The PartoMa Project: Assisting birth attendants to save lives in Tanzania
Since 2014, the PartoMa project has developed and implemented simple and locally achievable clinical guidelines and associated training. We aim to assist birth attendants in busy low-resource maternity units in delivering best possible safe and respectful care at birth.
Our finalized 4-years study in Zanzibar’s tertiary hospital from 2014-2018 revealed how simple,locally-tailored guidelines and training could assist birth attendants in delivering more timely and safe care to women giving birth. The results were encouraging, and concurrently survival during birth improved significantly.
In 2019, the PartoMa team began a new 5-year research project in Tanzania. The project aims to investigate whether the PartoMa pilot intervention from Zanzibar can be modified and scaled to other low-resource maternity units.
Watch this 7-minutes video of the PartoMa intervention in action!
Globally, 300,000 women and 5 million children die each year in relation to childbirth. Most would have survived with proper care during birth.
Clinical guidelines have been developed to improve maternity care in low-resource settings, however these guidelines are often incompatible with the contextual realities. Maternity units in low-resource settings often deal with limited capacity, high turnover of staff, and an overwhelming ratio of labouring women per birth attendant. These clinical realities make it practically impossible to adhere to international clinical guidelines. For example, spending ten minutes half-hourly with each labouring woman counting foetal heart rate and contractions is mathematically impossible when simultaneously caring for three or more women.
The disparity between low resource realities and international clinical guidelines highlights the importance of research on effective development, implementation, and upscaling of achievable clinical guidelines for low-resource settings.
The PartoMa project’s focus on generating evidence-based and respectful childbirth care is a key priority to reach the Sustainable Development Goals – particularly on birth-related survival and gender equality, but also more broadly in regards to health system strengthening, societal development and the reduction of poverty.
This section concerns our current research activities. For more information on our finalized study at Zanzibar’s tertiary hospital, please see the dropdown menu below.
Overall research aim:
To examine whether the PartoMa pilot intervention approach of tailoring clinical guidance and training to a specific hospital context, can be replicated at scale to improve maternal and perinatal health, and whether the process can serve as pre-service training of health students and as a model for other areas of health care.
I. To assess effects of a context-modified PartoMa intervention on birth attendants’ knowledge, skills and quality of care, and perinatal outcomes in PartoMa naïve maternity units.
II. To co-create and assess the effects of a pre-service PartoMa-based curriculum on health students’ in-service ability to deliver best possible care at birth.
III. To study mechanisms that strengthen or limit birth attendants’ ability to deliver best possible care at birth, including opportunities and barriers in co-creation, implementation and upscaling of the PartoMa intervention.
IV. Based on the experiences from study objectives I-III, to analyse opportunities and barriers in co-creating, implementing and upscaling clinical guidance and training, and develop a toolkit for this.
V. To strengthen research capacity in Tanzania regarding maternal health and the methodologies applied.
Overall principal investigator (PI):
- Dan Wolf Meyrowitsch, MSc, PhD, Associate Professor in Epidemiology, University of Copenhagen
- Nanna Maaløe, MD, PhD, Post Doc, University of Copenhagen
National PI, Tanzania:
- Hussein Lesio Kidanto, MD, MMed ObGyn, PhD, Professor, Associate Dean, Aga Khan University, Dar es Salaam Campus
National Co-PI, Tanzania:
- Natasha Housseine, MD, PhD, Post Doc, Aga Khan University, Dar es Salaam Campus
Core research team:
- Jane Brandt Sørensen, MA, PhD, Assistant Professor, University of Copenhagen
- Columba Kokusiima Mbekenga, MPh, PhD, Aga Khan University Dar es Salaam
- Thomas van den Akker, MD, PhD, Professor, Vrije Universiteit Amsterdam
- Andreas Kryger Jensen, MSc, PhD, Associate Professor, University of Copenhagen
- Morten Skovdal, MSc, PhD, Associate Professor, University of Copenhagen
- Britt Pinkowski Tersbøl, MA, PhD, Associate Professor, University of Copenhagen
- Jos van Roosmalen, MD, PhD, Professor, Vrije Universiteit Amsterdam
- Ib Christian Bygbjerg, MD, DMSc, Professor, University of Copenhagen
- Tarek Meguid, MD, MPhil, MSc, Village Health Works Burundi
- Brenda Sequiara DMello, MD, PhD student, Aga Khan University Dar es Salaam / University of Copenhagen
- Monica Lauridsen Kujabi, MD, PhD student, University of Copenhagen
- Thomas John, MD, PhD student, Aga Khan University Dar es Salaam / University of Copenhagen
- Haika Osaki, MPh, PhD student, Aga Khan University Dar es Salaam / University of Copenhagen
- Rashid Saleh Khamis, MD, PhD student, University of Copenhagen
- Josephine Obel, MD, MIH, University of Copenhagen and Hvidovre University Hospital
Study advisory board:
- Dr Ahmed Makhani, Assistant Director of RMNCH, Tanzania Ministry of health
- Dr. Jamala A. Taib, Director General, Zanzibar Ministry of Health
- Prof. Lynn Freedman, Columbia University, United States
- Prof. Marian Knight, University of Oxford, UK
- Assistant Professor, Sangeeta Mookherji, Washington University
The PartoMa study in Zanzibar from 2014-2018 forms the pilot study for ongoing PartoMa research. The study was a collaboration between University of Copenhagen and Zanzibar’s tertiary Mnazi Mmoja Hospital, led by Nanna Maaløe as primary investigator.
During the study years, the research team and birth attendants at Mnazi Mmoja Hospital worked together to develop and implement a pocket booklet with simple and locally achievable clinical guidance for safe and respectful care at birth. The initial version was completed in 2015 and has since been further adjusted to match the needs expressed by staff and the resource-constrained reality. Quarterly, the birth attendants were offered training in the use of the booklet in 3-hour case-based seminars. On average 60-70% of the staff from the maternity unit participated together with staff from other Zanzibari maternity units.
One year after implementation, the study found multiple improvements in quality of care, and a concurrent 33 % decrease of stillbirths and a 46% decrease in newborns with immediate poor state of health compared to baseline.
In June 2018, Zanzibars Ministry of Health officially took over the up-scale and continuous support of the PartoMa intervention in Zanzibar. The seminars are now being held every three months in both of Zanzibar’s main islands, with financial support from UNFPA.
The current version of PartoMa clinical guidelines and training materials are available in the dropdown menu labeled “PartoMa guidelines and training material”.
Primary investigator: Nanna Maaløe
Research advisors: Ib Christian Bygbjerg, Jos van Roosmalen, Tarek Meguid, Britt Pinkowski Tersbøl and Birgitte Bruun Nielsen.
Research assistants: Natasha Housseine, Rashid Saleh Khamis, Ali Gharib Mohamed, Mbweni Makame Ali, Said Mzee Said, Camilla Byskou Andersen and Camilla Thomsen.
Sørensen JB, Housseine N, Maaløe N, Bygbjerg IC , Tersbøl BP and Konradsen F. 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, Global Health Action vol. 15, 2022, issue 1
Maaløe N, Housseine N, Sørensen JB, Obel J, DMello BS and Kujabi ML. 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), Global Health Action vol. 15, 2022, issue 1
Maaløe N, van Roosmalen J, Dmello BS, Kwast B, van den Akker T, Housseine N, Kujabi ML, Meguid T, Kidanto H. WHO next-generation partograph: revolutionary steps towards individualised labour care?, BJOG 2021
Maaløe N, Marie A, Ørtved R, Sørensen JB, Dmello BS, van ven Akker T, Kujabi ML, Kidanto HL, Meguid T, Bygbjerg IC, van Roosmalen J, Meyrowitsch DW, Housseine N. The injustice of unfit clinical practice guidelines in low-resource realities. Lancet Global Health 2021
Sequeira Dmello B, Sellah Z, Magembe G, Housseine N, Maaløe N, Van Den Akker T, Meyrowitsch DW, Mushi T, Masweko M, Jidayi D, van Roosmalen J, Kidanto HL.Learning from changes concurrent with implementing a complex and dynamic intervention to improve urban maternal and perinatal health in Dar es Salaam, Tanzania, 2011-2019. BMJ Global Health 2020
Housseine N, Punt MC, Mohamed AG, Said SM, Maaløe N, Zuithoff NP, Meguid T, Franx A, Grobbee DE, Browne JL, Rijken MJ. Quality of intrapartum care: direct observations in a low-resource tertiary hospital. Reprod Health 2020.
Dmello BS, Housseine N, van den Akker T, van Roosmalen J, Maaløe N. Impact of COVID-19 on maternal and child health. Lancet Global Health 2020.
Housseine N, Punt MC, Browne JL, Van J, Maaløe N, Meguid T, Theron GB, Franx A, Grobbee DE, Visser GHA, Rijken MJ. Delphi consensus statement on intrapartum fetal monitoring in resource settings. Int J Gynaecol Obstet. 2019. 146(1):8-16.
Maaløe N, Meguid T, Housseine N, Tersbøl BP, Nielsen KK, Bygbjerg IC, van Roosmalen J. Local adaption of intrapartum clinical guidelines, United Republic of Tanzania. Bull World Health Organ 2019; 97:365–370.
Housseine N, Punt MC, Browne JL, Meguid T, Klipstein-Grobusch K, Kwast BE, Franx A, Grobbee DE, Rijken MJ. Strategies for intrapartum foetal surveillance in low- and middle-income countries: A systematic review. PLoS One 2018; 13: e0206295.
Maaløe N, Andersen CB, Housseine N, Meguid T, Bygbjerg IC, van Roosmalen JJM. Effect of locally-tailored clinical guidelines on intrapartum management of severe hypertensive disorders at Zanzibar’s tertiary hospital (The PartoMa study). Int J Gynecol Obstet 2018. DOI:10.1002/ijgo.12692.
Maaløe N, Housseine N, Meguid T, Nielsen BB, Jensen AKG, Khamis RS, et al. 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(2):235–45.
Maaløe N, Housseine N, van Roosmalen J, Bygbjerg IC, Tersbøl BP, Khamis RS, et al. Labour management guidelines for a Tanzanian referral hospital: The participatory development process and birth attendants’ perceptions. BMC Pregnancy Childbirth. 2017;17(175).
Maaløe N, Housseine N, Bygbjerg IC, Meguid T, Khamis RS, Mohamed AG, et al. 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).
WHO guidelines are unattainable in poor countries, Videnskab.dk / University of Copenhagen, October 2021
WHO-guidelines er uopnåelige i fattige lande, Videnskab.dk, October 2021
Dyster fremskrivning: Flere børn vil dø af coronarestriktioner end det totale antal corona-døde lige nu, Videnskab.dk, august 2020
Hvad skal der til for at redde liv på en afrikansk fødegang? Det begynder med en læge, der undrer sig – og en simpel idé, Zetland, October 2019
Fødselslæge vender dyster statistik: »Hver morgen lå der et eller flere døde børn svøbt i deres mødres tørklæder«, Article and podcast in the Danish Medical Bulletin, October 2019
The PartoMa study and the dangerous coexistence of ‘too much too soon care’ and ‘too little too late care’, Podcast (in Danish) on Stetoskopet, September 2019
In arme landen loont het om richtlijnen realistisch aan te passen, Medisch contact - a weekly magazine for medical doctors in the Netherlands, May 2019
Tanzania redder børns liv i samarbejde med dansk læge, The World’s Best News, February 2019
PartoMa seminars – Closing the gap between clinical guidelines and reality, Anthropologist and filmmaker Lara Meguid, March 2018
Video abstract - Effect of locally tailored labour management guidelines on intrahospital stillbirths and birth asphyxia, British Journal of Obstetrics and Gynaecology, September 2017
The current PartoMa research is supported by the Danida Fellowship Centre, Ministry of Foreign Affairs of Denmark. Additional funding for embedded sub-studies has been granted by the Laerdal Foundation, University of Copenhagen, UNICEF and Dr. Thorvald Madsens Legat.
The finalized PartoMa study at Zanzibar’s tertiary hospital was supported by the Lundbeck Foundation, the Laerdal Foundation, the Augustinus Foundation, University of Copenhagen and ‘Aase og Ejnar Danielsens Fond’.
We are furthermore grateful for support to the ongoing PartoMa intervention in Zanzibar from Health Improvement Project Zanzibar (HIPZ), UNFPA Zanzibar, the Kanga Maternity Trust and Soroptimist International, the Netherlands.
The 2018 updated guidelines and training materials from Zanzibar’s tertiary hospital are here available as PDF:
For inquiries regarding the PartoMa research, please contact:
National PI in Tanzania, Professor and Associate Dean
Aga Khan University, Dar es Salaam Campus
National Co-PI in Tanzania, MD, PhD
Aga Khan University, Dar es Salaam Campus
News from The PartoMa Project
Our protocol papers are now published2022.04.12
Nordic Global Health Talk about the PartoMa project: The missing link between clinical guidelines and reality2022.03.04
Co-creation finalized in Dar es Salaam: The PartoMa Pocket Guide for Safe and Respectful Childbirth Care 20222022.01.04
New publication in BJOG: Is the WHO next-generation partograph revolutionary steps towards individualised labour care?2021.09.14
All identifiable people appearing on this website in photos or text have given their oral consent.