20 October 2017

Fewer stillbirths at East African hospital following introduction of childbirth guidelines

Childbirth guide

In collaboration with the health staff at Zanzibar’s main hospital, Danish researchers have developed and introduced a short guide on childbirth care. The booklet seems to have had a significant effect, according to new research from the University of Copenhagen. After the guidelines were introduced, the number of stillbirths at the hospital fell by 33 per cent. The study reveals an opportunity to customise clinical guidelines more effectively to low-income countries, according to the researchers.

Health care professional with the PartoMa guide in hand (Photo: Rune Maaløe Andersen)

Worldwide, more than three million children die each year on the day they are born – either during birth or shortly afterwards. If their mothers had received acceptable care during childbirth, almost all of these children would be alive, fit and healthy. This is particularly a problem in low-income countries in Africa, where there is alarming pressure on the stretched healthcare systems. For example, in Zanzibar’s main hospital, Mnazi Mmoja Hospital, each doctor or midwife assists an average of four to six women in labour simultaneously.

However, researchers from the University of Copenhagen in cooperation with local health staff at Mnazi Mmoja Hospital have conducted an inexpensive project, which holds considerable promise. They have developed a brief and easy-to-understand childbirth guide tailored to the local reality, the PartoMa guidelines. After the guide was introduced, the number of stillbirths has fallen by 33 per cent, and the number of newborns in obvious poor health has almost been halved. The findings have just been published in the British Journal of Obstetrics and Gynaecology.

“The international guidelines available were often too complicated, time-consuming and resource-demanding for the health staff at Mnazi Mmoja Hospital - they gathered dust on the shelves in the hectic maternity ward, where the staff desperately need knowledge, yet barely knew that the guidelines existed. Therefore, we developed the simple PartoMa childbirth guide, where the dogma is that our recommendations should be possible to follow under the conditions which are found at this overstretched hospital where resources are in short supply,” says the main author of the study, Nanna Maaløe, a PhD student at the Global Health Section at the Department of Public Health, University of Copenhagen.

About the study

The researchers assessed the quality of care during childbirth by reviewing patients’ case files and measured the number of stillbirths and newborn children in poor health on two occasions: First for a four-month period before the childbirth guide was introduced, a total of 3,690 births. Then the researchers conducted further assessments from the ninth until the twelfth month after the guide was introduced at the hospital, a total of 3,087 births.


Between the first and second period, the number of stillbirths fell from 59 to 39 children per 1,000 total births.


Between the first and second period, the number of newborn infants showing immediate obvious signs of poor health fell from 52 to 28 children per 1,000 live births.


Between the first and second period, the quality of care provided during childbirth improved. Among other things, the children’s heartbeat was registered more frequently in the second period, and labour-augmenting drugs were used more correctly and safely. 

Eight-pages of hands-on advice
The guide comprises an eight-page pocket booklet, and it was developed in cooperation with the local doctors and midwives at Mnazi Mmoja Hospital. In addition, it was approved by seven international experts in obstetric care in order to quality-assure the content. Much of the work has involved making international recommendations more specific, simple and practical. And it looks as though it is saving human lives.

The researchers measured the number of stillbirths over a four-month period prior to phasing in the guidelines. Next, the guidelines were implemented through reoccurring quarterly afternoon seminars where the staff practiced on it’s use. Then, the number of stillbirths was measured for four months after introduction. Other factors may have had an impact on the fall in the number of stillbirths, but the researchers also demonstrated improvements in the quality of childbirth care in accordance with the guidelines in the pocket booklet and found a halving of numbers of newborns with immediate signs of poor health. This indicates also that the childbirth guidelines had a significant effect.

“The quality of childbirth care and the number of staff assisting births at Mnazi Mmoja Hospital remains heartbreakingly poor. However, we are seeing promising signs of improvement after the introduction of the PartoMa guidelines. This is a good example of how far we can get by using existing resources more effectively. It’s a good idea to look at whether tailoring clinical guidelines to local conditions in the form of an easily accessible pocket booklet can also be used elsewhere in low-income countries,” says Ib Christian Bygbjerg, professor of international health and co-author of the study.

Pocket booklet still in use
In Zanzibar, the childbirth guide is still used at Mnazi Mmoja Hospital, even though the research project was concluded some time ago, and the researchers and health staff are now collaborating on a second edition.

“We’re still using the guide after more than two and a half years. Our employees, particularly the younger doctors, tell us that it helps them provide better health care. Other health facilities in Zanzibar are also showing an interest in the guidelines,” says Tarek Meguid, a consultant obstetrician at Mnazi Mmoja Hospital, who also advised on and co-authored the study.

The study was supported by the Lundbeck Foundation, the Laerdal Foundation and the Augustinus Foundation.

Read the full study “Effect of locally tailored labour management guidelines on intrahospital stillbirths and birth asphyxia at the referral hospital of Zanzibar: a quasi-experimental pre-post study”