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INTRODUCTION Globally, evidence suggests that one-third of nulliparous women experience delay in the first stage of labor with an increased risk of poor maternal and neonatal outcomes. With this study, we explore how clinical challenges related to prolonged labor are perceived by nurse-midwives and doctors in Tanzania. METHODS A qualitative study with group interviews of either nurse-midwives (7 interviews) or doctors (2 interviews). A total of 37 respondents, among them 32 registered nursemidwives and 5 doctors participated, all with experience from labor wards. A qualitative content analysis was performed. The study setting comprised one zonal consultant university hospital and one regional referral hospital in Northern Tanzania. RESULTS Clinical challenges were expressed in relation to: 1) various ways of understanding prolonged labor, manifested by variations in expected duration of labor and the usage of different terms to describe prolonged labor; 2) assessing progress in labor, the partograph being described as an important tool but also a template defining a too narrow normal; 3) appropriate intervention at the appropriate time, the respondents reflect on the correct time for artificial rupture of membranes, oxytocin augmentation and cesarean section; 4) monitoring fetal heart rate, distrust in the monitoring equipment with experiences of surprisingly poor neonates; and 5) working as a team, where the perception of urgency varies and distrust is present. CONCLUSIONS Nurse-midwives and doctors in Tanzania face major challenges related to diagnosing prolonged labor, monitoring fetal heart rate and providing high quality health services as a team.

Background: Globally, some evidence suggests that up to one third of nulliparous women experience delay in the first stage of labour. Diagnosing prolonged labour is complicated by uncertainty related to the definition of both onset of labour and normal labour progression.Prolonged labour inhabits an increased risk of poor neonatal and maternal outcomes. To our knowledge, few studies have assessed the clinical challenges of prolonged labour from a health care professional perspective. In this study we aim to improve understanding of how clinical challenges related to prolonged labour are perceived by doctors and nurse-midwives in Tanzania. Methods: A qualitative study with group interviews of either doctors (2 interviews) or nurse-midwives (7 interviews). A qualitative content analysis was performed. The study setting comprised one zonal consultant university hospital and one regional referral hospital in Northern Tanzania. Results: A total of 37 respondents, among them 32 registered nurse-midwives and 5 doctors, all with experience from labour ward. Five categories emerged. Challenges were expressed in relation to 1) various ways of understanding prolonged labour, 2) assessing progress in labour, 3) monitoring foetal heart rate, 4) appropriate intervention at the appropriate time and 5) working as a team. Conclusions: The study provides a broader understanding of the clinical challenges encountered by nurse-midwives and doctors when managing prolonged labour. The grounds on which decisions are made, are somewhat inconsistent. The respondents request clear guidelines and frequent training.

Background The Safe Childbirth Project is a campaign, launched by WHO in 2012, to improve the quality of care for women and babies during childbirth by promoting evidence-based practice and a midwifery-led approach to care. It was intended to contribute towards achieving UN Sustainable Development Goal 3: ensure healthy lives and promote wellbeing for all at all ages. In September, 2015, the project was launched in the maternity ward of Dar Al-Shifa Hospital, Gaza City, to promote midwifery-led care for low-risk deliveries, with de-medicalisation of normal birth, early initiation of breastfeeding, and early detection of complications during the postpartum period. Methods Dar Al-Shifa Hospital is the largest Ministry of Health hospital in the Gaza Strip, is the referral hospital for the whole area, and includes medical, surgical, and maternity departments. Most women who attend the maternity department (70%) have high-risk pregnancies. The caesarean section rate in 2016 was 27%. 88 midwives and 82 doctors are employed on the maternity wards. We did a descriptive retrospective analysis of all women admitted in labour to the maternity hospital from the start of the Safe Childbirth Project on Sept 1, 2015, to June 30, 2018. Data were extracted from patients’ files then aggregated and analysed. Six indicators of quality of care were assessed: risk assessment on admission to the labour ward; use of partograms; oxytocin augmentation of labour; babies delivered by a midwife; breastfeeding initiation within 1 h of birth; and the number of postnatal examinations. Ethics approval was obtained from the Helsinki Committee, at the Palestinian Health Research Council. Findings Of 16 400 births at Dar Al-Shifa Hospital during the study period, 11 480 (70%) were normal vaginal deliveries. The percentages of women risk assessed on admission increased from 65% at the start of the study to 100% at the end, but the proportions of pregnancies classified as being at low risk or high risk remained at roughly one-third to two-thirds (low risk 20% and high risk 45% at the start of the study vs 30% and 70%, respectively, at the end of the study). Partograms were used in all women throughout the study period. Use of oxytocin augmentation of labour decreased from 24% to 8%. Midwives delivered 53% of low-risk women at the beginning of the study and 100% at the end. The proportion of women who initiated breastfeeding within 1 h of birth increased from 45% to 81% and the percentage of women who had five or more postpartum examinations increased from 27% to 81%. Interpretation Implementation of the Safe Childbirth Project in Dar Al-Shifa Hospital improved most of our indicators of quality of care and was maintained along with regular clinical auditing. Management commitment and close clinical supervision have been the cornerstones of success. Funding None.

Aims and objectives To examine whether interprofessional simulation training on management of postpartum haemorrhage enhances self-efficacy and collective efficacy and reduces the blood transfusion rate after birth. Background Postpartum haemorrhage is a leading cause of maternal morbidity and mortality worldwide, although it is preventable in most cases. Interprofessional simulation training might help improve the competence of health professionals dealing with postpartum haemorrhage, and more information is needed to determine its potential. Design Multimethod, quasi-experimental, pre–post intervention design. Methods Interprofessional simulation training on postpartum haemorrhage was implemented for midwives, obstetricians and auxiliary nurses in a university hospital. Training included realistic scenarios and debriefing, and a measurement scale for perceived postpartum haemorrhage-specific self-efficacy, and collective efficacy was developed and implemented. Red blood cell transfusion was used as the dependent variable for improved patient outcome pre–post intervention. Results Self-efficacy and collective efficacy levels were significantly increased after training. The overall red blood cell transfusion rate did not change, but there was a significant reduction in the use of ≥5 units of blood products related to severe bleeding after birth. Conclusion The study contributes to new knowledge on how simulation training through mastery and vicarious experiences, verbal persuasion and psychophysiological state might enhance postpartum haemorrhage-specific self-efficacy and collective efficacy levels and thereby predict team performance. The significant reduction in severe postpartum haemorrhage after training, indicated by reduction in ≥5 units of blood transfusions, corresponds well with the improvement in collective efficacy, and might reflect the emphasis on collective efforts to counteract severe cases of postpartum haemorrhage. Relevance to clinical practice Interprofessional simulation training in teams may contribute to enhanced prevention and management of postpartum haemorrhage, shown by a significant increase in perceived efficacy levels combined with an indicated reduction of severe postpartum haemorrhage after training.

Source at: https://doi.org/10.1186/s12884-017-1478-2 Background: Tanzania has a relatively high maternal mortality ratio of 410 per 100,000 live births. Severe postpartum hemorrhage (PPH) is a major cause of maternal deaths, but in most cases, it is preventable. However, most pregnant women that develop PPH, have no known risk factors. Therefore, preventive measures must be offered to all pregnant women. This study investigated the effects of multi-professional, scenario-based training on the prevention and management of PPH at a Tanzanian zonal consultant hospital. We hypothesized that scenario-based training could contribute to improved competence on PPH-management, which would result in improved team efficiency and patient outcome. Methods: This quasi-experimental, pre-vs. post-interventional study involved on-site multi-professional, scenario-based PPH training, conducted in a two-week period in October 2013 and another 2 weeks in November 2014. Training teams included nurses, midwives, doctors, and medical attendants in the Department of Obstetrics and Gynecology. After technical skill training on the birthing simulator MamaNatalie®, the teams practiced in realistic scenarios on PPH. Each scenario was followed by debriefing and repeated scenario. Afterwards, the group swapped roles and the observers became the participants. To evaluate the effects of training, we measured patient outcomes by determining blood transfusion rates. Patient data were collected by randomly sampling Medical birth registry files from the pre-training and post-training study periods (n = 1667 and 1641 files, respectively). Data were analyzed with the Chi-square test, Mann-Whitney U-test, and binary logistic regression. Results: The random patient samples (n = 3308) showed that, compared to pre-training, post-training patients had a 47% drop in whole blood transfusion rates and significant increases in cesarean section rates, birth weights, and vacuum deliveries. The logistic regression analysis showed that transfusion rates were significantly associated with the time period (pre- vs. post-training), cesarean section, patients tranferred from other hospitals, maternal age, and female genital mutilation and cutting. Conclusions: We found that multi-professional, scenario-based training was associated with a significant, 47% reduction in whole blood transfusion rates. These results suggested that training that included all levels of maternity staff, repeated sessions with realistic scenarios, and debriefing may have contributed to reduced blood transfusion rates in this high-risk maternity setting.

Background Postpartum hemorrhage (PPH) is a major cause of maternal morbidity and mortality. In Tanzania, PPH causes 25% of maternal deaths. Skilled attendance is crucial to saving the lives of mothers and their newborns during childbirth. This study is a follow-up after multi-professional simulation training on PPH in northern Tanzania. The purpose was to enhance understanding and gain knowledge of important learning features and outcomes related to multi-professional simulation training on PPH. Methods The study had a descriptive and exploratory design. After the second annual simulation training at two hospitals in northern Tanzania, ten focus group discussions comprising 42 nurse midwives, doctors, and medical attendants, were carried out. A semi-structured interview guide was used during the discussions, which were audio-taped for qualitative content analysis of manifest content. Results The most important findings from the focus group discussions were the importance of team training as learning feature, and the perception of improved ability to use a teamwork approach to PPH. Regardless of profession and job tasks, the informants expressed enhanced self-efficacy and reduced perception of stress. The informants perceived that improved competence enabled them to provide efficient PPH management for improved maternal health. They recommended simulation training to be continued and disseminated. Conclusion Learning features, such as training in teams, skills training, and realistic repeated scenarios with consecutive debriefing for reflective learning, including a systems approach to human error, were crucial for enhanced teamwork. Informants’ confidence levels increased, their stress levels decreased, and they were confident that they offered better maternal services after training.

Background Out-of-hospital maternity care in Norway is randomly organised and not properly formalized. We wished to examine the extent, organisation and quality of this service. Material and method We obtained information from the Norwegian Medical Birth Registry on all unplanned out-of-hospital births in 2008. A questionnaire was sent to all maternity institutions, municipalities and emergency dispatch centres, with questions regarding the practical and formal organisation of the service using figures from 2008. Result 430 children, all above 22 weeks gestation, were born unplanned outside of hospitals in Norway in 2008. Of these, 194 were born unplanned at home, 189 while being transported and 47 in other locations (doctor's offices, infirmaries, unknown). Five out of 53 maternity institutions (9 %) confirmed they had a formal midwife service agreement for out-of-hospital births. 247 municipalities (79 %) claimed to have no such assistance. Of these, 33 are located at least 90 minutes away from the nearest maternity ward. Half of the emergency dispatch centres had no registration identifying formal agreements on assistance by midwives for out-of-hospital births. Interpretation There is an urgent need to put in place formal agreements between the regional health authorities and the municipalities on out-of-hospital midwife services. A distance of 90 minutes' journey time to a maternity ward to fulfil the right to qualified assistance is not well-founded.

Objective To investigate whether inter-professional simulation training influenced the rate of red blood cell (RBC) transfusions after birth. Design Two cohorts were compared retrospectively using a pre–post design. Setting Norwegian university hospital with 4800 deliveries annually. Population Women with estimated blood loss >500 mL within 24 h after birth in 2009 and 2011. Methods In 2010, all maternity staff attended a 6-h, scenario-based training on emergency obstetrics including postpartum hemorrhage, using a birthing simulator. The simulation focused on prevention, identification, and treatment of postpartum hemorrhage and on communication and leadership. Debrief immediately after the scenarios involved reflection and self-assessment. Main outcome measures The frequency of women receiving RBC transfusions as a marker for blood loss. Secondary outcome was the frequency of surgical procedures in the management of postpartum hemorrhage. Results In 2009, 111/534 (20.8%) women with estimated blood loss >500 mL after birth received RBC transfusions vs. 67/546 (12.3%) in 2011 (p

Out-of-hospital maternity care in Norway is randomly organised and not properly formalized. We wished to examine the extent, organisation and quality of this service.We obtained information from the Norwegian Medical Birth Registry on all unplanned out-of-hospital births in 2008. A questionnaire was sent to all maternity institutions, municipalities and emergency dispatch centres, with questions regarding the practical and formal organisation of the service using figures from 2008.430 children, all above 22 weeks gestation, were born unplanned outside of hospitals in Norway in 2008. Of these, 194 were born unplanned at home, 189 while being transported and 47 in other locations (doctor's offices, infirmaries, unknown). Five out of 53 maternity institutions (9 %) confirmed they had a formal midwife service agreement for out-of-hospital births. 247 municipalities (79 %) claimed to have no such assistance. Of these, 33 are located at least 90 minutes away from the nearest maternity ward. Half of the emergency dispatch centres had no registration identifying formal agreements on assistance by midwives for out-of-hospital births.There is an urgent need to put in place formal agreements between the regional health authorities and the municipalities on out-of-hospital midwife services. A distance of 90 minutes' journey time to a maternity ward to fulfil the right to qualified assistance is not well-founded.