Labour management guidelines for a Tanzanian referral hospital: The participatory development process and birth attendants’ perceptions

Abstract

BackgroundWhile 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.MethodsPart 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.ResultsPart 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.ConclusionsThe 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 registrationThis paper describes the intervention of the PartoMa trial, which is registered on ClinicalTrials.org (NCT02318420, 4th November 2014).Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-017-1360-2) contains supplementary material, which is available to authorized users.

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)

“…Acknowledging contextual constraints, a participatory and internationally peer‐reviewed guidelines development process was conducted to formulate partograph‐associated, locally achievable, and easy‐to‐use clinical practice guidelines for common intrapartum care. This resulted in the PartoMa guidelines booklet, which was launched together with reoccurring quarterly seminars . We here present an analysis of the associated effect on rates of stillbirth and birth asphyxia, through behavioural changes in clinical practice.…”

Delphi consensus statement on intrapartum fetal monitoring in low‐resource settings

“…A key methodologic finding of the study may be how clearly difficult it is for experts to deviate from international guidelines or common practice (culture and tradition) in order to reach reality. Yet, the actuality of the gap in human resources in many labor wards in LMICs implies that such guidelines are physically unachievable . If one SBA simultaneously attends three laboring women with FHR according to the recommended 30‐minutes interval, there would be no time for any other activities.…”

“…Respectful patient care during labor requires high frequency and sufficient communication about fetal monitoring. Until human resource needs are met and rigorous evidence is available, respectful guidance for overworked health providers requires an achievable frequency of assessments for routine intrapartum care . Therefore, it should be explored how future Delphi studies can better include the “reality‐based evidence,” including task prioritization, in the decision‐making for best possible management in resource‐constrained settings.…”

“…A systematic review was conducted to identify the different fetal monitoring techniques available in LMICs (registered in PROSPERO: CRD42016038679). Five electronic databases (Pubmed/MEDLINE, Cochrane Library, EMBASE, POPLINE, and Global Health Library) were searched to identify studies with a title or abstract containing MeSH/Emtree terms related to “intrapartum,” “fetal surveillance,” “outcomes,” and “low‐ and middle‐income countries.” In addition, international, national, and local guidelines were searched for recommendations on the frequency and duration of FHR and contraction monitoring (Table ) . The definitions used to guide participants are given in Box 1, and the outcomes are listed in Supplementary Tables .…”

“…A substantial mismatch exists between international guidelines and what is locally achievable. In high‐volume low‐resource settings, the ratio of skilled birth attendants (SBAs) to deliveries often exceeds one to three . The challenges in labor monitoring are well known, yet current recommendations do not take into consideration the limited (human) resources in settings where one‐to‐one care and/or CTG are not feasible.…”