Revitalizing the Partograph: Does the Evidence Support a Global Call to Action?
The following is a summary of a meeting hosted by the Fistula Care Project in New York in November.
Prolonged or obstructed labor is a major contributes to maternal and newborn morbidity and mortality; it can lead to postpartum hemorrhage, infection, obstetric fistula, and fetal injury or death. One of the tools used to monitor labor and prevent prolonged or obstructed labor is the partograph, a preprinted one-page form on which labor observations are recorded. The purpose of the partograph is to help health care providers record, interpret, analyze, and use data to make decisions on labor management. The form, which is an early warning system, provides a graphic overview of labor. The partograph provides information which alerts health providers to any problems with the mother or baby and deviations from the normal progress of labor.
The World Health Organization recommends universal use of the partograph during childbirth. Fistula Care promotes correct and consistent use of the partograph as one of its key fistula prevention initiatives. The findings of a 2011 EngenderHealth Fistula Care literature review on partograph use in developing countries indicate that rates of use and health provider skills are low. After more than 50 years of training and investment in the partograph in low-resource settings, most would agree that the tool has failed to reach its potential.
In November 2011, Fistula Care and the Maternal Health Task force convened an expert meeting in New York to review the evidence about partograph effectiveness, identify barriers to partograph use, develop strategies for overcoming those barriers, and determine future research needs. The experts included midwives, physicians, researchers, clinical educators, managers of health services, and representatives of professional associations. The meeting focused primarily on the use of the partograph in low-resource settings.
Participants agreed that the partograph is an essential tool for monitoring and management of labor. However, they identified a number of obstacles which stand in the way of effective use of the tool. Lack of support from the health system was seen as the most important barrier. To be effective, the partograph requires champions within facilities and at national level to model its importance and to ensure that the necessary resources are allocated to enable providers to use the tool effectively – financial, human and supplies. For example, in many places, facilities lack the financial resources to train providers and even the most basic requirements, such as partograph forms and blood pressure machines may be missing.
Referral systems for laboring women who experience complications are often nonexistent or inadequate. Trained labor and delivery personnel who are competent in the use of the partograph are in short supply. The tool itself may present difficulties for health providers because they lack the underlying knowledge and skills that it requires.
Three innovations in partography were presented at the meeting: an electronic partograph on a handheld device under development and field testing by JHPIEGO; a “pictorial partograph” for home birth designed for use by traditional birth attendants, skilled birth attendants and family members created by LAMB Hospital in Bangladesh (a Fistula Care supported site) and the World Health Organization’s Safe Birth Checklist, which highlights partograph use as a key intervention and which is being pilot tested in India.
There was general agreement that future research should focus on improving implementation of the partograph. Health professionals need to know more about effective methods of training, supervision and maintaining the clinical skills of providers.
It was a lively and productive meeting. Despite the challenges, meeting participants agreed that the partograph is an essential tool for monitoring and management of labor and expressed a strong desire for an action plan to enable the partograph to reach its full potential. At the conclusion of the meeting, the group described a series of next steps that will help revitalize the partograph, enhance the performance of providers, and assess the value of the tool in labor and delivery.