FISTULA CARE

Use of the Partograph:

Effectiveness, Training, Modifications,
and Barriers





A Literature Review


Karen Levin, M.S.W and Jeanne dArc Kabagema, M.D.

Fistula Care, EngenderHealth




Submitted to
United States Agency for International Development
Washington, DC

April 11, 2011



EngenderHealth, 440 Ninth Avenue, New York, NY 10001, USA
Telephone: (212) 561-8000, Fax (212) 561-8067, Email: [email protected]


















2011 Fistula Care/EngenderHealth

Fistula Care
c/o EngenderHealth
440 Ninth Avenue
New York, NY 10001 U.S.A.
Telephone: 212-561-8000
Fax: 212-561-8067
e-mail: [email protected]
www.fistulacare.org

This publication is made possible by the generous support of the American
people through the U.S. Agency for International Development (USAID),
under the terms of cooperative agreement GHS-A-00-07-00021-00. The
contents are the responsibility of the Fistula Care Project, managed by
EngenderHealth, and do not necessarily reflect the views of USAID or the
United States Government.

Fistula Care is a five-year cooperative agreement funded by the U.S. Agency for International Development
(USAID) and managed by EngenderHealth. The project works to address the enormous backlog of women awaiting life-
altering fistula repair, ensuring that they receive timely, high-quality care from trained providers. At the same time, it
works to remove barriers to emergency obstetric care that lead to fistula in the first place, so that women in labor get to
the right place with the right services at the right time. The project is supporting a network of facilities offering a
continuum of services, from emergency obstetric care, referrals, and family planning to complex fistula repairs and
advanced surgical training.

Printed in the United States of America. Printed on recycled paper.

Suggested citation: Levin, K., and Kabagema, J. dA. 2011. Use of the partograph:
Effectiveness, training, modifications, and barriersA literature review. New York:
EngenderHealth/Fistula Care.


Contents


Acknowledgments .............................................................................................................................. v
Acknowledgements ............................................................................................................................ iv
Executive Summary .......................................................................................................................... vi

Introduction and Methodology ........................................................................................................ 1
Background............................................................................................................................. 1
Objectives .............................................................................................................................. 1
Methods ................................................................................................................................. 2
Findings ............................................................................................................................................... 3
Background on the Partograph .......................................................................................... 3
Knowledge and Use of the Partograph ............................................................................. 6
The quality of labor monitoring practices ........................................................... 6
Poor completion of partograph can be due to lack of knowledge ...................8
Higher-level public providers are more familiar with partograph than
are lower-level public- or private-sector providers ..............................................8
Partograph Training and Monitoring/Supervision .......................................................... 9
Formal training may be the most effective strategy ........................................... 9
Task shifting from obstetricians and physicians to midwives ....................... 10
Supervision is essential for continuous proper use of the partograph ......... 10
Use of the Partograph As a Referral Tool ..................................................................... 12
Effect of the Partograph on Labor and Maternal and Neonatal Outcomes ............. 12
Partograph use and incidence of prolonged or augmented labor
and/or operative delivery .................................................................................... 14
Impact of partograph use on maternal and perinatal complications ............ 15
Providers Attitudes about the Partograph and Barriers to Use ................................. 16
Lack of access to partograph forms .................................................................. 18
Partograph improves quality ............................................................................... 18
Partograph is well used for referral, but transport can be inadequate ......... 18
Lack of emotional consideration ....................................................................... 18
Adaptations to the WHO Partograph ............................................................................ 19
Conclusions ...................................................................................................................................... 23
References ........................................................................................................................................ 25





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Acknowledgments



This publication was made possible by the generous support of the American people
through the U.S. Agency for International Development (USAID), under the terms
of the cooperative agreement GHS-A-00-07-00021-00. The information provided
here does not necessarily represent the views or positions of USAID or the U.S.
Government.

The authors thank our colleagues and partners of the Fistula Care Project for their
dedication and compassion, and all those working worldwide to improve maternal and
child health. In particular, we thank Karen Beattie, Betty Farrell, Evie Landry, Isaac
Achwal, Joseph Ruminjo, Peter Mukasa and Renee Fiorentino for their technical input
and feedback on this literature review.

Thanks to Sarah Burgess for her work on formatting and shepherding this work
through publication. Thanks to Julianne Deitch for her assistance in obtaining all the
articles reviewed. The final report was edited by Janet Field; Michael Klitsch managed
its publication.

It is our hope that this research contributes, in some small part, to the global efforts to
prevent maternal mortality and morbidity throughout the world.



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Use of the PartographA Literature Review Fistula Care/EngenderHealth
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Use of the PartographA Literature Review Fistula Care/EngenderHealth
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Executive Summary



Improving labor monitoring to reduce obstructed labor is an important component of
efforts to prevent the occurrence of obstetric fistula. The partograph is recognized as a
monitoring tool that can contribute to the quality of care provided to a woman in labor. The
Fistula Care project, which works to address the backlog of women awaiting fistula repair by
supporting training and repair, as well as removing barriers to emergency obstetric care,
carried out a literature review with the objective of identifying and summarizing the available
literature in scientific and programmatic publications on:
Use and efficacy of the partograph
Training strategies for introducing and effectively implementing use of the partograph
Barriers to partograph use

Utilizing public health and medical databases as well as Web-based search engines, we
identified more than 80 publications for review, including articles, technical manuals, and
book chapters. Based on the findings of the literature review, we suggest areas for future
research.

Key findings include the following:
Actual rates of use and levels of knowledge about the partograph among health care
facility staff vary greatly from country to country and by cadre and type of facility. In
general, levels of knowledge, skill, and implementation are low.
Only a small number of controlled and quasi-controlled studies have examined the
impact of partograph use on labor or cesarean section rates, and evidence of positive
impact is limited. However, other noncontrolled and generally smaller studies have
provided support for such an effect, as well as evidence of a positive impact on maternal
and perinatal health outcomes.
Evidence supports the need for a strong supervision and monitoring component to be
included in any partograph introduction or training activities. Quality assurance is needed
to ensure that training translates into ongoing practice.
The partograph may have benefits that go beyond the evaluation of medical outcome
improvements, including the potential to improve quality of care and provider attitudes
and to increase knowledge about labor practices.
Available evidence does not indicate that elimination of the latent phase of the
partograph has a significant impact on labor decisions or on maternal or neonatal
outcomes.

Variations in the rates of use and the cadres of staff using the partograph must be taken into
account when planning to introduce the partograph or train staff in its use. Effective
supervision and monitoring are a crucial component for success. Overall improvement in
knowledge and skills development for labor monitoring is needed to best provide
meaningful obstetric care and reduce obstructed labor and poor maternal and neonatal
outcomes.


There are multiple versions of the partograph available, but regardless of which version of
the partograph is used, facilities must ensure that women admitted during the latent phase of
labor receive adequate care and monitoring.

Operational research addressing the actual use of the partograph as a referral tool, examining
the role of the partograph in decision making, and looking more closely at different training
strategies and outcomes would make a valuable contribution to the existing body of data.
Fistula Care has developed and is field-testing a tool for monitoring partograph use on-site.
This tool facilitates monitoring and supervision to ensure that the partograph is used
correctly and appropriately at facilities at different levels.




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Introduction and Methodology


Background
Pregnancy and delivery are expected to be joyful for the family, free from injury or death for
the mother and her child. Though global maternal mortality rates have declined in the last
15 years, they remain unacceptably high. In 2008, nearly 350,000 women died in pregnancy
and childbirth (Hogan et al, 2010). Of those who do not perish, an unknown number suffer
long-term health problems. The maternal injury with perhaps the most devastating aftermath
is obstetric fistula. A fistula is a hole, or abnormal opening, in the birth canal, which results
in chronic leakage of urine and/or feces.

Obstetric fistula due to obstructed labor is by far the most common form of genital fistula in
low-resource settings in Africa and Asia, constituting an estimated 90% of all genital fistula
cases (Hilton, 2001). Obstetric fistula is usually caused by several days of obstructed labor,
without timely medical intervention or cesarean section. During this time, the soft tissues of
the pelvis are compressed between the fetus head and the womans pelvic bones. The lack
of blood flow causes tissue to die, creating a hole between the womans vagina and bladder
or between the vagina and rectum, or both, and resulting in leakage. Generally, the fetus will
be stillborn.

Prolonged labor can lead to postpartum hemorrhage, infection, and fetal injury or death, as
well as fistula. The risk of experiencing these birth-related morbidities and mortalities
increases in low-resource settings with limited health services. Lack of resourceshuman,
medical, and technologicalcan contribute to missed opportunities for interventions during
labor.

The partograph (also referred to as the partogram) is a simple, inexpensive preprinted form
on which labor observations are recorded. It generally comprises three sections of
information: maternal condition, fetal condition, and labor progress. The form provides a
graphic overview of the progression of a womans labor. Monitoring the progression of
labor can assist health care workers in identifying deviations from normal labor progression,
first alerting health care workers that a woman may need intervention and then calling for
action, if indicatedin the form of direct intervention via labor augmentation or cesarean
section, as necessaryor referral to a higher-level health facility.


Objectives
To promote quality of care during labor, Fistula Care undertook a literature review to:
Identify and summarize the available literature on the use and efficacy of the partograph
in scientific and programmatic publications
Identify published information on the attitudes of health care providers toward the
partograph
Identify and evaluate training strategies for introduction to and effective implementation
of the partograph

Use of the PartographA Literature Review Fistula Care/EngenderHealth
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Identify barriers to use of the partograph
Propose areas for future research

The specific research questions that framed the review included the following:
Does the literature provide evidence supporting the assumption that the partograph is a
useful tool in reducing prolonged labor and/or adverse maternal and neonatal
outcomes?
What does the research show regarding frequency, quality, and types of partograph use
at health facilities in low-resource settings?
What are the barriers to the use of the partograph, particularly regarding logistical and
attitudinal constraints?
And finally, what training strategies have been documented to show particular success in
introducing and sustaining effective use of the partograph in a health facility?

Methods
Our literature search used the search term partograph and partogram and utilized Web-
based search engines as well as public health and medical databases, including Ovid,
Information Exchange Online, PubMed, POPLINE, the British Library for Development
Studies, and MEDLINE, to identify relevant articles published in the last 20 years on
partograph use. We reviewed more than 80 publications, including articles, technical
manuals, and book chapters. Assessment of the currently available information will lead to
the development of strategies for introducing and strengthening partograph use in countries
working to improve maternal health care.


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Findings



Background on the Partograph
Friedman (1954) was the first obstetrician to graphically identify four phases of cervical
dilation, in a study of 100 women in their first pregnancy: the latent phase, the acceleration
phase, the phase of maximum slope, and the deceleration phase. His graphic recordings of
labor progression became known as a cervicograph. Philpott and Castle (1972) expanded on
this cervicograph by including other intrapartum information, such as the relationship to the
presenting part and uterine contractions, producing the first partograph. They then
introduced action and alert lines, in an effort to manage labor in the best possible way in a
setting where doctors were generally unavailable.

Years later, during the 1987 Safe Motherhood Conference in Nairobi, Kenya, the World
Health Organization (WHO) revised, approved, and promoted the universal use of the
partograph with a view toward reducing maternal and fetal mortality. After some years of
practice with the composite partograph, WHO developed a simplified version omitting the
latent phase and the descent of the presenting part (see Figure 1). Currently, many health
facilities use the second partograph proposed by WHO, though some continue to use the
earlier composite version. Ministries of health and facilities have also adapted the partograph
design to fit their needs and capacity.

The partograph is composed of the following sections:
Fetal condition, including fetal heart rate monitored using a Pinnards stethoscope,
assessment of membranes and the color of the liquor if ruptured, and assessment of the
presence of molding;
Maternal condition, including temperature, blood pressure, pulse, and drugs administered;
Progress of labor, including cervical dilation and effacement, contractions, and descent of
the presenting part (in composite version);
Alert line, indicating normal labor progression, and action line, indicating crossing into
the range where action should be taken.












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Figure 1: Original and simplified WHO partographs
Original WHO partograph
(Source: WHO. 1994c)



Simplified WHO partograph
(Source: WHO. 2008)

In 1994, WHO published a four-section manual on the use of the partograph (WHO,
1994c). Part I covers principles and strategies, Part II is a users manual, Part III is a
facilitators guide, and Part IV provides guidelines for operational research. This publication
was developed in 1988 and was updated in 1994 based on findings from a prospective
nonrandomized study of an adapted partograph that WHO had produced.

The WHO (1994a) study testing the use of this WHO-adapted partograph with 35,484
women in Southeast Asia concluded that the partograph was a necessary tool in the
management of labor and recommended that it be universally adopted. The study showed
reductions in prolonged labor, in the proportion of labors requiring augmentation, and in
emergency cesarean sections and stillbirths. Only a small number of studies have examined
the partograph in a similar way, and only two of these in Africa, both of which took place
years earlier (Philpott, 1972; Kwast & Rogerson, 1973). The findings of the two African
studies are similar to the WHO results, with statistically significant results. The WHO study
included a much larger sample of women and used a more rigorous methodology. Since it
was not a randomized controlled clinical trial study, however, some have questioned whether
it could in fact be considered definitive in providing evidence that the partograph

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improves the outcomes and management of women in labor. Despite the lack of evidence
from any large-scale randomized controlled study (Lavender, Hart and Smyth, 2008), the
general consensus is that the partograph is a useful and effective tool for preventing
obstructed labor in lower-resource settings. There is less consensus on the effectiveness of
the use of the partograph in higher-resource settings.

One of the intended benefits of the publication of the WHO simplified partograph was to
promote a more uniform model of partograph, so that all users could work with the same
guidelines. Lack of conformity had been seen as a possible obstacle to partograph use.
However, despite the introduction of the simplified WHO partograph in 1994, countries
continue to modify the partograph to fit their particular needs, resulting in many different
versions of the partograph in use throughout the world.

Use of the partograph is predicated on the existence of a functioning referral system and the
ability to provide obstetric care. Additionally, the partograph can be used only in situations
where health care workers have enough training in basic obstetric skills to be able to perform
normal deliveries, vaginal examinations, and assessments of cervical dilation, as well as where
necessary supplies are available. Therefore, it is essential that a successful introduction of the
partograph be done in conjunction with: a) an assessment of the level of understanding and
skills of health care staff in these areas, b) a comprehensive training program that addresses
supervision and quality assurance, and c) detailed training that covers the mechanics of use
of the partograph.

WHO (1994c) recommends that partograph introduction begin in teaching hospitals and
referral centers and then extend outward into the peripheral health centers. Midwives and
other personnel from peripheral health centers can come to central hospitals, where there
are likely to be adequate caseloads and trainers, to undergo training, and they can then return
to introduce the partograph in their workplaces. At the local health center level, emphasis
should be on the use of the partograph as a referral tool, rather than as a tool for labor
management, since obstetric interventions may not be available. Additionally, medical and
midwifery schools should include the principles and use of the partograph in their curricula.
According to WHOs recommendations (1994c), partograph training should consist of an
intensive period of training in the use of the partograph, preferably including tutors who
have used the partograph elsewhere. The training should begin with a theoretical approach,
followed by practical examples. WHO recommends close supervision of the partographs
introduction into a labor ward, so that any difficulties can be identified and addressed.

Finally, WHO (1994c) recommends operations research topics for gathering useful
information on the application of the partograph, particularly as a referral tool. With the
belief that their multicenter trial, supported by previous studies, had firmly established the
efficacy of the partograph when used appropriately, operational research was the logical next
frontier for exploration. Four major goals were presented:
To assess whether an education program for health workers will result in correct
application of the partograph
To determine the effect of introducing the partograph in rural health centers on the rate
at which women in prolonged or obstructed labor are referred for care

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To determine the effect of introducing the partograph on the incidence of prolonged
labor, of augmented labor, and of operative delivery
To determine whether appropriate interventions based on the partograph will reduce
maternal and perinatal complications

The four operational research topics above helped to shape the focus of this literature
review. Despite WHOs strong recommendations regarding operational research, few such
studies have been carried out over the last 15 years. Little published information is available
on actual programmatic use of the partograph. Nearly all studies have focused on rates of
use or on the clinical significance of the partograph instead of looking at how it is actually
used. The focus on outcome datarather than on assessment of the quality of partograph
use, barriers to use, strategies for training and supervision, and so onhas left many areas
unexamined.

Knowledge and Use of the Partograph
Reported rates of partograph use vary from study to study. Additionally, while some studies
report on general rates of use, others report on rates of correct usage, which differ greatly.
Findings most often indicate rare or incorrect use of the partograph. Low rates of use and of
correct use of the partograph are most frequently seen in health care settings where labor
management practices are generally poor. Many studies had a larger scope and addressed the
partograph as one of several indicators to assess overall labor monitoring or management
skills and practices, and thus they report only on rates of use, with little in-depth background
or qualitative data to round out these findings.

Where doctors and midwives are familiar with the partograph, recognition does not
necessarily translate to usage. Umezulike, Onah, and Okaro (1999) found that although 94%
of doctors and midwives in one area of Nigeria thought the partograph was useful, only 25%
used it routinely. Most of the time, those entrusted with the intensive care of women in labor
were relatively inexperienced and often were unsupervised by more senior and experienced
personnel. While nearly all respondents had heard of the partograph, only 33% could
correctly define it.

At many facilities, completion of a partograph in a clients record was the exception rather
than the norm. In their retrospective study at a general hospital in Kenya, Wamwana et al.
(2007) found that the partograph was used in only 11% of cases. Delvaux et al. (2007), in
their study of urban maternity wards in Cte dIvoire, found that partographs were
completed in only 5% of cases and that contractions were monitored in only 9% of cases. At
two of the sites included in that study, the partograph was completed after delivery in more
than 60% of deliveries, indicating it was being utilized only as a record-keeping procedure,
not as a monitoring tool.

The quality of labor monitoring practices
When looking at use of the partograph, it is important to also examine what a facilitys
broader practices are regarding labor monitoring in general and what services are available to
women in labor. Partograph usage alone will not ensure or even facilitate positive health
outcomes if no services are available to women identified as needing intervention. Many

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studies included in this review made note of the gross deficiencies of health care staff in
terms of their knowledge of normal labor expectations and assessment of labor progression.

In Njoroges (1993) study in rural Kenya, 50% of health care workers had low knowledge of
the partograph. Their ability to use parameters on the partograph to make decisions was low,
and 60% could not apply the findings on the partograph to make a decision on the active
management of labor. Delvaux et al. (2007) reported finding that providers assessment of
womens condition at admission was poor; vital signs and labor progress were not routinely
monitored in the maternity wardsor even measured at all, in most cases. As a result of
their findings, the authors challenged the conventional practice of using the proportion of
births with a skilled attendant as the key indicator for tracking progress in maternal health, as
skilled attendant does not translate into skilled or appropriate care. In their efforts to
assess maternal and neonatal health services in 49 developing countries, Bulatao and Ross
(2002) found that health centers tended neither to use the partograph nor to have
transportation available in the event of obstructed labor.

As part of a series of Safe Motherhood Studies conducted by the the Quality Assurance
Project (QAP) (Boucar et al., 2004; Burkhalter et al., 2006; Gbangbade et al., 2003), the
competence of skilled birth attendants was assessed in Benin, Ecuador, Jamaica, and
Rwanda. With the exception of Jamaica, all of the countries had guidelines recommending
use of the partograph. Despite this, incorrect use was observed in more than half of the case
observations (with variation between countries). The ability to correctly use and interpret the
partograph was low. Findings indicated a wide gap between current evidence-based
standards and provider competence to manage selected obstetric and neonatal
complications. Labor monitoring appeared to be inadequately performed. Fetal heart rate
monitoring was conducted well below the recommended standard of twice hourly, and
vaginal examinations and maternal blood pressure monitoring were conducted more
frequently than indicated. Overall, cases were not monitored sufficiently often to detect fetal
distress or maternal complications.

The Safe Motherhood Studies also looked at quality of obstetric care and the elements that
contribute to the third delay: the delay in receiving medical attention after a woman arrives
at a health care facility (Boucar et al., 2004; Burkhalter et al., 2006; Gbangbade et al., 2003).
In Benin, providers used partographs about two-thirds of the time. In partograph case study
competency assessments, doctors scored significantly higher than midwivesa discrepancy
that the authors found to be cause for concern, as the midwives or first-line birth attendants
are the ones who actually provide care to laboring women at most facilities. In Rwanda,
there was no significant difference by type of provider or health facility. Competency scores
in Rwanda were low, around 50% for overall knowledge and for overall skills. Knowledge
and skills related to active management of the third stage of labor were noted to be
particularly poor. Partographs were completed in fewer than half of all cases. The authors
also found no correlation in either Rwanda or Benin between providers self-assessments of
competency and actual competency levels as measured by knowledge and skills tests.

In both Rwanda and Benin, labor monitoring appeared to be poorly performed, with
inadequate monitoring of fetal heart rate as well as poor monitoring of the mothers blood
pressure and contractions. In addition, vaginal examinations were being performed more
often than necessary or appropriateon average, more than twice per hour. The authors

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noted significant delays in providing care and diagnosing obstructed labor and severe
eclampsia or pre-eclampsia in Benin and stated that cases were not monitored sufficiently in
Rwanda to detect fetal distress or maternal complications.

Rates for knowledge and use of the partograph vary depending on the type of facility (i.e.,
tertiary vs. primary/secondary, public vs. private) and the level of provider training (i.e.,
physician vs. midwife vs. community health worker). Responsibility for monitoring labor and
for completing the partograph (where used) fall on different cadres of staff in different
locations.

A study by Oladapo, Daniel, and Olatunji (2006), focusing on peripheral maternity centers,
found that just over half of maternity care providers on site were aware of the partograph.
While the vast majority of those aware of it also could correctly identify its definition and
purpose, only 10% demonstrated good levels of knowledge regarding its use. Overall, only
10% of personnel routinely used the partograph to manage labor, and almost all of those had
poor levels of knowledge. Fawole, Hunyinbo, and Adekanle (2008) echoed these results,
finding that only just over one-third of all respondents could correctly identify at least one
component of the partograph. Knowledge about the function of both the alert and action
lines was generally poor: Only 17% of respondents could explain the function of the alert
line, while 24% could explain the function of the action line.

Poor completion of partograph can be due to lack of knowledge
Ijadunola et al. (2007) identified lack of knowledge and lack of skills as major factors
hindering the use of the partograph at the primary health care level (where most deliveries
take place) in Nigeria. They found that at 96% of primary health care facilities, partographs
were neither available nor being used to monitor labor progress.

Higher-level public providers are more familiar with partograph than are lower-
level public- or private-sector providers
Fawole, Hunyinbo, and Adekanle (2008) looked at how the cadre of provider corresponded
to their level of knowledge about the partograph: The higher the level of formal job training,
the higher the level of knowledge (while still low across the board). Additionally, the more
highly trained the providers were, the more they felt the partograph had value. Oladapo,
Daniel, and Olatunji (2006) similarly found that junior staff members had particularly poor
levels of knowledge. In the study by Fawole, Hunyinbo, and Adekanle (2008), respondents
indicated that staff from tertiary facilities were significantly more knowledgeable about the
value of the partograph for monitoring labor. Just fewer than half of all respondents had
received training on the partograph. Health care staff from public-sector health facilities
were more likely to have received prior training, and they displayed better knowledge than
respondents from private-sector health facilities.

The available data on actual rates of use of and levels of knowledge about the partograph
among health care facility staff vary greatly from country to country and by cadre and type of
facility. In general, studies indicated low levels of implementation of and knowledge about
the partograph. There is also a clearly identified need for improvement in the labor-
monitoring knowledge and skills of health care workers.


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Partograph Training and Monitoring/Supervision
Evaluation of training programs has been described by WHO (1994c) as perhaps the most
difficult part of operational research on the use of the partograph. We did not find much
literature addressing training strategies and success rates, though training was clearly involved
in many of the published studies.

In their review, Lennox and Kwast (1995) cited evidence supporting the idea that trained
midwives at the village or health center level can use a partograph successfully to monitor
labor and refer clients to the district hospital, where cesarean sections should be available.
They referred to studies from the early 1990s carried out in Ghana, Indonesia, Nigeria, and
Uganda that demonstrated this, as well as studies in Malawi and Zimbabwe that
demonstrated correct referral among nurse-midwives and maternity assistants.

Lennox and Kwast recommended that partograph training begin at the district level and
make its way down the chain of health care facilities, so that sites receiving referral cases will
definitely know how to use the partograph and will act accordingly. The authors also cited
the tangential benefit of a potential increase in community understanding of prolonged labor
as a danger sign, due both to the process of monitoring involved in completing the
partograph and to the potential actions based upon it. They also noted increased confidence
in and use of maternity services after introduction
of the partograph.

Fatusi et al. (2007) evaluated a training intended to
improve use of the partograph among primary
health care workers in Nigeria. They found that
lower cadres of primary health care workers can be
effectively trained to use the partograph with
satisfactory results and thus can contribute toward
improved maternal outcomes in developing
countries where skilled attendants are scarce. The
training utilized didactic sessions and practical
examples drawn from the WHO facilitators guide
(WHO, 1994c, Part III) and included close supervision for two weeks following the training,
to address any initial difficulties. The training concentrated on the partograph as a tool for
facilitating early identification of women at risk of prolonged labor (moving to the right of
the alert line), rather than for managing prolonged labor (reaching or crossing the action
line).
Key Partograph Training Issues
Whole-site training should occur, including
the lower cadres of staff who actually
implement the partograph.
Training can begin at the district level and
make its way down the chain of health care
facilities.
Close supervision and monitoring are
essential to ensure consistent and accurate
use of the partograph after training.

Formal training may be the most effective strategy
Another Nigerian study (Oladapo, Daniel, & Olatunji, 2006) found that individuals who had
received formal training in the partograph had higher levels of knowledge than those who
cited their place of work as their main source of knowledge. However, the authors also
found that many of those who were routinely using the partograph showed less knowledge
of it than those not using it at all. This finding was surprising; one would assume that routine
use would improve levels of knowledge. The authors attributed the finding to the fact that
clients at the health centers are most often cared for by the lowest cadre staff, who generally
have poor knowledge of the partograph. These individuals may be using the partograph

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routinely as a matter of rote practice and policy in the facility rather than as a tool that is
actively useful for monitoring labor. That practice, combined with a lack of quality assurance
measures, would contribute to little improvement. The authors emphasized the need for
continuous reinforcement and quality assurance to check improper use of the partograph
and for efforts to ensure that junior staff also receive training. Though senior staff are
usually the ones who are trained, the junior staff often actually work with clients, and the
training does not trickle down appropriately to them. This situation highlights issues with
trainee selection and availability.

A Safe Motherhood Demonstration Project (SMDP) was introduced in four districts of
Western Province, Kenya. It included job training in Safe Motherhood which included
collection and utilisation of maternal health care services data, and provided the opportunity
to improve record keeping in the intrapartum period (Wamwana et al., 2007). Prior to the
project, the partograph was used in 11% of cases, compared with 85% during
implementation of the project. Improvement was also shown in utilization of data, since
100% of cases during the project period had a diagnosis and plan of management, as
opposed to 86% and 84% previously. Record keeping improved, as did rates of diagnosis
and plans for case management. The authors did not report what, if any, impact these
improvements had on action to manage labor or on outcomes. Furthermore, this study did
not look at longer-term follow-up after the demonstration project period ended. Without
examining the sustainability of improvements, it is difficult to assess the effectiveness of a
training approach.

Task shifting from obstetricians and physicians to midwives
Christensson et al. (2006) documented pre- and postintervention status of an effort by
Maputo Central Hospital (MHC), in collaboration with the Karolinska Institute, to improve
perinatal care in Mozambique. Preintervention findings identified poor quality of midwifery
care and low rates of use of the partograph and led to an intervention consisting of seminars
for midwives that presented and addressed pretesting results. The seminars led to a decision
to transfer responsibility for the partograph away from obstetricians and physicians to the
midwives. Additional seminars were then conducted to provide education on partograph
documentation and interpretation and reinforcement of all areas covered. Follow-up
observations found that the intervention had no significant effect on the midwives
performance. In fact, the graphic section of the partograph was completed less often
following the intervention. In cases identified as having maternal risk, there was no increase
in initiation of partographs. Overall, documentation of the partographs, when initiated, was
inadequate and could therefore not serve as a guide for either monitoring or intervention,
and the midwives did not take on responsibility for their completion. The authors felt that
possible reasons for failure of the intervention could be high rotation of personnel, a
problem with the intervention itself, and the lack of a real motivating figure to push through
the changes on-site. As they aptly observed, changes in performance do not automatically
follow education and awareness-raising interventions. Behavioral change is difficult to
achieve.

Supervision is essential for continuous proper use of the partograph
Another evaluation of an educational intervention for midwives was carried out in a
peripheral delivery unit in Angola (Petterson, Svensson, & Christensson, 2000). The WHO

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partograph had been introduced years earlier as a tool for midwives working without medical
support in all peripheral delivery units in Luanda. However, regular supervision of midwives
revealed failures and difficulties in the operational use of the instrument. Therefore, a plan
was developed to carry out additional in-service education, consisting of theoretical and
practical lectures in groups; individual supervision, evaluation, and feedback using actual
partographs; and practical situations. Significant improvement occurred postintervention in
the majority of the variables of the partograph completed by the midwives. In general, while
the midwives improved their documentation on the partograph after the educational
intervention, they tended to keep clients at the peripheral units rather than transfer them
when indicated. The authors noted that women may resist transfer because they know that
maternal deaths frequently occur at the central hospitals. Additionally, the midwives knew
the peripheral delivery unit had better stocks of certain medicines, supplies, and equipment
than the central maternity hospital.

A WHO-sponsored study (Fahdhy & Chongsuvivatwong, 2005) assessing the effectiveness
of an intervention to promote the use of the partograph among midwives in Indonesia
found that before the intervention, despite education in the use of the partograph, none of
the midwives used it regularly. The intervention consisted of a standard training providing
theoretical and practical skills training, with a significant focus on supervision and
monitoring of the trainees postintervention. The training team made weekly visits in the
month after the intervention to ensure that the midwives were using the partograph
consistently and correctly. In the following six-month period, partographs were correctly
completed in 92% of the cases. Sixty-five percent of women with a graph that went beyond
the alert line were referred to a hospital, which suggests that appropriate time of referral
needs more emphasis in continuing education.

Bosse, Massawe, and Jahn (2002) assessed the quality of labor monitoring in routine
maternity care following introduction of the partograph in Southern Tanzania. While rates of
use of the partograph were quite high following introduction (95%), only 58% partographs
were filled out satisfactorily.

A consistently and correctly completed partograph can provide evidence, as a component of
a functioning supervision system, in reviewing any cases of maternal death or near misses.
The information provided can be utilized to reflect on medical practices and opportunities to
change or improve practices and systems. While this was not cited in any of the sources for
this literature review, it is an important potential benefit of partograph use that should be
noted.

Partographs have been introduced in many countries and at many facilities, with national
guidelines and training workshops developed and implemented. The available evidence
indicates that there is a crucial need for strong supervision and monitoring in any partograph
introduction or training activities. Quality assurance is needed to ensure that training
translates into ongoing practice. Training should also address decision making about actions
to be taken, both for physicians managing labor and delivery and for nonphysician staff who
need to be able to interact with physicians to ensure that action is taken in a timely manner.



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Use of the Partograph As a Referral Tool
Few studies have specifically examined how the partograph is used as a referral tool. The
critical role of the partograph in peripheral settings is to indicate when referral is appropriate.
The partograph can be effective as a referral tool only if transport is available from the
referring location to another, higher-level facility and if there is in fact a higher-level facility
able to provide the necessary medical care. Additionally, as Christensson et al. (2006) point
out, many women are admitted to facilities late in labor, which should be a point of
discussion when considering how to implement the partographwhether it should be in
general use, or its use should be focused on cases in which there is an already identified
maternal risk.

Fahdhy and Chongsuvivatwong (2005) evaluated the implementation of the WHO
partograph in Indonesia and found that 35% of women who crossed the alert line were not
referred, despite guidelines clearly saying this should happen. The reasons were that
midwives tried to manage these cases themselves, women refused transfer because they felt
their condition was not serious, women sometimes became fully dilated before the transfer
could take place, and women were concerned about the expense of the hospital and the
feeling of alienation at the hospital (in that order). While referral should have been
logistically easy to accomplish, both midwives and clients resisted.

Nkyekyers (2000) descriptive study of peripartum referrals to a teaching hospital in Ghana
found that of all clients expected to arrive at the hospital with a partograph, only about 17%
actually did so. The author commented that the very low percentage of referrals with
partographs may result from the referring facility staffs lack of use of partographs for
monitoring the progress of labor or their view that it was not necessary to send the
partograph along with the client.

One study of the use of the Angolan model of the WHO partograph as a referral tool
(Phillips, 1993) elaborated on the criteria required for transfer to the central maternity
hospital. The conclusion was that as result of rigid criteria, unnecessary transfers were taking
place, adding a burden to already congested hospitals. The author suggested that to decrease
the congestion at central maternity hospitals, peripheral delivery units should attend to
women classified as low risk.

Additional operational research or systematic record reviews on the actual use of the
partograph as a referral tool would make a valuable contribution toward understanding
current practice and identifying areas where programmatic inputs and training would be
valuable. Whole-site training of facility supervisors, administrators, and staff may be an
effective approach to establishing the necessary support for and facilitation of referrals.


Effect of the Partograph on Labor and Maternal and Neonatal
Outcomes
As discussed earlier, the prospective nonrandomized study carried out by WHO (1994a)
remains a seminal study in determining that the partograph is an effective and necessary tool
in the management of labor, showing reductions in prolonged labor, proportions of labor
requiring augmentation, emergency cesarean sections, and stillbirths. While often cited as

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providing proof of the merit of the partograph, the study has also been criticized for not
following a randomized controlled trial methodology. Other studies have compared different
partograph models, but there is a dearth of data comparing partograph use versus no
partograph use.


Quick Look: Studies on Partograph Use and Impact on Maternal and
Neonatal Outcomes
A Cochrane database review (Lavender, Hart, & Smyth, 2008) of randomized and quasi-
randomized controlled trials (five studies) indicated no evidence of any difference
between partograph and no-partograph groups in cesarean section, instrumental vaginal
delivery, or an Apgar score less than seven at five minutes.
A WHO prospective nonrandomized study (1994a) provided data supporting reductions
in prolonged labor, labor requiring augmentation, emergency cesarean rates, and
stillbirths.
Smaller studies showed the following results:
o Cesarean rates
Lowered (Pattinson et al., 2003; Fawole & Fadare, 2007)
Neutral impact (Lennox, Kwast, & Farley, 1998; Bosse, Massawe, & Jahn, 2002)
o Need for labor augmentation
Reduced (Javed, Bhutta, & Shoaib, 2007)
Increased (Fawole & Fadare, 2007)
o Perinatal outcome
Increased (Fahdhy & Chongsuvivatwong, 2005; Javed, Bhutta, & Shoaib, 2007;
Bosse, Massawe, & Jahn, 2002; Lennox, Kwast, & Farley, 1998; Fawole &
Fadare, 2007)
Neutral impact (Apgar scores: WHO, 1994a)
o Maternal outcome
Increased (Bosse, Massawe, & Jahn, 2002; Fawole & Fadare, 2007; primigravidae
only: Javed, Bhutta, & Shoaib, 2007, and Fahdhy & Chongsuvivatwong, 2005)
Neutral impact (multigravidae only: Javed, Bhutta, & Shoaib, 2007; maternal
death and postpartum hemorrhage: WHO, 1994a)
In the following section, we summarize the existing data on the impact of the partograph on
labor and on maternal and neonatal outcomes. The argument has been made that use of the
partograph can also improve the quality of labor management practices in health facilities
and can raise general awareness of danger signs of labor. For the partograph to be used
correctly, health care staff need to check on the laboring woman multiple times, monitoring
her vital signs and the progress of labor and interacting with her. Most studies reviewed
referred to findings of overall poor quality of care regarding labor management practices and
womens perceived levels of care. In addition to potential improvements in medical
outcomes, the use of the partograph may in fact act as a catalyst to better quality of care
through the increased amount of attention paid to each laboring woman.




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Partograph use and incidence of prolonged or augmented labor and/or operative
delivery
The Cochrane database review (Lavender, Hart, & Smyth, 2008), in reviewing randomized
and quasi-randomized controlled trials, found no evidence that using a partograph reduced
or increased cesarean section rates or had any effect on other aspects of labor. Most studies
included in the Cochrane review were carried out in high-resource settings. Studies that
specifically focused on lower-resource settings (Pattinson et al., 2003; Walss-Rodriguez,
Gudino-Ruiz, & Tapia-Rodriquez, 1987) showed some reduction in cesarean rates with
partograph use and early intervention for delayed progress in labor, which the reviewers cite
as an area warranting further investigation. However, the Cochrane reviewers questioned the
quality of these studies.

Lennox, Kwast, and Farley (1998) looked at breech presentation in a hospital-based study in
Southeast Asia to examine use of the WHO partograph in labor management. There was a
small (nonsignificant) reduction in cesarean sections in multigravida women after the
partograph was introduced and no impact on primigravida women. Prolonged labor (longer
than 18 hours) was reduced significantly among all women, despite reduced use of oxytocin.

The QAPs series of Safe Motherhood Studies (Burkhalter et al., 2006) found that increased
partograph use was associated with more frequent labor monitoring. However, even when
increases were achieved in partograph use, the quality of the completed partographs, as well
as the general quality of labor monitoring, remained poor. Fewer than half of the alert and
action lines were performed to standard, with a wide range between countries. Benin showed
the highest rates of performance and Ecuador the lowest. Maternal pulse was never checked
in 40% of the cases (more than 60% of the cases in Benin and Rwanda), and 50% of women
never had their contractions checked.

In the QAP studies, when the investigators looked for a possible association between correct
partograph use and better labor monitoring, the results varied depending on how the analysis
was performed. Correct partograph completion did not seem to have a consistent and
substantial effect on the percentage of indicators monitored at least once within the hospital,
except in Ecuador, where correct partograph use correlated with a higher percentage of
maternal indicators monitored at least once. The investigators noted that a substantial
number of cases with correct partograph use had poor monitoring. This finding may relate
to the variety of partograph forms in use in the different countries and the different
interpretations of how observers were to carry out their observations during the study.
Partograph use may have been judged to be correct if a single indicator was graphed at a few
points, even if other key indicatorspulse, blood pressure, and intervals between
contractionswere never checked. Such an interpretation highlights the potential difference
between rates of correct or complete use of the partograph.

The QAP studies also found that the average duration of observed labor was substantially
longer in cases with correct partograph use than in those with incorrect partograph use.
Given that the partograph is often not used during short labors, this finding was expected.

There is some concern that introduction of the partograph may increase the rate of obstetric
interventions (Walraven, 1994; Lavender & Malcolmson, 1999). Available evidence on this is

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mixed. Bosse, Massawe, and Jahn (2002) found that following introduction of the
partograph in southern Tanzania, there was no significant increase in cesarean sections. In
their audit of partograph use at a tertiary hospital in Nigeria, Fawole and Fadare (2007)
found that use of the partograph was associated with an increased rate of labor
augmentation, earlier decision to augment labor, and reduced rates of cesarean section. An
increase in cesarean rates may occur and may in fact be a positive outcome if they are being
carried out appropriately, but it can be a negative if the result is an increase in unnecessary
surgeries. When the partograph is being used properly, the alert function prompts staffs
attention to a laboring womans situation prior to the need for cesarean section.

The WHO study (1994a) indicated that use of the partograph seemed to bring about
improvements over the previous pattern of care, with reductions in the percentage of
women given oxytocin to speed up labor and also a reduction in the average duration of
labor. Postpartum infection was reduced by two-thirds, and a slight decrease in cesarean
rates was reported. The study indicated that women in Southeast Asia had been having their
labors artificially sped up with oxytocin, to an extent that was not beneficial to them or their
babies. As Robinson (1995) writes, the introduction of the partograph appears to have
replaced this intervention with another: It reduced the number of women getting oxytocin
but led to recommendations for universal artificial rupture of membranes. Studies have
shown that artificial rupture of membranes may shorten labor but does not improve
outcome. Robinson questions why WHO included artificial rupture of membranes as part of
their protocol.

Javed, Bhutta, and Shoaib (2007) found that following introduction of the partograph at a
public tertiary care facility in Pakistan, the duration of labor, labor augmentation, and vaginal
exams for both primigravidae and multigravidae were all reduced. (A reduction in vaginal
exams can lessen the potential for infection.) For primigravidae, the number of augmented
labors and vaginal examinations also fell significantly. In Fahdhy and Chongsuvivatwongs
(2005) study, the referral rate of cases was significantly increased, and there were fewer
instances of vaginal examination, oxytocin use, and obstructed labor.

The Cochrane review of controlled and quasi-controlled studies did not support the
commonly held belief that use of the partograph has an impact on any aspect of labor or
cesarean section rates. However, the WHO study and other smaller-scale, noncontrolled
studies have provided support for those contentions.

Impact of partograph use on maternal and perinatal complications
In their paper on use of the partograph in community obstetrics, Lennox and Kwast (1995)
stated that no study has demonstrated that the partograph reduces maternal mortality. The
WHO (1994a) study found no reductions in maternal deaths (but most women had severe
complications on admission) or in rates of ruptured uterus or postpartum hemorrhage.
Stillbirths fell slightly, but in most cases the baby had already died before the woman was
admitted to the health care facility. There was no significant change in Apgar scores.

In Fahdhy and Chongsuvivatwongs (2005) study of an intervention to reintroduce the
WHO partograph in Indonesia, the proportion of cases with correctly completed
partographs went from virtually none to more than 90%. Initial Apgar scores improved, but

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fetal death and early neonatal death rates were too low to compare. Bosse, Massawe, and
Jahn (2002) found that in Tanzania, fetal and maternal outcomes improved following
introduction of the partograph.

In Lennox, Kwast, and Farleys (1998) study of breech presentations in hospitals in
Southeast Asia, intrapartum stillbirths fell (nonsignificantly) from 1.9% to 1.1% following
introduction of the partograph. Fetal outcome (by intrapartum deaths and Apgar scores) was
significantly better for cesarean delivery than for vaginal delivery, regardless of use of the
partograph. In their audit of partograph use in a tertiary hospital in Nigeria, Fawole and
Fadare (2007) found that partograph introduction was followed by a reduction in maternal
and perinatal morbidity, improved Apgar scores, reduced admissions to special care baby
units, and reduced postpartum hospital stay for mothers.

Javed, Bhutta, and Shoaibs (2007) study in a tertiary care facility in Pakistan found that
introduction of the partograph had a significant impact on neonatal outcome for
primigravidae, with perinatal mortality decreasing from 3.6% to 0.8%. There was also a
reduction in the number of babies needing resuscitation with Apgar scores lower than 6. For
primigravidae, there was a significant reduction in obstructed labor, uterine rupture, and
postpartum hemorrhage. For multigravidae, there was no significant impact on mode of
delivery, complications of labor, or neonatal outcome.

Seffah (2003) documented research on whether the introduction of the WHO partograph in
labor wards in Accra, Ghana, in 1990 was followed by a reduction in the incidence of
ruptured uterus and an improvement in maternal and perinatal mortalities. While the
findings indicated a steep reduction in the incidence of ruptured uterus, the methodology of
this study calls its validity into question. It compares a five-year period of recent data (1996
2001) with only one year of much earlier data (1971), without any documentation of any
other meaningful changes that may have occurred during the intervening period. There was a
slight, nonsignificant reduction in maternal deaths in the postintroduction period.

The WHO study (1994a) found that postpartum infection was reduced by two-thirds and
that a slight decrease in cesarean rates was reported as a result of partograph introduction.
The Cochrane review found no impact on the proportion of neonates with low Apgar scores
(taken at five minutes).

In summary, while few randomized controlled study data are available that support
partograph use, the 1994 WHO study and many smaller studies suggest that partograph use
leads to improvements in both maternal and perinatal outcomes.

Providers Attitudes about the Partograph and Barriers to Use
Providers attitudes have the potential to greatly impact both the introduction of the
partograph and the ability to sustain high-quality, effective use of it at a health facility. Some
studies have looked at providers opinions of the utility of the partograph and have tried to
identify barriers to effective implementation.

Several factors are frequently cited as contributing to poor use of the partograph. These
include lack of adequate staffing levels and time pressures (staff are too busy looking after

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too many women to chart the partograph); supply issues (difficulty keeping adequate
numbers of partographs on hand); inadequate monitoring of the indicators (both maternal
and fetal) recorded on the partograph; and, even when information is collected, lack of
understanding or use of the partograph as a tool for action when necessary (Lawn & Kerber,
2006).

The Cochrane database review found some evidence to suggest that midwives felt the
partograph is a useful tool, citing benefits such as ease of use, time efficiency, and assistance
with continuity of care (Lavender & Malcolmson, 1999). However, in higher-resource
settings, midwives also offered criticism that the partograph can actually impede clinical
practice, reducing their autonomy to act based on their own clinical judgment and limiting
their ability to make case-by-case decisions. Walraven (1994) also raised the concern that
partograph use can increase the number of interventions, which can result in a more negative
experience for the laboring woman.

Fahdhy and Chongsuvivatwong (2005) found that the main reason Indonesian midwives did
not complete the partograph was that they felt doing so required too many details. Lennox
and Kwast (1995) outlined several problems they encountered when examining partograph
use in community obstetrics. One major barrier was that providers found it difficult to
identify the onset of labor, though it is very important that the partograph not be used until
true labor begins. Clear definitions regarding cervical dilation and contraction patterns are
necessary for accurate partograph use. The problem of a prolonged latent phase shrinks
when these definitions are properly delineated and employed.

Mathews et al. (2007) also identified several aspects of the partograph that health care staff
found difficult to implement. Like Lennox and Kwast (1995), they found that completing
data for the latent phase of labor and transferring the cervical dilation value from the latent
to the active phase by means of a broken line on the form were challenging. The transfer
was difficult for staff to understand and led to mistakes when they filled out partographs.
The usefulness of recording the latent phase in the partograph has been questioned
(Dujardin et al., 1995), since a prolonged latent phase is relatively infrequent and not usually
associated with poor perinatal outcome. In 2000, in an attempt to reduce the number of
details that need to be charted, WHO introduced a simplified partograph that eliminated the
need to record the latent phase. This adaptation, among others, is discussed later in this
review.

Complementing the barriers cited regarding defining and recording the latent phase, Delvaux
et al. (2007) also noted that midwives may perceive use of the partograph to be redundant,
given that a substantial number of women are admitted very late in labor when birth is
imminent. They advocated for investigating the barriers to early admission.

Lennox and Kwast (1995) remarked on the difficulty of accurately performing cervical
assessment by vaginal examination, a skill that is essential for use of the partograph. Lack of
skill in this assessment may limit partograph use (along with vaginal examinations) in the
community setting, where there may be no trained midwives. Literacy is also an essential
skill, as drawing lines on the partograph may present problems even for the literate.


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Lack of access to partograph forms
Umezulike, Onah, and Okaros (1999) study of doctors and midwives in Nigeria indicated
that despite acknowledging the usefulness of the partograph, only about one-quarter used it
routinely. More than half indicated they did not use it because it was not available. One-
quarter of midwives said they did not use it because they lacked adequate knowledge. The
authors of this study felt that the partographs lack of availability in maternity units reflects a
lack of commitment to its useand, in effect, a lack of commitment to reducing maternal
mortality and morbidity. Oladapo, Daniel, and Olatunjis (2006) Nigerian study found that
among those who were aware of the partograph but never used it to monitor labor, reasons
for not routinely using it included little or no knowledge of the partograph, nonavailability of
the partograph (most frequently cited), and lack of adequate number of personnel (cited by
nearly half of the respondents). Nearly all of those aware of the partograph desired training
in its use.

Partograph improves quality
In contrast to several other studies, Lavender, Lugina, and Smith (2007) found very positive
opinions of the partograph when they surveyed African midwives attending a regional
midwifery conference. This was, however, not a representative sample, in that midwives
attending such a conference were likely to have higher levels of engagement, motivation, and
(possibly) education than the average midwife. Results indicated that the midwives views
were consistent with those of midwives in the United Kingdom. Most respondents described
the partograph as a practical management tool that helps ensure standardized quality of care
for women in labor and as a tool that saves lives. The midwives described it as a watchdog
that attracts attention.

Partograph is well used for referral, but transport can be inadequate
Despite the low levels of use reported in many other studies, the African midwives who
responded to the survey (Lavender, Lugina, & Smith (2007) stated that resource-poor
facilities do use the partograph to ensure standard practice and as a timely intervention to
save lives. Many reported, in particular, that the partograph is indispensable at government
facilities, where most women present late and with complications. For these reasons,
respondents indicated that most midwives act before the alert or action lines are reached.
They also stated that transport is frequently not available. As mentioned earlier, essential
obstetric functions, such as transportation and access to appropriately equipped centers,
must in fact be available if the partographs potential to act as a referral tool is to be fully
met. Given that appropriate use of the partograph will very likely result in increases in
referral rates, one must make sure that those needs will be met.

Lack of emotional consideration
One additional area that emerged in the midwife survey (Lavender, Lugina, & Smith (2007)
is that the emotional needs of women were not adequately addressed by the partograph.
Midwives suggested adapting charts to record womens appearance, anxiety level, opinions,
and cultural needs, echoing others who have been critical of the WHO partograph for
lacking a consumer focus. However, this viewpoint needs to be balanced with criticisms
that the tool already has too much detail, making it unnecessarily difficult to utilize.


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Introduction of the partograph as a labor-monitoring tool can have benefits that go beyond
the evaluation of medical outcome improvements. It can affect the perception of the
birthing process and of labor monitoring by increasing the frequency of contact between the
health provider and the laboring woman (Bergstrm, 2001). Provider attitudes and concerns
need to be addressed through the training process, as well as through implementation of
effective supervision and monitoring systems that ensure that the correct individuals are
being trained and are implementing the skills they have learned in their workplace. Provider
concerns about low skill levels, lack of resources, and repetitive paperwork need to be
assessed and addressed in any attempt to introduce or strengthen use of the partograph on-
site.


Adaptations to the WHO Partograph
The WHOs 1994 version of the partograph included both the latent and active phases of
labor; its 2000 modification of that partograph omitted the latent phase of labor and
commenced with the active phase, at 4 cm cervical dilation (see Figure 1). Several articles,
both pre- and postintroduction of this modified version, have examined whether the latent
phase of the partograph is useful or necessary.

The Cochrane database review aimed to provide an overview of all data on the effect of
partograph design on maternal and neonatal outcomes (Lavender, Hart, & Smyth, 2008). In
a summary of studies comparing partographs using a two-hour action line versus a four-hour
action line, both conducted in high-resource settings (Lavender, Alfirevic, & Walkinshaw,
1998; Lavender, Alfirevic, & Walkinshaw, 2006), no significant differences in cesarean
section rates were found. In comparing the two-hour action line with the three-hour action
line, one trial in a high-resource setting found no difference in cesarean section or other
clinical maternal or neonatal outcomes (Lavender, Alfirevic, & Walkinshaw, 1998). In a
comparison of three-hour versus four-hour action lines in a high-resource setting,
statistically significant findings indicated cesarean rates were lowest in the four-hour action
line group (Lavender, Alfirevic, & Walkinshaw, 1998). There were, however, no differences
in other clinical outcomes, maternal or neonatal.

The Cochrane review also included information on studies investigating the impact of use of
a partograph with an alert line only (2000 modification) versus a partograph with alert and
action lines (1994 original version). One study in a low-resource setting found cesarean
section rates to be lower in the alert lineonly group, with no difference in other maternal or
neonatal outcomes. When the review looked overall at the studies to determine the effects of
earlier or later intervention, three studies were pooled together (Lavender, Alfirevic, &
Walkinshaw, 1998; Lavender, Alfirevic, & Walkinshaw, 2006; Pattinson et al., 2003), and
there were no differences among cesarean rates based on early or late intervention (two-hour
vs. four-hour or alert vs. action/alert). However, in the low-resource setting, the early
intervention correlated with lower cesarean rates.

Mathews et al. (2007) compared two versions of the WHO partograph in India: a composite
partograph including the latent phase, and a simplified partograph without the latent phase.
While most maternal and perinatal outcomes were similar, labor values crossed the action
line significantly more often when the composite partograph was used, and the women were

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more likely to undergo cesarean deliveries. The simplified partograph was more user-
friendly, was more likely to be completed, and was associated with better labor outcomes.

Kwast et al. (2008) carried out a descriptive retrospective study in Ethiopia, looking at the
mode of delivery of women admitted in the latent and active phases of labor. Women
admitted in the latent phase had more operative deliveries as labor progressed to the right of
the alert line in the active phase, compared with women admitted in the active phase of
labor. The authors were concerned that omission of the latent phase from the modified
partograph may result in higher rates of operative delivery because women admitted in the
latent phase may not get the attention they require or could be shunted off to an area outside
the labor ward, where they may not be closely observed.

This concern echoes one shared by participants at a workshop preceding the 2005
International Confederation of Midwives Congress. In discussions about the introduction of
the modified partograph, some participants indicated that in such countries, women were
being left alone and not monitored appropriately because they are not yet in the active
phase of labor. They felt this carried risks, because a prolonged latent phase could then go
undiagnosed. Participants agreed that if this partograph were introduced, caregivers would
need to be encouraged to continue to monitor the womans condition and progress of labor,
as they had done before (ICM, 2005).

Research by Groeschel and Glover (2001) and Lavender and Malcolmson (1999) looked at
attitudes about the partograph among midwives in Australia and England, respectively. In
contrast to low rates of use elsewhere, the partograph is an official document of labor used
universally in these countries and is included in health records. The authors found mixed
opinions regarding the value of the latent phase and the action line in the partograph. While
many felt that action lines help to manage labor and diagnose prolonged labor at a
glance, the majority of midwives surveyed believed that documentation of the latent phase
was unnecessary and of little clinical value. Groeschel and Glover (2001) found that in
Australia, alert and action lines are not used; instead, clinical judgment is used to decide
when to intervene. Additionally, the point was made that action lines focus only on dilation,
whereas significant progress can be made with effacement and descent of the head without
dilation. Both studies were relatively small and were not able to be generalized to other
settings.

Fahdhy and Chongsuvivatwongs (2005) evaluation of the newer WHO partograph, with no
latent phase, in Indonesia found that removal of data from the latent phase caused some
important incompleteness in the partograph. Lacking the starting time of attendance made it
difficult to judge whether the latent phase was prolonged. They also found that a lack of
information on amniotic fluid might mean missing early membrane leakage or rupture.

Kwast et al. (2008) stressed the importance of developing a protocol for the care and
assessment of women in the latent phase, but they did not discuss their own protocol or the
issues associated with its implementation. The authors acknowledged that the validity of
their study is limited by its small size, and only half of the women in the in-depth analysis
had assessable partographs (though this speaks to the low rate of quality completion of the
partograph). Discussion within this article elaborates that the issue of exclusion or inclusion
of the latent phase is a question that needs to be explored further, remarking that it would be

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a cruel irony if the main aim of modifying the original partographto avoid confusion
and improve clinical decision makingshould result in serious detriment to those women
who came to the hospital earlier on in labor.

While not looking specifically at modifications to the WHO partograph, Leti (2008) reports
that variation in the formatting of the cervicograph can impact rate of intervention. The
cervicograph is the visual graph of cervical dilation versus time and can be formatted with
different time-to-dilation ratios. The steeper formats were associated with fewer
interventions, while the tendency to intervene was increased with shallow formats (Cartmill
& Thornton, 1992; Tay & Yong, 1996). The explanation is that the shallower format gives
the impression that the progress of labor is too slow and therefore attempts are made to try
to accelerate it.

Despite the concerns noted in several articles, the available evidence does not seem to
indicate that eliminating the latent phase from the partograph had a significant impact on
labor decisions or on maternal or neonatal outcomes. It is worth noting that several sources
emphasized the need to have support for women admitted during the latent phase, to ensure
that those women are not forgotten within the health facility, even when the partograph
record begins with the active stage of labor. A prolonged latent phase is cause for concern,
and any womans condition needs to be monitored.





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Conclusions



This literature review indicates that there are few controlled or quasi-controlled studies
examining the impact of partograph use on labor or on cesarean section rates and that
evidence of positive impact from these studies is limited. Other, noncontrolled studies,
however, provide supporting evidence of a positive impact on maternal and perinatal
outcomes.

Actual rates of partograph use vary greatly from region to region and from facility to facility.
In addition, the cadre of staff actually utilizing the partograph appears to vary greatly. Those
planning training for the partograph must take this variability into account to ensure that the
appropriate staff are receiving the information and developing the skills needed for
implementation. An effective supervision and monitoring component to any partograph
introduction and training is crucial.

In general, the low rates of use and of provider knowledge of the partograph are situated
within a larger context of poor labor-monitoring skills and practice. Partograph use is but
one component of this larger picture, and it is clear that overall skills development is needed
in this area to best provide meaningful obstetric care and reduce obstructed labor and poor
maternal and neonatal outcomes.

Despite the lack of consistent, high-quality data on the partographs impact on medical
outcomes, its introduction and implementation may in fact have other benefits that go
beyond the evaluation of medical outcome improvements. It has the potential to increase
quality of care, improve attitudes of providers and the general public, and expand knowledge
about labor practices. An additional potential benefit of consistent and correct partograph
use is the evidence it can provide, as a component of a functioning supervision system, in
reviewing any cases of maternal death or near misses.

Finally, while the available evidence does not indicate that eliminating the latent phase from
the partograph has a significant impact on labor decisions or on maternal or neonatal
outcomes, it would be helpful if researchers could examine more closely whether those
utilizing the partograph find the simplified version significantly easier to implement.
Regardless of which version is used, facilities must ensure that women admitted during the
latent phase receive adequate care and monitoring.

Fistula Care has developed and is field-testing a protocol and tool for monitoring partograph
use on-site on an annual basis. This tool can facilitate monitoring and supervision to ensure
that the partograph is being used correctly and appropriately at facilities of different levels.

Operational research addressing actual use of the partograph as a referral tool, examining the
partographs role in decision making, looking more closely at different training strategies and
outcomes, and strengthening labor monitoring skills and practice would make a valuable
contribution to the existing body of data.


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