Utilization of Partograph during Labour and Birth Outcomes at Jimma University

Sena Belina Kitila; Abebe Gmariam; Ashagire Molla; Gugsa Nemera

doi:10.4172/2376-127X.1000101

ISSN: 2376-127X

Journal of Pregnancy and Child Health

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Utilization of Partograph during Labour and Birth Outcomes at Jimma University

*Sena Belina Kitila^1, Abebe Gmariam², Ashagire Molla¹ and Gugsa Nemera¹**
¹Principal Investigator, Department of Nursing and Midwifery, College of Public Health and Medical, Jimma University, Ethiopia
²Department of Population and Family health, College of Public Health and Medical, Jimma University, Ethiopia
Corresponding Author :	Sena Belina Kitila Lecturer, Principal Investigator Department of Nursing and Midwifery College of Public Health and Medical Jimma University, Ethiopia E-mail: Senabalina26@gmail.com
Received March 29, 2014; Accepted June 04, 2014; Published June 11, 2014
Citation: Kitila SB, Gmariam A, Molla A, Nemera G (2014) Utilization of Partograph during Labour and Birth Outcomes at Jimma University. J Preg Child Health 1:101. doi: 10.4172/2376-127X.1000101
Copyright: © 2014 Kitila SB, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Background: Globally, at least 585,000 women die each year with complications of pregnancy and child birth. This high level of maternal morbidity and mortality has been remained as big challenge in developing countries and there is a woman who dies of pregnancy and birth related complication every minute passes. Majority of these deaths and complications could be prevented by cost-effective and affordable health interventions like utilization of partograph; a graphic representation of progress of labour, maternal and fetal conditions in relation to time. The aim of this study is to identify the extent of utilization of partograph and birth outcomes at Jimma University Specialized Hospital.

Methods and Materials: Cross sectional retrospective study which involved quantitative methods of data collection was employed from February to March 2012. A total of 340 delivery records were reviewed from 7 years records selected by systematic sampling method using pre-tested structured check list.

Results: Of 340 reviewed delivery records 274/340(80.6%) files had partograph attached. However; utilized in only 19 (6.9%) of the records and some of fetal, labour and maternal parameters were correctly documented in 10.5%.

Conclusion and Recommendation: Utilization of partograph and documentation of the key events were poor. Hence, relevant authorities have to facilitate its actual availability, develop a system for its routine utilization and efforts should be made to maintain a high index of its utilization.

Keywords

Partograph; Labour; Utilization of partograph; Jimma University Specialized Hospital

Abbreviations

ACOG: American College of Obstetricians and Gynecologists; ANC: Antenatal Care; BP: Blood Pressure; CEmOC: Comprehensive Emergency Obstetric Care; C/S: Cesarean Section; FHR: Fetal Heart Rate; FMC: Federal Medical Center; GA: Gestational Age; GNS: Garnering National Support; HEWs: Health Extension Workers; HSU: Health Service Utilization; IOES: Internal and Obstetrics Emergency Surgeon; IUFD: Intra Uterine Fetal Death; JU: Jimma University; JUSH: Jimma University Specialized Hospital; KAP: Knowledge Attitude Practice; MDs: Medical Doctors; MGDs: Millennium Development Goals; MNHP: Maternal and Neonatal Health Program; MOH: Ministry of Health; NDUTH: Niger Delta University Teaching Hospital, NGO: Non-Governmental Organization; PEN: Predisposing Enabling Need; PMTCT: Prevention of Mother To Child Transmission; PPH: Post-Partum Hemorrhage; SMDP: Safe Motherhood Demonstration Project; SNNP: Southern Nations, Nationalities and People; SVD: Spontaneous Vaginal Delivery; WHO: World Health Organization

Introduction

Globally, at least 585, 000 women die each year with complications of pregnancy and child birth [1]. This high level of maternal morbidity and mortality has been remained as big challenge in developing countries and there is a woman who dies of pregnancy and birth related complication every minute passes [2]. Majority of these deaths and complications could be prevented by cost-effective and affordable health interventions like utilization of partograph [3-6].

Partograph is a universal tool for monitoring progress of labour. It is a pre-printed paper form on which labour progress observations are recorded [7,8]. It was initially introduced by Philpot; and endorsed by WHO as simple and accurate instrument for early recognition of complications of labour [9]. It gained popularity since 1970’s and today most labor and delivery wards use it [8]. As many partographs have been developed that of WHO is arguably the most popular and serves as a standard both in developed and developing countries [1,2].

The aim of the partograph is to provide a pictorial overview of labour to alert care providers to deviations in labour progresses, maternal and fetal wellbeing [10-12]. If used effectively it helps to ensure careful monitoring of the woman in labour, avoids unnecessary interventions, recognizes and responds to complications in a timely manner all of which can help to prevent maternal and neonatal morbidity and mortality [13-16]. It also serves as an “early warning system” and a simple method valuable in preventing prolonged and obstructed labour, those are sources of many maternal deaths and disabilities such as infection, obstetric fistula and nerve injuries, as well as stillbirths, neonatal deaths due to asphyxia and long-term disabilities [16,17].

It is one of the most appropriate technologies in the developing world for intrapartum management and helps for easily identification of prolonged and/or obstructed labour, which accounts for about 8% of maternal deaths to know when to take appropriate actions that results in reduction of duration of labor by 3%, augmentation by 11%, PPH by 5%, assisted delivery by 0.9% and increase SVD by 2% [3,15-22]. Even though the overall use of it in East African was very low, only 14% of the records of mothers monitored with partograph had correct documentation of the key events of labour [5].

Methods, Materials and Subjects

Facility based cross-sectional study design with both quantitative and qualitative methods of data collection was employed from February to March 2012 at Jimma University Specialized Hospital which is one of the oldest public hospitals established in 1937 as Jimma hospital, located in Jimma city 352 Kms South West of Addia Ababa. It is the only teaching and referral hospital in the South Western part of the country. It provides services for approximately 9000 inpatient and 80000 outpatient attendies a year coming from the catchment population of about 15,000 million people. The hospital has different departments those renders comprehensive health services by care providers from different departments and professional levels. Currently owing to the fast growing service and teaching role of the hospital, the construction of a new level best hospital which is basement started in 2008 [23,24].

The population for the study is all delivery records used at JUSH from January 2005 - December 2011. The study population were all selected 340 delivery records from 1st January 2005 - 31st December 2011 purposely based on endorsement of MDG in Ethiopian to assess the level of utilization of partograph.

The data was collected through record review using pre tested structured check lists. The procedure of data collection from records was: looking for the files, reviewing the files for presence of partograph in it and whether used or not, if partograph is not used checking for maternal identifications, birth outcomes and qualification of care provider who conducted the delivery and if used checking for maternal identifications, labour, fetal and maternal parameters, the standards of key events managements, birth outcomes, profession and qualification of care provider who conducted the delivery.

Prior to analysis, data cleaning, coding, checking for normality, completeness was done, then data was entried in to SPSS version 16.0. Descriptive statistics was computed to determine the proportion of utilization. Bivariate analysis (chi square test) was carried out between the dependant and independent variables to determine their association. Binary logistic regression analysis was made to obtain odds ratio and the CI for statistical association variables. And multivariable logistic regression analysis was carried out to assess strength of statistical association (AOR) of utilization of partograph with health care providers, maternal and health care facility related variables. The strength of statistical association was measured by adjusted odds ratios at 95% confidence intervals. Statistical significance is declared at P<0.05. Finally the result was presented using tables, figures and charts.

Results

The data were compiled from 340 records of mothers’ delivered at the hospital. The results are presented under subheadings as follows.

Maternal characteristics

One hundred seventy nine (52.6%) of mothers were in age group between 15-24 years, 207(60.9%) were multiparous, 152 (44.7%) come to the hospital before 12 hours of onset of labour, 221(65.0%) were before rupture of membrane, 179(52.6%) had gestational age of less than or equals to 37 weeks and 57 (16.8%) had at least one bad obstetric history (Table 1).

Utilization of partograph and documentation of key parameters

Out of the total 340 reviewed maternal records, partograph was present in 274(80.6%) of the files but only utilized for 19/274 (6.9%) mothers. Also from care providers 29(38.2%) were reported its availability but concerning its utilization only 1(4.8%) of them said always. As to fetal, labour and maternal parameters; out of the 19 (6.9%) mothers for those in which partograph was used; FHR was monitored to standard in 3 (15.8%), states of membrane (liquor) was in 1 (5.3%) but in none of the cases the molding status of fetal head was monitored to standard; labour parameters (cervical dilation, station, uterine contractions, interval of contraction, and duration of contraction) were monitored to standard in 2(10.5%) of the cases and; alert and action line were crossed in 5(26.3%) and 3(15.8%) correspondingly but drugs and fluid given were piloted in 3(15.8%) of the records. Concerning the maternal parameters merely in 2(10.5%) pulse, BP and temperature were completed to standard and in 3(15.8%) urine test result was recorded As to the overall level of documentations of the parameters in majority 16 (84.2%) of the cases monitored to substandard.

Based on the number of normal deliveries conducted, utilization of partograph for them and level of documentation of the key events of labour, the utilization levels of the partograph were classified into good and poor. Accordingly none of the documents fit the good utilization level criteria since it was utilized only for 15/130(11.5%) of the normal deliveries conducted at the unit and in only 2(10.5%) some of the key parameters were monitored to standard.

Birth outcomes

Of the reviewed documents, 313 (92.1%) had birth outcome information attached to mothers ‘documents. Of these 46(14.7%) were assisted and delivered by C/S, 34 (10.9%) augmented, for 54(17.3%) analgesia was provided, 12 (3.8%) developed PPH, for 15 (4.8%) blood transfused, 54(17.3%) delivered by instrumental delivery, in 27 (8.6%) of cases duration of labour was greater than /equals to 18hours and in 2(0.6%) of the case the number of time the vaginal examination done was greater than or equals to four times.

Regarding to the fetal outcomes in 253 (80.0%) of the cases APGAR scores at 5th minuet was greater than or equals to seven, 44 (14.1%) were admitted to special nursery unit and 24(7.7 %) died during the first 6hours of delivery (Table 2).

Nature of occurrence of birth outcome indicators and birth outcome levels

The birth outcome measures were further evaluated to see the nature of occurrence of outcomes. Accordingly only 130/313 (41.5%) were normal spontaneous vaginal delivery. As to the level of birth outcomes 130(41.5%) indicated good birth outcome and 183 (58.5%) were poor birth outcome.

Association between dependant and independent variables

Dependant and independent variables were cross tabulated with each maternal characteristics related factors and use of partograph. There were no significant statistical associations observed between utilization of partograph and maternal age, parity, gestational age, bad obstetric history.

On contrary there were significant statistical association (p<0.05) between utilization of partograph with time of admission to the hospital (χ²=4.137, p=0.042), nature of membrane on admission (χ²=6.897, p=0.009). Bivariate logistic regression analysis shows mothers admitted after 12 hours of onset of labour were 2.723 times less likely to be monitored with partograph UOR of 2.723 and mothers admitted before rupture of membrane were 9.48 times more likely to monitor with partograph UOR of 9.48. However; multi-variate logistic regression showed only those mothers admitted before rupture of membrane were 8.090 times more likely to monitored with partograph than those after rupture of membrane [AOR (95% CI)=8.090(1.072,61.041)].

There were no significant statistical associations (p<0.05) observed between partograph use with caesarean section, augmentation of labour, use of analgesia, occurrences of PPH, blood transfusion, number of babies admitted to special nursery unit and number of babies died during the first 6hours of delivery maternal.

On contrary there were significant association between instrumental delivery (χ²=4.164, p=0.041), duration of labour (χ²=60.849, p=0.000), number of time the vaginal examination done (χ² = 25.874, p=0.000), APGAR scores at 5th minute (χ²=4.754, p=0.029) with utilization of partograph and utilization of partograph with birth out comes levels (χ² =14.403, p=0.000). Bivariate logistic regression analysis shows mothers whose duration of labour was less than 18hours were 5.79 times more likely to monitor with partograph UOR of 5.79 and mothers monitored with partograph were 8.276 times more likely to have good birth out comes UOR of 8.276. However; in multi-variate logistic regression showed mothers whose duration of labour was less than 18hours were 34.9% times more likely to be monitored with partograph [AOR (95% CI)=0.349(0.190,0.641)] and mothers monitored with partograph were 41.564 times more likely to have good birth out comes [AOR (95% CI)=41.564(7.76,222.66)] (Table 3).

Discussion

The partograph is a tool that has been recommended by WHO and other authorities in maternal health for routine monitoring of labour to provide early warning system [25].

From this study, the utilization of partograph was very poor as only 19/274 (6.9%) of mothers were monitored with it, while 274 (80.6%) had a partograph in their file. Surprisingly only in 2(10.53%) of the records of the mothers’ monitored with it had correct documentation of some of the key events which indicates poor monitoring of the key events against standards and of the utilized partograph none of them fits the criteria for good utilization.

This finding was not constant with what has been observed in Kenya Kakamega province hospital where its utilization was very low and 24% of the records of the mothers’ monitored with it had correct documentation of the key events, while 88.2% had a partograph in their files (56), in eight Ecuador hospitals where in 17.7% of the records of the mothers’ had documentation of the key events but only 5.4% correctly graphed, in Nigeria, Bangladesh, East African where the utilization was 24(8.7%), 6%, 14% respectively, in South Africa where utilization was 69.9% but that to the standard was only 2% and in Ethiopia 312/666 women were arrived before fully dilation and for about 90% ((85(12.8%)) partograph used and about 80% of the key events completed correctly [22,26-28].

The likely explanations for this dissimilarity might be difference in sample size, hospital policies, set up, study subjects, negligency of care providers, operationalisation of utilization and correct documentation. Also this could be supported by the study conducted in eight Ecuador hospitals indicated as there was a difference in utilization level of partograph not only among countries but also among types of health facility [27].

In this study the factors that have been indicated as predictors for the low utilization of partograph were: none availability of partograph as reported by more than three fifth (61.8%), staff shortage, lack of protocol, attitude of care providers, time of admission of mothers for delivery, lack of controlling system and availability of other modern tools.

In this study, the overall birth outcome was poor as 183 (58.5%) of the mothers had at least one of the poor birth outcome indicators.

This was not consistent with the findings of the study in Jinnah Postgraduate Medical Center; Harvard university medical science hospital, Karachi in which 88% had normal vaginal delivery, 21 (72.4%) had combination [2].

The possible explanations for this contrast might be due to variation in study setup, health care providers believes, awareness of health, guideline on child birth and delivery, training, availability of modern tools and disparity in judging birth outcome as good or poor.

This study further revealed the association between utilization of partograph with birth outcome and there was significant statistical association observed between them where mothers monitored with partograph were 41.564 times more likely to have good birth out comes [AOR (95% CI) = 41.564(7.76,222.66)].

This result was similar with what had been observed in Iran at medical science university hospitals, Nigeria, East African countries, Pakistan, India as appropriate partograph utilization prevents more than 85% infection because of repeated vaginal examinations which results in maternal deaths and reduces prolonged labor from 6.4% to 3.4%, need for augmentation 20.7% to 9.1%, cesarean delivery 9.9% to 8.3%, and stillbirth 0.5% to 0.3%, operative vaginal delivery, neonatal outcome (perinatal mortality) decreased from 3.6% to 0.8% after its utilization and number of babies need resuscitation with Apgar score less than 6 dropped from, 48 (9.6%) to 21 (4.2%) [16,29-31,33-35].

This cross-sectional study has possible limitations that may arise from care providers readiness and ability to record every information about the mothers delivered at hospital correctly based on which birth outcome measured. However; measure has been taken to minimize these limitations were using check list targeted information specifically on utilization of partograph.

Conclusion

Based on the finding of the study we have made concluded as utilization of the partograph during labour, documentation of the key events of labour and birth outcomes poor. The significant predictors of utilization of partograph were: time of admission, nature of membrane on admission. There was significant association (p<0.05) between utilization of partograph and overall birth out comes.

Acknowledgement

We would like to thank Jimma University, College Public Health and Medical Sciences Research and Post graduate coordination Office, IRB and department of Nursing and Midwifery for financing and encouraging us to do this research relevant to our settings and the country at large in addition to our teaching responsibilities in the University. We are also grateful to all those, who in one way or another, helped us to undertake this research. A great deal of gratitude goes to our family for supporting and inspiring us to be engaged in the work of this research project and data collators and study participants.