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)

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 2014 until 31 January 2015). 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 livesEvery 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 b...

Effect of locally tailored clinical guidelines on intrapartum management of severe hypertensive disorders at Zanzibar's tertiary hospital (the PartoMa study)

“…The present findings show that, although care remained substandard, several improvements had occurred during the ninth to 12th invention months, such as progress in surveillance, a 37% increase in antihypertensive treatment, and a 44% reduction in risk of stillbirth. Taken together with previous studies, the findings suggest that the PartoMa intervention was an important determinant of improvements. This indicates how effective locally tailored clinical guidelines and associated quarterly, low‐dose training can be in a weak healthcare system with critical shortages in human resources.…”

“…Throughout the study, each birth attendant (nurse‐midwife or doctor) simultaneously cared for an average of 3–6 laboring women, and 30% were intern doctors conducting their initial 6‐week rotation. Turnover was high among staff in permanent positions: 25% of nurse‐midwives and 40% of doctors during the initial 6 months of the intervention were no longer working there after 1 year . As a result, most staff had limited experience with childbirth care.…”

“…) and one of five seminar cases concerned intrapartum care for women with sHDP. Detailed descriptions of guidelines development and the seminars are presented elsewhere …”

“…Structural changes at the study site that might potentially explain outcome changes (or lack of changes) after implementation of the PartoMa intervention were assessed quarterly and have been previously described . In brief, staff numbers, supply shortages, and available emergency obstetric and neonatal care signal functions were similar throughout the baseline and first intervention year, but there were 16% fewer deliveries during the ninth to 12th intervention months compared with baseline.…”

“…Only one birth attendant received formalized training externally. The department started conducting maternal death audits in August 2015, but the audit findings were first presented for staff after the 12th intervention month …”