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Sørensen JB, Housseine N, Maaløe N, Bygbjerg IC, Pinkowski Tersbøl B, Konradsen F, Sequeira Dmello B, van Den Akker T, van Roosmalen J, Mookherji S, Siaity E, Osaki H, Khamis RS, Kujabi ML, John TW, Wolf Meyrowitsch D, Mbekenga C, Skovdal M, L Kidanto H. Scaling up Locally Adapted Clinical Practice Guidelines for Improving Childbirth Care in Tanzania: A Protocol for Programme Theory and Qualitative Methods of the PartoMa Scale-up Study. Glob Health Action 2022; 15:2034136. [PMID: 35311627 PMCID: PMC8942528 DOI: 10.1080/16549716.2022.2034136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Effective, low-cost clinical interventions to improve facility-based care during childbirth are critical to reduce maternal and perinatal mortality and morbidity in low-resource settings. While health interventions for low- and lower-middle-income countries are often developed and implemented top-down, needs and circumstances vary greatly across locations. Our pilot study in Zanzibar improved care through locally co-created intrapartum clinical practice guidelines (CPGs) and associated training (the PartoMa intervention). This intervention was context-tailored with health-care providers in Zanzibar and now scaled up within five maternity units in Dar es Salaam, Tanzania. This PartoMa Scale-up Study thereby provides an opportunity to explore the co-creation process and modification of the intervention in another context and how scale-up might be successfully achieved. The overall protocol is presented in a separate paper. The aim of the present paper is to account for the Scale-up Study’s programme theory and qualitative methodology. We introduce social practice theory and argue for its value within the programme theory and towards qualitative explorations of shifts in clinical practice. The theory recognizes that the practice we aim to strengthen – safe and respectful clinical childbirth care – is not practiced in a vacuum but embedded within a socio-material context and intertwined with other practices. Methodologically, the project draws on ethnographic and participatory methodologies to explore current childbirth care practices. In line with our programme theory, explorations will focus on meanings of childbirth care, material tools and competencies that are being drawn upon, birth attendants’ motivations and relational contexts, as well as other everyday practices of childbirth care. Insights generated from this study will not only elucidate active ingredients that make the PartoMa intervention feasible (or not) but develop the knowledge foundation for scaling-up and replicability of future interventions based on the principles of co-creation and contextualisation.
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Affiliation(s)
- Jane Brandt Sørensen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Natasha Housseine
- Medical College, Aga Khan University, Medical College East Africa, Dar Es Salaam Campus Tanzania
| | - Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of Obstetrics and Gynaecology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Ib Christian Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Britt Pinkowski Tersbøl
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Flemming Konradsen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Brenda Sequeira Dmello
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Medical College, Aga Khan University, Medical College East Africa, Dar Es Salaam Campus Tanzania.,Comprehensive Community Based Rehabilitation in Tanzania Tanzania
| | - Thomas van Den Akker
- Athena Institute is the department, Athena Institute, VU University, Amsterdam, The Netherlands.,Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jos van Roosmalen
- Athena Institute is the department, Athena Institute, VU University, Amsterdam, The Netherlands.,Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Sangeeta Mookherji
- Department of Global Health, George Washington University Milken Institute School of Public Health, Washington DC, US
| | - Eunice Siaity
- Medical college, Aga Khan University, School of Nursing and Midwifery East Africa, Dar Es Salaam Campus Tanzania
| | - Haika Osaki
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Medical College, Aga Khan University, Medical College East Africa, Dar Es Salaam Campus Tanzania
| | - Rashid Saleh Khamis
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Monica Lauridsen Kujabi
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Wiswa John
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Medical College, Aga Khan University, Medical College East Africa, Dar Es Salaam Campus Tanzania
| | - Dan Wolf Meyrowitsch
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Columba Mbekenga
- Medical college, Aga Khan University, School of Nursing and Midwifery East Africa, Dar Es Salaam Campus Tanzania
| | - Morten Skovdal
- Section for Health Services Research, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Hussein L Kidanto
- Medical College, Aga Khan University, Medical College East Africa, Dar Es Salaam Campus Tanzania
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Maaløe N, Housseine N, Sørensen JB, Obel J, Sequeira DMello B, Kujabi ML, Osaki H, John TW, Khamis RS, Muniro ZSS, Nkungu DJ, Pinkowski Tersbøl B, Konradsen F, Mookherji S, Mbekenga C, Meguid T, van Roosmalen J, Bygbjerg IC, van den Akker T, Jensen AK, Skovdal M, L. Kidanto H, Wolf Meyrowitsch D. Scaling up context-tailored clinical guidelines and training to improve childbirth care in urban, low-resource maternity units in Tanzania: A protocol for a stepped-wedged cluster randomized trial with embedded qualitative and economic analyses (The PartoMa Scale-Up Study). Glob Health Action 2022; 15:2034135. [PMID: 35410590 PMCID: PMC9009913 DOI: 10.1080/16549716.2022.2034135] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 01/21/2022] [Indexed: 11/04/2022] Open
Abstract
While facility births are increasing in many low-resource settings, quality of care often does not follow suit; maternal and perinatal mortality and morbidity remain unacceptably high. Therefore, realistic, context-tailored clinical support is crucially needed to assist birth attendants in resource-constrained realities to provide best possible evidence-based and respectful care. Our pilot study in Zanzibar suggested that co-created clinical practice guidelines (CPGs) and low-dose, high-frequency training (PartoMa intervention) were associated with improved childbirth care and survival. We now aim to modify, implement, and evaluate this multi-faceted intervention in five high-volume, urban maternity units in Dar es Salaam, Tanzania (approximately 60,000 births annually). This PartoMa Scale-up Study will include four main steps: I. Mixed-methods situational analysis exploring factors affecting care; II. Co-created contextual modifications to the pilot CPGs and training, based on step I; III. Implementation and evaluation of the modified intervention; IV. Development of a framework for co-creation of context-specific CPGs and training, of relevance in comparable fields. The implementation and evaluation design is a theory-based, stepped-wedged cluster-randomised trial with embedded qualitative and economic assessments. Women in active labour and their offspring will be followed until discharge to assess provided and experienced care, intra-hospital perinatal deaths, Apgar scores, and caesarean sections that could potentially be avoided. Birth attendants' perceptions, intervention use and possible associated learning will be analysed. Moreover, as further detailed in the accompanying article, a qualitative in-depth investigation will explore behavioural, biomedical, and structural elements that might interact with non-linear and multiplying effects to shape health providers' clinical practices. Finally, the incremental cost-effectiveness of co-creating and implementing the PartoMa intervention is calculated. Such real-world scale-up of context-tailored CPGs and training within an existing health system may enable a comprehensive understanding of how impact is achieved or not, and how it may be translated between contexts and sustained.Trial registration number: NCT04685668.
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Affiliation(s)
- Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Obstetrics and Gynaecology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Natasha Housseine
- Medical College East Africa, Aga Khan University, Dar Es Salaam, Tanzania
| | - Jane Brandt Sørensen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Josephine Obel
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Brenda Sequeira DMello
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Medical College East Africa, Aga Khan University, Dar Es Salaam, Tanzania
- Comprehensive Community Based Rehabilitation in Tanzania, Dar Es Salaam, Tanzania
| | - Monica Lauridsen Kujabi
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Haika Osaki
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Medical College East Africa, Aga Khan University, Dar Es Salaam, Tanzania
| | - Thomas Wiswa John
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Medical College East Africa, Aga Khan University, Dar Es Salaam, Tanzania
| | - Rashid Saleh Khamis
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Medical College East Africa, Aga Khan University, Dar Es Salaam, Tanzania
| | | | | | - Britt Pinkowski Tersbøl
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Flemming Konradsen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Sangeeta Mookherji
- Department of Global Health, George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - Columba Mbekenga
- School of Nursing and Midwifery East Africa, Aga Khan University, Dar Es Salaam, Tanzania
| | | | - Jos van Roosmalen
- Athena Institute, VU University, Amsterdam, Netherlands
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, Netherlands
| | - Ib Christian Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Thomas van den Akker
- Athena Institute, VU University, Amsterdam, Netherlands
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, Netherlands
| | - Andreas Kryger Jensen
- Section for Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Morten Skovdal
- Section for Health Services Research, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Hussein L. Kidanto
- Medical College East Africa, Aga Khan University, Dar Es Salaam, Tanzania
| | - Dan Wolf Meyrowitsch
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Herklots T, van Acht L, Khamis RS, Meguid T, Franx A, Jacod B. Validity of WHO's near-miss approach in a high maternal mortality setting. PLoS One 2019; 14:e0217135. [PMID: 31095635 PMCID: PMC6522045 DOI: 10.1371/journal.pone.0217135] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 05/06/2019] [Indexed: 11/19/2022] Open
Abstract
Objective To evaluate the validity of WHO’s near-miss approach in a low-resource, high maternal mortality setting. Design Prospective cohort study. Setting Mnazi Mmoja Hospital, the main referral hospital of Zanzibar, Tanzania, from 1 April 2017 until 31 December 2018. Population All women, pregnant or until 42 days after the end of pregnancy, admitted at Mnazi Mmoja Hospital, the tertiary referral hospital in Zanzibar. Methods Cases of maternal morbidity and mortality were evaluated according to WHO’s near-miss approach. The approach’s performance was determined by calculating its accuracy through sensitivity, specificity and positive and negative likelihood ratios. The approach’s validity was assessed with Pearson’s correlation coefficient between the number of organ dysfunction markers and risk of mortality. Main outcomes measures Correlation between number of organ dysfunction markers and risk of mortality, sensitivity and specificity. Results 26,842 women were included. There were 335 with a severe maternal outcome: 256 maternal near-miss cases and 79 maternal deaths. No signs of organ dysfunction were documented in only 4 of the 79 cases of maternal death. The number of organ dysfunction markers was highly correlated to the risk of mortality with Pearson’s correlation coefficient of 0.89. Conclusions WHO’s near-miss approach adequately identifies women at high risk of maternal mortality in Zanzibar’s referral hospital. There is a strong correlation between the number of markers of organ dysfunction and mortality risk.
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Affiliation(s)
- Tanneke Herklots
- Division of Woman and Baby, University Medical Centre Utrecht, Utrecht, The Netherlands
- * E-mail:
| | - Lieke van Acht
- Division of Woman and Baby, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Rashid Saleh Khamis
- Department of Obstetrics and Gynaecology, Mnazi Mmoja Hospital, Stone Town, Zanzibar, United Republic of Tanzania
| | - Tarek Meguid
- Department of Obstetrics and Gynaecology, Mnazi Mmoja Hospital, Stone Town, Zanzibar, United Republic of Tanzania
- School of Health & Medical Sciences, State University of Zanzibar (SUZA), Zanzibar, United Republic of Tanzania
| | - Arie Franx
- Division of Woman and Baby, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Benoit Jacod
- Department Obstetrics & Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Maaløe N, Housseine N, Meguid T, Nielsen BB, Jensen AKG, Khamis RS, Mohamed AG, Ali MM, Said SM, van Roosmalen J, Bygbjerg IC. Authors' reply re: Effect of locally tailored labour management guidelines on intrahospital stillbirths and birth asphyxia at the referral hospital of Zanzibar: A quasi-experimental pre-post-study (The PartoMa study). BJOG 2017; 125:394-395. [PMID: 29266853 DOI: 10.1111/1471-0528.14962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Natasha Housseine
- Mnazi Mmoja Hospital, Zanzibar, Tanzania.,Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Tarek Meguid
- Mnazi Mmoja Hospital, Zanzibar, Tanzania.,School of Health & Medical Sciences, State University of Zanzibar, Zanzibar, Tanzania
| | - Birgitte Bruun Nielsen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | | | | | | | - Jos van Roosmalen
- Athena Institute, VU University of Amsterdam, Amsterdam, the Netherlands
| | - Ib Christian Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Maaløe N, Housseine N, Meguid T, Nielsen BB, Jensen A, Khamis RS, Mohamed AG, Ali MM, Said SM, van Roosmalen J, Bygbjerg IC. Effect of locally tailored labour management guidelines on intrahospital stillbirths and birth asphyxia at the referral hospital of Zanzibar: a quasi-experimental pre-post study (The PartoMa study). BJOG 2017; 125:235-245. [PMID: 28892306 DOI: 10.1111/1471-0528.14933] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate effect of locally tailored labour management guidelines (PartoMa guidelines) on intrahospital stillbirths and birth asphyxia. DESIGN Quasi-experimental pre-post study investigating the causal pathway through changes in clinical practice. SETTING Tanzanian low-resource referral hospital, Mnazi Mmoja Hospital. POPULATION Facility deliveries during baseline (1 October 2014 until 31 January 2015) and the 9th to 12th intervention
month (1 October 2015 until 31 January 2016) [corrected]. METHODS Birth outcome was extracted from all cases of labouring women during baseline (n = 3690) and intervention months (n = 3087). Background characteristics and quality of care were assessed in quasi-randomly selected subgroups (n = 283 and n = 264, respectively). MAIN OUTCOME MEASURES Stillbirths and neonates with 5-minute Apgar score ≤5. RESULTS Stillbirth rate fell from 59 to 39 per 1000 total births (RR 0.66, 95% CI 0.53-0.82), and subanalyses suggest that this was primarily due to reduction in intrahospital stillbirths. Apgar scores between 1 and 5 fell from 52 to 28 per 1000 live births (RR 0.53, 95% CI 0.41-0.69). Median time from last fetal heart assessment till delivery (or fetal death diagnosis) fell from 120 minutes (IQR 60-240) to 74 minutes (IQR 30-130) (Mann-Whitney test for difference, P < 0.01). Oxytocin augmentation declined from 22% to 12% (RR 0.54, 95% CI 0.37-0.81) and timely use improved. CONCLUSION Although low human resources and substandard care remain major challenges, PartoMa guidelines were associated with improvements in care, leading to reductions in stillbirths and birth asphyxia. Findings furthermore emphasise the central role of improved fetal surveillance and restricted intrapartum oxytocin use in safety at birth. TWEETABLE ABSTRACT: #PartoMa guidelines aided in reducing stillbirths and birth asphyxia at a Tanzanian low-resource hospital PLAIN LANGUAGE SUMMARY: PartoMa guidelines help birth attendants in Tanzania to save lives Every year, 3 million babies die on the day of birth. The vast majority of these deaths occur in the poorest countries. If their mothers had received better care during birth, most babies would have survived. At Mnazi Mmoja Hospital, an East African referral hospital, the PartoMa study shows that use of locally developed guidelines helps birth attendants to deliver better quality of care, which has led to improved survival at birth. At the hospital studied, resources are scarce. Each birth attendant assists four to six birthing women simultaneously, and many have less than 1 year of professional experience. International guidelines are available, but they are often unachievable and seldom applied. The PartoMa guidelines were developed in close collaboration with the birth attendants and approved by seven international experts. The result is an 8-page pocket booklet providing locally achievable and simple decision support for care during birth. Use of the PartoMa guidelines began in February 2015. As the staff group frequently changes, quarterly seminars are conducted where birth attendants are welcomed after working hours to learn about the guidelines. The guidelines have been positively received, and seminar attendance remains high. Use of the PartoMa guidelines is associated with: A decrease by one-third in stillbirths (59 to 39 per 1000 total births) A nearly halving in the number of babies born in immediate poor medical condition (52 to 28 per 1000 live births) The results presented here derive from a comparison of births before using the PartoMa guidelines and during the 9th-12th month of use. Such a 'before-after' study cannot exclude the possibility of other causes of better survival at birth. However, the improved survival is consistent with improved care during birth, which is in line with the PartoMa guidelines.
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Affiliation(s)
- N Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - N Housseine
- Mnazi Mmoja Hospital, Zanzibar, Tanzania.,Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - T Meguid
- Mnazi Mmoja Hospital, Zanzibar, Tanzania.,School of Health & Medical Sciences, State University of Zanzibar, Zanzibar, Tanzania
| | - B B Nielsen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Akg Jensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - R S Khamis
- Mnazi Mmoja Hospital, Zanzibar, Tanzania
| | | | - M M Ali
- Mnazi Mmoja Hospital, Zanzibar, Tanzania
| | - S M Said
- Mnazi Mmoja Hospital, Zanzibar, Tanzania
| | - J van Roosmalen
- Athena Institute, VU University of Amsterdam, Amsterdam, the Netherlands
| | - I C Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Maaløe N, Housseine N, van Roosmalen J, Bygbjerg IC, Tersbøl BP, Khamis RS, Nielsen BB, Meguid T. Labour management guidelines for a Tanzanian referral hospital: The participatory development process and birth attendants' perceptions. BMC Pregnancy Childbirth 2017; 17:175. [PMID: 28592237 PMCID: PMC5463375 DOI: 10.1186/s12884-017-1360-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 05/26/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While international guidelines for intrapartum care appear to have increased rapidly since 2000, literature suggests that it has only in few instances been matched with reviews of local modifications, use, and impact at the targeted low resource facilities. At a Tanzanian referral hospital, this paper describes the development process of locally achievable, partograph-associated, and peer-reviewed labour management guidelines, and it presents an assessment of professional birth attendants' perceptions. METHODS Part 1: Modification of evidence-based international guidelines through repeated evaluation cycles by local staff and seven external specialists in midwifery/obstetrics. Part 2: Questionnaire evaluation 12 months post-implementation of perceptions and use among professional birth attendants. RESULTS Part 1: After the development process, including three rounds of evaluation by staff and two external peer-review cycles, there were no major concerns with the guidelines internally nor externally. Thereby, international recommendations were condensed to the eight-paged 'PartoMa guidelines ©'. This pocket booklet includes routine assessments, supportive care, and management of common abnormalities in foetal heart rate, labour progress, and maternal condition. It uses colour codes indicating urgency. Compared to international guidelines, reductions were made in frequency of assessments, information load, and ambiguity. Part 2: Response rate of 84% (n = 84). The majority of staff (93%) agreed that the guidelines helped to improve care. They found the guidelines achievable (89%), and the graphics worked well (90%). Doctors more often than nurse-midwives (89% versus 74%) responded to use the guidelines daily. CONCLUSIONS The PartoMa guidelines ensure readily available, locally achievable, and acceptable support for intrapartum surveillance, triage, and management. This is a crucial example of adapting evidence-based international recommendations to local reality. TRIAL REGISTRATION This paper describes the intervention of the PartoMa trial, which is registered on ClinicalTrials.org ( NCT02318420 , 4th November 2014).
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Affiliation(s)
- Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353 Copenhagen K, Denmark
| | - Natasha Housseine
- Department of Obstetrics and Gynaecology, Mnazi Mmoja Hospital, Zanzibar, Tanzania
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands
| | - Jos van Roosmalen
- Athena Institute, VU University of Amsterdam, De Boelelaan 1105, 1081 HV Amsterdam, the Netherlands
| | - Ib Christian Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353 Copenhagen K, Denmark
| | - Britt Pinkowski Tersbøl
- Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353 Copenhagen K, Denmark
| | - Rashid Saleh Khamis
- Department of Obstetrics and Gynaecology, Mnazi Mmoja Hospital, Zanzibar, Tanzania
| | - Birgitte Bruun Nielsen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 København Ø, Denmark
| | - Tarek Meguid
- Department of Obstetrics and Gynaecology, Mnazi Mmoja Hospital, Zanzibar, Tanzania
- School of Health & Medical Sciences, State University of Zanzibar, P.O.Box:146, Zanzibar, Tanzania
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Maaløe N, Housseine N, Bygbjerg IC, Meguid T, Khamis RS, Mohamed AG, Nielsen BB, van Roosmalen J. Stillbirths and quality of care during labour at the low resource referral hospital of Zanzibar: a case-control study. BMC Pregnancy Childbirth 2016; 16:351. [PMID: 27832753 PMCID: PMC5103376 DOI: 10.1186/s12884-016-1142-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 11/01/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND To study determinants of stillbirths as indicators of quality of care during labour in an East African low resource referral hospital. METHODS A criterion-based unmatched unblinded case-control study of singleton stillbirths with birthweight ≥2000 g (n = 139), compared to controls with birthweight ≥2000 g and Apgar score ≥7 (n = 249). RESULTS The overall facility-based stillbirth rate was 59 per 1000 total births, of which 25 % was not reported in the hospital's registers. The majority of singletons had birthweight ≥2000 g (n = 139; 79 %), and foetal heart rate was present on admission in 72 (52 %) of these (intra-hospital stillbirths). Overall, poor quality of care during labour was the prevailing determinant of 71 (99 %) intra-hospital stillbirths, and median time from last foetal heart assessment till diagnosis of foetal death or delivery was 210 min. (interquartile range: 75-315 min.). Of intra-hospital stillbirths, 26 (36 %) received oxytocin augmentation (23 % among controls; odds ratio (OR) 1.86, 95 % confidential interval (CI) 1.06-3.27); 15 (58 %) on doubtful indication where either labour progress was normal or less dangerous interventions could have been effective, e.g. rupture of membranes. Substandard management of prolonged labour frequently led to unnecessary caesarean sections. The caesarean section rate among all stillbirths was 26 % (11 % among controls; OR 2.94, 95 % CI 1.68-5.14), and vacuum extraction was hardly ever done. Of women experiencing stillbirth, 27 (19 %) had severe hypertensive disorders (4 % among controls; OR 5.76, 95 % CI 2.70-12.31), but 18 (67 %) of these did not receive antihypertensives. An additional 33 (24 %) did not have blood pressure recorded during active labour. When compared to controls, stillbirths were characterized by longer admissions during labour. However, substandard care was prevalent in both cases and controls and caused potential risks for the entire population. Notably, women with foetal death on admission were in the biggest danger of neglect. CONCLUSIONS Intrapartum management of women experiencing stillbirth was a simple yet strong indicator of quality of care. Substandard care led to perinatal as well as maternal risks, which furthermore were related to unnecessary complex, time consuming, and costly interventions. Improvement of obstetric care is warranted to end preventable birth-related deaths and disabilities. TRIAL REGISTRATION This is the baseline analysis of the PartoMa trial, which is registered on ClinicalTrials.org ( NCT02318420 , 4th November 2014).
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Affiliation(s)
- Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353 Copenhagen K, Denmark
| | - Natasha Housseine
- Mnazi Mmoja Hospital, Zanzibar, Tanzania
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ib Christian Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353 Copenhagen K, Denmark
| | - Tarek Meguid
- Mnazi Mmoja Hospital, Zanzibar, Tanzania
- School of Health & Medical Sciences, State University of Zanzibar, P.O.Box:146, Zanzibar, Tanzania
| | | | | | - Birgitte Bruun Nielsen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Jos van Roosmalen
- Athena Institute, VU University of Amsterdam, De Boelelaan 1105, 1081 HV Amsterdam, The Netherlands
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