Effect of locally tailored clinical guidelines on intrapartum management of severe hypertensive disorders at Zanzibar's tertiary hospital (the PartoMa study)

Abstract

Objective: To estimate the effect of locally tailored clinical guidelines on intrapartum care and perinatal outcomes among women with severe hypertensive disorders in pregnancy (sHDP).

Methods: A pre-post study at Zanzibar's low-resource Mnazi Mmoja Hospital was conducted. All labouring women with sHDP were included at baseline (October 2014 to January 2015) and at 9-12 months after implementation of the ongoing intervention (October 2015 to January 2016). Background characteristics, clinical practice, and delivery outcomes were assessed by criterion-based case file reviews.

Results: Overall, 188 of 2761 (6.8%) women had sHDP at baseline, and 196 of 2398 (8.2%) did so during the intervention months. The median time between last blood pressure recording and delivery decreased during the intervention compared with baseline (P=0.015). Among women with severe hypertension, antihypertensive treatment increased during the intervention compared with baseline (relative risk [RR] 1.37, 95% confidence interval [CI] 1.14-1.66). Among the neonates delivered (birthweight ≥1000 g), stillbirths decreased (RR 0.56, 95% CI 0.35-0.90) and Apgar scores of seven or more increased during the intervention compared with baseline (RR 1.17, 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.

Conflict of interest statement

The authors have no conflicts of interest.

© 2018 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.

Figures

Figure 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].

Figure 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).

Figure 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.