|Year : 2021 | Volume
| Issue : 3 | Page : 190-197
Determinants of use of partograph among primary healthcare workers in Enugu State, South-East Nigeria
George Onyemaechi Ugwu1, Cosmas Kenan Onah2, Casmir Ndubuisi Ochie3, Thaddeus Chijioke Asogwa4, Nympha Onyinye Enebe5, Godwin Uchenna Ezema6
1 Department of Obstetrics and Gynaecology, University of Nigeria, Nsukka, Enugu State; Enugu State Primary Health Care Development Agency, Enugu, Nigeria
2 Enugu State Primary Health Care Development Agency, Enugu; Department of Community Medicine, Alex Ekwueme Federal University Teaching Hospital Abakaliki, Ebonyi State, Nigeria
3 Department of Community Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
4 Enugu State Primary Health Care Development Agency, Enugu; Department of Community Medicine, Enugu State University Teaching Hospital, Enugu, Nigeria
5 Department of Community Medicine, University of Nigeria Teaching Hospital,Enugu, Nigeria
6 Enugu State Primary Health Care Development Agency, Enugu, Nigeria
|Date of Submission||19-Jul-2020|
|Date of Decision||18-Dec-2020|
|Date of Acceptance||02-Jan-2021|
|Date of Web Publication||20-Apr-2021|
Cosmas Kenan Onah
Department of Community Medicine, Alex Ekwueme Federal University Teaching Hospital Abakaliki, Ebonyi State.
Source of Support: None, Conflict of Interest: None
Background: World Health Organization (WHO) recommended use of partograph during childbirth to ensure early identification of abnormalities and prompt referral for emergency obstetrics care. However, factors that determine use of partograph during childbirth among primary healthcare workers (PHCWs) remain inadequately documented. Objective: This study investigated the determinants of use of partograph in conduct of labor among PHCWs in Enugu, South-East Nigeria. Materials and Methods: It was a cross-sectional descriptive survey of public PHCWs in Enugu State, Nigeria. Multistage sampling technique was used to select 393 respondents. Data were collected using a structured self-administered questionnaire and analyzed with IBM-SPSS version 22. Tests of statistics were conducted using χ2 and binary logistic regression, and statistical significance was determined at P-value of < 0.05. Results: Majority (87.0%) of the respondents have good knowledge of partograph. Reported regular availability of partograph is 32.8% but regular use of it is 25.2%. Statistically significant association exists between use of partograph and reception of training on it (P=0.001), knowledge of it (P=0.001), and availability of it (P=0.001). Availability of partograph was a predictor of use of it (adjusted odds ratio (AOR)=27.129; confidence interval=14.780–49.797). Conclusion: Although there is high knowledge of partograph among PHCWs in Enugu state, there is poor usage of it. There are 27 times higher odds of using partograph when it is made available compared with when it is not. We recommend regular provision of partograph to labor ward personnel in PHCWs in Enugu state and other similar populations.
Keywords: Childbirth, determinants, labor, maternal health care, partograph, primary healthcare workers
|How to cite this article:|
Ugwu GO, Onah CK, Ochie CN, Asogwa TC, Enebe NO, Ezema GU. Determinants of use of partograph among primary healthcare workers in Enugu State, South-East Nigeria. Int J Med Health Dev 2021;26:190-7
|How to cite this URL:|
Ugwu GO, Onah CK, Ochie CN, Asogwa TC, Enebe NO, Ezema GU. Determinants of use of partograph among primary healthcare workers in Enugu State, South-East Nigeria. Int J Med Health Dev [serial online] 2021 [cited 2021 Dec 9];26:190-7. Available from: https://www.ijmhdev.com/text.asp?2021/26/3/190/313952
| Introduction|| |
In 2017, approximately 810 women were reported to have died every day from preventable causes related to pregnancy and childbirth. Although maternal mortality has been declining in Nigeria, from 630 maternal deaths per 100,000 live births estimated by World Health Organization (WHO) in 2010 to 512 maternal deaths per 100,000 live births reported by Nigeria National Demographic Health Survey (NDHS) in 2018, it remains unacceptably high. The lifetime risk of maternal death in Nigeria indicates that 1 in 34 women will have a death related to maternal causes.
Maternal and fetal well-being during childbirth is a function of prudent management of labor, which includes monitoring the mother’s physical and emotional wellbeing. Regular monitoring of women during labor and birth is critical for essential care that is appropriate to the woman’s case, to prevent the onset of complications and to identify risks or complications that require urgent action or referral for better outcome for both the mother and the newborn. Recognizing this fact and in response to the call for management of labor using practical and relevant technology by the Safe Motherhood Conference organized jointly by the World Bank, the WHO, and the United Nations Population Fund in Nairobi in 1987, the WHO developed a project to investigate and promote the management of labor using partograph, a tool that was pioneered by Philpott in Zimbabwe.
The partograph is a graphical presentation of the progress of labor and of fetal and maternal conditions during labor. It is a health facility standard form for clinical progress notes and monitoring events during labor and best tool to help labor attendants detect whether labor is progressing normally or abnormally and to warn as soon as possible if there are signs of fetal distress or if the mother’s vital signs deviate from the normal range. The partograph has been described as the simplest and most effective aid to logical management of labor that has ever been devised. Utilization of partograph allows for early identification of abnormal labor and referral for advanced care to emergency obstetric care facilities.
Critical barriers to use of partograph and partograph-based referral decision-making had been reported in previous studies and include poor knowledge of partograph among health workers,,,, and non-availability of the tool in workplaces., Ability of the health workers at first-level primary care facilities to interpret and act on partograph data in a timely manner ensures that women in labor receive the prompt quality care they and their babies require to survive. The factors affecting the use of partograph by birth care providers in public primary healthcare (PHC) facilities in Enugu State, South-East Nigeria are not well documented. This study was carried out to investigate the determinants of use of partograph among personnel who conduct normal labor in public PHC facilities in Enugu State. Findings from this study could inform targeted interventions to improve childbirth in public PHC facilities through effective use of partograph in conduct of labor and prompt referral of eligible women for emergency obstetric care.
| Materials and Methods|| |
This study was carried out in Enugu State in the south-east geopolitical zone of Nigeria. The state is bounded by Imo and Abia States on the south, Anambra State on the west, Benue State on the north-east, Kogi State on the north-west, and Ebonyi State on the east. As of 2016, the state had a projected population of 4,411,119. The economy of the State is mainly public sector-driven. Commonest occupations of the people are civil service, farming as well as trading. Enugu people are mainly of Igbo ethnicity and Christian religion. There are 17 local government areas (LGAs) and 291 political wards in the state. Five LGAs are in the urban and 12 are in the rural areas.
There are over 500 health facilities in Enugu State including four tertiary hospitals, one of which is owned by the State Government. The health system of the state is managed at different levels but is coordinated at the center by the State Ministry of Health. These levels of health management are public health institutions established by law to oversee the provision of health services at various levels of care: the Hospital Management Board is in charge of the General Hospitals which provide secondary-health services; the Enugu State Primary Health Care Development Agency (ENS-PHCDA) coordinates PHC service delivery; and the State Agency for Universal Health Coverage is in charge of health insurance scheme of the state. Other institutions include the Enugu State Agency for Control of HIV/AIDS, Enugu State Drug Management Agency, Enugu State Medical Emergency Response Department, among others. At the LGA level, there is Local Government Health Authority (LGHA), a body in charge of provision of PHC services at the LGA level and at the ward level; Ward Health Development Committee (WHDC) is responsible for health service delivery in the wards. The LGHA reports to the ENS-PHCDA and the WHDC reports to the LGHA.
The ENS-PHCDA is responsible for the coordination of planning, budgeting, implementation, monitoring, and evaluation of PHC services in the State in line with the implementation strategy for Primary Health Care Under One Roof (PHCUOR) concept, a governance reform introduced by the Federal Government of Nigeria. Unpublished information in the Minimum Service Package Document of the ENS-PHCDA obtained with written permission from the ENS-PHCDA shows that there are 512 public PHC facilities and 2,941 public PHCWs. The PHCWs comprise 2,013 clinical healthcare workers and 928 non-clinical health workers. The clinical healthcare workers include Nurses, Community Health Officers (CHO), Community Health Extension Workers (CHEW), and Junior Community Health Extension Workers (JCHEW).
The study was a cross-sectional descriptive survey of clinical PHCWs in Enugu State. All the clinical healthcare workers in the public PHC facilities in the state were included, but those who were neither labor ward personnel nor Officer-in-Charge (OIC) of a facility were excluded. A purposive sampling technique was applied to recruit a total of 393 respondents who were either labor ward personnel, OIC of a facility, or doubled as both. The respondents were selected from the 17 LGAs of Enugu State in proportion to size of clinical PHCWs in each LGA. Twenty-eight PHCWs were selected from Nsukka LGA, 26 were selected from Igbo-Eze North, and 25 from Udi LGA. Twenty-four respondents were selected from each of Nkanu West, Igbo-Etiti, and Oji-River LGAs whereas 23 respondents were selected from each of Isi-Uzo, Ezeagu, Nkanu East, Igbo-Eze South, and Uzo-Uwani LGA. Each of Awgu, Enugu East, Enugu North, and Enugu South LGAs had 22 respondents, whereas Udenu and Aninri LGAs had 21 and 18 respondents, respectively. The data collection process took place during the meetings of the management of ENS-PHCDA with the public PHCWs at the LGA levels in the month of December 2019.
Ethical approval was obtained from the Research and Ethics Committee of Enugu State Ministry of Health. Verbal and written consent of the respondents was also sought for and obtained prior to data collection. The respondents were assured of the confidentiality of information to be provided, and their participation was voluntary. Data were collected using a self-administered questionnaire that had sections on sociodemographic characteristics, knowledge, availability, and use of partograph in conduct of childbirth.
The data were analyzed using IBM-SPSS version 22. Relationships between independent variables and use of partograph were assessed with χ2 test, and statistical significance was determined at P < 0.05. Variables with P ≤ 0.2 were further inputted into binary logistic model to test for predictors of use of partograph. Respondents’ knowledge of partograph was assessed with 15 short answer questions. Each of the questions on knowledge carried a score of one (1) mark for correct and zero (0) mark for incorrect response. A composite knowledge score was computed for each respondent. A score of ≥8 marks (≥53.3%) out of a total score of 15 (100%) was categorized as good knowledge, whereas a score below 50% was graded as poor knowledge. Respondents who scored ≥11 marks (≥73.3%) were further graded as having very good knowledge. Availability and use of partograph were assessed with one question each, and the responses were categorized into three: “always,” “sometimes,” and “never.”
| Results|| |
The mean age of our respondents was 44.1±7.3 years and the predominant age group was 40–49 years [Table 1]. Majority of the respondents were females (95.2%), married (84.7%), and practiced Christianity (98.2%). Most of the respondents acquired higher education (92.6%) and were of CHEW (71.5%) cadre; only 5.9% of them were nurses or midwives. Concerning years of professional practice, 42.5% of the respondents had practiced for more than 21 years; more than half (55.7%) of them had received training on use of partograph and majority (82.4%) expressed desire to be trained or retrained.
Eighty-seven percent of the respondents had good overall knowledge (very good: 56.7%; good: 30.3%) of partograph [Table 2]. Majority of them knew the importance of partograph as a tool used for reduction of neonatal morbidity (88.0%) and mortality (88.8%); maternal morbidity (84.0%) and mortality (90.3%); and increase in the efficiency of personnel attending to women in labor (83.0%). However, only few of the respondents knew the characteristics of graph on a partograph in normal labor: 51.4% knew that the graph should fall to the left of the alert line and much smaller proportions knew that it should neither fall on the line (21.9%) nor to the right of it (25.4%).
The knowledge of characteristics of normal labor among respondents was generally good. Majority of them knew: that progress of labor is assessed by the degree of cervical dilation and descent of the presenting part (90.1%), that labor is prolonged when active phase lasts more than 12 h (84.0%), that three to four contractions in every 10 min is normal (79.4%); and that prolonged labor causes fetal distress (72.0%) and increases need for augmentation (60.6%) and cesarean section (59.3%) [Table 3].
Whereas only 32.8% of our respondents reported that partograph is always available in their health facilities, up to 24.9% of them reported that the tool is never available in their place of work [Table 4]. Out of the PHCWs to whom the tool is always made available, only 25.2% always used it in monitoring labor. Among the reasons given by some of the respondents for not using partograph to monitor labor routinely are non-availability of the tool (75.6%) and shortage of staff in work places (72.8%). Close to half (45.8%) of the respondents reported little or no knowledge of the tool as a reason for not using it routinely to monitor labor.
[Table 5] shows the factors that are associated with use of partograph in conduct of childbirth among PHCWs. There are statistically significant associations between: use of partograph and training on it (χ2=25.097; df=2; P = 0.001), knowledge of the tool (χ2=33.362; df=4; P = 0.001), and availability of it (χ2=260.028; df=4; P = 0.001). In [Table 6], the predictors of use of partograph among PHCWs are presented. The odds of using partograph in conduct of labor when the tool is available were 27 times higher compared to when the tool is not available (adjusted odds ratio (AOR)=27.129; confidence interval (CI)=14.780–49.797; p=0.001). Respondents who have good knowledge of partograph are twice likely to use it in monitoring labor compared with those with poor knowledge of the tool (AOR=2.109; CI=0.751–5.923; p=0.157).
| Discussion|| |
This study has shown that use of partograph in conduct of labor is determined by availability and knowledge of the tool and that making the tool available in PHC facilities increases the likelihood of use of it by 27 times. These findings place regular provision of partograph to PHC labor ward personnel a high priority, and management of PHC at all levels should ensure that the tool is always made available to the concerned staffs. The study also showed that previous training on partograph is significantly associated with its use. A significant relationship between knowledge and utilization of partograph has also been reported previously. This finding suggests a need for training of PHC staffs involved in management of labor on the use of partograph in monitoring of labor.
Despite that 32.8% of our respondents reported that partograph is always available in their ward, only 25.2% always used it in monitoring labor, indicating that even when it is available, some (7.6%) of them do not make use of the tool. In south western part of Nigeria, Fawole et al. also reported 2.9% use of the tool in monitoring of labor, even though it was available in 9.1% of the cases. The utilization rate among our respondents is however similar to 22.2% reported by Umar et al. in Sokoto metropolis of northern Nigeria but lower than 32.4% reported in Cameroun. In the case of Sokoto, the most commonly cited barrier to its use was unavailability of the tool.
Although our respondents had good knowledge of partograph as a tool used for reduction of complications of childbirth, their poor knowledge of the details of the graph of partograph during labor may partly explain the discrepancy between availability and use of the tool. Their superficial knowledge of the tool is an indication that the respondents may need to be trained to ensure that they have an in-depth knowledge of partograph and be able to interpret it and use the information obtained from it to take prompt decision during childbirth. This is important since majority (82.4%) of them expressed desire to be trained or retrained.
A quarter (24.9%) of the respondents reported that partograph has never been made available in their wards, and a quarter (24.7%) reported that they have never used it in monitoring labor. The non-availability of the tool, coupled with lack of in-depth knowledge of it, could partly or wholly explain why some of the health workers have never used the tool in conduct of labor. These findings underscore the need to ensure that there is regular provision of partograph in labor wards of all PHC facilities and to organize refresher training of the PHCWs who work there. The fact that close to half (45.8%) of the respondents reported that little or no knowledge of partograph is a reason for not using it routinely to monitor labor further lends credence to the need for the training aforementioned. The reported shortage of staff as a reason for non-utilization of partograph in labor management calls for recruitment of staff to fill up the human resource gap. These reasons had also been reported in previous studies in Nigeria.,,
Interestingly, our respondents had good knowledge of normal labor, and this could probably be due to their wealth of experience, in management of labor, gathered over the long years of service in provision of maternal health care, most of them having put up more than 10 years into service. With this good knowledge of labor, provision of partograph and refresher training for PHC workers on use of partograph are hoped to remarkably improve maternal and neonatal health care through early identification of deviation in progress of labor and prompt decision for referral for emergency obstetrics care and hence reduction in morbidities and mortalities occurring during childbirth.
The mean age of our respondents was 44.1±7.3 years with predominance of 40–49-year-age group. This is in agreement with findings in a similar study done in Calabar, south-south Nigeria, with dominance of same age group but at variance with another done in Sokoto in north-west Nigeria in which 20–39-year-age group constituted majority. Majority of the respondents were females (95.2%). This is not unexpected in view of the fact that male midwifery is a rare occurrence and most laypeople do not perceive it as strange that there are so few men in the profession. In a previous study in Nigeria, however, a greater percentage of childbearing women agreed that male midwives should be encouraged but regretted that their partners who do not feel comfortable with the presence of a male as a midwife.
Most of the respondents acquired higher education (92.6%) and were of CHEW (71.5%) cadre; only 5.9% of them were nurses or midwives. This agrees with the report by Ango et al. in Sokoto in which CHEW were the majority but differs from a similar study done in Ethiopia in which nurses and midwives were highest in number. The predominance of CHEW in our study may be because of their high employment in the PHC system in Nigeria. The fact that up to 42.5% of the respondents have practiced for more than 21 years and another 29.3% for 11–20 years may mean that majority of them have gathered wealth of experience in provision of maternal health services, having spent many years in practice. However, the small proportion of nurses and midwives in PHC system, especially in relation to conduct of childbirth, suggests the need for the government to engage more nurses and midwives in the PHC system.
Limitation to the study
Our respondents were drawn from the PHCWs who attended the meeting of the management of ENS-PHCDA with the public PHCWs at the LGA levels. Findings in this study may not have completely revealed the factors associated with the use of partograph among public PHCWs in Enugu State. Further research using a more representative sample of all PHC staffs involved in management of labor is recommended.
| Conclusion|| |
This study has shown that use of partograph is significantly determined by availability of the tool and that previous training on it and knowledge of it are also significantly associated with its use in conduct of labor. The odds of using partograph when it is made available are 27 times higher compared with when it is not available. The authorities in charge of the management of PHC at all levels including the national, state, local, ward, and health facility levels should leverage on this finding to better the maternal health situation in the country by ensuring that partograph is provided to the PHC personnel attending to women in labor. The authorities should also conduct training to improve the knowledge of health workers and their ability to interpret and use the information on a partograph in taking prompt and appropriate decision about referral for emergency obstetrics care.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]