Effect of locally tailored clinical guidelines on intrapartum management of severe hypertensive disorders at Zanzibar's tertiary hospital (the PartoMa study)

Maaløe, Nanna; Andersen, Camilla; Housseine, Natasha; Meguid, Tarek; Bygbjerg, Ib Christian; Roosmalen, Jos van

doi:10.1002/ijgo.12692

Cited by 9 publications

(7 citation statements)

References 19 publications

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“…We conducted a pre–post-intervention study, comparing case files at baseline (October 2014 to January 2015) and one year later (October 2015 to January 2016). As previously published, 10 , 11 we found multiple significant improvements in quality of care, such as reduced median time from last recorded fetal heart rate to delivery; reduced proportion of births using oxytocin augmentation; and an increased proportion of women with severe hypertension receiving antihypertensive drugs. The numbers of stillbirths decreased 34% to 39 per 1000 total births (relative risk, RR: 0.66; 95% confidence interval, CI: 0.53–0.82), while newborns with an Apgar score of 1–5 halved to 28 per 1000 live births (RR: 0.53; 95% CI: 0.41–0.69).…”

Section: Relevant Changessupporting

confidence: 68%

Local adaption of intrapartum clinical guidelines, United Republic of Tanzania

Maaløe

Meguid²,

Housseine³

et al. 2019

Bull. World Health Organ.

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ProblemGaps exist between internationally derived clinical guidelines on care at the time of birth and realistic best practices in busy, low-resourced maternity units.ApproachIn 2014–2018, we carried out the PartoMa study at Zanzibar’s tertiary hospital, United Republic of Tanzania. Working with local birth attendants and external experts, we created easy-to-use and locally achievable clinical guidelines and associated in-house training to assist birth attendants in intrapartum care.Local settingAround 11 500 women gave birth annually in the hospital. Of the 35–40 birth attendants employed, each cared simultaneously for 3–6 women in labour. At baseline (1 October 2014 to 31 January 2015), there were 59 stillbirths per 1000 total births and 52 newborns with an Apgar score of 1–5 per 1000 live births. Externally derived clinical guidelines were available, but rarely used.Relevant changesStaff attendance at the repeated trainings was good, despite seminars being outside working hours and without additional remuneration. Many birth attendants appreciated the intervention and were motivated to improve care. Improvements were found in knowledge, partograph skills and quality of care. After 12 intervention months, stillbirths had decreased 34% to 39 per 1000 total births, while newborns with an Apgar score of 1–5 halved to 28 per 1000 live births.Lessons learntAfter 4 years, birth attendants still express high demand for the intervention. The development of international, regional and national clinical guidelines targeted at low-resource maternity units needs to be better attuned to input from end-users and the local conditions, and thereby easier to use effectively.

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Section: Relevant Changessupporting

confidence: 68%

Local adaption of intrapartum clinical guidelines, United Republic of Tanzania

Maaløe

Meguid²,

Housseine³

et al. 2019

Bull. World Health Organ.

Self Cite

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“…Their ‘bottom up’ approach was similar to ours and appeared to be associated with significant reductions in stillbirths and improvement of treatment of hypertensive disorders of pregnancy [6, 7, 46]. The PartoMa Guideline Development in Zanzibar and our strategy in Suriname were both achievable due to the smaller size of the island or country [6, 7, 46]. However, when healthcare workers are fully engaged in the quality cycle of plan-do-check-act, nationwide improvement can also be made in larger countries [47].…”

Section: Discussionmentioning

confidence: 72%

“…The recently published PartoMa study from in a low-resource referral hospital in Zanzibar, Tanzania, is one of the few examples of a systematic approach to evidence-based international recommendations adaptation to local reality and evaluation of it’s impact on health outcomes. Their ‘bottom up’ approach was similar to ours and appeared to be associated with significant reductions in stillbirths and improvement of treatment of hypertensive disorders of pregnancy [6, 7, 46]. The PartoMa Guideline Development in Zanzibar and our strategy in Suriname were both achievable due to the smaller size of the island or country [6, 7, 46].…”

Section: Discussionmentioning

confidence: 72%

Bottom-up development of national obstetric guidelines in middle-income country Suriname

Verschueren

Kodan

Brinkman

et al. 2019

BMC Health Serv Res

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Background Obstetric guidelines are useful to improve the quality of care. Availability of international guidelines has rapidly increased, however the contextualization to enhance feasibility of implementation in health facilities in low and middle-income settings has only been described in literature in a few instances. This study describes the approach and lessons learned from the ‘bottom-up’ development process of context-tailored national obstetric guidelines in middle-income country Suriname. Methods Local obstetric health care providers initiated the guideline development process in Suriname in August 2016 for two common obstetric conditions: hypertensive disorders of pregnancy (HDP) and post partum haemorrhage (PPH). Results The process consisted of six steps: (1) determination of how and why women died, (2) interviews and observations of local clinical practice, (3) review of international guidelines, (4) development of a primary set of guidelines, (5) initiation of a national discussion on the guidelines content and (6) establishment of the final guidelines based on consensus. Maternal enquiry of HDP- and PPH-related maternal deaths revealed substandard care in 90 and 95% of cases, respectively. An assessment of the management through interviews and labour observations identified gaps in quality of the provided care and large discrepancies in the management of HDP and PPH between the hospitals. International recommendations were considered unfeasible and were inconsistent when compared to each other. Local health care providers and stakeholders convened to create national context-tailored guidelines based on adapted international recommendations. The guidelines were developed within four months and locally implemented. Conclusion Development of national context-tailored guidelines is achievable in a middle-income country when using a ‘bottom-up’ approach that involves all obstetric health care providers and stakeholders in the earliest phase. We hope the descriptive process of guideline development is helpful for other countries in need of nationwide guidelines.

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“…But still, 29.6% of women age 25–49 in the study had never had their blood pressure measured, despite a total fertility rate of 5.1 [ 28 ], and 99% of pregnant women attend antenatal care (ANC) at least once [ 16 ]. This may be explained by poor recall, however, despite BP measurement being an integral part of ANC, one out of five women attending ANC never get their BP measured, 3 and approximately 22% of women delivering at the tertiary level hospital did not have a single BP measurement done during admission [ 29 ].…”

Section: Discussionmentioning

confidence: 99%

Hypertension and diabetes in Zanzibar – prevalence and access to care

et al. 2020

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Background: Cardiovascular diseases are among the most common causes of hospital admissions and deaths in Zanzibar. This study assessed prevalence of, and antecedent factors and care access for the two common cardiovascular risk factors, hypertension and diabetes, to support health system improvements. Methods: Data was from a population based nationally representative survey. Prevalence of hypertension was defined as systolic blood pressure ≥ 140 mmHg, diastolic blood pressure ≥ 90 mmHg or a self-reported diagnosis of hypertension; diabetes was defined as a fasting blood glucose ≥6.1 mmol/L or a self-reported diagnosis of diabetes. Care-cascades for hypertension and diabetes were created with four stages: being tested, diagnosed, treated, and achieving control. Multivariable logistic regression models were constructed to evaluate individual-level factorsincluding symptoms of mental illness-associated with having hypertension or diabetes, and with progressing through the hypertension care cascade. Whether people at overt increased risk of hypertension or diabetes (defined as > 50 years old, BMI > 30 kg/m2, or currently smoking) were more likely to be tested was assessed using chi squared. Results: Prevalence of hypertension was 33.5% (CI 30.6-36.5). Older age (OR 7.7, CI 4.93-12.02), some education (OR 0.6, CI 0.44-0.89), obesity (OR 3.1, CI 2.12-4.44), and raised fasting blood glucose (OR 2.4, CI 2.38) were significantly independently associated with hypertension. Only 10.9% (CI 8.6-13.8) of the entire hypertensive population achieved blood pressure control, associated factors were being female (OR 4.8, CI 2.33-9.88), formally employed (OR 3.0, CI 1.26-7.17), and overweight (OR 2.5, CI 1.29-4.76). The prevalence of diabetes was 4.4% (CI 3.4-5.5), and associated with old age (OR 14.1, CI 6.05-32.65) and almost significantly with obesity (OR 2.1, CI 1.00-4.37). Only 11.9% (CI 6.6-20.6) of the diabetic population had achieved control. Individuals at overt increased risk were more likely to have been tested for hypertension (chi2 19.4) or diabetes (chi2 33.2) compared to the rest of the population. Symptoms of mental illness were not associated with prevalence of disease or progress through the cascade. Conclusion: High prevalence of hypertension and suboptimal management along the care cascades indicates a large unmet need for hypertension and diabetes care in Zanzibar.

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Effect of locally tailored clinical guidelines on intrapartum management of severe hypertensive disorders at Zanzibar's tertiary hospital (the PartoMa study)

Cited by 9 publications

References 19 publications

Local adaption of intrapartum clinical guidelines, United Republic of Tanzania

Local adaption of intrapartum clinical guidelines, United Republic of Tanzania

Bottom-up development of national obstetric guidelines in middle-income country Suriname

Hypertension and diabetes in Zanzibar – prevalence and access to care

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