WHO Bulletin: Local adaption of intrapartum clinical guidelines, United Republic of Tanzania (2)

8 May, 2019

Dear Neil and others,

Thank you very much for sharing the PartoMa project at HIFA, and for the important points raised. We are of course eager to be a part of this discussion, and learn from the perspectives of HIFA’s members.

The PartoMa project’s bottom-up co-creation of clinical guidelines with birth attendants at Zanzibar’s tertiary hospital grew into a critical analysis of the applicability of leading international guidelines targeting maternity care in low-resource settings. Developing the PartoMa clinical guidance emphasized crucial obstacles for international maternal health guidelines to be easily adaptable to realities in maternity units carrying the highest burden of adverse outcomes. It was a time- and resource-consuming process that appeared unfeasible as a process to be conducted routinely within fragile health care systems, whether on national or facility level. Compared to international guidelines targeting maternity care in low-resource settings, alterations were necessary in frequency of clinical assessments, information load, ambiguity, and safety of treatment regimens.

It is mind-boggling that the bulk of internationally-derived clinical guidelines targeting low-resource settings are published with little, if any, inputs from health workers at the grass root level, and often without pilot testing or post-implementation assessment.

We acknowledge that improved clinical guidelines on the national levels are paramount– but do health ministries in low-income countries have the capacities to effectively adapt and modify international guidelines that are so unnecessarily far from realities in their countries? We are not intending to sidestep national guidelines, and we do call for research on alternative interactive steps to ensure that large-scale guidelines development targeting low-resource settings - on global, regional and national levels- is better attuned to inputs from the end-users, and thereby easier to adapt and use effectively. As Orem et al. found by reviewing 137 of Uganda’s health sector guidelines, lack of involvement of end users in the development process was a key contributor to ineffective, impractical, unclear, or too complex recommendations (Implement. Sci. 2012).

We agree that it is a crucial next step of the PartoMa project to see whether the PartoMa clinical guidelines from Zanzibar’s tertiary hospital can be modified and replicated at scale for improved health and survival at birth, and whether the process can serve as a model for other areas of health care. We are happy to share that we recently were granted 1.84 million USD from Danida, Ministry of Foreign Affairs of Denmark, to conduct larger implementation research. The key part of this will be to explore modifications needed and usefulness of the PartoMa intervention at five urban, mega maternity units in Dar es Salaam, Tanzania. This will of course include an analysis of related national guidelines in Tanzania mainland.

Please find more information on the PartoMa project at our website: publichealth.ku.dk/partoma/

On behalf of the PartoMa research team,

kind regards,

Nanna Maaloe, MD, PhD

The PartoMa Project

Nanna Maaloe, MD, PhD

Post. doc.

University of Copenhagen

Global Health Section

Department of Public Health

& Copenhagen University Hospital, Hvidovre

Department of Gynecology and Obstetrics

HIFA Profile: Nanna Maaloe is a medical doctor and PhD fellow at the Global Health Section, University of Copenhagen & Mnazi Mmoja Hospital, Zanzibar, Tanzania and is based in Denmark.

Professional interests: Obstetrics & Gynecology/childbirth care, development of clinical guidelines, health system research in low resource settings.

Email: nannamaaloe AT outlook.com