Enabling Best Possible Childbirth Care in Tanzania - The PartoMa Project
Since 2014, we have worked on developing and implementing simple and locally achievable clinical guidelines and associated training. We aim at assisting birth attendants at 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 revealed how simple and locally-tailored guidelines and training could assist birth attendants in delivering best possible safe and respectful care to women giving birth. The results were promising with improvements in quality of care and birth outcomes.
In April 2019, we commenced a 5-years research project in Tanzania, which aims to assess whether the PartoMa pilot intervention from Zanzibar can be modified and replicated at scale for improved health and survival at birth. We will furthermore assess whether the process can serve as pre-service training of health students and as a model for other areas of health care.
Globally, 300,000 women and 5 million children die each year in relation to childbirth. Most would have survived had they been given proper care.
Multiple clinical guidelines have been developed to improve maternity care in low-resource settings. However, they are often incompatible with the contextual realities. Maternity units in low-resource settings often deal with limited capacity, high turnover of staff and an unworkable ratio of labouring women per birth attendant. This often makes it impossible to adhere to international clinical guidelines and calls for research on effective development, implementation and upscaling of achievable clinical guidelines for such 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 in regards to societal development and poverty reduction. Also, the PartoMa project might serve as an example of context-tailored development and implementation of guidelines for other areas of health care.
This section concerns our current research activities. For more information on our finalized study at Zanzibar’s tertiary hospital,please see the dropdown menu on this website.
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.
The project consists of three work packages which each covers the methodology of one or more of the study objectives (SO).
Work package 1 is primarily of relevance to SOI, and will investigate the effects of an up-scaled, modified PartoMa intervention.
The specific aims are:
- To carry out a baseline mixed-methods care assessment at five high-volume maternity units in Tanzania.
- To explore and develop the necessary modifications for the subsequent PartoMa intervention of clinical guidelines and training to be implemented in these facilities.
- To assess birth attendant’s reaction and learning related to the modified PartoMa intervention.
- To measure the effect on quality of care and perinatal outcomes.
- To perform a costing analysis of the modified PartoMa intervention.
The modified PartoMa intervention will be implemented at the five highest volume maternity units in Dar es Salaam in close collaboration with,Comprehensive Community Based Rehabilitation in Tanzania (CCBRT), a Tanzanian NGO.
Work package 2 is primarily of relevance to SOII and will assess a pre-service PartoMa-based curriculum module.
The specific aims are:
- To carry out a baseline mixed-methods assessment among a cohort of nursing and medical students before and after transitioning to in-service clinical realities in maternal health care, including their perceptions of the pre-service education, preparedness and expectations for these in-service realities, and knowledge, skills and motivation.
- To co-create a PartoMa-related, multidisciplinary, pre-service curriculum module for final-year nursing and medical students, in order to enhance preparedness for in-service realities at maternity units, including knowledge, skills, motivation, interdisciplinary teamwork and work satisfaction.
- To assess the effects of the pre-service module on in-service knowledge, skills, motivation, interdisciplinary teamwork and study satisfaction.
Work package 2 will be conducted at State University Zanzibar (SUZA), and in collaboration with Mnazi Mmoja Hospital, Zanzibar’s tertiary university hospital.
Work package 3 is primarily of relevance to SOIII and SOIV, and explores the opportunities and barriers for co-creation, implementation and upscale.
The specific aims are to qualitative explore:
- What organizational and individual-level factors enable or hinder birth attendants in delivering best possible safe and respectful care for women giving birth.
- What practices in the everyday routines of birth attendants, as well as organizational and individual-level factors, make engagement with the PartoMa intervention desirable and possible for some, but less so or not for others.
Data will be collected in the five selected mainland hospitals and in the Zanzibari health facilities where the PartoMa intervention in currently being up-scaled.
This section concerns our current research activities. For more information on our finalized study at Zanzibar’s tertiary hospital, please see the dropdown menu on this website.
Overall principal investigator (PI):
- Dan Wolf Meyrowitsch, MSc, PhD, Associate Professor in Epidemiology, University of Copenhagen
National PI, Tanzania:
- Hussein Lesio Kidanto, MD, MMed ObGyn, PhD, Aga Khan University in Dar es Salaam
Core research team:
- Nanna Maaløe, MD, PhD, Post Doc, University of Copenhagen
- Jane Brandt Sørensen, MA, PhD, Post Doc, University of Copenhagen
- Natasha Housseine, MD, PhD student, Aga Khan University in Dar es Salaam
- Columba Kokusiima Mbekenga, BScN, RN, Msc Public Health, PhD, Aga Khan University in Dar es Salaam
- Thomas van den Akker, MD, PhD, MMed ObGyn, Vrije Universiteit in Amsterdam
- Andreas Kryger Jensen, Biostatistician, MSc, PhD, University of Copenhagen
- Brenda D’Mello, MD, MMed ObGyn, Aga Khan University in Dar es Salaam
- Morten Skovdal, MSc, PhD, Associate Professor, University of Copenhagen
- Britt Pinkowski Tersbøl, Anthropologist, Cand.scient, PhD, Associate Professor, University of Copenhagen
- Jos van Roosmalen, MD, PhD, Professor in Safe Motherhood and Health Systems, , Vrije Universiteit in Amsterdam
- Ib Christian Bygbjerg, MD, DMSc, Professor in International Health, University of Copenhagen
- Josephine Obel, MD, MIH, MMed ObGyn, Chief Physician, Copenhagen University Hospital Hvidovre
- Tarek Meguid, MD, MPhil in Maternal-Child Health, MSc in International Human Rights Law, Burundi
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
The finalized PartoMa study in Zanzibar ran from 2014-2018 and now forms the pilot study for the 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, leading to a 33 % decrease of stillbirths and almost a halving in newborns with immediate poor state of health compared to baseline.
In June 2018, Zanzibar Ministry of Health overtook 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 on this website.
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.
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.
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).
News articles and online debate fora:
In arme landen loont het om richtlijnen realistisch aan te passen, Medisch contact - a weekly magazine for medical doctors in the Netherlands, May 2019
Online debate on the PartoMa guidelines initiative, Healthcare Information For All (HIFA), a global community with more than 19,000 members in 177 countries, May 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.
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 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:
The PartoMa Pocket Guide 2.0
The PartoMa Case Stories for Problem-Based Learning
The PartoMa Background Document – Development, Implementation and Evaluation
An electronic and smartphone friendly version of the PartoMa guide in both English and Swahili are currently under development.
News from The PartoMa Project
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