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

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).

Keywords: Guidelines; Labour; PartoMa; Partograph; Quality of care; Tanzania.

Fig. 1

Systematic literature search: Labour and delivery guidelines for African low-income settings. A more detailed search description is available in Additional file 3

Fig. 2

The six-steps participatory and internationally peer-reviewed development process of the PartoMa guidelines. ** Major concerns: If the reviewer feared that a specific guideline or graphic presentation could be dangerously used or misunderstood in clinical work. Minor comments: Any additional ideas for changes, including the graphical presentation, typos, etc.

Fig. 3

The three parts of the PartoMa guidelines most appreciated by staff: (a) Management of abnormal foetal heart rate; (b) Management of poor progress in first stage of active labour (cervical dilatation ≥4 cm and regular painful contractions); (c) Management of hypertensive disorders. The graphics are based on the WHO partograph, and the star symbols (*) refer to recommendations further described on the page below in the guidelines. A full overview of the PartoMa guidelines is available in Additional file 2. ARM, artificial rupture of membranes; BP, blood pressure; bpm, beats per minute; CS, caesarean section; FHR, foetal heart rate; PV, vaginal examination; Temp, temperature. © 2015 The PartoMa Study, University of Copenhagen. All Rights Reserved

Fig. 4

Five-point Likert scale evaluation of health providers’ perceptions and use of the PartoMa guidelines 12 months after implementation. The respondents included 12 medical doctors and 23 nurse midwives in permanent positions at the Department of Obstetrics, as well as 49 intern doctors who had conducted their six-weeks obstetric rotation during the past ten months. Nurse-midviwes disagreed more often to question 2 (mean score 3.30), when compared to intern doctors (mean score 3.94) and doctors in permanent positions (mean score 4.50). Otherwise, no major differences were found between the groups. * Concerning questions 4 and 8, 1 (1%) and 2 (2%) health providers, respectively, did not respond