The PartoMa Project: For Improving Monitoring, Action and Triage During Labour
The PartoMa Project: For Improving Monitoring, Action and Triage During Labour
OVERALL OBJECTIVE In an East African referral hospital, to develop and analyze the effect of
 locally agreed and achievable guidelines and a continual in-house training program for
 strengthening partogram-based monitoring-to-action during labour.

 INTERVENTION Paper partograms (WHO), locally developed labour management guidelines (the
 PartoMa guidelines) and continual in-house education.

 OVERALL DESIGN A quasi-experimental pre-post-study (The PartoMa study).

 SETTING Department of Obstetrics and Gynaecology, Mnazi Mmoja Hospital, Zanzibar.

 POPULATION Labouring women delivering at the study site from October 2014 to January 2016 and
 their offspring, as well as health providers. Women and their offspring will be enrolled
 at/after unset of labour and followed until discharge.

 ENDPOINTS The primary composite endpoint is stillbirths and birth asphyxia. For further
 description and secondary outcomes, please see below.

 STUDY TIME Data collection from October 2014 to January 2016, supplemented by a post-exit
 collection of case file data from October 2016 - January 2017.
SPECIFIC OBJECTIVES

 I (a) To analyze in depth current quality of intrapartum care by a mixed methods approach,
 including exploration of underlying challenges in care delivery and an association between
 suboptimal labour care and perinatal mortality. (b) To conduct a criterion-based audit of
 stillbirths investigating direct and indirect causes and related maternal risks.

 II. To develop locally achievable and agreed partogram-associated labour monitoring-to-action
 guidelines (the PartoMa guidelines) for strengthening the partogram use as a decision support
 tool, and study its acceptability by skilled birth attendants.

 III. To implement the PartoMa guidelines and low cost, low dose, high frequency, in-house
 training for strengthening the use of the partogram as a decision support tool, and study the
 effect on knowledge, skills, quality of intrapartum care, record keeping, and perinatal
 outcome.

 IV. To conduct a post-exit 2 years evaluation of use and effect of the PartoMa guidelines and
 recurring training.

 V. To develop an electronic smartphone application (the PartoMa app), which includes the
 PartoMa guidelines.

 VI. To estimate the cost-effectiveness of the interventions studied (specific objectives
 III-V).

 SETTING

 The East African Mnazi Mmoja Hospital (MMH) in Zanzibar is a governmental referral facility
 serving the population of Zanzibar. As East Africa in general, the Zanzibarian archipelago
 struggles with poverty and a resource constraint health system, and half of the population
 live below the basic needs poverty line.

 At the facility's Department of Obstetrics and Gynecology, the yearly number of deliveries is
 approximately 12,000. Approximately 50 maternal deaths occur annually (420 deaths per 100 000
 live births). While the facility-based neonatal death rate is unknown, our baseline study
 revealed a stillbirth rate of 59 per 1000 total births, of which approximately half were
 alive at the time of admission.

 Prior to this study, maternal and perinatal death audits were not conducted routinely and
 little is known about direct and indirect causes for the perinatal deaths.

 METHODS

 This study presents a quality improvement process of intrapartum monitoring, action and
 triage. The overall study design is here presented in relation to the four specific
 objectives:

 I. The intervention-based study is based on an in-depth baseline quality of care assessment,
 which includes criterion-based audit of intrapartum management in cases of stillbirths
 compared to cases with Apgar scores of 7-10, and qualitative exploration of contributing
 causes to substandard labour management (including participant observations and in depth
 interviews).

 II. Together with local doctors and nurse-midwives, international evidence-based guidelines
 are adapted to be locally achievable (the PartoMa guidelines). Additionally, they are
 internationally peer-reviewed with the aim of representing best possible care with the
 limited resources available at the facility.

 III. A concept for reoccurring in-house training in monitoring-to-action during labour is
 developed, based on the PartoMa guidelines and implemented together with the guidelines. This
 PartoMa intervention (guidelines and reoccurring in-house training) is evaluated by comparing
 clinical practice and birth outcome (please see the specific outcome measures below) in the
 baseline period (October 2014 - January 2015) with the 9th-12th month of the intervention
 (October 2015 - January 2016).

 IV. After the first intervention year (February 2016), a local steering group takes over the
 continual implementation of the PartoMa guidelines. If the intervention is still running,
 clinical practice and birth outcome will be analysed during the 21st - 24th month of the
 intervention (October 2016 - January 2017) and compared with previous assessments.

 V. If the PartoMa guidelines show to be accepted among birth attendants and effective in
 improving quality of care, an electronic smartphone application (the PartoMa app) will be
 developed, which includes the PartoMa guidelines.

 VI. A cost-effectiveness analysis of the intervention steps is carried out.
Inclusion Criteria:

 -  All women in labour delivering at the study site and their outcome, October 2014 -
 January 2015 and October 2015 - January 2016

 -  All health care providers at the department during the baseline and intervention
 period, October 2014 - January 2016

 For the different substudies, sub-groups are selected (please see the secondary outcomes
 for a description).