The Partograph: Knowledge, Attitude, and Utilization by Professional Birth Attendances in Port-Said and Ismailia Cities

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1 Med. J. Cairo Univ., Vol. 78, No. 1, June: , The Partograph: Knowledge, Attitude, and Utilization by Professional Birth Attendances in Port-Said and Ismailia Cities NAGAT S. SALAMA, D.N.Sc.*; INAS M. ABD ALLAH, D.N.Sc.** and MANAR F. HEEBA, D.N.Sc.* The Departments of Maternity and Gynecological Nursing, Faculty of Nursing, Port-Said, Suez Canal* and Ismailia, Suez Canal** Universities. Abstract The partograph has been proven to be the single most important tool that when effectively used, any deviations from normal can be quickly detected and actions taken in good time. The aims of this study were to assess the existing knowledge, attitude and practice of professional birth attendants (PBAs) (Nurses/Physicians) regarding the use of partograph as well as to explore the factors limiting its use in the Health Centers and District Hospitals in Port-Said and Ismailia cities. A cross sectional descriptive study was conducted on 103 professional birth attendances (Nurses and Physicians). Two tools were used to collect the data named self administered questionnaire, was used to collect the necessary data in relation to the PBAs' knowledge and attitude toward partograph and revision audit to evaluate the accuracy of recording data on partograph. Results of the study revealed that the majority of nurses (91.3%) had an unsatisfactory score of knowledge regarding using of partograph, while more than half of physicians (55.9%) had a satisfactory score. The great majority of PBAs either physicians or nurses (97.1%, 91.3% respectively) had positive attitude toward partograph. Regarding the actual use of partograph, about two third of physicians and one fifth of the nurses, reported that they may use the partograph to manage a selected cases. The absence of obligation from health settings policy to perform the partograph was the most reason that limits its utilization as described by PBAs. In relation to the PBAs' accuracy in recording and plotted the data on partographs, there were incomplete and poor monitoring of parameters on the partograph against the recommended standards; that reflects poor skills of birth attendances on the use of a partograph. It recommended supporting usage of partograph in all institutions where women go for delivery services, and training all birth attendances on the use of the partograph and enforcing its use. Key Words: Partograph Knowledge Attitude Utilization Professional birth attendances. Introduction ALTHOUGH normal labor constitutes 80 percent of all deliveries [1], it is not risk free. Significant Correspondence to: Prof. Nagat S. Salama, The Department of Maternity and Gynecological Nursing, Faculty of Nursing, Port-Said, Suez Canal. proportions of maternal deaths are attributable to direct and indirect complications of prolonged and obstructed labor [2] In Egypt Maternal mortality rates is 84 (per live births) [3]. Obstructed labor is a common cause of maternal and neonatal morbidity and deaths worldwide [4,5]. It is responsible for up to 8% of maternal deaths in the world [6]. Other causes of maternal deaths such as postpartum hemorrhage and puerperal sepsis are closely linked to the abnormal course of labor [7,8]. Postpartum hemorrhage is a cause for 10-60% of maternal deaths globally [9], the majority of it are following normal labor [10]. Severe morbidities such as vesico-vaginal fistulae, chronic pelvic pain, and mental retardation in children can also result from prolonged and obstructed labor [11]. So continuous monitoring of labor and provision of rapid care to deal with problems are most crucial for preventing adverse obstetric outcomes related to childbirth. Partograph provided health professionals with a pictorial overview of labor progress, maternal and fetal condition to allow early identification and diagnosis of pathological labor. Its use is critical in preventing maternal and perinatal morbidity and mortality. The partograph has was originally designed and used by prof. R.H Philpou in It was later modified and simplified by the world health organization (WHO). The World Health Organization (WHO) recommends partograph with a 4-hour action line from alert line, denoting the timing of intervention for prolonged labor; others recommend earlier intervention to allow for referral [12,13]. Partograph is a composite record of all important and necessary features of the vital events taking place during labor on a single sheet of paper. It essentially describes cervical dilatation against time. This provides a basis 165

2 166 The Partograph: Knowledge, Attitude & Utilization of early recognition of any deviation from the normal. Timely detection of delay in progress of labor at one glance, directs in management of dysfunctional labor [14]. It is basically a graphic representation of events of labor plotted against time in hours. It consists of three components: The fetal condition which emphasis on fetal heart rate, status of the liquor amnii, and degree of molding. The progress of labor monitored using the cervical dilatation, uterine contractions and the descent of presenting part and finally. The maternal condition which include the vital signs, along with determination of the urine volume and analysis for proteinuria, glycosuria and ketonuria [7,15]. The partograph is an inexpensive tool that serves as an "early warning system" and can assist in early decision making on transfer, augmentation, and termination of labor. The partograph increases the quality and regularity of all observations on the fetus and the mother in labor, and aids early recognition of problems in either party [16,17]. Physicians, midwives, nurses, and doulas, all be involved in caring for the woman as she experiences labor and gives birth. Nurses have both the privilege and responsibility of caring for women during labor and birth in the hospital setting. The goal of nursing during labor and birth is to promote the maximum physical and emotional well-being of the woman, her baby, and her family [18]. In hospital, nurses have more contact than other professionals with the woman during childbirth and her family. Nurses thus have a great influence on shaping the childbirth experience of both the woman and her family [19]. Nurses caring for women during labor and birth should be knowledgeable about the normal and abnormal processes of labor and birth; have a mastery of appropriate technical skills; communicate and collaborate well with the health care team, and possess the necessary judgment, self-confidence, and skills to cope with stressful, emergency conditions [20]. Poor knowledge and lack of skills in using partograph, in addition to scanty staff and inefficient health care systems has been cited among possible causes of adverse obstetric outcomes [21]. Because of the partograph serves a simple and inexpensive tool to monitor labor in a cost-effective way, it is a suitable method to use in low income countries to improve the maternity care. In Egypt, the proportion of health care workers consistently using the partograph is not estimated and little is known about the utilization of it in practices and practitioner adherence to its protocol. So it is important to study the using of partograph and the related knowledge and attitudes in hospitals in our country and what factors restrict its use. Aim: The aim of the study had two folds to assess the existing knowledge, attitude and practice of profession (Nurses/Physicians) birth attendants regarding the use of partograph of labor as well as to explore the factors limiting its usage in the Health Centers and District Hospitals in Port-Said and Ismailia cities. Research questions: What is the level of knowledge of professional birth attendants (PBAs) (Nurses/physician) regarding partograph? What is the attitude of PBAs toward the usage of partograph? Are PBAs whose using partograph used it correct? What are the factors affecting the usage of partograph? Material and Methods Study design: A cross sectional descriptive study was performed. Study sitting: The study was conducted at the obstetric department at the following setting: Suez Canal University Hospital in Ismailia. El amery General Hospital in Ismailia. El amery General Hospital in Port Said. El-Tadamon Hospital in Port Said. Port Foad Hospital in Port Said. El-kweit Health Center in Port Said. El-zahra Health Center in Port Said. Umer Iben El- Khatab Health Center in Port Said. Sample: Convenience sample of (103) PBAs (69 Nurses/ Midwifes and 34 Physicians) who are eligible to conduct normal vaginal delivery and worked in the previous eight setting were recruited in this study according to the inclusion criteria. Inclusion criteria: Every nurse/midwife or Physicians who attends to labor cases in the selected setting

3 Nagat S. Salama, et al. 167 Work on Obstetric department at least 2 years. Tools of data collection: Two tools were used for data collection: Self administrative questionnaire: Was used to collect the necessary data in relation to the general characteristics of the birth attendances recruited in the study, to evaluate their knowledge about partograph and method of plotting data on it, and to evaluate their attitude toward using the partograph in practice. This sheet divided into four parts as following: First part: Included socio-demographic data such as; age, qualification, experience, work place... ect. Second part: Included questions to assess participant' knowledge about partograph. Open and closed questions about definition, indication, and component of partograph was used. Also this part included closed questions about method of plotting the data on partograph such as fetal condition, progress of labor and maternal status. Third part: Included questions to assess the PBAs' attitudes toward the using of partograph, where they answer against scale of "agree", "sometimes", and "disagree". Fourth part: Included open question about reasons of not using the partograph. Revision audit: Revision audit was constructed to evaluate the accuracy of recording the data on partographs that actually filled by birth attendances. The construction of this audit was in accordance with the WHO approved partograph and contains the details items of administrative data, fetal condition, progress of labor, drugs administration, maternal condition, time interval of recording the data, time of stopping partograph, and time of delivery. The items of the audit were checked on the scale of "recorded accurately", "recorded inaccurately", and "not recorded" The questionnaire and the revision audit were pre-tested and evaluated before commencement of the study. Fieldwork: Data were collected during one month (July 2009). The study setting was visited three days per week. The researchers interviewed each of the participating birth attendance individually to simply explain the designed questionnaire form. Each participant was requested to fill the questionnaire individually. The rates of using the partographs in relation of the number of deliveries were estimated in each setting of this study. There is an important observation that all the partographs reviewed were found only in Suez Canal University Hospital in Ismailia where other hospitals and centers didn't use any partograph in monitoring labors. The rate of using the partograph in Suez Canal University Hospital was one partograph every two deliveries. Other observation was that all partographs found were filled by physicians, and no one filled by the nurse. When reviewing the actually filled partograph, we found that there were no available copies of partograph in any studied setting. While some of PBAs in Ismailia University Hospital recorded the data in a hand drawing table corresponding to time. It is already not a graph so there weren't alert or action line showed. The available labor sheets that actually plotted by the birth attendances (63 sheets filled through the previous 2 months from Suez Canal University Hospital) were reviewed and evaluated by the researchers retrospectively using the constructed check list that prepared depending on the standard of WHO approved partograph, in which we found that some evaluation items were present and others were neglected. Ethical considerations: All official permissions to carry out the study were secured from pertinent authorities. An informed oral consent was obtained from all the participants before collecting data. Explanation of the study aim in a simple manner was done. No harmful maneuvers were performed or used. All data were considered confidential. Participants were informed about their right to withdraw from the study at any time without giving any reason. Statistical analysis: Scoring system: Knowledge Score: For the knowledge items, a correct response was scored 1 and the incorrect Zero. For each area of knowledge, the scores of the items were summed-up and the total divided by the number of the items, giving a mean score for the area. These scores were converted into a percent score. The birth attendants; knowledge was considered satisfactory if the percent score was 60% or more and unsatisfactory if less than 60%.

4 168 The Partograph: Knowledge, Attitude & Utilization Attitude scale: For attitude, the responses "agree", "sometimes", and "disagree" were respectively scored 2,1 and zero. The scoring was reversed for negative statements. The scores of the items were summedup and the total divided by the number of the items, giving a mean score. These scores were converted into a percent score, and means and standard deviations were computed. The attitude was considered positive if the percent score was 60% or more and negative if less than 60%. Data entry and statistical analysis were done using SPSS 14.0 statistical software package. Was used chi-square test whenever the expected values in one or more of the cells in 2x2 tables was less than 5, Fisher exact test was used instead. Kurskal-Wallis test was used for assessment of the inter-relationships among quantitative variables, and mann-whitney test for ranked ones. Statistical significance was considered at p-value <0.05. Results Table (1) revealed that the majority of nurses were in the age group less than 30 years with mean 29.6± 10.6 years, while the majority of physicians were in the age group more than 30 years with mean 33.7±7.9 years. As regards qualification, the great majority of nurses (92.8%) had nursing diploma. Table (1): Characteristics of professional birth attendants (PBAs). Physicians (n=34) Group Nurses (n= 69) Total (n=103) No. % No. % No. % Age (year): < Range Mean ± SD 33.7± ± 10.6 Qualification: Bachelor of medicine Nursing diploma Bachelor of nursing Experience (year): < Range Mean ± SD 10.4± ±9.5 Workplace: Hospital PHC center Studied the partograph: Yes No Trained to use partograph: Yes No Utilization of partograph: Used Partograph Never used partograph The same table shows about two thirds of nurses and physicians (60.9%, 61.9%) had experience less than 10 years, respectively. With that mean year of experience of nurses and physicians were 11.1 ±9.5 years and 10.4±7.9 years. Regarding the workplace the table revealed that, about three quarters of the nurses (71%) were worked in PHC center. Meanwhile, more than three quarters (79.4%) of the physicians were worked in hospital. Also the table indicates that about three quarters (73.5%) of physicians studied partograph and more

5 Nagat S. Salama, et al. 169 than two third (67.6%) trained on and used it. On other hand, only 15.9% of nurses studied partograph and one fifth of them (20.3%) had training courses on and used it. Table (2) shows that the total knowledge of partograph component among birth attendants, it reveals that; more than half of physicians (55.9%) had a satisfactory score, while majority of nurses (91.3%) had an unsatisfactory score. Regarding to total knowledge of about method of recording data on partograph, almost nurses and physicians had an unsatisfactory score of total knowledge (97.1 % and 79.1%) respectively. Overall, majority of nurses (98.6%) and physicians (82.4%) had unsatisfactory score of total knowledge. Table (2): Level of Knowledge about partograph and method of recording data on it among PBAs. Level of knowledge Physicians (n=34) Group Nurses (n=69) No. % No. % Partograph component: Satisfactory (60%+) Unsatisfactory (<60%) Recording data on partograph: Satisfactory (60%+) Unsatisfactory (<60%) Total knowledge: Satisfactory (60%+) Unsatisfactory (<60%) Table (3): Professional birth attendants' attitude towards partograph use. Group Items describe attitudes Physicians Nurses (n=34) (n= 69) Agree Some times Disagree Agree Some times Disagree No. % No. % No. % No. % No. % No. % Partograph is an important tool to monitor labor Partograph should be used in all normal labor Use of partograph decreases risks on mother/infant Partograph helps early identification of cases for surgery I want to be trained on partograph use I wish to use partograph as a routine Not all normal labors need partograph All team members must be trained on partograph The partograph is the responsibility of the physician only It is not necessary to train nurse on partograph Partograph is not effective in assessment of parturient women Partograph is a loss of time I have difficulties in using partograph Total attitude: Positive (60%+) Negative (60%+)

6 170 The Partograph: Knowledge, Attitude & Utilization It was obvious the great majority of birth attendants (either physicians or nurses) (97.1%, 91.3% respectively) had positive attitude toward partograph. Most of nurses and physicians (from 88.2% to 100%) agreed that partograph is an important tool to monitor labor; use of partograph decrease risks on mother and infant, and partograph helps an early identification of cases for surgery. Also agreed that they want to be trained on partograph use; and all team members must be trained on partograph. Moreover, most of physicians (94.1%) agreed that partograph should be used in all normal labor and they wish to use partograph as a routine but less than two third of nurses agreed those (65.2%, and 56.5% respectively) these differences in attitude were statistically significant ( p=0.001, p<o.001 respectively). In addition, this table show, more than half of physicians (52.9%) and about two third of nurses (66.7%) agreed that not all normal labors need partograph. Also, more than half of nurses (59.4%) but less than half of physicians (47.1 %) agreed that they have difficulties in using partograph. Partograph is the responsibility of the physician only is an attitude of more than one third of birth attendance (38.2% of physicians, and 37.7% of nurses). In addition, more than one tenth (11.8% of physician, and 15.9% of nurses) agreed that it is not necessary to train nurses on partograph. Partograph is not effective in assessment of parturient women is an answer of 17.4% of nurses but 2.9% of physicians. The lowest frequencies of participants (2.9% of physicians and 7.2% of nurses) were agreed that partograph use is a loss of time. Table (4): Relation between PBAs' knowledge and attitude towards partograph and their qualifications. Qualification Mean ± SD Kurskalwallis test p value Total knowledge: Bachelor of Medicine 47.8± 14.3 Nursing diploma 31.4± <0.001 * Bachelor of nursing 12.7± 19.4 Attitude towards partograph: Bachelor of medicine 73.3±7.5 Nursing diploma 70.8± Bachelor of nursing 70.4±8.0 (*) Statistically significant at p<0.05. Table (4) revealed that the level of knowledge were statistically significant associated with the qualifications of birth attendances. But the attitude towards using of partograph wasn't statistically significant associated with the qualifications of birth attendances. Table (5) shows that there wasn't statistically significant relation between participant knowledge and their attitude towards partograph ( p=1.00 for all physicians and nurses). Table (5): Relation between PBAs' knowledge and attitude towards partograph. Total knowledge Total attitude Physicians Nurses No. % No. % X test p value Nurses: Satisfactory (n=1) Unsatisfactory Fisher 1 (n=68) Physicians: Satisfactory (n=6) Unsatisfactory Fisher 1 (n=28) Table (6) the accuracy of recording the data in partographs that filled by physicians in S.C.U Hospital. The number of partograph reviewed were 63 where the results indicated that there some data were not recorded at all as date, time of admission, molding of fetal head, maternal condition. Alert and action lines not found in any labor sheet, and actions taken when needed were not recorded. The recording of uterine contraction and time of delivery are neglected in the majority of reviewed sheets (71.4%, 96.8% respectively). No data recorded as standard WHO partograph except the numbers of previous pregnancies, deliveries, abortions drugs, IV fluid given, time of delivery, and time of stopping partograph (in 76.2%, 100%, 3.2% and 38.1% of reviewed sheets respectively). The data that recorded but in accordance with stander of WHO partograph were fetal heart rate, Liquor, oxytocine administration, cervical dilatation, and head descent in all reviewed sheets. But, uterine contraction recorded in accordance with stander in less than one third (28.1%) of reviewed sheets was. The partographs reviewed were stopped before complete dilatation of cervix for the majority (61.9%). This figure shows the factors that limited the utilization of partograph, it indicated that the great majority of physician (93.3%) and about three quarter of nurses mentioned that the absence of obligation from hospital policy to perform the partograph is the most common reason limit its utilization; However about one fifth of nurses (15.9%) stated there was no in-service training on it.

7 Nagat S. Salama, et al. 171 Table (6): Accuracy of recording the data in partographs that filled by physicians, S.C.U Hospital in Ismailia (n=63 labor sheets). Data recorded Accurate Not accurate Not recorded or not present No. % No. % No. % Admission data: Date, Time of admission Mother name Numbers of previous pregnancies, deliveries, abortions State of membrane (state and time of rupture) Fetal condition: Fetal heart rate (frequency & method of recording) Liquor (frequency & method of recording) Molding (frequency & method of recording) Drugs administration: Oxytocine (dose & rate of drops) Medications & IV fluid (name & dose) Maternal condition: Pulse (frequency & method of recording) Blood pressure(frequency & method of recording) Temperature (frequency of recording) Urine analysis (frequency of recording) Progress of labor: Cervical dilatation (frequency & method of recording) Head descent (frequency & method of recording) Uterine contraction (frequency & method of recording) Alert & action lines: Lines draw as stander Record action when taken Time of stopping partograph: (according to complete cervical dilatation) Time of delivery Not in No training No No hospital during inservices resources policy study training Nurses/Midwives Physicians Fig. (1): Factors limiting usage of partograph as mentioned by PBAs. 3 Discussion Prolonged labor and delay in decision-making are important causes of adverse obstetric outcomes. In such settings, the partograph serves a simple and inexpensive tool to monitor labor in a costeffective way. When the partograph has been used to manage labor, research has shown improvements in fetal and newborn survival as well as significant reductions in unnecessary interventions [17]. The utilization of partograph and the quality of its use need to assess, and the obstacles for use need to recognize as a first step to overcome the adverse obstetric outcomes. Finding from this study may be regards as a window that provides a glimpse into the current knowledge base, attitude and the quality of obstetric practice at the governorate health settings in Port Said and Ismailia cities.

8 172 The Partograph: Knowledge, Attitude & Utilization The study findings revealed that there were a gross deficiencies regarding knowledge about partograph among great majority of nurses and about half of physicians in all parameter assessed. Also, although all physicians know the partograph and about three quarter of them studying it and two thirds of them admitted to previous training on the partograph, only about two thirds were used the partograph in monitoring labor. This finding is corresponding with the study done among health care providers in peripheral maternity centers in Ogun state, Nigeria, which revealed low level of utilization and poor knowledge of partograph [22]. This may be due to utilizing of partograph not obligated by the policy of the hospital. The assessment of knowledge regarding to usage of partograph showed that the majority of birth attendances expressed lack of knowledge (98.6% of nurses and 82.4% of physicians). This result similar to the report of Chisembele [23], and Muiva [24] ; Which conducted on 1215 labor records and 81 skilled birth attendants, mainly midwives and a few clinical officers, participated in two days'training workshops, and founded that inadequate knowledge on partograph usage particularly plotting and interpretation. This finding might be due to there is no continuous in-service training. Data and experience across Africa suggest that although the partograph is a well-known intervention, it is often not used or not used correctly. There are varying reasons for this, including lack of human resources and time pressure. One midwife working in a labor ward of a large African teaching hospital remarked, "There is no time to chart the partograph unless there are students around. The findings revealed that the PBAs had positive attitude toward using the partograph (97.1 % physicians, 91.3% of nurses). Although absence of partograph copies in the health settings under the study and absence of administrative obligation to its use, some birth attendances recorded the labor data in a hand drawing table. This strongly indicated to their positive attitude toward partograph use, and their need to support and enforcing its use. The positive attitude toward using the partograph was also found in study of Ogwang [25] ; who found that the health workers perceived the partograph to be useful in helping them to detect abnormal labor. But this finding in contrast with the finding of Muiva [24] who found that, there was a negative attitude towards using partograph among professional birth attendants. Regarding the actual use of partograph in practice by birth attendances, all health settings under the study not obligate the using of partograph in the monitoring labors, but some health attendances, about two third of physicians and one fifth of the nurses, reported that they may use the partograph to manage selected cases in labor but the reminder never used it. This inconstant and infrequent use of partograph by limited numbers of birth attendances reflect inadequate intrapartum monitoring of labor that has also been reported to exist in other studies [26], Ogwang [25], Clow [27], Mativandlela [28]. Massawe [29], Greenfield [30], Jackson [31]. On other hand, Azandegbé [32] study show very high coverage of partograph use. From the reviewed labor sheets, there were incomplete and poor recording of parameters on the partograph against the recommended standards of WHO partograph that reflect poor skills of birth attendances on the use of a partograph. These results were similar to studies whose found that most partograph files had incomplete information, for proper decision making and the maternal condition was rarely assessed [25,26,32]. Regarding the time of stopping partograph only about one thirds of PBAs continued until complete cervical dilatation, while the others stopped before that. Stopping partograph early were also showed in the study of Massawe [29], Clow [27], Mativandlela [28], and Azandegbé [32]. In the current study, the factors affecting the using of partograph as mentioned by Professional birth attendants were the hospital policy not obligated to perform partograph in monitoring labor. Also, the absence of in-service training on partograph and most of professional birth attendants didn't studying the partograph. Finally 3% of physicians see that unavailable resources were constructed the using of partograph. So, the unsatisfactory level of knowledge about using of partograph in the majority of the study subjects, in addition to lack of in-services training on partograph in all health settings are indicators to restrict using of partograph. A similar study conducted in South-west Nigeria identified lack of knowledge and skills as major factors hindering the use of the partograph [17,34]. As well as difficulty with use partograph, the existence of many versions, detailed tool and lack of time, In addition to the absence of guidelines/protocols on the use of the partograph, are reported by Bogaert [34] and Nyamtema [26]. Conclusion and recommendations: At the light of the present study findings, it can be concluded that; the Professional birth attendants participated in this study has unsatisfactory level

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