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In their recent commentary, Hofmeyr et al. anticipate that departure from the familiar partograph 'may provoke anxiety and even antipathy among healthcare professionals'.1 We agree that change is urgently needed to reach beyond the coexistence of "too little, too late" and "too much, too soon" care during childbirth.2 In particular, we applaud the World Health Organization (WHO) for their underlying Better Outcomes in Labour Difficulty (BOLD) project, which has revealed the urgency of delaying the onset of the active phase of the first stage of labour from 3-4 cm of cervical dilatation to at least 5 cm.3 We do agree that the previously premature designation was 'a major iatrogenic cause of apparent poor labour progress and unnecessary interventions', which has contributed to the epidemic of caesarean sections in many countries globally.1 For the Labour Care Guide (LCG) to catalyse change, we urge the WHO to consider three major concerns, relevant for labour practice, before any further LCG implementation. World Health Organization partograph in management of labour. As the LCG stands now, the new "partograph" may work in private practice with one-to-one care, a birth companion present and pain relief available. [Extracted from the article]

Objective: To evaluate effect of locally tailored labour management guidelines (PartoMa guidelines) on intrahospital stillbirths and birth asphyxia.Design: Quasi-experimental pre-post study investigating the causal pathway through changes in clinical practice.Setting: Tanzanian low-resource referral hospital, Mnazi Mmoja Hospital.Population: Facility deliveries during baseline (1 October 2014 until 31 January 2015) and the 9th to 12th intervention month (1 October 2015 until 31 January 2016) [corrected].Methods: Birth outcome was extracted from all cases of labouring women during baseline (n = 3690) and intervention months (n = 3087). Background characteristics and quality of care were assessed in quasi-randomly selected subgroups (n = 283 and n = 264, respectively).Main Outcome Measures: Stillbirths and neonates with 5-minute Apgar score ≤5.Results: Stillbirth rate fell from 59 to 39 per 1000 total births (RR 0.66, 95% CI 0.53-0.82), and subanalyses suggest that this was primarily due to reduction in intrahospital stillbirths. Apgar scores between 1 and 5 fell from 52 to 28 per 1000 live births (RR 0.53, 95% CI 0.41-0.69). Median time from last fetal heart assessment till delivery (or fetal death diagnosis) fell from 120 minutes (IQR 60-240) to 74 minutes (IQR 30-130) (Mann-Whitney test for difference, P < 0.01). Oxytocin augmentation declined from 22% to 12% (RR 0.54, 95% CI 0.37-0.81) and timely use improved.Conclusion: Although low human resources and substandard care remain major challenges, PartoMa guidelines were associated with improvements in care, leading to reductions in stillbirths and birth asphyxia. Findings furthermore emphasise the central role of improved fetal surveillance and restricted intrapartum oxytocin use in safety at birth. TWEETABLE ABSTRACT: #PartoMa guidelines aided in reducing stillbirths and birth asphyxia at a Tanzanian low-resource hospital PLAIN LANGUAGE SUMMARY: PartoMa guidelines help birth attendants in Tanzania to save lives Every year, 3 million babies die on the day of birth. The vast majority of these deaths occur in the poorest countries. If their mothers had received better care during birth, most babies would have survived. At Mnazi Mmoja Hospital, an East African referral hospital, the PartoMa study shows that use of locally developed guidelines helps birth attendants to deliver better quality of care, which has led to improved survival at birth. At the hospital studied, resources are scarce. Each birth attendant assists four to six birthing women simultaneously, and many have less than 1 year of professional experience. International guidelines are available, but they are often unachievable and seldom applied. The PartoMa guidelines were developed in close collaboration with the birth attendants and approved by seven international experts. The result is an 8-page pocket booklet providing locally achievable and simple decision support for care during birth. Use of the PartoMa guidelines began in February 2015. As the staff group frequently changes, quarterly seminars are conducted where birth attendants are welcomed after working hours to learn about the guidelines. The guidelines have been positively received, and seminar attendance remains high. Use of the PartoMa guidelines is associated with: A decrease by one-third in stillbirths (59 to 39 per 1000 total births) A nearly halving in the number of babies born in immediate poor medical condition (52 to 28 per 1000 live births) The results presented here derive from a comparison of births before using the PartoMa guidelines and during the 9th-12th month of use. Such a 'before-after' study cannot exclude the possibility of other causes of better survival at birth. However, the improved survival is consistent with improved care during birth, which is in line with the PartoMa guidelines. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Drost E, van Lonkhuijzen L, Meguid T, Landis Lewis D, Zeeman G. Implementing safe motherhood: a low-cost intervention to improve the management of eclampsia in a referral hospital in Malawi. BJOG 2010;117:1553-1557. We evaluated the effect of so-called monitoring and treatment charts on the management of eclampsia in a referral hospital in Malawi. Baseline characteristics, clinical management, as well as overall maternal and perinatal outcome were compared by reviewing the medical files of two groups, before and after introduction of the charts in 2006. The use of the charts has resulted in improved monitoring of women with eclampsia and may have contributed to the reduction in the planned prelabour caesarean section rate from 87% to 33%, as more women underwent induction of labour after stabilisation ( P = 0.020). Overall maternal and perinatal outcomes were similar. [ABSTRACT FROM AUTHOR]