Title: Level of satisfaction on the maternal health care services as perceived

by the clients of the well family midwife clinic in Davao City

Maslow’s hierarchy of needs in 1943 Goldstein theory of self actualization

in 1964 that the maternal health system leaves much to be desired every July 11,

throughout the globe, observe World population Day.

The title appropriately indicates the target population sampled Level of

satisfaction on the maternal health care services as perceived by the clients of

the well family midwife clinic in Davao City. The clinical problem and study

objectives are clearly presented in the abstract and text of the article. A specific

research hypothesis about self-reported safety behaviors (experimental > control

group) is presented just prior to the Methods section. Limitations of existing

research and a gap in scientific knowledge about the study topic (lack of scientific

study of the effects of interventions) are clearly articulated in the introduction to

the article and provide an adequate foundation/rationale for the study.

The clinical problem and study objectives are clearly presented in the

abstract and text of the article. A specific research hypothesis about self-reported

safety behaviors (experimental > control group) is presented just prior to the

Methods section. Limitations of existing research and a gap in scientific

knowledge about the study topic (lack of scientific study of the effects of

interventions) are clearly articulated in the introduction to the article and provide

an adequate foundation/rationale for the study.

A strength of this article is the incorporation of theoretical perspectives

from the domestic violence literature (Walker’s cycle of violence and Curnow’s
open window phase), which are used to inform the sampling and approach

(abused women seeking a civil protection order who are hypothesized to be in

phases when they are relatively most receptive to intervention) and the timing of

the intervention (within the window of openness/most receptivity to the

intervention).

This study used a true experimental study in which women were randomly

assigned to control versus experimental group conditions. The independent

variable is the exposure status to the intervention (exposed versus not exposed

to the intervention), and this is clearly articulated in the text of the article. A pre-

test/post-test design with repeated measures was used, in which baseline data

were gathered from all women prior to implementation of the intervention in the

experimental group. The intervention (six follow-up phone calls) was carried out

in the experimental group between the baseline data collection and 8 weeks

following the enrollment into the study. Two follow-up observations were made at

3 and 6 months following entry into the study. This study design is strong for

detecting the causal effects of an intervention, which is consistent with the aim of

the study to evaluate an intervention designed to increase safety-seeking

behaviors of women being abused by intimate partners.

The sampling design for this study appears to have been well planned,

including the calculation of a power analysis based on projected effect sizes and

study attrition rates. The study setting on (maternal health care services as

perceived by the clinics of the well family midwife clinics in Davao City) was well

matched to the sample the researchers sought to obtain (services on obtain

with a distressed, in-transition population, as is the high study retention rate in

both groups (>97%).

A very good level of detail is provided about the data collection procedures

and measures used in this study, including the scoring of applicable safety

behaviors. One issue that is not fully addressed by the authors is how changes in

women’s life situations may have affected the applicable safety behaviors over

time in this study. The authors did explore the possible effects of a significant

difference in mean age of the experimental and control groups but found no

systematic effects of the age difference; however, other factors such as

experiences of violence could have played a larger role in the impact well family

clinics in Davao City.

The data analysis plan appears generally appropriate, with the exception

of the relative lack of control for confounding variables occurring at the time of

the intervention. To compare the experimental and control groups on descriptive

variables, t-tests (tests of group mean differences) and chi-square analyses

(tests of differences in proportions between groups) were used in the applicable

contexts. Repeated measures analysis of covariance (RM ANCOVA) was used

to examine over-time group effects in self-reports of safety behaviors, and logistic

regression analyses were used to explore group differences in the safety

behaviors that were applicable to >90% of the women. Type I error inflation was

controlled via the Bonferroni method, and a trend analysis was used to assess
the form of the pattern of uptake of safety behaviors across the six intervention

phone calls in the experimental group.

The results are generally consistent with the hypothesis of over-time

improvement in uptake of safety behaviors being more pronounced in the

experimental group compared to the control group. This is consistent with the

hypothesis that the intervention would produce improved outcomes for the

experimental group (received telephone intervention) relative to the control group

(received standard care). However, a careful inspection of the over-time results

for both groups in Table 2 shows that the control group also had an increase in

some of the safety behaviors over time. This could have represented a “cueing”

effect of the data collection sessions in the control group. In addition, there are a

variety of competing hypotheses for the observed effects, including the women’s

ongoing life experiences, living conditions, and other services received, to name

a few variables that were not modeled/controlled for in this study.

In this study, it is also important to note the distinction between self-

reported behaviors versus observational measures of the behaviors that are

reported. For at least some of the behaviors, particularly those that may have

been most challenging to implement, it is possible that maternal in the

experimental group may have responded as they expected that the researchers

would want them to respond (a social desirability bias). Given the high study

recruitment and retention rates, the sample likely reflects a well-motivated

sample for study participation, which may also be associated with an increased

likelihood of social desirability bias in self-report ratings. In addition, future

time, not only for the average length of phone interviews, but also for the

time/resources used to retain midwife in the study, such as contacting the

participants via additional approaches such as “field community tracking.”

The overall presentation and clarity of this article are excellent.