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Received: 23 March 2018    Revised: 19 July 2018    Accepted: 8 October 2018    First published online: 26 October 2018

DOI: 10.1002/ijgo.12692

CLINICAL ARTICLE
Obstetrics

Effect of locally tailored clinical guidelines on intrapartum

management of severe hypertensive disorders at Zanzibar’s
tertiary hospital (the PartoMa study)

Nanna Maaløe1,* | Camilla B. Andersen1,2 | Natasha Housseine3,4 | Tarek Meguid3,5 | 

Ib C. Bygbjerg1 | Jos van Roosmalen6

1
Global Health Section, Department of
Public Health, University of Copenhagen, Abstract
Copenhagen, Denmark Objective: To estimate the effect of locally tailored clinical guidelines on intrapartum
2
Department of Clinical Sciences, Lund
care and perinatal outcomes among women with severe hypertensive disorders in
University, Malmö, Sweden
3 pregnancy (sHDP).
Mnazi Mmoja Hospital, Zanzibar
City, Tanzania Methods: A pre–post study at Zanzibar’s low-­resource Mnazi Mmoja Hospital was
4
Julius Center for Health Sciences and Primary conducted. All labouring women with sHDP were included at baseline (October 2014
Care, UMC Utrecht, Utrecht, Netherlands
5
to January 2015) and at 9–12 months after implementation of the ongoing interven-
O’Neill Institute for National and Global
Health Law, Georgetown University, tion (October 2015 to January 2016). Background characteristics, clinical practice, and
Washington, DC, USA delivery outcomes were assessed by criterion-­based case file reviews.
6
Athena Institute, VU University of
Results: Overall, 188 of 2761 (6.8%) women had sHDP at baseline, and 196 of 2398
Amsterdam, Amsterdam, Netherlands
(8.2%) did so during the intervention months. The median time between last blood
*Correspondence
pressure recording and delivery decreased during the intervention compared with
Nanna Maaløe, Global Health Section,
Department of Public Health, University of baseline (P=0.015). Among women with severe hypertension, antihypertensive treat-
Copenhagen, Copenhagen, Denmark.
ment increased during the intervention compared with baseline (relative risk [RR]
Email: nannam@sund.ku.dk
1.37, 95% confidence interval [CI] 1.14–1.66). Among the neonates delivered (birth-
Funding Information
weight ≥1000 g), stillbirths decreased (RR 0.56, 95% CI 0.35–0.90) and Apgar scores
Lundbeck Foundation; Laerdal Foundation;
Augustinus Foundation; University of seven or more increased during the intervention compared with baseline (RR 1.17,
of Copenhagen
95% CI 1.03–1.33).
Conclusion: Although health system strengthening remains crucial, locally tailored
clinical guidelines seemed to help work-­overloaded birth attendants at a low-­resource
hospital to improve care for women with sHDP.
ClinicalTrials.org: NCT02318420.

KEYWORDS
Birth asphyxia; Guidelines; Labor; PartoMa; Pre-eclampsia; Severe hypertensive disorders;
Stillbirth; Tanzania

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any
medium, provided the original work is properly cited and is not used for commercial purposes.
© 2018 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and
Obstetrics

Int J Gynecol Obstet 2019; 144: 27–36 wileyonlinelibrary.com/journal/ijgo  |  27

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28       Maaløe ET AL.

1 |  INTRODUCTION study was approved by Mnazi Mmoja Hospital and Zanzibar Medical
and Research Ethical Committee (ZAMREC/0001/JUNE/014), and
Hypertensive disorders in pregnancy (HDP) cause one-­tenth of mater- registered with ClinicalTrials.org (NCT02318420). Patient identities
nal deaths in Africa. 1,2
A previous facility-­based survey in low-­ and were anonymized, and thus informed consent not required.
middle-­income countries found that the likelihood of maternal near-­ Throughout the study, each birth attendant (nurse-­midwife or
miss was eightfold and perinatal death threefold higher in a group of doctor) simultaneously cared for an average of 3–6 laboring women,
women with pre-­eclampsia than in a reference group without HDP.2 and 30% were intern doctors conducting their initial 6-­week rota-
Although most cases are preventable, undiagnosed or suboptimally tion. Turnover was high among staff in permanent positions: 25% of
treated HDP is repeatedly reported in sub-­Saharan Africa.3–10 This nurse-­midwives and 40% of doctors during the initial 6 months of the
violates human rights and is a key priority for safe motherhood. 11,12 intervention were no longer working there after 1 year.19 As a result,
Hypertensive disorders in pregnancy can rapidly progress in sever- most staff had limited experience with childbirth care. Only two had
ity, with increased risk of organ failure such as cerebral hemorrhage, a master in midwifery and there were only two obstetricians. At base-
coagulopathy, eclampsia, and pulmonary edema. Lifesaving treatment line, clinical intrapartum guidelines were not routinely used. The WHO
includes induction and/or oxytocin augmentation of labor while sta- composite partograph was recommended for all deliveries.20
bilizing blood pressure (BP) and supporting vital organ functions. 13,14 The “PartoMa Pocket Guide” (File S1) was launched on January
In high-­volume low-­resource hospitals, urgent intrapartum diagnosis, 27–28, 2015, at the first “PartoMa seminars”. These 3-hour seminars
surveillance, and management of such complex diseases are challeng- were conducted quarterly in order to establish use of the guidelines via
ing and need realistic practical guidance. 3,5–9,15,16 case-­based discussions. They were conducted outside working hours
In Tanzania, however, only one-­third of maternity units have and without ‘per diems’ or other allowances. An average of 74% of doc-
emergency obstetric care guidelines available, and only one-­quarter tors and 62% of nurse-­midwives from the obstetric division attended
have at least one birth attendant with adequate training in applying each of five seminar rounds during the first intervention year. One page
these. 17
Even if available, guidelines are often not tailored to low-­ of the pocket guide (Fig. 1) and one of five seminar cases concerned
resource settings.9,15,16,18 Unachievable international guidelines limit intrapartum care for women with sHDP. Detailed descriptions of guide-
implementation and may demoralize staff. Clinical guidelines tailored lines development and the seminars are presented elsewhere.18,19,21
and disseminated to facilitate effective application in low-­resource set- Quality of intrapartum care for women with sHDP was delineated
tings are required. 15,17,18 to diagnosis, surveillance, and treatment, and based on pre-­selected
Zanzibar is a low-­income, semiautonomous archipelago of the indicators (Fig. S1). In addition, maternal background characteristics,
United Republic of Tanzania, with a facility delivery rate of 55%. In maternal mortality, neonatal Apgar score, and stillbirth were recorded,
its tertiary Mnazi Mmoja Hospital, approximately 12 000 births are including the proportion of stillbirths with fetal heart rate (FHR) pres-
attended to annually. There were 59 stillbirths per 1000 births in ent on admission. The indicators were chosen to represent unambig-
2014–2015, and 52 neonates per 1000 live births had an Apgar score uous audit criteria for low-­resource settings that were sensitive in
of 1–5. Approximately half of the stillborn fetuses were alive on admis- monitoring progress in care and could be retrieved from case files.
sion, and the quality of intrapartum care was widely unacceptable.3 Structural changes at the study site that might potentially explain
This prompted, in collaboration with doctors and nurse-­midwives, outcome changes (or lack of changes) after implementation of the
the development of locally achievable clinical guidelines for common PartoMa intervention were assessed quarterly and have been pre-
intrapartum care. The resulting eight-­page PartoMa pocket book- viously described.19 In brief, staff numbers, supply shortages, and
let has subsequently been implemented among doctors and nurse-­ available emergency obstetric and neonatal care signal functions
midwives by quarterly seminars. 18
In particular, doctors have reported were similar throughout the baseline and first intervention year, but
finding the booklet’s page on essential intrapartum management of there were 16% fewer deliveries during the ninth to 12th intervention
HDP useful. 18
The aim of the present study was therefore to estimate months compared with baseline. Daily clinical meetings were intro-
the effects of the PartoMa intervention of pocket guides and quarterly duced 7 months before baseline and continued similarly throughout
low-­dose training on care and delivery outcomes among women with the study. No other formalized in-­house training or obstetric or early
severe HDP (sHDP). neonatal interventions were organized. Only one birth attendant
received formalized training externally. The department started con-
ducting maternal death audits in August 2015, but the audit findings
2 |  MATERIALS AND METHODS were first presented for staff after the 12th intervention month.19
For the present study, the baseline period was limited to October
In a retrospective pre–post study, case files were reviewed for all 1, 2014, to January 31, 2015, because the hospital’s case file storage
women with sHDP (defined as systolic BP 160 mm Hg or higher and/ system did not work properly before this period.19 The intervention
or diastolic BP 110 mm Hg or higher and/or eclampsia pre-­delivery) period studied, October 1, 2015, to January 31, 2016 (the ninth to
who attended Mnazi Mmoja Hospital before the PartoMa interven- 12th intervention months), was previously used in the overall evalua-
tion (October 1, 2014, to January 31, 2015) and 9–12 months after tion of PartoMa.19 For the assessment of sHDP, the calculated sample
implementation (October 1, 2015, to January 31, 2016). The PartoMa size for the intervention months was based on a two-­sided comparison
Maaløe ET AL. |
      29

F I G U R E   1   Intrapartum management of hypertensive disorders in pregnancy: page 7 of the PartoMa Pocket Guide version 1. A full overview of
the PartoMa guidelines applied is available in File S1. Abbreviations: BP, blood pressure; CS, cesarean; FHR, fetal heart rate. Reproduced from [18].
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30       Maaløe ET AL.

of proportions. The proportion of women with sHDP treated with anti- women retrieved from the study periods had no BP recorded during
hypertensives was used as a key indicator of care and was 86/184 the whole admission period (RR 0.93, 95% CI 0.85–1.01), respectively,
(47%) at baseline. Post-­implementation, an improvement of at least which could lead to an underestimation of sHDP (Fig. 2).
50% in the number of women treated was expected. Thus, the sam- The background characteristics of women with sHDP were
ple size of approximately 180 women in each group resulted in 99.9% comparable between the baseline and intervention groups: approx-
power at a 5% significance level. imately 40% were nulliparous; 75% had completed 34 weeks
A structured form in Excel (Microsoft, Redmond, WA, USA) was (birthweight ≥2000 g) of pregnancy; more than 80% had attended
used to collate data, with statistical analyses performed in RStudio ver- prenatal care at least once and 40% had at least four prenatal vis-
sion 1.1.383 (RStudio, Boston, MA, USA). Background characteristics its. Among the multiparous women, 30% had previously lost one or
were compared by using Fisher exact test. Care and delivery outcomes more children (documentation was inadequate to distinguish peri-
were compared by using relative risk (RR) and 95% confidence intervals natal deaths from deaths later in life). Labor progress on admission
(CIs) for dichotomous indicators, and Mann-­Whitney test for time inter- was similarly comparable between the two groups: 50% were admit-
vals. A P value of less than 0.05 was considered statistically significant. ted before active labor and 2% in the second stage. Fifteen percent
were referred from lower level facilities. On admission, 9% were
diagnosed with intrauterine fetal death (Table S1). Among the 188
3 |  RESULTS women at baseline, 184 (97.9%) had severe hypertension (systolic
BP ≥160 mm Hg and/or diastolic BP ≥110 mm Hg) and 70 (37.2%)
According to the hospital registers, 3599 women gave birth at base- had a systolic BP of 180 mm Hg or higher. These proportions
line and 3002 did so during the four intervention months studied, but were comparable with the intervention group: 193 (98.5%) and 85
case files of 3609 and 3067 women were retrieved from the respec- (43.4%). The incidence of proteinuria (dipstick measurement ≥2+)
tive study periods. Of these, 2761 (76.5%) and 2398 (78.2%) women, was slightly higher during the intervention months, which might be
respectively, had at least one BP measurement, or had eclampsia doc- due to fewer women in this group lacking a urine test (Table S1).
umented without a BP recording, of whom 188 (6.8%) and 196 (8.2%) The routine BP assessments of all laboring women did not
fulfilled the criteria for sHDP and were included in the baseline and improve between the two periods (RR 0.93, 95% CI 0.85–1.01)
intervention groups. An additional 848 (23.5%) and 669 (21.8%) of the (Fig. 2). Among women with sHDP, diagnosis was more frequent

Total no. of women giving birth

(n = 6709) (register-based)

Baseline 9–12 mo post intervention

(October 2014 – January 2015) (October 2015 – January 2016)
(n = 3599) (register-based) (n = 3002) (register-based)

Case files retrieved Case files retrieved:

(n = 3609) (>100%) (n = 3067) (>100%)

No BP recording during admission At least one BP recording during No BP recordings during admission At least one BP recording during
and eclampsia not described admission or eclampsia described: and eclampsia not described: admission or eclampsia described:
(n = 848) (23%) a (n = 2761) (77%) (n = 669) (22%) a (n = 2398) (78%)

Severe hypertensive Severe hypertensive Severe hypertensive Severe hypertensive

disorders pre-delivery disorders post-delivery disorders pre-delivery disorders post-delivery
(n = 188) (7%) (n = 6) (0.2%) (n = 196) (8%) (n = 10) (0.4%)

Severe pre-eclampsia/eclampsia Severe pre-eclampsia/eclampsia

(n = 121) (64%) (n = 144) (73%)

Eclampsia Eclampsia
(n = 23) (19%) (n = 31) (22%)

F I G U R E   2   Flow chart showing women included in the study. The inclusion criteria were severe hypertension (systolic blood pressure [BP]
≥160 mm Hg and/or diastolic BP ≥110 mm Hg) and/or eclampsia. A subgroup of women with severe pre-­eclampsia/eclampsia were defined as
having at least one recording of severe hypertension and a proteinuria measurement of at least 2+, and/or eclampsia recorded before or during
admission. Abbreviations: BP, blood pressure; RR, relative risk; CI, confidence interval. aAmong all women in labor, routine BP assessments did
not improve (RR 0.93, 95% CI 0.85–1.01).
Maaløe ET AL. |
      31

on admission in the intervention months (110 [56.1%]), compared dysfunction postpartum in the study hospital; one patient had pulmo-
with the baseline group (82 [43.6%]) (RR 1.29, 95% CI 1.05–1.58). nary edema and hypoxia, one had eclampsia and cerebral edema, and
Among the women not diagnosed on admission, only one had mild-­ one had eclampsia and renal failure.
to-­moderate HDP diagnosed prior to severe disease. There was a
tendency toward a decrease in women remaining undiagnosed
despite recorded inclusion criteria (RR 0.72, 95% CI 0.51–1.00) 4 | DISCUSSION
(Fig. 3, Table 1). More women had proteinuria tested in the interven-
tion group (177 [90.3%]) than in the baseline group (156 [83.0%]) The present findings show that, although care remained substand-
(RR 1.09, 95% CI 1.01–1.18) (Table S1). ard, several improvements had occurred during the ninth to 12th
Among women with vaginal delivery and at least one recorded BP invention months, such as progress in surveillance, a 37% increase in
pre-­delivery, the median time between last BP and delivery was 162 min- antihypertensive treatment, and a 44% reduction in risk of stillbirth.
utes (interquartile range [IQR], 80–328 minutes; n=126) at baseline ver- Taken together with previous studies,3,18,19 the findings suggest that
sus 129 minutes (IQR, 60–245 minutes; n=130) during the intervention the PartoMa intervention was an important determinant of improve-
months (Mann-­Whitney test, P=0.015). The proportion of women with ments. This indicates how effective locally tailored clinical guidelines
at least one recorded BP post-­delivery improved from 126 (67.0%) at and associated quarterly, low-­dose training can be in a weak health-
baseline to 151 (77.0%) during the intervention months (RR 1.15, 95% care system with critical shortages in human resources.
CI 1.01–1.30). Among 140 women at baseline and 164 during inter- The study has both strengths and limitations. The low-­cost,
vention months with at least one documented FHR, the median time pre–post approach had applicable process and outcome indicators.
between the last FHR and delivery (or identified intrauterine fetal death) The comparable background characteristics of women between
decreased from 150 minutes (IQR, 60–296 minutes) to 90 minutes (IQR baseline and the intervention months strengthened its internal
35–180 minutes) (Mann-­Whitney test, P=0.001) (Fig. 3, Table 1). validity. Two baseline periods would have enabled potential time-­
Among the women with severe hypertension (184 at baseline related changes to be examined, but the hospital’s poor case file
and 193 during the intervention months), initiation of antihyper- storage prevented this approach. There were few contextual con-
tensive treatment increased, from 86 (46.7%) women at baseline to founders identified, but the 16% fewer deliveries in the interven-
124 (64.2%) during the intervention months (RR 1.37, 95% CI 1.14– tion months might have allowed better care.19 Birth attendants
1.66). In both periods, 90% of women with severe pre-­eclampsia/ were not paid to attend the seminars. Therefore, the high atten-
eclampsia had magnesium sulfate treatment initiated. Among the dance after working hours appeared to indicate staff motivation to
110 women at baseline and 127 during the intervention months with improve care, which was a mediator of improvements.19 Through
magnesium sulfate initiated, 20 (18.2%) compared with 44 (34.6%), retrieving all available case files from the months studied and
respectively, had patellar reflexes and respiratory rate recorded at reviewing them manually, the number of women in labor identi-
least once for surveillance of toxicity (RR 1.91, 95% CI 1.20–3.03) fied was 2% higher than if hospital registers alone had been used.
(Fig. 3, Table 2). The median duration of labor from diagnosing sHDP This close approximation in a low-­resource hospital was a strength.
to delivery was approximately 7 hours in both groups (IQR, 161– The present findings are further strengthened by triangulation
790 minutes and 225–745 minutes, respectively; Mann-­Whitney with similar results of the other PartoMa studies, emphasizing low
test, P=0.356) (Table 2). inter-­observer bias and unambiguity of indicators.3,18,19 Although
Among all deliveries (203 at baseline and 206 in the intervention the effect of the PartoMa intervention was explored in terms of
months), the mode of delivery was comparable; 58 (28.6%) were deliv- care and birth outcomes, the available case file data did not enable
ered by cesarean at baseline compared with 63 (30.6%) during the analyzing the frequency of organ failure and neonatal mortality,
intervention months. Among 65 (34.6%) women at baseline and 66 the in-­depth quality of monitoring and treatment, and whether the
(33.7%) during the intervention months, there were no records in their birth attendants’ interactions with the women were respectful.
medical file after the day of delivery; although it seems unlikely, it is Furthermore, data from case file reviews might be biased owing to
unknown whether these women had been discharged. under-­ or over-­recording.3
Birthweight was 1000 g or more for 201 (99.0%) neonates at base- The current study shows that the previously reported overall
line and 196 (95.1%) during the intervention months. Of these, the inci- reduction in stillbirths from 59 to 39 per 1000 total births between
dence of stillbirth decreased from 42 (20.9%) at baseline to 23 (11.7%) baseline and the ninth to 12th intervention months19 was also true
during intervention months (RR 0.56, 95% CI 0.35–0.90), and the inci- within the sHDP subgroup; stillbirths reduced from 20.9% to 11.7%.
dence of an Apgar score of seven or higher increased from 130 (64.7%) Although not reaching statistical significance, the results suggest
to 148 (75.5%), respectively (RR 1.17, 95% CI 1.03–1.33) (Table 3). that the reduction predominantly occurred among intra-­hospital
One woman at baseline and five during the intervention months stillbirths. Whereas a decrease in over-­use of oxytocin augmenta-
died (RR 4.80, 95% CI 0.57–40.67). The woman at baseline died from tion seemed to be a major contributor among non-­sHDP women,19
obstetric hemorrhage. In the intervention group, one woman died from it did not explain the present reduction in stillbirths observed among
obstetric hemorrhage, and one had been referred from elsewhere and sHDP women. Taken together with our previous evaluation,19 the
died on admission. The other three women experienced severe organ improvements observed seem to relate to the three pages of the
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32       Maaløe ET AL.

F I G U R E   3   Comparison of key findings at baseline (October 2014–January 2015) and at 9–12 months of the PartoMa study (October 2015–
January 2016). (A) Stillbirths (defined as fetal death with weight ≥1000 g) and newborns with an Apgar score of 7 or higher. (B) Median time
between last recorded fetal heart rate (FHR) or blood pressure (BP) measurement and delivery. (C) Additional quality indicators of diagnosis,
surveillance, and treatment of women with severe hypertensive disorders during pregnancy (sHDP). Abbreviations: CI, confidence interval; IQR,
interquartile range; RR, relative risk. Asterisk indicates significant difference.
Maaløe ET AL. |
      33

T A B L E   1   Univariable analysis of the diagnosis and surveillance of women with severe hypertensive disorders during childbirth, comparison
of relative risk of outcomes during the ninth to 12th months of the intervention (October 1, 2015, to January 31, 2016) compared with during
the baseline period (October 1, 2014, to January 31, 2015).a

At baseline At 9–12 intervention

Characteristic (n=188) months (n=196) P value RR (95% CI)

Time of diagnosis severe hypertensive disorder

Prenatal care visit 9 (4.8) 9 (4.6) 0.96 (0.39–2.36)
During admission assessment 82 (43.6) 110 (56.1) 1.29 (1.05–1.58)
After admission assessment 38 (20.2) 33 (16.8) 0.83 (0.55–1.27)
Undiagnosed 59 (31.4) 44 (22.4) 0.72 (0.51–1.00)
Physical examination recorded on diagnosis
Minimum: headache, epigastric pain, vision 25 (13.3) 41 (20.9) 1.57 (1.00–2.48)
Blood count: taken: renal and liver function tests as minimum 23 (12.2) 61 (31.1) 2.54 (1.65–3.93)
Documentation sheets at least partially appliedb
Women in first stage of labor 161 155
Partograph 114 (70.8) 107 (69.0) 0.97 (0.84–1.13)
All study women 188 196
Specific observation and treatment sheet for HDP 86 (45.7) 91 (46.4) 1.01 (0.82–1.26)
Fluid balance sheet 14 (7.4) 31 (15.8) 2.12 (1.17–3.86)
Blood pressure
BP recorded on admission 181 (96.3) 195 (99.5) 1.03 (1.00–1.06)
Women with known start of active phase of labor 149 140
BP recorded at least once during active phase of labor 127 (85.2) 121 (86.4) 1.01 (0.92–1.11)
All study women 188 196
BP at least once between delivery and dischargec 126 (67.0) 151 (77.0) 1.15 (1.01–1.30)
Women with vaginal delivery and ≥1 BP recording during admission 126 130
Time from last BP till delivery, min 162 (80–328) 129 (60–245) 0.022d
Fetal heart rate
Women in active phase of labor, no IUFD 144 131
FHR at least once during active phase of labor 113 (78.5) 113 (86.3) 1.10 (0.99–1.23)
Women with recorded FHR 140 164
Time from last FHR till delivery, min 150 (60–296) 90 (35–180) 0.001d
Labor progression
Women in active phase of labor 165 156
<5 h between any two cervical assessmentsd 103 (62.4) 112 (71.8) 1.15 (0.99–1.34)

Abbreviations: BP, blood pressure; CI, confidence interval; FHR, fetal heart rate; HDP, hypertensive disorders in pregnancy; IUFD, intrauterine fetal death;
relative risk.
a
Values are given as number (percentage), absolute number, or median (interquartile range), unless indicated otherwise.
b
The documentation sheets included a partograph sheet (at least the first cervical dilatation in active labor plotted correctly on the alert line), a specific
sheet for HDP (at least one recorded observation and treatment, and fluid balance sheet (at least one recording of input and output).
c
Overall, 70/188 (37%) at baseline and 82/196 (42%) during the intervention had at least one BP recording every 24 h during the first 2 days postpartum
(RR 1.12, 95% CI 0.88–1.44).
d
By Mann-­Whitney test for difference. This incude the interval between the last recording of cervical dilatation and delivery.

PartoMa pocket guide that were highest rated among birth atten- organizational and individual aspects associated with the changes,
dants (FHR, labor progress, and intrapartum HDP).18 Furthermore, and with lack of changes.22
this is consistent with challenges identified in the baseline case– Two other criterion-­based audits from East African referral hos-
3
control study of stillbirth. It seems that the PartoMa intervention’s pitals also included locally tailored guidelines and similarly proved
integrated recommendations and training in routine and emergency effective in strengthening care for women with HDP. However, their
intrapartum care have helped to trigger quality improvements. interventions were narrowly targeted at pre-­eclampsia/eclampsia
Qualitative implementation research is warranted to further identify and included additional structural changes.6,8 To our knowledge, no
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34       Maaløe ET AL.

T A B L E   2   Univariable analysis of the treatment of women with severe hypertensive disorders during childbirth, comparison of relative risk of
outcomes during the ninth to 12th months of the intervention (October 1, 2015, to January 31, 2016) compared with during the baseline
period (October 1, 2014, to January 31, 2015).a

At baseline At 9–12 intervention

Characteristic (n=188) months (n=196) P value RR (95% CI)

Antihypertensive treatment
All women with severe hypertensionb 184 193
Hydralazine or nifedipine administered 86 (46.7) 124 (64.2) 1.37 (1.14–1.66)
Anticonvulsant treatment
Women with urine protein ≥2 or eclampsiac 121 144
MgSO4 treatment initiated 110 (90.9) 127 (88.2) 0.97 (0.89–1.05)
Women receiving MgSO4 110 127
Patellar reflexes and respiratory rate at least once 20 (18.2) 44 (34.6) 1.91 (1.20–3.03)
Labor progression
All women with the required date and time recorded: 173 189
Time from inclusion criteria recorded till delivery, min 390 (161–790) 457 (225–745) 0.356d
All study women 188 196
Partograph action line crossed (prolonged first stage) 22 (11.7) 22 (11.2) 0.96 (0.55–1.67)
e
Induction of labor 48 (25.5) 75 (38.3) 1.50 (1.11–2.03)
Oxytocin for augmentation in active phase of laborf 45 (23.9) 36 (18.4) 0.77 (0.52–1.13)

Abbreviations: CI, confidence interval; MgSO4, magnesium sulfate; RR, relative risk.
a
Values are given as absolute number, number (percentage), or median (interquartile range), unless indicated otherwise.
b
Diagnostic criteria for severe hypertension applied: systolic BP ≥160 mm Hg and/or diastolic BP ≥110 mm Hg.
c
Diagnostic criteria for severe pre-­eclampsia/eclampsia applied: severe hypertension on at least one reading and urine protein ≥2, or eclampsia/convulsions
described (owing to poor data quality, women without severe hypertension or eclampsia, but fulfilling the WHO criteria of severe pre-­eclampsia due to
symptoms of organ failure could not be identified). For an additional 28/188 (15%) women at baseline and 12/193 (6%) during the intervention, urine
dipstick was not performed.
d
Mann-­Whitney test for difference.
e
One woman was induced by balloon catheter; all others were induced by misoprostol with or without subsequent oxytocin.
f
Women were excluded if induced. For 11/45 (24%) and 7/36 (19%), respectively, membranes were still intact when starting oxytocin augmentation (RR
0.80, 95% CI 0.34–1.84).

other studies of broader guidelines have been shown to be effective considered. As part of the internationally formulated obstetric care
in strengthening care and perinatal survival for women with HDP in signal functions, maximizing magnesium sulfate coverage has been
low-­income countries. repeatedly emphasized.25 At the study hospital, it was administered
Nevertheless, the five maternal deaths in the ninth to 12th inter- to 90% of women with severe pre-­eclampsia/eclampsia during both
vention months reflect the unacceptable quality of care throughout baseline and intervention months. Although evidence suggests that
the study. Moreover, the 7%–8% prevalence of severe hyperten- severe hypertension is a similarly important contributor to maternal
sive disorders, with 85% of affected women admitted directly from mortality in sHDP,14 antihypertensives are not included in the signal
home and only one diagnosed with mild-­moderate disease prior to functions, and this omission might have contributed to more than half
this, might in itself indicate missed opportunities for early detection of the women with sHDP at baseline not receiving antihypertensive
and treatment, both prenatally and intrapartum. Data from another treatment. A similar mismatch in pre-­eclampsia/eclampsia treatment
Tanzanian tertiary hospital reported an incidence of eclampsia of was reported in Ghana, where health providers described how clini-
6%,6 whereas a facility-­based survey of mild-­severe HDP in multiple cal guidelines were adhered to more closely if they were given more
low-­ and middle-­income countries found an overall prevalence of attention and if local adjustments were made.9 A second version of the
only 2.7%.2 The high prevalence of sHDP in the present study may brief and simple PartoMa pocket guide was launched in 2018, with the
also be associated with a high predisposition in the target popula- focal point broadened further by including additional essential intra-
tion, which further emphasizes the need to strengthen early detec- partum and postpartum care, and PartoMa seminars have now been
tion and management: 19% of Zanzibari women aged 25–44 years conducted for nearly 4 years.21
are affected by hypertension,23 with the risk of gestational aggrava- It remains crucial to address the human resources crisis and sub-
2,24
tion and superimposed pre-­eclampsia. standard clinical competencies among staff, as well as unacceptable
In quality improvement processes, the potential effects, and shortages in supplies and space. Nevertheless, in the meantime,
adverse effects, of more or less broad focal points must be carefully locally tailored clinical guidelines and associated reoccurring, in-­house
Maaløe ET AL. |
      35

T A B L E   3   Birth outcomes among women with severe hypertensive disorders, comparison of relative risk of outcomes during the ninth to 12th
months of the intervention (October 1, 2015, to January 31, 2016) compared with during the baseline period (October 1, 2014, to January 31, 2015).a

Outcome Baseline At 9–12 intervention months RR (95% CI)

Maternal outcomes 188 196

Maternal death 1 (0.5) 5 (2.6) 4.80 (0.57–40.67)
b
Day of discharge postpartum
Delivery day 65 (34.6) 66 (33.7) 0.97 (0.74–1.29)
1–2 d postpartum 35 (18.6) 64 (32.7) 1.75 (1.22–2.51)
≥3 d postpartum 88 (46.8) 67 (34.2) 0.73 (0.57–0.93)
Neonatal outcomes 203 206
Mode of delivery
Spontaneous vaginal 133 (65.5) 130 (63.1) 0.96 (0.83–1.11)
Vaginal breech 10 (4.9) 6 (2.9) 0.59 (0.22–1.60)
Vacuum extraction 0 4 (1.9)
Cesarean 58 (28.6) 63 (30.6) 1.07 (0.79–1.44)
Unknown 2 (1.0) 3 (1.5) 1.48 (0.25–8.75)
c
Neonatal outcomes for those with birthweight ≥1000 g 201 196
Apgar score
≥7 130 (64.7) 148 (75.5) 1.17 (1.03–1.33)
6 5 (2.5) 7 (3.6) 1.44 (0.46–4.45)
1–5 19 (9.5) 12 (6.1) 0.65 (0.32–1.30)
0 (stillbirths) 42 (20.9) 23 (11.7) 0.56 (0.35–0.90)
Information missing 5 (3.0) 6 (2.9) 1.23 (0.38–3.97)
Stillbirths, time of death
Pre-­hospital (fetal death diagnosed on admission) 18 (9.0) 14 (7.1) 0.80 (0.41–1.56)
Intra-­hospital (positive FHR on admission) 18 (9.0) 9 (4.6) 0.51 (0.24–1.11)
Time unknown (no documented FHR during admission) 6 (3.0) 0

Abbreviations: CI, confidence interval; FHR, fetal heart rate; RR, relative risk.
a
Values are given as absolute number or number (percentage), unless indicated otherwise.
b
The last recording in the file was treated as the last day of stay.
c
Of all neonates, 2/203 (1%) at baseline and 10/206 (4.9%) during the intervention had birthweight <1000 g approximate pregnancy duration <28 wk). At
the study hospital, stillbirths at <28 weeks are classified as late spontaneous abortions. Although there might be a risk of mis-­categorizing stillbirths
affected by severe intrauterine growth restriction, those stillbirths were excluded from the perinatal outcome data.

training, which takes account of the current resource constraints, are AC KNOW L ED G M ENTS
warranted in assisting work-­overloaded birth attendants in improving
The PartoMa study is financed by grants from the Lundbeck
care. Achievable guidance is a basic right for birth attendants holding
Foundation (R164-­2013-­16038), the Laerdal Foundation (40108), the
the lives of others in their hands.
Augustinus Foundation (14-­1059), and University of Copenhagen.
The funding bodies have no role in the design, implementation, inter-
AUT HOR CONTRI B UTI O N S pretation, or reporting of the study.

NM contributed to the design of the study, data collection and

analysis, data interpretation, and writing the manuscript. CBA CO NFL I C TS O F I NT ER ES T
contributed to the design of the study, data collection and analy-
The authors have no conflicts of interest.
sis, and revising the manuscript. NH contributed to data collection
and analysis, and revising the manuscript. TM contributed to data
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