title: Midwives' intrapartum monitoring process and management resulting in emergency referrals in Tanzania: a qualitative study.
abstract: BACKGROUND
  In the United Republic of Tanzania, the maternal mortality ratio, and neonatal mortality rate have remained high for the last 10 years. It is well documented that many complications of pregnancy are avoidable by providing skilled midwifery care during and immediately after childbirth. However, there have been delays in providing timely and necessary obstetric interventions, most likely due to lack of proper monitoring during labor. Yet, there has been little research concerning how midwives monitor the process of childbirth. Therefore, this study aimed to describe how midwives monitored and managed the process of childbirth to achieve early consulting and timely referral to obstetricians.
  
  
  METHODS
  The design was qualitative and descriptive, using data from comprehensive semi-structured interviews of midwives. The interviews were conducted at one hospital and one health center in Dar es Salaam, Tanzania's largest city. Eleven participants were purposively recruited and interviewed about their experiences managing complicated intrapartum cases. After the interviews, data were analyzed using content analysis.
  
  
  RESULTS
  Derived from the data were three activity phases: initial encounter, monitoring, and acting. During these phases, midwives noticed danger signs, identified problems, revised and confirmed initial problem identification, and organized for medical intervention or referral. The timing of taking action was different for each midwife and depended on the nature of the prolonged and obstructed labor case.
  
  
  CONCLUSIONS
  For the majority of midwives, the processing of assessments and judgments was brief and without reflection, and only a few midwives took time to continue to monitor the labor after the initial identification of problems and before taking actions. To make a final judgment that the labor was becoming prolonged or obstructed, midwives should consider taking time to review and synthesize all their findings.
authors.affiliation: Doctoral Program, St. Luke's International University, 10-1, Akashi-cho, Chuo-ku, Tokyo, 104-0044, Japan. 14DN008@slcn.ac.jp.
authors.forename: Kana
authors.initials: K
authors.lastname: Shimoda
authors.affiliation: School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. seolesh@yahoo.com.
authors.forename: Sebalda
authors.initials: S
authors.lastname: Leshabari
authors.affiliation: St. Luke's International University, Tokyo, Japan. shigeko-horiuchi@slcn.ac.jp.|St. Luke's Birth Clinic, Tokyo, Japan. shigeko-horiuchi@slcn.ac.jp.
authors.forename: Shigeko
authors.initials: S
authors.lastname: Horiuchi
authors.affiliation: St. Luke's International University, Tokyo, Japan. yoko-shimpuku@slcn.ac.jp.
authors.forename: Yoko
authors.initials: Y
authors.lastname: Shimpuku
authors.affiliation: St. Luke's International University, Tokyo, Japan. junko-tashiro@slcn.ac.jp.
authors.forename: Junko
authors.initials: J
authors.lastname: Tashiro
mesh_terms: D003657:Decision Making; D003906:Developing Countries; D004420:Dystocia / Q000175:diagnosis* / Q000628:therapy; D004630:Emergencies; D005260:Female; D005323:Fetal Monitoring; D006340:Heart Rate, Fetal; D006801:Humans; D007747:Labor Stage, First / Q000502:physiology*; D008880:Midwifery / Q000379:methods*; D008991:Monitoring, Physiologic; D036801:Parturition / Q000502:physiology*; D010388:Pelvis / Q000033:anatomy & histology; D011247:Pregnancy; D036301:Qualitative Research; D012017:Referral and Consultation; D013636:Tanzania