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Introduction

The Safe motherhood initiative is a fundamental aspect of healthcare that was launched in 1987 with an  aim to reduce maternal mortality and ensure positive birth outcomes in developing countries(1) [1]. In many parts of the world, women face numerous challenges during childbirth. As a result, maternal and child mortality remains a global concern as the rates continue to remain high with more than 69% of maternal deaths occurring in African countries with rates ranging between 500 and 999 deaths per 100 000 live births (2) [2]. These elevated rates of maternal mortality are generally attributed to complications that arise, during pregnancy, before birth, during birth or after birth, and are commonly avoidable through appropriate interventions. WHO set as part of the 2030 Sustainable Development Goals (SDG), to reduce maternal deaths to 70 maternal deaths per 100 000 live births (1) [1]. Despite significant progress in healthcare, complications during labour and delivery continue to contribute to a substantial number of preventable deaths.  The partograph, a simple yet effective tool, has shown promising results in reducing these mortality rates during labour. Yet, its use remains relatively low in some medical facilities in Cameroon (2,3) [2,3]. This article aims to shed light on the importance of the partograph, its role in improving maternal and child health outcomes and highlights its role in reducing complications during labour.

Understanding a partograph

The partograph also known as a ‘partogram’ is a graphical tool of key data used by healthcare providers (midwives, nurses, doctors) to monitor to progress of labour. The assessment and admission of pregnant women in a health facility under normal circumstances results in the initiation of monitoring labour using the tool. The relevant measurements within this tool include statistics such as cervical dilation, foetal heart rate, duration of labour, blood pressure, pulse rate and other vital signs. It is intended to provide an accurate record of the progress in labour, by plotting these measurements against time, which is commonly recorded at an interval of one hour. If filled correctly, healthcare providers can assess the progress of labour and identify deviations from the expected progress. It permits any delay or deviation from normal to be detected quickly and treated accordingly (3,4) [3, 4]. Nevertheless, several studies reveal poor knowledge hence of this inexpensive paper printed tool in African countries(5–7). [5,6,-7]

Early Identification of Labour Progression Abnormalities and timely intervention

‘Normal labour’ may be defined as the spontaneous onset of uterine contractions that results in progressive dilatation and effacement of the cervix (7,8) [7,8]. Labour is made of different stages, and is affected by the parity of the woman.  Abnormalities that may occur during labour are said to occur either at the level of the passage (pelvis), the passenger (fetus) or the powers (contractions) (7) [7]. Any abnormality that occurs during labour places both mother and fetus at risk of mortality and morbidity. Slow or arrested labour, prolonged rupture of membranes, and fetal distress are some of the irregularities that may occur in labour. Obstructed labour, which may cause slow or arrested labour has been a major (4.1%) contributor to maternal death in African countries (8). [8]

Fortunately, one of the key benefits of the partograph is its ability to detect such deviations from normal labour progression at an early stage. By analyzing the trend of cervical dilation, descent of the fetal head, and uterine contractions, they can determine whether labour is progressing normally or if an intervention is required. When the rate of dilatation falls to the right of the expected normal labour curve depicted on the partograph, it raises an alert which requires a timely intervention by the healthcare provider to reduce adverse outcomes. Interventions such as transfer to a hospital with adequate facilities, augmentation of labour by administering oxytocin, amniotomy, or conducting emergency caesarean section when obstructed labour or prolonged labour are experienced by the woman may be performed to mitigate the current situation and ensure the safety of both the mother and child (9) [9].

Continuity of care

Accurate communication and documentation among healthcare personnel is said to improve patient care and safety through, reducing medical errors and patient injury (11) [11]. The partograph serves as a valuable communication tool among healthcare providers, enabling the entire care team to have a clear understanding of the labour progress especially during shift changes. For this reason, accurate and efficient documentation of labour is crucial. This shared decision-making approach ensures that appropriate actions are taken promptly based on the graphical representation of labour parameters.  It also makes it easier for the incoming healthcare provider to take over the management of labour seamlessly. This smooth transition in shifts promotes effective teamwork and reduces the chances of missed critical information.

Barriers to using the partograph

Despite the numerous benefits associated with the use of the partograph, and its recommendation by the WHO, (9) [9] its underutilized nature is not quite understood. While many healthcare professionals may not be familiar with the partograph and/or may not fully understand its correct usage, in a country like South Africa the law stipulates the using the tool to observe the progress of labour (10) [10]. In Ga South Municipal government health facilities located in Ghana, midwives are reported to routinely use the tool as, they exhibit a mastery of it  (11) [11] The effectiveness of this tool entirely relies on accurate and complete documentation of the woman’s labour progress. Failure to accurately efficiently and correctly use the partograph to record the necessary parameters, may provide incomplete or inaccurate information that can be misunderstood. The effective use of this tool in some African countries like Ethiopia are hampered by lack of commitment and minimal supervision, as reported by in a study conducted among midwives in public institutions in Addis Ababa  (4) [4]. Similarly, among obstetric care givers in Calabar, Nigeria, of the 58.6% of participants who reported feeling very confident in their use of the partograph, they lacked knowledge on the details of the various component of the tool (12) [12]. The poor use of this tool in other African countries has been attributed to limited training and knowledge on the use of a partograph (4,6,12) [4, 6, 12] which can lead to misinterpretation of the graph which in turn can cause improper decision-making.  ConclusionThe partograph is a simple yet valuable tool that can significantly contribute to reducing maternal and child mortality rates during labour. Its simplicity, cost-effectiveness, and ability to guide healthcare providers in decision-making make it an indispensable tool in improving birth outcomes. Despite being recommended by WHO its use across African countries is still low. By enabling healthcare providers to monitor labour progress, identify complications, and initiate timely interventions, the partograph plays a vital role in improving maternal and child health outcomes. By promoting its widespread adoption and addressing implementation challenges, we can take a significant step towards reducing maternal and neonatal mortality globally. Recommendations: –          Conduct regular training of healthcare providers on the use of the partograph. Adequately trained healthcare providers would ensure its widespread implementation and ultimately save the lives of countless mothers and children worldwide.  –          Enforce supervision and monitoring of the partograph effective use in maternities.

References

  1. Mahler H. The safe motherhood initiative: a call to action. Lancet Lond Engl. 1987 Mar 21;1(8534):668–70.
  2. iAHO_Maternal_Mortality_Regional_Factsheet.pdf [Internet]. [cited 2023 Oct 3]. Available from: https://files.aho.afro.who.int/afahobckpcontainer/production/files/iAHO_Maternal_Mortality_Regional_Factsheet.pdf
  3. Dalal AR, Purandare AC. The Partograph in Childbirth: An Absolute Essentiality or a Mere Exercise? J Obstet Gynaecol India. 2018 Feb;68(1):3–14.
  4. Hagos AA, Teka EC, Degu G. Utilization of Partograph and its associated factors among midwives working in public health institutions, Addis Ababa City Administration,Ethiopia,2017. BMC Pregnancy Childbirth. 2020 Jan 21;20(1):49.
  5. Oladapo OT, Daniel OJ, Olatunji AO. Knowledge and use of the partograph among healthcare personnel at the peripheral maternity centres in Nigeria. J Obstet Gynaecol. 2006 Jan 1;26(6):538–41.
  6. Fawole AO, Hunyinbo KI, Adekanle DA. Knowledge and utilization of the partograph among obstetric care givers in south west Nigeria. Afr J Reprod Health. 2008 Apr;12(1):22–9.
  7. Bedada KE, Huluka TK, Bulto GA, EphremYohannesRoga. Low Utilization of Partograph and Its Associated Factors among Obstetric Care Providers in Governmental Health Facilities at West Shoa Zone, Central Ethiopia. Int J Reprod Med. 2020 Jul 17;2020:3738673.
  8. World Health Organization, World Bank, United Nations Population Fund, United Nations Children’s Fund (UNICEF). Trends in maternal mortality: 1990-2015: estimates from WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division [Internet]. Geneva: World Health Organization; 2015 [cited 2024 Jan 9]. Available from: https://iris.who.int/handle/10665/194254
  9. WHO partograph cuts complications of labour and childbirth. Safe Mother. 1994;(15):10.
  10. Brits H, Joubert G, Mudzwari F, Ramashamole M, Nthimo M, Thamae N, et al. The completion of partograms: knowledge, attitudes and practices of midwives in a public health obstetric unit in Bloemfontein, South Africa. Pan Afr Med J. 2020 Aug 18;36:301.
  11. Asirifi VH. Knowledge and Utilization of the Modified WHO Partograph by Midwives at Ga South Government Health Facilities in the Greater Accra Region of Ghana [Internet] [Thesis]. Ensign Global College; 2019 [cited 2024 Jan 18]. Available from: https://repository.ensign.edu.gh/xmlui/handle/123456789/105
  12. Asibong U, Okokon IB, Agan TU, Oku A, Opiah M, Essien EJ, et al. The use of the partograph in labor monitoring: a cross-sectional study among obstetric caregivers in General Hospital, Calabar, Cross River State, Nigeria. Int J Womens Health. 2014 Oct 13;6:873–80.