Institute of Health and Society, Department of Community Medicine and Global Health, Faculty of Medicine, University of Oslo, Oslo, Norway.
Department of Obstetrics and Gynaecology, Sekotoure Regional Referral Hospital, Mwanza, Mwanza Region, Tanzania.
Reprod Health. 2018 Jan 27;15(1):14. doi: 10.1186/s12978-018-0463-1.
Making use of good, evidence based routines, for management of normal childbirth is essential to ensure quality of care and prevent, identify and manage complications if they occur. Two essential routine care interventions as defined by the World Health Organization are the use of the Partograph and Active Management of the Third Stage of Labour. Both interventions have been evaluated for their ability to assist health providers to detect and deal with complications. There is however little research about the quality of such interventions for routine care. Qualitative studies can help to understand how such complex interventions are implemented. This paper reports on findings from an observation study on maternity wards in Tanzania.
The study took place in the Lake Zone in Tanzania. Between 2014 and 2016 the first author observed and participated in the care for women on maternity wards in four rural and semi-urban health facilities. The data is a result of approximately 1300 hours of observations, systematically recorded primarily in observation notes and notes of informal conversations with health providers, women and their families. Detailed description of care processes were analysed using an ethnographic analysis approach focused on the sequential relationship of the 'stages of labour'. Themes were identified through identification of recurrent patterns.
Three themes were identified: 1) Women's movement between rooms during birth, 2) health providers' assumptions and hope for a 'normal' birth, 3) fear of poor outcomes that stimulates intervention during birth. Women move between different rooms during childbirth which influences the care they receive. Few women were monitored during their first stage of labour. Routine birth monitoring appeared absent due to health providers 'assumptions and hope for good outcomes. This was rooted in a general belief that most women eventually give birth without problems and the partograph did not correspond with health providers' experience of the birth process. Contextual circumstances also limited health worker ability to act in case of complications. At the same time, fear for being held personally responsible for outcomes triggered active intervention in second stage of labour, even if there was no indication to intervene.
Insufficient monitoring leads to poor preparedness of health providers both for normal birth and in case of complications. As a result both underuse and overuse of interventions contribute to poor quality of care. Risk and complication management have for many years been prioritized at the expense of routine care for all women. Complex evaluations are needed to understand the current implementation gaps and find ways for improving quality of care for all women.
利用良好的、基于证据的常规方法来管理正常分娩对于确保护理质量以及预防、识别和处理并发症至关重要。世界卫生组织定义的两项基本常规护理干预措施是使用产程图和积极管理第三产程。这两项干预措施都经过了评估，以评估其帮助卫生保健提供者检测和处理并发症的能力。然而，关于此类常规护理干预措施的质量的研究很少。定性研究可以帮助我们了解此类复杂干预措施的实施情况。本文报告了坦桑尼亚妇产病房观察研究的结果。
该研究在坦桑尼亚的湖区进行。在 2014 年至 2016 年期间，第一作者观察并参与了四家农村和半城市卫生机构的产妇病房的妇女护理。该数据来自大约 1300 小时的观察记录，主要以观察记录和与卫生保健提供者、妇女及其家属进行的非正式对话记录的形式记录。使用以产程的“阶段”的顺序关系为重点的民族志分析方法分析了护理过程的详细描述。通过识别反复出现的模式来确定主题。
确定了三个主题：1）妇女在分娩过程中在房间之间的移动，2）卫生保健提供者对“正常”分娩的假设和希望，3）对不良结果的恐惧刺激分娩时的干预。妇女在分娩过程中在不同的房间之间移动，这会影响她们所接受的护理。很少有妇女在第一产程期间受到监测。由于卫生保健提供者“对良好结果的假设和希望”，常规分娩监测似乎不存在。这源于一种普遍的信念，即大多数妇女最终都会顺利分娩，并且产程图与卫生保健提供者对分娩过程的经验不符。背景情况也限制了卫生工作者在出现并发症时采取行动的能力。与此同时，对因结果而承担个人责任的恐惧触发了第二产程的积极干预，即使没有干预的迹象。
监测不足导致卫生保健提供者对正常分娩和并发症都准备不足。因此，干预措施的使用不足和过度使用都会导致护理质量下降。多年来，风险和并发症管理一直优先于所有妇女的常规护理。需要进行复杂的评估，以了解当前实施差距，并找到改善所有妇女护理质量的方法。
