From training to workflow: a mixed-methods assessment of integration of Doppler into maternity ward triage and admission in Tanzania

# Background Globally, an estimated 2.7 million neonates died in 2015 during the neonatal period, including approximately 0.7 million intrapartum deaths. In Tanzania, 46,000 neonates died in 2016. Nearly two-thirds of these deaths could have been prevented through improvements in quality of care at the time of delivery. Scaling up the use of Doppler for fetal assessment may support such improvements. We describe and assess the inputs and processes used to integrate Doppler into the workflow of maternal triage upon admission to Tanzanian labor and delivery wards. # Methods We conducted a mixed-methods study on the inputs and processes used to integrate Doppler use into the workflow of maternal triage upon admission to maternity services. Our study took place in 10 health facilities in Kagera Region, Tanzania, from November 2016 to April 2017. We trained providers on using the Doppler and assessed the logistical and resource inputs needed to integrate the Doppler into routine care. To assess the transfer of knowledge and skills, we administered pre- and post-assessments at the time of training and then observed providers in practice 6 months after the training. **Results** We trained 163 providers to use the Doppler and record initial fetal heart rates in the facility registry; 87 providers underwent observation while triaging 112 women for admission to maternity services. Providers' mean knowledge score increased significantly from pre-test to post-test. Twelve percent of the providers failed the 15-question, objective structured clinical examination on their first try, but all passed upon coaching and remediation. The average admission took 30.6 minutes, 4.1 minutes of which were used to assess fetal heart rate using the Doppler (including locating and using the device and storing and recording the results). # Conclusions The training sessions effectively conveyed knowledge and skills for integrating the Doppler into routine triage and admission workflows. This bodes well for the potential scale-up of Doppler use in labor and delivery services. Findings on structural needs indicated that minimal resource inputs will likely be required to maintain the use of the device in practice.