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Scaling Up Doppler to Improve Intrapartum Fetal Heart Rate Monitoring in Tanzania: A Qualitative Assessment of National and Regional/District Level Implementation Factors
Absence Of Accelerations During Labor Is Of Little Value In Interpreting Fetal Heart Rate Patterns
By Marya Plotkin 1, * , John George 2 , Felix Bundala 3 , Gaudiosa Tibaijuka 4 , Lusekelo Njonge 4 , Ruth Lemwayi 4 , Mary Drake 4 , Dunstan Bishanga 4 , Barbara Rawlins 1 , Rohit Ramaswamy 5 and Stephanie Singer Wheel 5 , Kavitie
Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
Received: October 1, 2019 / Revised: February 26, 2020 / Accepted: March 5, 2020 / Published: March 16, 2020
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High-quality antenatal care, including intermittent fetal heart rate (FHR) monitoring to detect and manage abnormalities, is recommended by WHO and the Government of Tanzania (GoT) and has the potential to save newborn lives in Tanzania. Handheld Doppler devices have been investigated in several low-resource countries as an alternative to Pinard stethoscopes and are more sensitive in detecting accelerations and decelerations of the fetal heart compared to Pinard. This study assessed the perspectives of high-level Tanzanian policymakers on facilitators and barriers to scaling up the use of the hand-held Doppler to assess FHR during labor and delivery. From November 2018–August 2019, nine high-level policy makers and subject matter experts were interviewed using a semi-structured questionnaire, with theoretical domains drawn from Proctor’s Implementation Outcomes Framework. Interviewees largely saw the use of Doppler to improve FHR monitoring in labor as consistent with national priorities, although they noted competing demands on resources. They believed that GoT should fund Doppler, but prioritization and budgeting should be driven from the district level. Recommended ways forward included learning from scaling up the Helping Babies Breathe rollout, making training methods effective, using clinical mentoring, and establishing systematic monitoring of outcomes. To be most effective, the introduction of Doppler must occur concurrently with improved case management practices for abnormal intrapartum FHR. WHO guidance on scale-up, as well as implementation science frameworks, should be considered to guide implementation and evaluation.
Doppler; scale up; maternity care; fetal heart monitoring; Tanzania; qualitative Doppler; scale up; maternity care; fetal heart monitoring; Tanzania; qualitative
Globally, an estimated 2.1 million early neonatal deaths and 2.6 million stillbirths occurred in 2015, including 1.3 million intrapartum stillbirths [1]. Almost all of these (98%) occurred in low- and middle-income countries (LMICs) [1, 2, 3]. Skilled antenatal care, where prenatal care and newborn care follow globally recommended quality standards, could prevent a significant proportion of these deaths [4].
Abnormal fetal heart rate (FHR) during the labor period may indicate a hypoxic condition of a fetus due to interruption of placental blood flow [5]. Because abnormal FHR is a potential predictor of neonatal asphyxia, FHR monitoring is important for quality care in labor. Conversely, poor quality intrapartum FHR monitoring contributes to intrapartum stillbirths [6]. In Tanzania, studies have provided strong evidence for fetal heart abnormalities as a predictor of new stillbirth, birth asphyxia and neonatal death [7]. Improvements in intrapartum monitoring have shown results, as in a 1989 study in southwestern Tanzania where an intervention related to intrapartum monitoring was associated with a reduction in perinatal mortality from 71 to 39 deaths per 1000 births [8]. Despite this evidence, the quality of FHR monitoring in labour, both on admission to labor and delivery services and intermittently during labour, is often poor in Tanzania [ 6 ].
Effect Of Structured Bed Exercise On Uterine Contractions, Fetal Heart Rate Patterns, And Maternal Psychophysical Symptoms Of Hospitalized High Risk Pregnant Women: A Randomized Control Trial
The World Health Organization (WHO) recommends intermittent FHR monitoring during labor in the LMIC setting, but does not endorse a specific tool [9]. In LMIC healthcare facilities, the Pinard stethoscope is widely used to assess FHR during the labor period, rather than cardiotocography (the standard of care in high-resource countries) or hand-held Doppler [10]. However, several randomized controlled trials in sub-Saharan Africa have shown that Doppler is superior to Pinard stethoscope in detecting abnormal FHR [ 11 , 12 , 13 , 14 , 15 ]. And although evidence of client preferences for Doppler over Pinard is not strong, a small study in South Africa showed that laboring women preferred Doppler over Pinard for FHR monitoring [16]; and in a qualitative study in Tanzania, laboring women showed a strong preference for Doppler for continuous FHR monitoring [17]. Although further evidence is needed, a growing base of findings suggests that use of Doppler to monitor FHR during labor in the LMIC setting can improve both the quality of clinical care and women’s experience of intrapartum care.
In 2008, following a call for a joint plan to address strategies for reproductive, maternal, newborn and child health, Tanzania’s Ministry of Health (now the Ministry of Health, Community Development, Gender, Elderly and Children) developed “The National Road Map the strategic plan to accelerate the reduction of maternal, newborn and child mortality in Tanzania 2008–2015, “called One Plan [18]. The One Plan included basic objectives for emergency obstetric and neonatal care (BEmONC), such as intermittent FHR monitoring through the use of of the partograph. The Sharpened One Plan, created in 2013, emphasized obstetrics and family planning and focused on Tanzania’s western and maritime zones [19]. An evaluation of the sharpened plan showed that achievements fell short of targets; for example, the proportion of public health facilities offering BEmONC services was 45% in 2015 against a target of 70% [19].Currently, the policy framework to improve maternal and newborn care is guided by One Plan II, the country’s second national nella strategic plan, covering 2016–2020.
Tanzania’s 2013 National Service Quality Improvement Tool recommends FHR monitoring every 5 minutes when a woman is in the second stage of labor [ 20 ]. Similar to the WHO guidance, the tool does not say whether Doppler or Pinard stethoscopes should be used to monitor FHR.
The Helping Babies Breathe (HBB) training method and set of materials are designed to strengthen caregivers’ skills for neonatal resuscitation in a low-resource health setting. HBB has been used in many LIMCs to improve the quality of immediate newborn care [21]. As a capacity-building intervention in childbirth, HBB sets a precedent for scale-up that FHR monitoring in childbirth can use as a model. The Tanzanian national HBB program, which started in 2013, was scaled up to 15 of Tanzania’s (then) 25 regions with a 1-day on-site training for health care providers, provision of supplies and equipment, and post-training health care mentoring. suppliers. Expansion of HBB has been evaluated in Tanzania in terms of programmatic approach to scale-up [21], validation of training tools and methods [22, 23] and cost-effectiveness [24, 25].
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This analysis presents the views of Tanzanian high-level policymakers and subject matter experts (SMEs) on the potential use of Doppler for FHR monitoring in large-scale health facilities. The interviews revolved around the following research questions:
The study will be useful to policy makers and program implementers developing policies, protocols, guidelines and standards to improve maternity care in Tanzania and similar settings.
This qualitative study used in-depth interviews to elicit the views and opinions of maternal and newborn health policy makers and SMEs on the environment and precedents for scaling up Doppler for FHR monitoring during antenatal care in Tanzania. The analysis uses a social ecological framework to contextualize the findings.
The social ecological model has proven useful in exploring potential barriers and facilitators to health care utilization [26]. The current study uses this model to examine national, subnational and organizational factors associated with the research question, What are the barriers and facilitators
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