Search

Context It was hypothesized that knowledge of skilled birth attendants (SBAs) about partograph and its utilization can be improved by modifying their predictors through training workshops. Aim To upgrade the knowledge regarding partograph and its utilization by SBAs by modifying their predictors through training workshops. Settings and design This was an intervention study, which was conducted in a rural area of the Jodhpur district of Rajasthan state. Subjects and methods The SBAs were interviewed through pre and postintervention with the help of a prevalidated semi-structured interview schedule. As a part of an intervention, a series of half-day training workshops were conducted in the intervention block. Data were analyzed using SPSS version 23. Statistical analysis used Descriptive statistics, univariate (Chi-square, t-test), and multivariate (logistic regression) analysis. Results A total of 213 SBAs (105 from intervention and 108 from control block) were included in the study. SBAs who had received training related to the partograph were having significantly higher odds of knowing (AOR = 22.6[10.7-47.9]) as well as utilization (AOR = 22.5[7.05-72.1]) of partographs as compared to their counterparts. Knowledge was also a significant predictor of the utilization of partograph. Intervention could significantly improve the knowledge of SBAs about partograph as well as its utilization in the intervention block. Conclusion Significant impact of the intervention on knowledge about partograph and its utilization was evidenced in the present study. There is a need to conduct training and refresher courses for healthcare workers on partograph use.

Introduction: Many women change their lifestyles and habits when they become pregnant, to avoid potentially harmful effects to themselves and their babies. This is especially so with respect to physical exercise, which is often greatly reduced due to ignorance of the benefits it provides during pregnancy. Aim: To evaluate the prevalence of spontaneous birth among women who participated in a water-based physical exercise program. Methods: A randomized clinical trial was conducted with a sample of 129 pregnant women (Control Group, CG = 64, Exercise Group, EG = 65). A physical exercise protocol, specifically designed for pregnant women, was created and applied. Those in the EG performed 60 min exercise sessions, three times per week for 17 weeks. The participants in the CG received routine check-ups and advice throughout their pregnancy. Findings: The women in the EG presented better results for the onset of spontaneous birth (OR = 2.060 (0.980&ndash, 4.332)) and for neonate Apgar score of 10 at five minutes (OR = 8.53 (3.60&ndash, 20.17)). Those who had normal weight at the start of pregnancy achieved better results for spontaneous delivery (OR = 2.099 (1.017&ndash, 4.335)) than those with overweight/obesity. The rate of caesarean delivery was higher in the women with overweight/obesity (OR = 3.570 ((1.226&ndash, 10.397)) than in those with normal weight. Conclusions: In our study, the women who followed the water-based exercise program gained less weight during pregnancy, which facilitated a better rate of spontaneous, non-instrumental childbirth, together with a better Apgar test score at five minutes.

Objectives Partograph is one of the best effective obstetric tools used to monitoring labor and prevent prolonged or obstructed labor which accounts for about 22% of maternal deaths in Ethiopia. This study was aimed to assess partograph utilization and associated factors among obstetric care givers. Facility based cross sectional study was used in the randomly selected health facilities. Total 220 obstetric care givers were selected using simple random sampling technique. Data were entered and analyzed using SPSS version 22.0. Bivariate and multivariate logistic regression analysis was used to identify the associations of each explanatory variable with the outcome variable. Finally, odds ratio with its 95% confidence interval and p-value of 0.05 was used to identify significant variables. Result Out of 198 obstetric care providers, 73.3% used partograph to monitor progress of labor. Those who were diploma holders (AOR = 3.8, CI = 2.2–6.2), receiving basic emergency obstetrics and new born care training (AOR = 5.6, CI 1.1–28.5), age between 20 and 29 years-old (AOR = 0.1, CI = 0.01–0.50), and male health care providers (AOR = 0.37, CI = 0.44–0.95) were factors significantly associated with partograph utilization. Partograph utilization in this study was below the WHO recommendation. Especial emphasizes and interventions should be given to increase partograph utilization. Electronic supplementary material The online version of this article (10.1186/s13104-018-3814-7) contains supplementary material, which is available to authorized users.

Background The ePartogram is a tablet-based application developed to improve care for women in labor by addressing documented challenges in partograph use. The application is designed to provide real-time decision support, improve data entry, and increase access to information for appropriate labor management. This study’s primary objective was to evaluate the feasibility and acceptability of ePartogram use in resource-constrained clinical settings. Methods The ePartogram was introduced at three facilities in Zanzibar, Tanzania. Following 3 days of training, skilled birth attendants (SBAs) were observed for 2 weeks using the ePartogram to monitor laboring women. During each observed shift, data collectors used a structured observation form to document SBA comfort, confidence, and ability to use the ePartogram. Results were analyzed by shift. Short interviews, conducted with SBAs (n = 82) after each of their first five ePartogram-monitored labors, detected differences over time. After the observation period, in-depth interviews were conducted (n = 15). A thematic analysis of interview transcripts was completed. Results Observations of 23 SBAs using the ePartogram to monitor 103 women over 84 shifts showed that the majority of SBAs (87–91%) completed each of four fundamental ePartogram tasks—registering a client, entering first and subsequent measurements, and navigating between screens—with ease or increasing ease on their first shift; this increased to 100% by the fifth shift. Nearly all SBAs (93%) demonstrated confidence and all SBAs demonstrated comfort in using the ePartogram by the fifth shift. SBAs expressed positive impressions of the ePartogram and found it efficient and easy to use, beginning with first client use. SBAs noted the helpfulness of auditory reminders (indicating that measurements were due) and visual alerts (signaling abnormal measurements). SBAs expressed confidence in their ability to interpret and act on these reminders and alerts. Conclusions It is feasible and acceptable for SBAs to use the ePartogram to support labor management and care. With structured training and support during initial use, SBAs quickly became competent and confident in ePartogram use. Qualitative findings revealed that SBAs felt the ePartogram improved timeliness of care and supported decision-making. These findings point to the ePartogram’s potential to improve quality of care in resource-constrained labor and delivery settings. Electronic supplementary material The online version of this article (10.1186/s12884-018-1760-y) contains supplementary material, which is available to authorized users.

Objective: To evaluate effect of locally tailored labour management guidelines (PartoMa guidelines) on intrahospital stillbirths and birth asphyxia. Design: Quasi-experimental pre-post study investigating the causal pathway through changes in clinical practice. Setting: Tanzanian low-resource referral hospital, Mnazi Mmoja Hospital. Population: Facility deliveries during baseline (1 October 2014 until 31 January 2015) and the 9th to 12th intervention month (1 October 2014 until 31 January 2015). Methods: Birth outcome was extracted from all cases of labouring women during baseline (n = 3690) and intervention months (n = 3087). Background characteristics and quality of care were assessed in quasi-randomly selected subgroups (n = 283 and n = 264, respectively). Main outcome measures: Stillbirths and neonates with 5-minute Apgar score ≤5. Results: Stillbirth rate fell from 59 to 39 per 1000 total births (RR 0.66, 95% CI 0.53–0.82), and subanalyses suggest that this was primarily due to reduction in intrahospital stillbirths. Apgar scores between 1 and 5 fell from 52 to 28 per 1000 live births (RR 0.53, 95% CI 0.41–0.69). Median time from last fetal heart assessment till delivery (or fetal death diagnosis) fell from 120 minutes (IQR 60–240) to 74 minutes (IQR 30-130) (Mann–Whitney test for difference, P < 0.01). Oxytocin augmentation declined from 22% to 12% (RR 0.54, 95% CI 0.37–0.81) and timely use improved. Conclusion: Although low human resources and substandard care remain major challenges, PartoMa guidelines were associated with improvements in care, leading to reductions in stillbirths and birth asphyxia. Findings furthermore emphasise the central role of improved fetal surveillance and restricted intrapartum oxytocin use in safety at birth. Tweetable abstract: #PartoMa guidelines aided in reducing stillbirths and birth asphyxia at a Tanzanian low-resource hospital. Plain Language Summary: PartoMa guidelines help birth attendants in Tanzania to save lives Every year, 3 million babies die on the day of birth. The vast majority of these deaths occur in the poorest countries. If their mothers had received better care during birth, most babies would have survived. At Mnazi Mmoja Hospital, an East African referral hospital, the PartoMa study shows that use of locally developed guidelines helps birth attendants to deliver better quality of care, which has led to improved survival at birth. At the hospital studied, resources are scarce. Each birth attendant assists four to six birthing women simultaneously, and many have less than 1 year of professional experience. International guidelines are available, but they are often unachievable and seldom applied. The PartoMa guidelines were developed in close collaboration with the birth attendants and approved by seven international experts. The result is an 8-page pocket booklet providing locally achievable and simple decision support for care during birth. Use of the PartoMa guidelines began in February 2015. As the staff group frequently changes, quarterly seminars are conducted where birth attendants are welcomed after working hours to learn about the guidelines. The guidelines have been positively received, and seminar attendance remains high. Use of the PartoMa guidelines is associated with: A decrease by one-third in stillbirths (59 to 39 per 1000 total births) A nearly halving in the number of babies born in immediate poor medical condition (52 to 28 per 1000 live births) The results presented here derive from a comparison of births before using the PartoMa guidelines and during the 9th–12th month of use. Such a ‘before-after’ study cannot exclude the possibility of other causes of better survival at birth. However, the improved survival is consistent with improved care during birth, which is in line with the PartoMa guidelines.

Background & objectives: India has recorded a marked increase in facility births due to government's conditional cash benefit scheme initiated in 2005. However, concerns have been raised regarding the need for improvement in the quality of care at facilities. Here we report the monitoring patterns during labour and delivery documented by direct observation in reference to the government's evidence-based guidelines on skilled birth attendance in five districts of India. Methods: A cross-sectional study design with multistage sampling was used for observation of labour and delivery processes of low-risk women with singleton pregnancy in five districts of the country. Trained research staff recorded the findings on pre-tested case record sheets. Results: A total of 1479 women were observed during active first stage of labour and delivery in 55 facilities. The overall frequency of monitoring of temperature, pulse and blood pressure was low at all facilities. The frequency of monitoring uterine contractions and foetal heart sounds was less than the expected norm, while the frequency of vaginal examinations was high at all levels of facilities. Partograph plotting was done in only 15.8 per cent deliveries, and labour was augmented in about half of the cases. Interpretation & conclusions: The findings of our study point towards a need for improvement in monitoring of maternal and foetal parameters during labour and delivery in facility births and to improve adherence to government guidelines for skilled birth attendance.

Background: Evidence shows that good knowledge of partographs and proper application of this knowledge results in a remarkable reduction in prolonged and obstructed labour and reduces maternal mortality. Obstructed labour can be prevented by a simple and cost-effective health intervention tool, the partograph. A partograph is a graphical record of the progress of labour and salient conditions of the mother and foetus plotted against time in hours. This provides an opportunity for early identification of deviation from normal progress. Early detection of prolonged labour greatly contributes to prevention of obstructed labour and related complications.Objective: To assess midwives’ knowledge and use of partographs in the maternity ward of Juba Teaching Hospital, South Sudan.Methods: A cross-sectional descriptive study was conducted to assess utilisation of partographs among healthcare providers in Juba Teaching Hospital. All providers working at the time of the study were included. An interviewer administered questionnaire prepared in English was used to assess socio-demographic and other related variables of respondents as well as knowledge and practice. Ethical procedures were followed at every step.Results: Only 20% of the 30 respondents were registered midwives, 67% knew the components -of a partograph, and 93% could differentiate between normal and abnormal labour with the use of a partograph. The factors affecting the use of partographs included; shortage of partographs in the ward, lack of protocols on partograph use, understanding semantics of the English language, absence of refresher training, late reporting of mothers to the ward, and a shortage of staff.Conclusions: Despite good knowledge of the partograph, about half of the providers do not use them. We recommend training and recruitment of more qualified midwives, a continuous supply of partographs to improve use of partographs continuous supportive supervision, mentoring of staff and motivation schemes.Keywords: maternal health, midwives, partograph, South Sudan

Introduction:the partograph is a pre-printed paper form used in monitoring the progress labor. It was initially introduced by Philpot; and endorsed by the World Health Organization as a simple and accurate instrument for early recognition of complications of labor. Our study was conducted to evaluate the utilization of the partograph and associated factors among obstetric care providers in the Eastern zone of Tigray, Northern Ethiopia 2017. Methods:a cross-sectional study was conducted in the Eastern zone of Tigray. Four hundred and fourteen participants were randomly selected from the Eastern zone weredas (districts). Data were collected using a self-administered questionnaire. The data were entered into epi data version 3.5 and exported to SPSS V-20 for analysis. Bivariate and multivariate analysis were done to determine the association between a dependent variable and independent variables at P-value

Abstrait Objectif Il n’ya pas de consensus sur les paramètres essentiels à surveiller pendant l’accouchement, quand commencer et le taux de surveillance. Le désaccord des utilisateurs contribue à une utilisation incohérente du partogramme modifié de l’Organisation mondiale de la Santé en douze éléments qui est. démarré lorsque le col. de l’utérus est. dilaté à au moins 4 cm. L’utilisation incohérente est. associée à de mauvais résultats à la naissance. Notre objectif était d’identifier les points de vue des experts en matière d’accouchement sur ce qu’il convient de surveiller régulièrement pendant l’accouchement dans les pays à faibles ressources, et à quel moment, afin de développer un outil d’aide à la décision clinique plus acceptable pour l’accouchement. Méthode Nous avons mené une étude Delphi avec deux enquêtes au début de 2018. Le questionnaire en ligne couvrait les éléments du partogramme tels que le cœur du fœtus, la dilatation du col. utérin et la pression artérielle, ainsi que leurs taux de surveillance. Nous avons invité des intervenants expérimentés dans les soins à l’accouchement en Afrique subsaharienne. Le consensus était prédéfini à 70%. Les membres du panel évaluaient un paramètre et quelques raisons qualitatives des choix recueillis. Résultats Nous avons analysé les réponses de 76 experts de 13 pays. Un consensus s’est. dégagé sur six paramètres importants, notamment la fréquence cardiaque fœtale, la clarté du liquide amniotique, la dilatation du col. utérin, la force des contractions utérines, le pouls maternel et la pression artérielle. Deux experts sur trois se sont déclarés favorables à la modification des intervalles de surveillance pour certains paramètres dans le partogramme. 63% des experts élèveraient le point de départ du partogramme alors que 58% en supprimeraient certains éléments. Un consensus s’est. dégagé sur le suivi de la dilatation cervicale toutes les 4 heures et un accord sur le suivi du rythme cardiaque fœtal toutes les heures. Cependant, d’autres paramètres ne montraient que les intervalles de majorité et sans atteindre les scores d’accord. Les intervalles suggérés étaient de deux heures pour la force des contractions utérines et de quatre heures pour l’épaisseur du liquide amniotique, le pouls de la mère et la pression artérielle. La raison la plus commune de leurs opinions était les conditions de travail les plus exigeantes. Conclusion il y avait accord sur le fait que six items du partogramme étaient essentiels pour le suivi systématique à la naissance, mais la fréquence du suivi pourrait être modifiée. Pour accroître l’acceptabilité, il est. nécessaire de réviser les lignes directrices sur la surveillance des naissances en tenant compte des opinions et des conditions de travail de plusieurs experts en matière d’accouchement dans des pays à faibles ressources.

Aim: to evaluate cervix dilation impact on birth outcomes on nulliparous. Objectives: 1. To determine cervix characteristics related to increasing need for the epidural analgesia and labor induction. 2. To determine cervix characteristics in which labor inducting procedures (amniotomy and oxytocin) are the most effective. 3. To determine birth outcomes differences between induced and non-induced women. Methods: a retrospective study. Object: women who gave birth in the hospital of Lithuanian University of Health Sciences Kauno Klinikos (LUHS KK), Obstetrics department in years 2016 – 2017. A study included medical records of 512 pregnant women. Records were divided into two groups: group 1 - women who gave birth without labor induction, group 2 – women to whom amniotomy and/or oxytocin infusion were performed. The results: Women who came to the hospital with less than 5 cm cervix dilation or cervix effacement have a higher risk to be induced. In addition, epidural analgesia in this group was used more often (p

Background Morbidity of birth asphyxia has been estimated to be 42 million disability-adjusted life years. The study sought to assess the impact of the use and completion of partograph during labour on reducing birth asphyxia at the St Anthony’s Hospital, Dzodze, in the Volta Region of Ghana. Methods A retrospective study design using a quantitative approach was adopted for the study. A simple random sampling technique was used to select a total of 200 folders of labouring women who were admitted and delivered at St Anthony’s Hospital, Dzodze, between 1st May 2015 and 30th April 2016. A structured checklist, which was developed by using labour and foetal monitoring parameters based on the standards of the World Health Organization partograph usage, was used to review all the 200 existing maternal records. Results The findings revealed that partographs were used by midwives at St Anthony’s Hospital with the majority of the maternal folders fully completed. The use and completion of partograph were found to be associated with less non-asphyxiated birth outcomes. Labours which were monitored with partograph were 4.29 times less likely to result in birth asphyxia [AOR (95% CI) 4.29 (1.35–14.81)], and those that were monitored with a completed partograph were 5.3 times less likely to result in birth asphyxia [AOR (95% CI) 5.31 (2.011–16.04)]. Conclusion Midwives used partographs during labour at St Anthony’s Hospital. The use and completion of partograph were significantly associated with a reduced incidence of birth asphyxia at the hospital. Birth asphyxia could be reduced if partographs are used and completed by midwives during labour in all cases.

Background Partograph is cost effective and affordable tool designed to provide a continuous pictorial overview and labour progress used to prevent prolonged and obstructed labour. It consists of key information about progress of labour, fetal condition and maternal condition. Its role is to improve outcomes and predict the progress of labour. The aim of this study was to assess utilization of partograph and its predictors among midwives working in public health facilities, Addis Ababa city administration, Ethiopia, 2017. Methods An institution based cross-sectional study design was conducted in Addis Ababa, Ethiopia from 15/10/2017–15/12/2017.Simple random sampling under multistage sampling technique was applied to select a total of 605 midwives working in maternity unit of selected public health facilities. Data were collected using structured self-administered questionnaire. Checklist based direct observations were made to all midwife participants to determine the actual practical use of partograph. Data first entered in to EpiInfo version 3.5.1 and transported to SPSS Version 21.Descriptive statistics such as frequency, percentage, mean, and median were calculated. Biviriate and multivariable logistic regression analysis were applied. Any personal identification of the study participants was not recorded during data collection to ensure confidentiality of information. Results In this study, the utilization of partograph was 409(69%) out of 594 study participants. Being mentored(AOR = 3.1; 95% CI: 1.7, 5.3),received training (AOR = 2.4; 95% CI:1.5,3.6),being knowledgeable about partograph (AOR = 1.6; 95% CI: 1.1, 2.5), health center workers(AOR = 12.6; 95% CI:5.1,31.6),supportive supervision 4 times per year (AOR = 18.6; 95% CI: 6.6,25),supportive supervision twice per a year (AOR = 4.7; 95% CI: 1.9, 11.3),supportive supervision once per year (AOR =3.8;95% CI:1.7,8.8) were positive predictors of partograph utilization. Two midwives per shift (AOR = 0.101; 95% CI: 0.05, 0.65), and 4 per shift (AOR = 0.105, 95% CI: 0.03, 0.40) were protective predictors of partograph utilization. Conclusions More than half of the respondents utilized partograph. All public health institutions avail partograph in their laboring room but didn’t utilize it according to WHO recommended standard. Working facility, supportive supervision, mentoring, training on partograph, number of midwives working per shift, and knowledge were factors affecting partograph utilization. Encouraging interventions are recommended to the response of the above significantly associated factors.

Background the partograph is a tool used to record labour observations and support decision-making. Although used globally, it has not reached its full potential. We aimed to determine whether an educational board game can improve labour-monitoring skills and influence practice. Study Design a quasi-experimental study, underpinned by Kirkpatrick’s evaluation model, was used. Midwives and student midwives from Malawi, Kenya and Tanzania were given an identical hypothetical case-scenario of a woman in labour pre-and post-implementation of a game, to assess recording and interpretation abilities. This was supplemented by qualitative inquiry 3 months post-game-playing using semi-structured interviews (n=24) and expert case-record reviews (n=24). Quantitative data were analysed using the paired t-test and qualitative data were subjected to framework analysis. Results 95 midwives and 97 students participated. In each country the mean test scores improved; Kenya from 86.5 (6.7) to 95.5 (3.7) (paired t=11.82, p

Background To study determinants of stillbirths as indicators of quality of care during labour in an East African low resource referral hospital. Methods A criterion-based unmatched unblinded case-control study of singleton stillbirths with birthweight ≥2000 g (n = 139), compared to controls with birthweight ≥2000 g and Apgar score ≥7 (n = 249). Results The overall facility-based stillbirth rate was 59 per 1000 total births, of which 25 % was not reported in the hospital’s registers. The majority of singletons had birthweight ≥2000 g (n = 139; 79 %), and foetal heart rate was present on admission in 72 (52 %) of these (intra-hospital stillbirths). Overall, poor quality of care during labour was the prevailing determinant of 71 (99 %) intra-hospital stillbirths, and median time from last foetal heart assessment till diagnosis of foetal death or delivery was 210 min. (interquartile range: 75–315 min.). Of intra-hospital stillbirths, 26 (36 %) received oxytocin augmentation (23 % among controls; odds ratio (OR) 1.86, 95 % confidential interval (CI) 1.06–3.27); 15 (58 %) on doubtful indication where either labour progress was normal or less dangerous interventions could have been effective, e.g. rupture of membranes. Substandard management of prolonged labour frequently led to unnecessary caesarean sections. The caesarean section rate among all stillbirths was 26 % (11 % among controls; OR 2.94, 95 % CI 1.68–5.14), and vacuum extraction was hardly ever done. Of women experiencing stillbirth, 27 (19 %) had severe hypertensive disorders (4 % among controls; OR 5.76, 95 % CI 2.70–12.31), but 18 (67 %) of these did not receive antihypertensives. An additional 33 (24 %) did not have blood pressure recorded during active labour. When compared to controls, stillbirths were characterized by longer admissions during labour. However, substandard care was prevalent in both cases and controls and caused potential risks for the entire population. Notably, women with foetal death on admission were in the biggest danger of neglect. Conclusions Intrapartum management of women experiencing stillbirth was a simple yet strong indicator of quality of care. Substandard care led to perinatal as well as maternal risks, which furthermore were related to unnecessary complex, time consuming, and costly interventions. Improvement of obstetric care is warranted to end preventable birth-related deaths and disabilities. Trial registration This is the baseline analysis of the PartoMa trial, which is registered on ClinicalTrials.org (NCT02318420, 4th November 2014). Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-1142-2) contains supplementary material, which is available to authorized users.

This work describes the design and preliminary evaluation of mLabour, a mobile application that aims to reduce death and injury in childbirth. mLabour incorporates a digital partograph and workflows to support labor ward management. This digital application reduces some of the barriers that prevent the partograph, a paper tool that has been shown to improve labor outcomes, from being fully utilized. We discuss design tradeoffs made during implementation, largely driven by prototype testing with labor ward nurses. We then discuss the results of a preliminary study of the application's usage, which suggests that mLabour has promise as a tool to improve patient care.

Background: The effective implementation of evidence-based practices including the use of partograph to improve maternal and newborn outcomes is critical on account of increased institutional delivery. However, despite clear guidelines, partograph use in India is not widely practiced. Materials and Methods: Quality improvement (QI) efforts along with training and mentoring were operationalized in a total of 141 facilities across 26 high priority districts of India. Assessments were conducted across baseline, intervention period, and end line. These included reviewing the availability of partograph and staff competency in filling them at baseline and end line, as well as reviewing monthly data for use and completeness of filling. The monthly data were tabulated quarter wise to study trends. Competency scores were tabulated to show the difference across assessments. Results: An overall upward trend from 29% to 61% was seen in the practice of partograph use. Simultaneously, completeness in filling up the partograph increased from 32% to 81%. Staff competency in filling partograph improved considerably: proportion of staff scoring low decreased over the intervention period from 63% to 2.5% (P < 0.0001), and the proportion scoring high increased from 13% to 72% (P < 0.0001) from baseline to end line. Conclusion: The integrated approach of training, mentoring, and QI can be used in similar settings to strengthen partograph use.

PurposeThe purpose of this paper is to describe a quality improvement (QI) intervention in primary health facilities providing childbirth care in rural Southern Tanzania.Design/methodology/approachA QI collaborative model involving district managers and health facility staff was piloted for 6 months in 4 health facilities in Mtwara Rural district and implemented for 18 months in 23 primary health facilities in Ruangwa district. The model brings together healthcare providers from different health facilities in interactive workshops by: applying QI methods to generate and test change ideas in their own facilities; using local data to monitor improvement and decision making; and health facility supervision visits by project and district mentors. The topics for improving childbirth were deliveries and partographs.FindingsMedian monthly deliveries increased in 4 months from 38 (IQR 37-40) to 65 (IQR 53-71) in Mtwara Rural district, and in 17 months in Ruangwa district from 110 (IQR 103-125) to 161 (IQR 148-174). In Ruangwa health facilities, the women for whom partographs were used to monitor labour progress increased from 10 to 57 per cent in 17 months.Research limitations/implicationsThe time for QI innovation, testing and implementation phases was limited, and the study only looked at trends. The outcomes were limited to process rather than health outcome measures.Originality/valueHealthcare providers became confident in the QI method through engagement, generating and testing their own change ideas, and observing improvements. The findings suggest that implementing a QI initiative is feasible in rural, low-income settings.

Background Making use of good, evidence based routines, for management of normal childbirth is essential to ensure quality of care and prevent, identify and manage complications if they occur. Two essential routine care interventions as defined by the World Health Organization are the use of the Partograph and Active Management of the Third Stage of Labour. Both interventions have been evaluated for their ability to assist health providers to detect and deal with complications. There is however little research about the quality of such interventions for routine care. Qualitative studies can help to understand how such complex interventions are implemented. This paper reports on findings from an observation study on maternity wards in Tanzania. Methods The study took place in the Lake Zone in Tanzania. Between 2014 and 2016 the first author observed and participated in the care for women on maternity wards in four rural and semi-urban health facilities. The data is a result of approximately 1300 hours of observations, systematically recorded primarily in observation notes and notes of informal conversations with health providers, women and their families. Detailed description of care processes were analysed using an ethnographic analysis approach focused on the sequential relationship of the ‘stages of labour’. Themes were identified through identification of recurrent patterns. Results Three themes were identified: 1) Women’s movement between rooms during birth, 2) health providers’ assumptions and hope for a ‘normal’ birth, 3) fear of poor outcomes that stimulates intervention during birth. Women move between different rooms during childbirth which influences the care they receive. Few women were monitored during their first stage of labour. Routine birth monitoring appeared absent due to health providers ’assumptions and hope for good outcomes. This was rooted in a general belief that most women eventually give birth without problems and the partograph did not correspond with health providers’ experience of the birth process. Contextual circumstances also limited health worker ability to act in case of complications. At the same time, fear for being held personally responsible for outcomes triggered active intervention in second stage of labour, even if there was no indication to intervene. Conclusions Insufficient monitoring leads to poor preparedness of health providers both for normal birth and in case of complications. As a result both underuse and overuse of interventions contribute to poor quality of care. Risk and complication management have for many years been prioritized at the expense of routine care for all women. Complex evaluations are needed to understand the current implementation gaps and find ways for improving quality of care for all women.

Background. WHO has developed the concept of partograph and recommended it as auxiliary tool to monitor progress of first stage of labour, detect complicating factors, and help midwives in decision making. Though various studies have proven the beneficial use of partograph, application of birth progress monitoring is not done properly. Aim: To observe midwives’ obedience in using partograph and explore the obstacles. Method. The study used mixed methods with sequential explanatory strategy. Quantitative study used cross-sectional design with observational method. Qualitative study used phenomenological approach through thorough interviews. Data collecting was done in November 2014 to March 2015 in health facilities in Bandung City, Bandung and Sukabumi Regency. 53 midwives were observed during childbirth processes and 27 involved in thorough interviews. Result. Observation showed 60.4% of midwives used partograph incompletely. Midwives had obstacles in using partograph properly. Knowledge was not main factor causing inobedience. Other contributing factors were skills, training, time with midwife-patient ratio, work burden, formality, supporting system, application of discipline/sanction, attitude. Conclusion. There are many obstacles faced by the midwives in applying partographs to monitor the birth progress and these conditions make its application to become unreasonable. Government needs to re-evaluate the policy of partograph usage. Keywords: Midwives, partograph, knowledge, skills, training, time with midwife-patient ratio, work burden, formality, supporting system, application of discipline/sanction, attitude., {"references":["Abebe, F et al. (2013). Assessment of knowledge and utilization of the partograph among health professionals in Amhara region, Ethiopia. Sci J Clin Med. 2(2):1-17. Retrieved from https://www.researchgate.net/profile/Fantu_Abebe/publication/236216606_Assessment_of_Knowledge_and_Utilization_of_Partograph_in_Amhara_region_Ethiopia/links/0deec5171045ba3791000000/Assessment-of-Knowledge-and-Utilization-of-Partograph-in-Amhara-region-Ethiopia.pdf","Chaturvedi, S et al. (2015). Implementation of the partograph in India's JSY cash transfer programme for facility births: a mixed methods study in Madhya Pradesh province. BMJ Open. 5(4):1-11. Retrieved from http://bmjopen.bmj.com/content/bmjopen/5/4/ e006211.full.pdf","Creswell, JW. (2009). Research design; qualitative, quantitative, and mixed methods approaches, third edition. Thousand Oaks California: Sage Publications. Retrieved from http://www.ceil-conicet.gov.ar/wp-content/uploads/2015/10/Creswell-Cap-10.pdf","Duysburgh, E et al. (2013). Quality of antenatal and childbirth care in selected rural health facilities in Burkina Faso, Ghana and Tanzania: similar finding. Trop Med Int Health. 18(5):534-47. Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1111/tmi.12076","Fatusi, AO et al. (2008). Evaluation of health workers' training in use of the partogram. Int J Gynecol Obstet. 100(1):41-4. Retrieved from https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1016/j.ijgo. 2007.07.020","Fawole, AO et al. (2010). Utilization of the partograph in primary health care facilities in Southwestern Nigeria. Niger J Clin Pract. 13(2):200-4. Retrieved from https://www.ajol.info/index.php/njcp/article/viewFile/53514/42085","Ferguson, P. (2002). Devolution and midwifery. 1: Wales and England. Delivering the future in Wales. Pract Midwife. 5(8):28-9. Retrieved from https://www.ncbi.nlm.nih.gov/ pubmed/12298332","Floyd, L. (2013). Helping midwives in Ghana to reduce maternal mortality. Afr J Midwifery Womens Health. 17(1):34-8. Retrieved from https://www.magonlinelibrary.com/doi/pdf/10.12 968/ajmw.2013.7.1.34","Gans-Lartey, F et al. (2013). The relationship between the use of the partograph and birth outcomes at Korle-Bu teaching hospital. Midwifery. 29(5):461-7. Retrieved from http://www.midwiferyjournal.com/article/S0266-6138(12)00044-7/pdf","Groeschel, N. (2001). The partograph. Used daily but rarely questioned. Aust J Midwifery. 14(3):22-7. Retrieved from http://www.womenandbirth.org/article/S1445-4386(01)80021-5/pdf","Ijadunola, KT et al. (2007). Unavailability of essential obstetric care services in a local government area of South-West Nigeria. J Health Popul Nutr. 25(1):94-100. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3013269/pdf/jhpn0025-0094.pdf","Indrayani et al. (2017). Please, understand why village midwife performance is not optimum! BJMS. 16(4):505-14. Retrieved from https://www.banglajol.info/index.php/BJMS/article/view/33603","Lavender, T & Malcolmson, L. (1999). Is the partogram a help or a hindrance? An exploratory study of midwives' views. Pract Midwife. 2(8):23-7. Retrieved from http://europepmc.org/abstract/med/10723398","Lavender, T et al. (2011). Students' experiences of using the partograph in Kenyan labour wards. Afr J Midwifery Womens Health. 5(3):117-22. Retrieved from https://www.magonlinelibrary.com/doi/pdf/ 10.12968/ajmw.2011.5.3.117","Lavender, T et al. (2012). Effect of partogram use on outcomes for women in spontaneous labour at term. Cochrane Database Syst Rev. 8:1-72. Retrieved from http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD005461.pub3/full","Mathai, M. (2009). The partograph for the prevention of obstructed labor. Clin Obstet Gynecol. 52(2):256-69. Retrieved from https://pdfs.semanticscholar.org/f670/76d44011b856baeb57d378eb2e1440b0985d.pdf","Mercer, SW et al. (2006). Using clinical audit to improve the quality of obstetric care at the Tibetan Delek Hospital in North India: a longitudinal study. BMC Reprod Health. 3(4):1-4. Retrieved from https://reproductive-health-journal.biomedcentral.com/track/pdf/10.1186/1742-4755-3-4","Ogwang, S et al. (2009). Assessment of partogram use during labour in Rujumbura Health Sub District, Rukungiri District, Uganda. Afr Health Sci. 9(S2):27-34. Retrieved from https://www.ajol.info/index.php/ahs/article/view/47809","Oladapoa, OT et al. (2006). Knowledge and use of the partograph among healthcare personnel at the peripheral maternity centres in Nigeria. J Obstet Gynaecol. 26(6):538-41. Retrieved from https://www.tandfonline.com/doi/full/10.1080/01443610600811243","Pettersson, KO et al. (2000). Evaluation of an adapted model of the World Health Organization partograph used by Angolan midwives in a peripheral delivery unit. Midwifery. 16(2):82-8. Retrieved from https://www.sciencedirect.com/science/article/pii/S0266613899902061","Philpott, RH & Castle, WM. (1972). Cervicographs in the management of labour in primigravidae. BJOG. 79(7):592–8. Retrieved from https://obgyn.onlinelibrary.wiley.com/doi/abs/ 10.1111/j.1471-0528.1972.tb14207.x","Spector, JM et al. (2012). Improving quality of care for maternal and newborn health: prospective pilot study of the WHO safe childbirth checklist program. PLos ONE. 2012;7(5):1-9. Retrieved from http://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0035151&type=printable","Umezulike, AC et al. (1999). Use of the partograph among medical personnel in Enugu, Nigeria. Int J Gynecol Obstet. 65(2):203-5. Retrieved from https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1016/S0020-7292%2898%2900168-4","Windrim, R et al. (2007). A randomized controlled trial of a bedside partogram in the active management of primiparous labour. J Obstet Gynaecol Can. 29(1):27-34. Retrieved from https://www.sciencedirect.com/science/article/pii/S170121 6316323672","Yisma, E et al. (2013a). Knowledge and utilization of partograph among obstetric care givers in public health institutions of Addis Ababa, Ethiopia. BMC Pregnancy Childbirth. 13(17):1-9. Retrieved from https://bmcpregnancychildbirth.biomedcentral.com/track/pdf/10.1186/1471-2393-13-17","Yisma, E et al. (2013b). Completion of the modified World Health Organization (WHO) partograph during labour in public health institutions of Addis Ababa, Ethiopia. BMC Reprod Health. 10(23):1-7. Retrieved from https://reproductive-health-journal.biomedcentral.com/track/pdf/10.1186/1742-4755-10-23"]}

Objective To assess the accuracy of the World Health Organization (WHO) partograph alert line and other candidate predictors in the identification of women at risk of developing severe adverse birth outcomes. Design A facility‐based, multicentre, prospective cohort study. Setting Thirteen maternity hospitals located in Nigeria and Uganda. Population A total of 9995 women with spontaneous onset of labour presenting at cervical dilatation of ≤6 cm or undergoing induction of labour. Methods Research assistants collected data on sociodemographic, anthropometric, obstetric, and medical characteristics of study participants at hospital admission, multiple assessments during labour, and interventions during labour and childbirth. The alert line and action line, intrapartum monitoring parameters, and customised labour curves were assessed using sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, and the J statistic. Outcomes Severe adverse birth outcomes. Results The rate of severe adverse birth outcomes was 2.2% (223 women with severe adverse birth outcomes), the rate of augmentation of labour was 35.1% (3506 women), and the caesarean section rate was 13.2% (1323 women). Forty‐nine percent of women in labour crossed the alert line (4163/8489). All reference labour curves had a diagnostic odds ratio ranging from 1.29 to 1.60. The J statistic was less than 10% for all reference curves. Conclusions Our findings suggest that labour is an extremely variable phenomenon, and the assessment of cervical dilatation over time is a poor predictor of severe adverse birth outcomes. The validity of a partograph alert line based on the ‘one‐centimetre per hour’ rule should be re‐evaluated. Funding Bill & Melinda Gates Foundation, United States Agency for International Development (USAID), UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), and WHO (A65879). Tweetable abstract The alert line in check: results from a WHO study., Tweetable abstract The alert line in check: results from a WHO study.

Background There is some evidence that appropriate use of partograph in monitoring the progress of labour could decrease delivery related complications. The documentation of parameters of partographs is however, poorly understood. The aim of the present study was to determine the extent to which health care workers are making use of the partograph in monitoring the progress of labour through checking the documentation of the parameters of the partographs. Methods A hospital-based descriptive study involving retrospective review of partographs for births that occurred in 2016 was conducted in Malawi’s South-West zone. A total of 1070 partographs that were used to monitor labour in two public hospitals were reviewed to determine the documentation of the parameters of partographs and descriptive statistics were computed using statistical package for the social science software version 22.0. Results Of the total 1070 partographs reviewed, 58.6% (n = 627) of the partographs had no recording of maternal blood pressure and 65.3% (n = 699) of the partographs had no temperature documentation. Moulding was not recorded in 25.4% (n = 272) of the partographs, foetal heart rate was not recorded in 14.9% (n = 159) of the partographs and descent of the foetal head was not recorded in 12.0% (n = 128) of the partographs. Conclusion There is poor documentation of vital parameters of the partographs. This suggests insufficient monitoring of the progress of labour, which may lead to adverse pregnancy outcomes. To improve the accurate documentation of parameters of the partograph, there is a need to understand the problem and provide tailor-made solutions to address them and ultimately improve pregnancy outcomes. In the meantime, in-service refresher courses on partograph use to health care workers need to be conducted regularly. Supportive supervision to obstetric care providers and regular partograph audit could also improve documentation.

Background: The partograph is a vital tool for health professionals who need to be able to identify pathological labor. It is used to recognize complications in childbirth on time and to take appropriate actions. We aimed to assess the knowledge and utilization of the partograph and associated factors among health professionals at public health institutions in eastern Ethiopia.Methods: An institution based cross-sectional quantitative study was carried out among health professionals who were working in public health institutions. Multistage sampling with proportional to size allocation was used to recruit a total of 441 study participants. Self-administered questionnaire was used to collect data in this study. Eight midwives were recruited and trained to facilitate the data collection activities. Data were entered into Epi data software and exported into SPSS (22.0) for analysis. Descriptive statistics, bivariate and multiple logistic regression were computed to determine proportions and significant association with knowledge and use of the partograph among health professionals.Results: More than half of health professionals, 232(53.7%) had a good level of knowledge about the partograph. However, only 196(45.4%) of health professionals had fair knowledge of partograph. Nevertheless, the proportion of the partograph utilization to follow labor progress by health professionals was 92.6%. Working in the health center [AOR = 0.31, 95% CI: 0.20, 0.48], being a midwife [AOR = 2.80, 95% CI: 1.60, 5.60] and in-service training [AOR = 2.0, 95% CI: 1.22, 3.42] were significantly associated with good level of knowledge. Health professionals who had inservice training about the partograph [AOR = 3.10, 95% CI: 1.35, 4.98] and who had positive attitude about the partograph [AOR = 2.90, 95% CI: 1.30, 6.30] were significantly associated with utilization of the partograph.Conclusion: Only less than half of health professionals had fair knowledge about the partograph. Having in-service obstetric care training, type of health institutions and profession were significantly associated with knowledge of the partograph. Health professionals who had positive attitude towards use of the partograph were significantly associated with the partograph utilization. We suggest regular in-service training of health professionals can enhance their knowledge and utilization of the partograph.

Introduction: Recent studies have proved that physical activity of the pregnant woman brings benefits not only for the mother but also for the fetus, given that it decreases the number of macrosomic newborns and their negative consequences in both of them.Objective: To analyze in pregnant women the influence of a moderate physical activity program in the aquatic environment on the weight of the newborn.Material and methods: A randomized clinical trial with 140 healthy pregnant women, aged between 21 and 43 years, divided into two groups, study (GE, n = 70) and control (GC, n = 70). The women were attracted at 12 weeks of gestation in the first trimester ultrasound control carried out in the different obstetrical services in Granada. They joined the program at week 20 of gestation and ended in week 37. The perinatal results were obtained from the partograph of each woman, included in the Delivery Room Services of the Complejo Hospitalario Universitario de Granada.Results: The median weight of the babies of the pregnant women who participated in the intervention was 3,250 g, compared to the babies of the control group, with a median of 3,460 g. There were statistically significant differences between the two groups (p = 0.011). Among newborns, 86.8% of both groups had weights within clinical normality, that is between 2,500 and 4,000 g. Women who followed the SWEP (Study Water Exercise Pregnant) method during pregnancy had a weight gain of 8.28 kg, compared to sedentary women, who presented a 11.17 kg weight gain. However, the rate of macrosomic infants was similar, so there were no significant differences between the two groups (GC n = 7, GE n = 6). There were no significant differences in gestation time between the two groups, with an average of 279.70 days (GC) and 280.09 days (SG) (p-value > 0.05).Conclusion: Moderate physical activity in the aquatic environment, following the SWEP methodology, does not present risks of preterm birth and does not alter the gestation time with regard to the sedentary women during pregnancy. Physical exercise has achieved a significant decrease in the weight of the newborn and a less profit ponderal during pregnancy. These two results have not been instrumental in reducing the rate of macrosomies in our study.

Background We sought to investigate the impact of the duration of second stage of labor on risk of severe perineal lacerations (third and fourth degree). Methods This population based cohort study was conducted in the Stockholm/Gotland region, Sweden, 2008–2014. Study population included 52 211 primiparous women undergoing vaginal delivery with cephalic presentation at term. Unconditional logistic regression analysis was used to calculate crude and adjusted odds ratios (OR), using 95% confidence intervals (CI). Main exposure was duration of second stage of labor, and main outcome was risks of severe perineal lacerations (third and fourth degree). Results Risk of severe perineal lacerations increased with duration of second stage of labor. Compared with a second stage of labor of 1 h or less, women with a second stage of more than 2 h had an increased risk (aOR 1.42; 95% CI 1.28–1.58). Compared with non-instrumental vaginal deliveries, the risk was elevated among instrumental vaginal deliveries (aOR 2.24; 95% CI 2.07–2.42). The risk of perineal laceration increased with duration of second stage of labor until less than 3 h in both instrumental and non-instrumental vaginal deliveries, but after 3 h, the ORs did not further increase. After adjustments for potential confounders, macrosomia (birth weight > 4 500 g) and occiput posterior fetal position were risk factors of severe perineal lacerations. Conclusions The risk of severe perineal laceration increases with duration until the third hour of second stage of labor. Instrumental delivery is the most significant risk factor for severe lacerations, followed by duration of second stage of labor, fetal size and occiput posterior fetal position.