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

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.

Organization of the overall PartoMa Project study team is described in the main study protocol [18]. Suffice to note that the team consists of an interdisciplinary group of scientists and clinicians, consisting of medical doctors, epidemiologists, statisticians, midwives and social scientists, the majority of whom are familiar with the Tanzanian context. The team is based on collaboration between Comprehensive Community-Based Rehabilitation in Tanzania (CCBRT), a non-governmental organization (NGO), and academic institutions in Tanzania, the Netherlands and Denmark. The PartoMa Project will be implemented in five government-run hospitals in Dar es Salaam, the largest and rapidly growing city of Tanzania. They include regional referral hospitals (Temeke, Amana and Mwananyamala) and two district hospitals (Mbagala Rangi Tatu and Sinza). Two of these hospitals will be selected purposively and followed ethnographically throughout the study. Birth attendants and women who have recently given birth in one of the five sites will be included in the co-creation part (step II) to capture contextual elements across hospital sites, including leadership, and the historical, geographical, economic, cultural and spiritual fabric. The hospitals are typical examples of overburdened urban maternity units in a lower-middle-income country, where the quality of care is impacted by lack of physical infrastructure, human resources and supplies. In 2019, the selected hospitals jointly cared for 40% of all hospital-based births in Dar es Salaam [19]. Each birth attendant typically takes care of multiple women simultaneously. Being public hospitals, they primarily serve women of lower socioeconomic backgrounds (17). Several efforts have been made to improve maternal and perinatal health in hospitals in Dar es Salaam. A public–private partnership between regional health authorities and CCBRT saw that positive changes in quality of care were related to further strengthening of health care providers’ competencies, stable access to equipment and medicine, improved data quality and decongestion of overburdened facilities. While these efforts resulted in significant improvements in the 22 health facilities participating in the initiative [19], an in-depth exploration of the mechanisms of change would be useful. Although qualitative research from the study sites is scarce, other studies focusing on Tanzanian women’s experiences of giving birth and birth attendants’ clinical practices, work conditions and perceived challenges have found examples of both respectful and disrespectful care [20,21]. These practices were mostly related to health system challenges, including difficult physical environment, lack of supportive supervision and supplies and lack of motivation among health care providers [20,22]. Furthermore, high patient flows and resource shortage are likely drivers of the dangerous coexistence of ‘too little, too late’ or and ‘too much, too soon’. These conditions underpin suboptimal care with unachievable workloads, lack of routine surveillance and underuse of the partograph as a decision-making tool during labour and doubtful caesarean section indications [23]. Birth attendants explained how suboptimal practices were outside of their control and responsibility, but caused by dysfunctional team work, insufficient support from senior colleagues and fear of being blamed by seniors and management in case of poor outcome [24,25]. As in other sub-Saharan African countries, birth attendants in Tanzania demand access to professional development, staff support and supervision, for which context-tailored clinical guidance is central [26]. Notably, in this already resource-constrained context, it is likely that COVID-19 has added to the burden on birth attendants [27]. On top of providing maternity care, birth attendants have to detect and manage COVID‐19 infection and prevent its spread with even fewer resources [28]. Overall, this leads to our initial hypothesis of how routinized socio-material practices drive suboptimal care. The PartoMa intervention has all the features of a non-linear complex intervention: it has multiple interacting components and actors, is influenced by context (including COVID-19 related changes) in all phases, seeks adaption to context, contains feedback loops and relates to multiple outcomes – as illustrated in Figure 1. Following the recommendations for developing and conducting complex intervention and implementation studies, the study team developed a programme theory, hypothesising how the intervention might instigate change, including the contextual conditions required for the changes to come about [5,29]. The programme theory is based on experiences from the PartoMa pilot study conducted in Zanzibar [14], existing context-relevant literature, informal stakeholder conversations and workshops with project team members, of which some are familiar with the study sites in Dar es Salaam. The PartoMa intervention’s programme theory. It is hypothesized that the intervention, with embedded co-creation, improves clinical practice and the desired health and health system outcomes through a reconfiguration of interacting mediators, which are divided into practice theory’s five analytical domains: Meaning, Materiality, Competence, Motivation, Relations as well as other life practices. These domains are further explained in Figure. In exploring the initial hypothesis of routinized socio-material practices driving suboptimal care, we draw on contemporary theories of social practice. Common to such theories is that they treat practices as primary units of enquiry and provide conceptual tools and language to explore and understand the actions of people from a social and structural perspective. In practice theory, it is argued that understanding how human behaviours – such as those surrounding childbirth care – take hold, is a matter of ‘understanding how the many practices that are reproduced in the course of daily life are synchronised and coordinated, and how some become more deeply embedded than others’ [30]. Practice theory thus helps us unpack everyday practices and experiences that influence birth attendants’ (dis)engagement with respectful and safe childbirth care (including current COVID-19-related practice and experience), across socio-ecological spheres of influence, space and time [31]. For this study, we draw on the social practice framework developed by Skovdal to support practice-based programme theory and research for health interventions in low-resource settings [32]. Drawing on the works of contemporary social practice theorists, Skovdal presents a two-step ‘table of questioning’ for interrogating and understanding the intersecting spheres of influence (step 1) and other everyday practices (step 2) that shape health care [30]. We draw on this framework to explore how the absence, presence or introduction of contextual factors meanings, materials, competencies, motivation and relations (social practice resources that we introduce below and in Figure 2) and other everyday practices come together to affect childbirth care. The latter allows us to recognise that birth attendants participate in a number of interwoven practices that may obstruct or support safe and respectful childbirth care [33]. We hypothesise that by involving birth attendants and stakeholders in a participatory process of modifying the PartoMa CPG (referred as the co-creation process), we are more likely to shift or reorganize the type of contextual factors, or spheres of influence, that routinize safe and respectful care at birth. Here, we elaborate on the social practice resources and other everyday practices – as far as they relate to childbirth care – that we hypothesise the intervention might affect. Overview of the expected socio-psychological mechanisms the intervention will facilitate using elements of practice theory. Meanings refer to norms, values, communitarian convictions, social representations and ideologies that circulate within the maternity units. The PartoMa intervention seeks to facilitate change in meanings. This starts with the co-creation process, which we expect will bring transparency to what is expected of a birth attendant and facilitation of social spaces for critical dialogue, which may contribute to re-negotiations of what constitutes best possible intrapartum care within the existing resource-constrained health care system. The co-creation process is also likely to facilitate ownership of both problems and solutions, allowing participants to rethink norms and values around their roles and responsibilities. Materials include ‘things’ such as tools, objects and infrastructure that make up the maternity units and the resources available. We hypothesise that the PartoMa intervention will contribute to a number of shifts in the availability of ‘materials’. Specifically, the intervention will provide birth attendants with a physical decision-support tool: the updated and co-adapted version of the PartoMa pocket book (Publichealth.ku.dk/partoma). This book constitutes material technology and is aimed to be locally achievable, practical, relevant, unambiguous, brief and easy to understand. Birth attendants in the PartoMa pilot study in Zanzibar referred to the booklet as ‘a friend in the pocket’ (unpublished data). We also believe that the co-creation process and intervention will bring about new ways of utilising existing tools and objects, including medical equipment, other CPGs, medicines, infrastructure, money and the body. The partograph has been available for many years to monitor vital signs and progress during birth. While the partograph is often exclusively seen in clinical practice as a medical record (22), the PartoMa intervention emphasizes its use as an integrated, early at a glance warning tool for the well-being of women, their babies and labour progress. Competence refers to the different understandings of childbirth care practices, as well as practical expertise, know-how and skills that birth attendants and hospitals need to perform. In addition to obtaining access to much needed resources (‘materials’), it is vital that birth attendants are aware of how to use them effectively. The PartoMa intervention aims to provide a positive, welcoming, social, safe, and enabling environment for participants to share and process information, taking ownership of previously alien or decontextualised medical information. Participants in the seminars in the PartoMa pilot study in Zanzibar referred to the training sessions as ‘therapeutic afternoons’ (unpublished data). Active participation with critical reflection was encouraged during the Zanzibar seminars, for instance regarding how to provide best possible triage as each birth attendant cares for multiple labouring women simultaneously. The PartoMa intervention integrates common routine and emergency care as well as guidance for how to prioritize, which in Zanzibar increased clinical knowledge, competencies, and skills in decision-making during intrapartum care [14]. Motivation refers to desires and visions that drive and direct people and organisations to engage with a practice. We hypothesise that co-creation as well as the participatory format of the training seminars will lead to increased intrinsic ownership and motivation to practice childbirth care in a different way [34]. Further, we hope that participants will invest themselves in the process and thereby take ownership. The participatory processes and the intervention itself may facilitate ‘bottom-up’ insights and formulations of positive social actions to improve childbirth care, and foster solidarity and the motivation needed to act, care and support shifts in the practice of childbirth care. In Tanzania, birth attendants’ motivation to engage in performance enhancing activities has been linked to financial gains [35]. A remarkable finding from the PartoMa pilot study in Zanzibar, however, was that ‘low-dose, high-frequency training’ which took place outside working hours, without per diems or allowances, still had a consistently high attendance rate (an average of 60–70% of staff) [14]. It thus appeared that birth attendants chose to participate in seminars not because it provided them with extrinsic material rewards, but because it created immaterial intrinsic rewards. Active participation of birth attendants in the training seminars is further expected to have a positive influence on their commitment and job-satisfaction [36]. Related to adult learning theory, it may even be argued that attending during their free time without allowances, amplified the birth attendants’ experience of self-directed learning, meaning that their gain in knowledge and skills was largely within their control and a free choice, thereby enhancing their striving and acceptance of a personal responsibility for own learning [37]. We hypothesise that this ‘new’ enabling environment with increased intrinsic motivation will also affect birth attendants who do not participate in the co-creation process as well as non-users of the intervention. Relations refer to the quality of relationships, partnerships, formal and informal networks, and group dynamics that characterise the maternity units. We hypothesize that the intervention will bring a change in social relations – both among birth attendants and the relationship they have with the women giving birth. A crucial assumption of the PartoMa intervention is that the social practice of interdisciplinary teamwork is key to obtaining changes in care, considering constraints in human resources. Through the participatory approach, birth attendants may experience an increased sense of being heard and understood. The blame-free, social space for critical dialogue and learning is expected to bring appreciation of colleagues doing well as role models and supervisors. Birth attendants participate in a number of interwoven life practices that may obstruct or support their clinical practices, e.g. many of the primarily female birth attendants have profound family obligations or additional employment in the private sector, which is likely to influence their work in public hospitals [38]. Having to stay after work for the PartoMa seminars might have a negative influence on family obligations and finances. On the other hand, we expect that an enabling working environment will positively influence other social practices in, during- and outside clinical practice. The programme theory led to developing the four-step study design (Table 1). Together, these investigations will help build a comprehensive understanding of the development and implementation process and impact as well as scalability and replicability analyses of the PartoMa Scale-up Study. While the overall study design for each step is presented in the general protocol [39], we here focus in-depth on the qualitative components. Overview of the four steps of the PartoMa scale-up study (I. situational analysis, II. Co-Creation, III. Intervention, and IV. Development of a framework based on findings) and the qualitative components associated with each phase

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