Background
Methods
Clarifying the scope of the review
Search for evidence
Appraisal of evidence
Data extraction and synthesis of the evidence
Results
Question | No of studies | Evidence synthesis | Quality |
---|---|---|---|
Do health workers use the partograph? |
n = 18 | Wide variation in the reported routine use of the partograph in practice, from 8 to 80%. The partograph is more likely to be used in tertiary settings, by physicians and midwives. The partograph is more likely to be used in public facilities. Specific training in the partograph may increase use. There is some evidence, although limited, to suggest that experience does not have any impact on use. There is some evidence, although limited to suggest that confidence in using the partograph increases its use in practice. | |
What are health workers’ attitudes towards the partograph? |
n = 9 | Evidence suggests that health workers display positive attitudes to the partograph. A positive attitude alone does not appear to increase partograph use in practice. | |
What is the impact of partograph use on clinical outcomes? |
n = 6 | Evidence from RCTs suggests there is no improvement in clinical outcomes when a partograph is used. Pre- and post-implementation studies suggest that use of the partograph may contribute to shorter labours, reduced sepsis, reduced postpartum haemorrhage, and improved fetal outcomes. There is evidence, although limited, to suggest that the partograph may improve outcomes in low-resource settings. | |
What is the impact of the partograph on quality of care? |
n = 0 | None of the included studies assessed quality of care in relation to partograph use. Data related to improved maternal outcomes post-intervention, such as fewer vaginal examinations, may indicate that women may have a better experience of labour, but there is no empirical evidence to support this. | |
What is the impact of partograph use on maternal satisfaction? |
n = 0 | No studies evaluated maternal satisfaction. | |
Is the partograph a useable tool? |
n = 3 | The modified partograph is easier for providers to use than the composite partograph and may improve outcomes. | **Low [3] |
Question | No of studies | Evidence synthesis | Quality |
---|---|---|---|
What is the organisational commitment to partograph use? |
n = 2 | There is very little available evidence of organisational commitment. There is limited evidence of organisational commitment in high-resource settings. | **Low [23] *Very Low [29]. |
What is the policy and guidance related to partograph use? |
n = 4 studies
n = 5 guideline documents | The main guidance documents are those produced by WHO. There is a lack of available guidance at the facility level. Limited evidence suggests that available facility level guidance promotes partograph use in practice. | |
Is the partograph available? |
n = 8 | There is a lack of availability of the partograph in some settings, particularly health centres. | |
Is there support for partograph use in terms of resource provision? |
n = 2 | Equipment required for partograph completion may not be available; for example sphygmomanometers, thermometers and fetoscopes. | |
How can the partograph be implemented effectively? |
n = 2, plus 1 audit | There is little evidence to determine the most effective method of partograph implementation. Pre-implementation training and post-implementation audit and feedback may have a positive impact on accuracy and frequency of partograph completion. | ***Medium [18] |
Question | No of studies | Evidence synthesis | Quality |
---|---|---|---|
Which methods of working ensure effective referral? |
n = 2 | There is confusion between healthcare worker roles, particularly between midwives and physicians, which may impact on the effectiveness of referral. The partograph is not always used as a communication tool between health workers at handover of care or referral. Partograph findings are not always acted upon. | |
What are the issues or barriers related to effective referral? |
n = 10 | The partograph is a trigger for referral. However, there is some inconsistency in referrals based on partograph findings. It is unclear if referrals made as a result of partograph use are appropriate. There was little evidence of additional barriers to transfer, e.g., transport, cost etc. |
Question | No of studies | Evidence synthesis | Quality |
---|---|---|---|
Is there sufficient availability of personnel to enable effective partograph use? |
n = 9 | Staff shortages and a heavy workload appear to negatively impact partograph use. Some health workers find the partograph time-consuming to complete. The was some evidence to suggest the partograph is completed in retrospect The partograph can successfully be completed by non-professional cadres. | |
What supervision and mentoring of staff is required? |
n = 3, plus 1 audit | Supervision may have a positive influence on partograph completion and use. Audit and feedback of findings to staff may improve completion rates and quality of completion. | **Low [23] |
Question | No of studies | Evidence synthesis | Quality |
---|---|---|---|
What is health workers knowledge of assessment using the partograph? |
n = 10 | Knowledge of assessment using the partograph is generally poor, particularly when to start the partograph, the plotting of normal labour and the function of the action and alert lines. Knowledge is better in health workers with professional qualifications and those in tertiary settings. There is a little available evidence of health workers’ understanding of the partograph as a tool to aid decision making. | |
Do education, training and experience impact on knowledge of the partograph? |
n = 5 | Professional education and/or training in partograph use improve knowledge of the partograph. There does not appear to be a link between length of experience in using the partograph and knowledge of the partograph. | |
What is the level of competence in partograph completion? |
n = 11 | The overall standard of partograph recording is poor and frequently not in accordance with WHO or other guidance. Particular aspects of the partograph are more likely to be completed; these are cervical dilatation, fetal heart rate, and condition of the neonate. Maternal observations are least likely to be completed well. | |
Do training interventions increase knowledge and use of the partograph? |
n = 8 | Training interventions do appear to improve knowledge and use of the partograph. Individualised training sessions and self-directed training (e.g., CD-ROM or maternal care manual) are most effective in increasing knowledge (in the included studies). Health workers desire training in partograph use, even if they have already received training. | ***Medium [56] **Low [54] |
Discussion
What is it about the partograph that works (or does not work); for whom does it work (e.g., midwives, obstetricians, women); and in what circumstances (e.g., urban/rural setting, country)?
What is it about the partograph that works?
For whom does it work?
In what circumstances?
What are the essential inputs required for the partograph to work?
Limitations
Recommendations
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The modified partograph is preferable to the composite partograph in terms of ‘user friendliness’.
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The partograph and equipment required to complete it need to be available.
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The partograph should be the main labour record, reducing unnecessary duplication of documentation.
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There should be clear policy/guidance available at facility level for healthcare workers’ reference.
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Effective supervision by healthcare workers/managers with training and clinical experience in partograph use is necessary for sustaining successful implementation.
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Regular training and updating should be provided for all healthcare workers using the partograph, using proven effective training techniques, e.g., multi-disciplinary, practical/clinical application. Training should include understanding of when to commence the partograph, decision making based on findings and understanding of role.
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Monitoring and audit of the partograph in practice, including completion, decision making and referral and outcomes, is recommended.