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CHAPTER ONE

INTRODUCTION

1. Background to the Study

Globally, labour has been defined as a physiological process characterized by an increase in myometrial activity resulting in cervical effacement and dilatation; followed by the expulsion of the foetus from the uterus to the outside world. It is therefore imperative for midwives to monitor the woman in labour utilising a partograph in order to have a safe delivery; and to avoid obstructed and prolonged labour (Ratchliffe, 2010).

A partograph is an effective clinical tool used during labour surveillance for early diagnosis of complications.  The partograph is a simple chart that, when used routinely for every birth, aids the monitoring of labour and provides early warning of the need for intervention so health workers can provide prompt, appropriate care (World Health Organisation, 2014). Partograph was developed by an obstetrician named Friedman, which he tagged as cervicograph as a result of its usefulness to monitor cervical dilatations. Furthermore, cervicograph was adopted by Philpott in 1972 and he redesigned it as partograph to serve as a practical device in the documentation of all intrapartum observations and not only to monitor cervical dilatation, hence, the phrase “Philpott’s partograph”. This new document contains action lines and alert lines which are used to determine cases of prolonged labour.

In 1988, Safe Motherhood Initiative established the adoption of partograph as a global practical device that is of high quality to monitor labour and avert prolonged labour. Furthermore, extensive examination was conducted in 2014 by WHO and the organisation established a scientific based rationale for the use of partograph as the aversion of maternal morbidity and prolonged labour. However, when correctly implemented, partograph minimize cases of obstructed and prolonged labour as well assist in identifying heart abnormalities which can have intrapartum foetal hypoxia as its consequences.

(Cronje and Grobler, 2012; Dangal, 2011) described the partograph as a graphical representation of progressive stages of labour, related situations or parameters on pregnant mother and foetus, displaying all investigation made during the first stage of labour in a manner that will enable midwives and medical practitioners to analyse, interpret and recognise if the pregnant woman has moved into a high risk category and to respond decisively to the identified problems.

With reference to the World Health Organisation (2014), the utility of partograph to observe pregnant women in labour does not serve as an alternative for proper assessment of conditions that needs instant reference of pregnant women on the arrival at the labour unit.  World Health Organisation (2014) further states that the partograph is developed for timely identification of abnormal progress of labour and the aversion of prolonged labour which would significantly reduce the risk of postpartum hemorrhage and sepsis as well eradicate obstructed labour, prolonged labour, uterine rupture and its sequelae. The organisation further affirm that the purpose of the use of partograph to examine pregnant women in labour is to lessen morbidity and mortality rate of pregnant women globally, to develop the level of care of pregnant women during labour session, to develop the observational abilities and skills of the midwives, to assist in the advancement of team work in a bid to ease the referral to specialist units and promote timely referral from the primary health units.

A randomized study was conducted on 434 women in Mexico in 1966 to test for the effectiveness of the utilisation of the partograph during labour using Friedman’s partograph and a non-graphical descriptive chart. The women were randomized to either Friedman’s partograph or a non-graphical descriptive chart. The study revealed that those who were not put on the partograph had more operative deliveries and more babies with low Apgar scores at 5 minutes.  Another study conducted in Karachi by Bhutta, Javed, and  Shoaib, (2010) tested the role of the partograph in preventing prolonged labour, the objective of the study was to determine the effect of the partograph on the frequency of prolonged labour, augmentation of labour, operative deliveries and appropriate interventions based on the partograph to reduce maternal and perinatal complications.  A case-controlled prospective and interventional study on 1000 women in labour was carried out in the obstetric units of Jinna Postgraduate Medical Centre, Karachi.  Five hundred (500) women were studied before and after the introduction of the partograph. The results showed that there was a reduction in both the duration of labour and the number of augmented labour and vaginal examinations.  It was concluded that by using the partograph to monitor pregnant women in labour reduced the frequency of prolonged labour, augmented labour, postpartum hemorrhage, ruptured uterus, puerperal sepsis and perinatal morbidity and mortality rates.

In spite of the continual use of the partograph in the health care industry; and wide record keeping of its effectiveness (Chongsuvivatwong & Fahdhy 2015; Fawole & Fadare, 2010)

 recorded variation attainable with the use of partograph across health care facilities in Nigeria. It was revealed that in two separate tertiary hospitals, 84% of midwives had good knowledge on partograph and average of 31% of partograph graphs was correctly filled. Hindrances in the effective utilisation of partograph were discovered by Opiah on cases such as absence on the use of partograph charts (30.3%), and under-staff (19.4%). The absence of knowledge and the use of partograph were discovered by (Fawole et al. (2010); Daniel, Oladapo, & Olatunji, 2016) among different levels of maternity health providers in all three levels of health care. A report was also submitted showing that previous training significantly improved the knowledge and accurate use of partograph.

Researchers also indicated that tertiary health workers employs partograph unlike their counterparts in secondary and primary level health workers. Furthermore, research also indicates that just 33.7% cases of 1,319 deliveries were monitored with the effective use of partograph which influenced decision making as well as associated positive labour result available among low and high risk cases. However the extent of which partograph is being employed neither attitude of midwives as a means to attainment of effective or non-utilisation of partograph is not available in literature. The aim of the utilisation of partograph is to empower midwives with plotting, analysis and interpretation skills when monitoring pregnant women in labour.

In the study conducted by Chongsuvivatwong & Fahdhy (2015), it is stated that the partograph was introduced in Indonesia in 1998, and the new version of the World Health Organisation (WHO) partograph was brought into Indonesia in 2000.  The aim of the study was to assess the effectiveness of promoting the utilisation of the partograph by midwives caring for women in labour.  Previously, before research, it was however discovered that utilisation of partograph was not carried out by midwives because complains were given that partograph’s completion is highly complicating. It was however observed that utilisation of partograph was as a result of midwives education, training and supervision which led to notable reduction in the number of vaginal assessment, augmentation of labour, obstructed labour, poor Apgar score and increased transfer to mention but a few. Furthermore Alfirevic, Lavendor and Walkinshaw (2016) support that if progress of labour crossed the action line; a diagnosis of prolonged labour was made and managed according to protocol. The results of this study showed that the use of the 4 hour action line partograph improved the maternal and neonatal outcomes.

The use of partograph as a device for intrapartum assessment by midwives in sub-Saharan Africa is still a challenge, a notion supported by the study conducted in South West Nigeria by Adekanle, Fawole and Hunyinbo (2008) who found that a partograph is commonly not employed to monitor pregnant women in Nigerian as a result of insufficient idea about partograph.

Furthermore, the authors concluded that the maternal mortality rate in Nigeria is a major public health issue and continues to rise since a partograph is not effectively used as a tool for monitoring labour. Nakkazi (2010) indicates that midwives often feel that completing the partograph is an additional time-consuming task, and they do not always understand how the utilisation of the partograph to monitor pregnant women in labour can be life-saving. Thus, some midwives take the partograph lightly as they plot the partograph when pregnant women who were in labour have already delivered. Midwives often argue that they do not have time to plot the partograph during the monitoring of pregnant women in labour. The National Department of Health (2010) further states that all midwives should employ the partograph when assessing pregnant women in labour so that problems identified during monitoring of labour can be attended to promptly by both the midwife and the attending doctor. Therefore, utilisation of the partograph increases the analysis and interpretation skills of midwives, the monitoring of pregnant women in labour and thus aids in providing standardized fetal and maternal care, and accordingly improves midwifery care.

Researchers ascertained that to effectively use the partograph, requires knowledge and skills. Therefore, education, training and supervision of the midwives will results in a higher rate of the utilisation of the partograph which will reduce the number of virginal examinations, prolonged labour, augmented labour, poor apgar score at first minute, obstructed labour and increased referral.

The focus of this research therefore is to identify midwives’ knowledge on the use of the partograph as a tool to monitor labor, comparatively assess the use of the partograph among midwives in the hospital, assess level of deployment of partograph as a device in each center, identify barriers to its use, determine the existing relationship with the length of years of experience and knowledge of the use of the partograph in the hospitals.

1.2     Statement of the Problem

A number of research studies revealed that there are challenges associated with the correct and consistent use of the partograph (Lester, 2010; Magon, 2011; Mathibe-Neke, 2009; Opiah, 2011).  The findings from these studies reveal that there is poor utilisation of the partograph, which were largely related to the midwives’ lack of competence and knowledge on the use of the partograph. They submit further that non- availability of the partograph, shortage of staff, lack of in-service training and the number of years of experience in intrapartum care are also some of the contributory factors associated with the poor utilisation of the partograph.

(Magon, 2011; Ogwang et al. (2009); Opiah, 2011) argued that caregivers may regard filling of the partograph as an additional chore.  The study conducted by Lavender, Lee, Mathai, Omoni and Wakasiaka (2011) also revealed that partographs were filled in retrospectively, and done only as a defensive practice to avoid being reprimanded by the matrons. The researcher has also observed from clinical practice that midwives do not utilise the partograph appropriately when monitoring pregnant women in labour either by not plotting or incompletely plotting the activities and also not interpreting the findings as appropriate. Consequently, labour cases which carry impending dangers to both mother and the foetus are not usually discovered and managed accordingly. These have often led to an increase maternal/foetal mortality, morbidity and irreversible damages on their lives. The purpose of this study, therefore, is to examine the Effect of training midwives on the utilisation of partograph in General Hospitals in Ogun East Senatorial District.

1.3    Objective of the study

The main objective of this study is to evaluate the effectiveness of training midwives on the utilisation of partograph in General Hospitals in Ogun East Senatorial District. The specific objectives are to:

1. assess the knowledge of partograph among midwives in general hospitals in ogun east senatorial district.
2. determine the utilisation of the partograph by midwives when monitoring progress of labour in general hospitals in Ogun east senatorial district.
3. assess the effect of training midwives on the usage of partograph.

1.4     Research Questions

The research questions focus on providing answers to the following concerns;

1. What skills and knowledge do midwives have on the utilisation of partograph for monitoring pregnant women in labour in General Hospitals in Ogun East Senatorial District?
   1. How well do midwives in selected General hospitals utilise partograph to monitor the progress of labour?
   1. What is the outcome of training midwives on the use of partograph to enhance its usage on patients care?

1.   Hypotheses

Ho₁ There is no significant difference in pre-test utilisation of partograph of trained and untrained midwives.

Ho₂ There is no significant difference in post-test utilisation of partograph of trained and untrained midwives.

1.6       Scope of the Study

This study evaluated the effect of training midwives to improve their knowledge on                          utilization of partograph in general hospitals in Ogun east senatorial district.

1.7       Significance of the Study

This research is essential to influence the reduction of maternal and neonatal mortality and morbidity rates, which are on the increase in Nigeria.  By creating innovative and other methods on how to use the partograph, it can increase confidence and facilitate supervision of junior and learner midwives working in the labour ward so that the partograph is used correctly and consistently and thus benefit these categories of staff (Fistula Care and Maternal Health Task Force, 2012). This could contribute to lifelong learning for all practitioners working in a labour ward. The barriers and challenges identified in the study could influence policy making and create an enabling environment for midwife practitioners in the operational field. Managers have knowledge from the research on how to plan pre and in-service training of the clinical staff, making them confident and competent. The most significant benefit would be the improved health care provided to the mother and child by improved support for the practitioner at the grassroots level. Confidence and competence in rendering care to the mother during labour would boost the confidence of the client in the health care system, and thus also improve its reputation.

1.8       Justification for the Study

The major determinant to the expansive inconsistency level in care and the outcome of reproductive health between the advanced and developing countries is based on maternal mortality ratio. This observation is supported by the global maternal mortality pattern in which annual loss of more than 515,000 maternal deaths from complications of pregnancy and childbirth occurring in developing countries. Among those who survive childbirth at least 8 million develop serious morbidities and a further 50 million suffer minor complications. Therefore, the partograph should be used for all women admitted in established labour as it serves as an “early warning system” and assists in early decision on transfer, augmentation and termination of labour. It also increases the quality and regularity of all observations on the fetus and the mother in labour and aids early recognition of problems.

Maternal morbidity rate increases because of insufficient facilities in the health care settings, inadequate attitude and knowledge of plotting the interventions in the partograph. Therefore, midwives need adequate knowledge regarding the partograph and its use to reduce the maternal mortality and morbidity rate. Partograph knowledge helps to improve good attitude and practice in the clinical performance. Hence, there is a need to assess the knowledge, attitude and practice of partograph among midwives.          

1.9       Operational Definition of Terms

Operational definition was used to describe the following terms:

Utilisation – To put to use especially to make profitable or effective use of an approach, in this study utilisation refers to plotting the partograph correctly and making appropriate decisions.

Partograph – in this study a partograph refers to the labour graph provided by Ogun State Ministry of Health.

Midwife –in this study, midwife refers to a person trained to assess, monitor, analyse and interpret labour and conduct delivery of pregnant women.

Effect – it refers to the extent to which the structured teaching program on partograph has achieved the desire effect in improving the knowledge of midwives as an evidenced by gain in knowledge scores.

Training- it refers to planned teaching programme regarding proper use of Partograph.