obstet. 2015;128(2):95\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHassan-Bitar S, Narrainen S. Shedding light' on the challenges faced by Palestinian maternal health-care providers. Midwifery. 2011;27(2):154\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGiacaman R, Wick L, Abdul-Rahim H, Wick L. The politics of childbirth in the context of conflict: policies or de facto practices? Health Policy. 2005;72 2:129\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMajaj L, Nassar M, De Allegri M. It's not easy to acknowledge that I'm ill: a qualitative investigation into the health seeking behavior of rural Palestinian women. BMC Womens Health. 2013;13:26.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKumar S. Burnout and Doctors: Prevalence, Prevention and Intervention. Healthc (Basel) 2016, 4(3).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWahdan Y, Abu-Rmeileh NME. The association between labor companionship and obstetric violence during childbirth in health facilities in five facilities in the occupied Palestinian territory. BMC Pregnancy Childbirth. 2023;23(1):566.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZapata T, Buchan J, De Silva D. Improving retention of health workers in rural and remote areas. Case studies from WHO South-East Asia Region; 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBradford BF, Wilson AN, Portela A, McConville F, Fernandez Turienzo C, Homer CSE. Midwifery continuity of care: A scoping review of where, how, by whom and for whom? PLOS Glob Public Health. 2022;2(10):e0000935.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHomer CS, Turkmani S, Wilson AN, Vogel JP, Shah MG, Fogstad H, Langlois EV. Enhancing quality midwifery care in humanitarian and fragile settings: a systematic review of interventions, support systems and enabling environments. BMJ Glob Health 2022, 7(1).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Characteristics of Healthcare Providers Participating in the Study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis table presents the demographic and professional characteristics of healthcare providers, including gender, profession, healthcare setting, years of experience, type of interview, and location of work in the West Bank.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e15 (93.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1 (6.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProfession\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eRegistered Midwife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e12 (75.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003ePhysician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e4 (25.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealthcare Setting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003ePrimary Health Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e8 (50.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eGovernment Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e8 (50.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears of Experience \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eMean (Range)\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e15.2 (3\u0026ndash;34)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003e1\u0026ndash;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1 (6.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e5 (31.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003e11\u0026ndash;20 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e5 (31.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003e\u0026gt;20 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e5 (31.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of Interview\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eFace-to-Face\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e8 (50.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eOnline (Zoom)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e8 (50.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlace of Current Work\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eSingle Facility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e7 (43.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eMultiple Facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e9 (56.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious Work Experience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eSame Facility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1 (6.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eDifferent Facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e15 (93.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation of Current Work\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eNorth West Bank\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e6 (37.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eCentral West Bank\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e5 (31.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eSouth West Bank\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e5 (31.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Maternal care quality, Newborn care quality, Healthcare in conflict settings, Midwifery, Reflexive thematic analysis, Qualitative research methods, Palestine","lastPublishedDoi":"10.21203/rs.3.rs-5989286/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5989286/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe Sustainable Development Goals highlight the need for high-quality antenatal, intrapartum, and postnatal care to reduce maternal morbidity and mortality and enhance overall well-being. This study aimed to explore healthcare providers' perceptions of maternal and newborn care quality in the West Bank, occupied Palestinian territories, where the healthcare system faces systemic and political challenges.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis qualitative study was undertaken in government hospitals and primary healthcare clinics operating under the Palestinian Ministry of Health across the north, central, and south regions of the West Bank. Between May and October 2023, sixteen in-depth, semi-structured interviews were conducted with healthcare providers, comprising 12 midwives and four physicians. The interviews were guided by the Quality Maternal and Newborn Care Framework, which focuses on practice, organization, values, philosophy, and care providers. Data were analyzed using the reflexive thematic analysis approach.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eTwo main themes were developed. The first, \"navigating high demands in an unpredictable system,\" highlights the toll of professional burnout and systemic challenges, including resource shortages, administrative inefficiencies, and the impact of the Israeli occupation. The second, \"opportunities for enhancing care quality,\" identifies pathways for improvement, including expanding the role of midwives in decision-making, encouraging respectful and person-centered care, increasing access to evidence-based clinical training, and strengthening care coordination and continuity.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe findings highlight critical challenges and key opportunities for improving maternal and newborn care quality in the West Bank. Addressing these issues holistically through the lens of the Quality Maternal and Newborn Care Framework aligns with global priorities and offers a pathway to strengthen quality of care in conflict-affected settings.\u003c/p\u003e","manuscriptTitle":"Healthcare providers' perceptions of maternal and newborn care quality in the West Bank, Palestine: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-13 10:04:10","doi":"10.21203/rs.3.rs-5989286/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ff06ca28-6e6b-491c-8707-36c9b33f36ff","owner":[],"postedDate":"August 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T23:53:54+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-13 10:04:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5989286","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5989286","identity":"rs-5989286","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}