Scaling up Locally Adapted Clinical Practice Guidelines for Improving Childbirth Care in Tanzania: A Protocol for Programme Theory and Qualitative Methods of the PartoMa Scale-up Study

ABSTRACT

Effective, low-cost clinical interventions to improve facility-based care during childbirth are critical to reduce maternal and perinatal mortality and morbidity in low-resource settings. While health interventions for low- and lower-middle-income countries are often developed and implemented top-down, needs and circumstances vary greatly across locations. Our pilot study in Zanzibar improved care through locally co-created intrapartum clinical practice guidelines (CPGs) and associated training (the PartoMa intervention). This intervention was context-tailored with health-care providers in Zanzibar and now scaled up within five maternity units in Dar es Salaam, Tanzania. This PartoMa Scale-up Study thereby provides an opportunity to explore the co-creation process and modification of the intervention in another context and how scale-up might be successfully achieved. The overall protocol is presented in a separate paper. The aim of the present paper is to account for the Scale-up Study’s programme theory and qualitative methodology. We introduce social practice theory and argue for its value within the programme theory and towards qualitative explorations of shifts in clinical practice. The theory recognizes that the practice we aim to strengthen – safe and respectful clinical childbirth care – is not practiced in a vacuum but embedded within a socio-material context and intertwined with other practices. Methodologically, the project draws on ethnographic and participatory methodologies to explore current childbirth care practices. In line with our programme theory, explorations will focus on meanings of childbirth care, material tools and competencies that are being drawn upon, birth attendants’ motivations and relational contexts, as well as other everyday practices of childbirth care. Insights generated from this study will not only elucidate active ingredients that make the PartoMa intervention feasible (or not) but develop the knowledge foundation for scaling-up and replicability of future interventions based on the principles of co-creation and contextualisation.

KEYWORDS:

• Practice theory
• obstetrics
• intervention
• co-creation
• respectful maternity care

Responsible Editor Julia Schröders

Responsible Editor Julia Schröders

Acknowledgments

We acknowledge the birth attendants working in low-resource settings as well as the women giving birth in sometimes difficult contexts. Especially, we recognize the doctors and nurse-midwives in charge of the five study sites and birth attendants and women playing a tremendous part of this study.

Author contributions

JBS drafted the manuscript. All authors have been involved in co-creating this study design, have critically reviewed the manuscript and approved the final version.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethics and consent

Ethical approval is obtained from the Tanzanian National Institute of Medical Research (NIMR/HQ/R.8a/Vol. IX/3324, NIMR/HQ/R.8c/Vol. I/1679, NIMR/HQ/R.8c/Vol. I/926). Research permits are obtained from the Tanzania Commission of Science and Technology, the regional and district medical officers in Dar es Salaam and participating hospitals. A data management agreement has been signed by the partners involved in storing and analysing data. The study is registered in ClinicalTrials.gov (NCT04685668). Further ethical considerations are presented in the paper.

Paper context

Context-appropriate, co-created clinical practice guidelines to ensure safe and respectful care during birth in low resource settings are crucial. The PartoMa Project aims to scale up co-created clinical practice guidelines developed in the pilot study phase. The project responds to the need for models of how to facilitate and achieve contextualised, co-created clinical practice guidelines at scale. This protocol presents the programme theory and qualitative methods applied to the PartoMa Project.

Additional information

Funding

The overall PartoMa Scale-up Study in Dar es Salaam is supported by the Danida Fellowship Centre (DFC), Ministry of Foreign Affairs of Denmark (DFC file no. 18-08-KU,Enabling best possible childbirth care in Tanzania). Additional funding for embedded sub-studies has been granted by the Laerdal Foundation for Acute Medicine;, Faculty of Health and Medical Sciences, University of Copenhagen, UNICEF, Global Affairs Canada, Comprehensive Community-Based Rehabilitation in Tanzania (CCBRT), Thorvald Madsens Legat, and Reinholdt W. Jorck og Hustrus Fond;