Monitoring Severe Pre-Eclampsia and Eclampsia Treatment in Resource Poor Countries: Skilled Birth Attendant Perception of a New Treatment and Monitoring Chart (LIVKAN Chart)

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.

Section: Resultsmentioning

confidence: 99%

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

Maaløe

Housseine

Roosmalen

et al. 2017

“…Apart from delivery, correct drug dosages, IV Fluid type and volume administered being critical to outcome, improvement in labour monitoring using the partogram is also pivot in the management of all patients who were undelivered hence the general improvement in the re-audit [14-16]. Management of eclamptic patient must focus on three components namely: monitoring maternal clinical status and fetal wellbeing by using a simple and locally accepted tool (partograph), performing laboratory tests for vital maternal functions and providing appropriate obstetrical intervention [13,17].…”

Section: Discussionmentioning

confidence: 99%

Improved quality of management of eclampsia patients through criteria based audit at Muhimbili National Hospital, Dar es Salaam, Tanzania. Bridging the quality gap

Kidanto

Wangwe

Kilewo

et al. 2012

BackgroundCriteria-based audits (CBA) have been used to improve clinical management in developed countries, but have only recently been introduced in the developing world. This study discusses the use of a CBA to improve quality of care among eclampsia patients admitted at a University teaching hospital in Dar es Salaam Tanzania.ObjectiveThe prevalence of eclampsia in MNH is high (≈6%) with the majority of cases arriving after start of convulsions. In 2004–2005 the case-fatality rate in eclampsia was 5.1% of all pregnant women admitted for delivery (MNH obstetric data base). A criteria-based audit (CBA) was used to evaluate the quality of care for eclamptic mothers admitted at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania after implementation of recommendations of a previous audit.MethodsA CBA of eclampsia cases was conducted at MNH. Management practices were evaluated using evidence-based criteria for appropriate care. The Ministry of Health (MOH) guidelines, local management guidelines, the WHO manual supplemented by the WHO Reproductive Health Library, standard textbooks, the Cochrane database and reviews in peer reviewed journals were adopted. At the initial audit in 2006, 389 case notes were assessed and compared with the standards, gaps were identified, recommendations made followed by implementation. A re-audit of 88 cases was conducted in 2009 and compared with the initial audit.ResultsThere was significant improvement in quality of patient management and outcome between the initial and re-audit: Review of management plan by senior staff (76% vs. 99%; P=0.001), urine for albumin test (61% vs. 99%; P=0.001), proper use of partogram to monitor labour (75% vs. 95%; P=0.003), treatment with steroids for lung maturity (2.0% vs. 24%; P=0.001), Caesarean section within 2 hours of decision (33% vs. 61%; P=0.005), full blood count (28% vs. 93%; P=0.001), serum urea and creatinine (44% vs. 86%; P=0.001), liver enzymes (4.0% vs. 86%; P=0.001), and specialist review within 2 hours of admission (25% vs. 39%; P=0.018). However, there was no significant change in terms of delivery within 24 hours of admission (69% vs. 63%; P=0.33). There was significant reduction of maternal deaths (7.7% vs. 0%; P=0.001).ConclusionCBA is applicable in low resource setting and can help to improve quality of care in obstetrics including management of pre-eclampsia and eclampsia.

“…It was decided that the standards should include routine labour care as well as management of frequent complications of labour, related to FHR and foetal distress, labour progression by dilatation and descent, and maternal vital signs with specific focus on severe hypertensive disorders and fever. Selected criteria were adapted from the Active management of labour package, modified by WHO, and supplemented with other evidence-based guidelines [23–31]. Frequency of routine assessments was reduced to reflect local reality.…”

Section: Methodsmentioning

confidence: 99%

Stillbirths and quality of care during labour at the low resource referral hospital of Zanzibar: a case-control study

Maaløe

Housseine

Bygbjerg

et al. 2016

BackgroundTo study determinants of stillbirths as indicators of quality of care during labour in an East African low resource referral hospital.MethodsA 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).ResultsThe 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.ConclusionsIntrapartum 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 registrationThis is the baseline analysis 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/s12884-016-1142-2) contains supplementary material, which is available to authorized users.