Scale-Up of Doppler to Improve Intrapartum Fetal Heart Rate Monitoring in Tanzania: A Qualitative Assessment of National and Regional/District Level Implementation Factors.

Marya Plotkin,John George,Kavita Singh,Barbara Rawlins,Rohit Ramaswamy,Ruth Lemwayi,Gaudiosa Tibaijuka,Dunstan Bishanga,Lusekelo Njonge,Felix Bundala,Stephanie Wheeler,Mary Drake

doi:10.3390/ijerph17061931

Abstract

High-quality intrapartum care, including intermittent monitoring of fetal heart rates (FHR) to detect and manage abnormalities, is recommended by WHO and the Government of Tanzania (GoT) and creates potential to save newborn lives in Tanzania. Handheld Doppler devices have been investigated in several low-resource countries as an alternative to Pinard stethoscope and are more sensitive to detecting accelerations and decelerations of the fetal heart as compared to Pinard. This study assessed perspectives of high-level Tanzanian policymakers on facilitators and barriers to scaling up use of the hand-held Doppler for assessing FHR during labor and delivery. From November 2018–August 2019, nine high-level policymakers and subject matter experts were interviewed using a semi-structured questionnaire, with theoretical domains drawn from Proctor’s implementation outcomes framework. Interviewees largely saw use of Doppler to improve intrapartum FHR monitoring as aligning with national priorities, though they noted competing demands for resources. They felt that GoT should fund Doppler, but prioritization and budgeting should be driven from district level. Recommended ways forward included learning from scale up of Helping Babies Breathe rollout, making training approaches effective, using clinical mentoring, and establishing systematic monitoring of outcomes. To be most effective, introduction of Doppler must be concurrent with improving case management practices for abnormal intrapartum FHR. WHO’s guidance on scale-up, as well as implementation science frameworks, should be considered to guide implementation and evaluation.

Highlights

An estimated 2.1 million early neonatal deaths and 2.6 million stillbirths occurred in2015, including 1.3 million intrapartum stillbirths [1]
Because abnormal fetal heart rate (FHR) is a potential predicator of newborn asphyxia, FHR monitoring is important for quality intrapartum care
Several interviewees felt that the local government and the central government and implementing partners (Tanzanian and international civil society organizations) should share responsibility for purchasing Dopplers, most stressed that Dopplers should be purchased with district or facility funds

Summary

Introduction

An estimated 2.1 million early neonatal deaths and 2.6 million stillbirths occurred in2015, including 1.3 million intrapartum stillbirths [1]. In Tanzania, studies have provided strong evidence of fetal heart abnormalities as a predictor of fresh stillbirth, birth asphyxia, and newborn death [7]. Improvements to intrapartum monitoring have had demonstrated results, as in a 1989 study in southwest Tanzania where an intervention related to intrapartum monitoring was associated with a reduction of perinatal mortality from 71 to 39 deaths per 1000 births [8]. Despite this evidence, quality of intrapartum FHR monitoring, both upon admission to labor and delivery services and intermittently throughout labor, is often poor in Tanzania [6]

Methods

Results

Discussion

Conclusion