Bridging the Gap: Leveraging Partograph Utilization Insights to Facilitate the Smooth Implementation of the Labour Care Guide at Mbale Regional Referral Hospital, Eastern, Uganda

Bridging the Gap: Leveraging Partograph Utilization Insights to Facilitate the Smooth Implementation of the Labour Care Guide at Mbale Regional Referral Hospital, Eastern, Uganda | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Bridging the Gap: Leveraging Partograph Utilization Insights to Facilitate the Smooth Implementation of the Labour Care Guide at Mbale Regional Referral Hospital, Eastern, Uganda RONALD KIBUUKA, Jill Apoya, Allan. G. Nsubuga, Enid Kawala Kagoya, and 18 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3776078/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Maternal and newborn care has seen significant advancements through evidence-based guidelines, including the labour care guide introduced by the World Health Organization (WHO). However, the successful implementation of these guidelines relies on analysing the level of effective utilization of tools such as the partogram. In this study, we aim to assess the effects of a QI project aimed at improving the utilization of the partogram, and the current level of its utilization at Mbale Regional Referral Hospital, Uganda, and identify the possible challenges in its use and design effective procedures in rolling out of the labour care guide into existing clinical practices. Methodology: A retrospective study combining quantitative and qualitative approaches was conducted. In March 2021 200 files were randomly sampled and checked for presence or absence of a partograph and this formed the baseline data before starting a QI project to improve utilization of a partograph to improve partograph utilization. In March 2023, 1120 patient files were reviewed from deliveries that happened between April to December 2022, these were analyzed to determine the presence or absence of a partogram in the file and the level of utilization. 6 key informant interviews were also conducted with healthcare workers to explore factors influencing partograph utilization and recommendations. Results: While certain mothers’ particulars were well-documented, critical information such as LNMP, EDD, and risk factors displayed higher rates of missing data. Monitoring rates decreased with subsequent times with an average level of partograph utilization of 39%. The presence of a partograph in patients’ files improved from 3% in March 2021 to 80% from April to December 2022. Key informant interviews revealed challenges related to heavy workload, inadequate human resources, poor attitudes towards partograph utilization, knowledge gaps, and policy-related issues. Conclusions: The level of partograph utilization at Mbale Regional Referral Hospital remains suboptimal (<50%), Which could hinder the successful rolling out of the LCG. Addressing the identified challenges is essential for improving maternal and newborn care practices. With the above insights in mind and with support from Seed Global Health, the team is set to effectively change its goal from improving the level of utilization, which improved from 3% to 80%, towards rolling out the LCG. Recommendations: To enhance partograph utilization and facilitate the smooth implementation of the labour care guide, we recommend increasing human resources, providing targeted training and education, improving hospital infrastructure, fostering positive attitudes among healthcare workers, and implementing continuous quality improvement programs. Partogram Partograph labour care guide maternal and newborn care Partograph utilization implementation insights healthcare workers barriers Mbale Regional Referral Hospital Uganda Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction In recent years, healthcare practices have made significant strides in improving maternal and newborn care, with a specific focus on enhancing safe and effective labour progress monitoring and management. One such advancement is the introduction of the next-generation partograph, the Labour Care Guide by the WHO in 2020, which is intended to replace the partograph 1 . The labour care guide is clear, relevant and appropriate, and has the potential to positively impact clinical decision-making and respectful maternity 2,3 . The aims of the labour care guide include guiding the monitoring and documentation of the well-being of women and babies and the progress of labour, guiding skilled health personnel to offer supportive care throughout labour to ensure a positive childbirth experience for women, assisting skilled health personnel to promptly identify and address emerging labour complications, by providing reference thresholds for labour observations that are intended to trigger reflection and specific action(s) if an abnormal observation is identified, prevent unnecessary use of interventions in labour and support audit and quality improvement of labour management, reducing primary cesarean delivery rate without increasing the duration of hospital stay and fetomaternal complications . 1,4,5 The partogram has been valuable in monitoring maternal and fetal well-being during active labour and aiding healthcare professionals in making timely decisions when abnormalities are detected 6 , thereby reducing maternal and neonatal morbidity and mortality. Worldwide, the partogram, has been used as a labor monitoring tool to detect difficulties early, allowing for referral, intervention, or closer observations 7 . The WHO model of the partogram was devised by an informal working group, in 1954 when E. A Friedman described the normal cervical dilatation amongst women in USA 8 . As healthcare systems strive to enhance the quality of care provided to expectant mothers, the adoption and utilization of evidence-based guidelines play a crucial role in achieving successful outcomes. However, despite proven effectiveness, the level of utilization of the partogram varies significantly across healthcare facilities and regions. For example at Mulago National Hospital 79.1% of the partographs reviewed had incomplete documentation of age, 52.7% gravidity, and 3.2% parity. In about 61%, the specific parameters for fetal monitoring, maternal monitoring and labour progress were incomplete 9 The maternal mortality ratio in developing countries in 2015 was 239 per 100 000 live births versus 12 per 100,000 live births in developed countries, with large disparities between countries, within countries, and between women within high and low income and those women living in rural and urban areas 10 . More than one-third of maternal deaths, half of stillbirths and a quarter of neonatal deaths result from complications during labour and childbirth 11 94% of all maternal deaths occur in low and lower-middle income countries, Appropriate care provided by skilled health professionals competent in sexual and reproductive health care, before, during and after childbirth can save the lives of women and newborn babies 12 . To curb this, WHO devised a more comprehensive monitoring tool to replace the partogram 1 . However in order to ensure its successful implementation it is prudent to have an insight into the level of utilization of the partograph plus factors contributing to this level of utilization. With support from SEED GLOBAL HEALTH we carried out an anecdotal research in March 2021 to identify the level of partograph use and of the 200 files sampled, only 3% of the files sampled had a partograph inserted, various interventions were then put in place to aid improvement of partograph utilization and these included trainings on correct filling of the partogram, printing partograms and ensuring that they are always available on ward and carrying out QI programs to continuously remind the different health workers to utilize the partogram, To ensure the successful implementation of the labour care guide and enhance maternal care, it is essential to understand the factors that influenced the utilization of the partogram. Targeted interventions can be designed to improve compliance and efficiency during labour management by identifying potential barriers and challenges hindering its widespread use. In response to this imperative, this study is aimed at identifying the effects of these interventions, determine the extensive level of utilisation of the partogram and make better planning for the effective rollingout of the labour care guide. The construction of the modified partogram in utilizing the new instrument would not compromise but rather advance the objectives of the earlier partogram 7 . By analyzing this data, we seek to understand the prevailing challenges and explore how these insights can facilitate the smooth rollingout of the labour care guide into existing clinical practices. This will Bridge the gap between research findings and practical implementation, our work aims to make a meaningful contribution to maternal and newborn healthcare. By offering evidence-based approaches, our study intends to guide policymakers, healthcare administrators, and frontline providers in improving maternal and newborn care, ultimately leading to better health outcomes for both mothers and infants. Methods We carried out a retrospective study at Mbale Regional referral hospital, were partographs were reviewed and Key informants interviewed, the study combined quantitative and qualitative methods of data collection. 6 key informant interviews were carried out. The quantitative component used a retrospective selective cluster randomized review of Partographs used in deliveries during April 2022 to December 2022, this was the second cohort and 1120 files were sampled and analyzed for presence or absence of a partograph, data from these partograph was captured using a predesigned questionnaire in form of google form, an excel sheet was then extracted cleaned and analyzed using STATA version 15 to determine the level of utilization under each section and then the overall level of utilization for those files that had a partograph,. Two cohorts were considered in the study one year apart. The first cohort of files was reviewed in March 2021 and in these 200 files were sampled and checked for presence or absence of a partograph Written informed consent was obtained for each participant during the key informant interview. The interviews were moderated by trained research assistants and audio recorded. We used an interview guide that had been developed by the multidisciplinary team of a public health specialist, an epidemiologist and social scientist. It was written in English and administered by trained research assistants (in qualitative research methods), under the supervision of the Principal Investigator to elicit data. We explored specific factors or reasons that affected utilization of the partograph through examining their experiences and identifying issues that confronted them collectively as well as individually plus asking for possible recommendations. All interviews were conducted in English, the commonly spoken language by the interviewees. The Key informant interviews were transcribed and analyzed thematically by an experienced social scientist using standard principles. The field team, together with the authors of the paper under the leadership of the principal investigator read through the transcripts and notes from the discussions several times, identifying meaning units. The meaning units were then condensed, coded and put into categories, from which themes emerged. Results Quantitative findings We conducted a retrospective review of 1120 partographs for the period noted from records office of Mbale Regional Referral Hospital. In a retrospective survey in March 2021 200 files were randomly sampled and checked for presence or absence of a partograph. Table 1 baseline vs current partograph use presence or absence of a partograph in the file baseline N=200 current N=1120 Files without a partograph Files with a partograph Files with a partograph Files without a partograph number 194 6 896 224 percentage 97% 3% 80% 20% Average level of utilisation 39% From table 1 above, two cohorts: a baseline cohort consisting of 200 cases and a current cohort of 1120 cases. The cases are divided into two categories: those with a partograph in the file and those without. For the baseline cohort, 97% of cases (n=194) had no partograph in the file, while 3% (n=6) had a partograph. In the current cohort, 80% of cases (n=896) had a partograph in the file, and 20% (n=224) did not. Figure 1 above presents a comprehensive overview of the recorded and not recorded mothers’ particulars for a sample of N = 1120. The graph displays the percentages of mothers’ particulars that were documented. The recorded mothers’ particulars, such as inpatient number, date of admission, and age, were well-documented in over 80% of cases., indicating a high level of data completeness in these areas. However, certain critical mothers’ particulars, such as weeks of gestation, risk factors, and time of membrane rupture, showed a being recorded in less than 50% of the partographs. Figure 2 above provides figures on the monitoring status of 1120 mothers during pregnancy and childbirth across various parameters. Monitoring rates displayed a decreasing trend with subsequent monitoring times. Fetal heart rate was monitored in 55.25% (619) of cases once, and this figure decreased to 26.61% (298), 12.05% (135), 7.05% (79), and 5% (56) for two, three, four, and five times, respectively. Only 13.75% (154) of mothers were monitored once for blood pressure and <1% of mothers had their blood pressures recorded for more than two times. Data in Figure 3 reveals the percentages of recorded details of the new borne baby. Notably, life status was recorded for 55.08% of newborns (625). The course of death was recorded for only 0.18% of cases (2), Time of delivery was relatively well-documented, with 74.11% of newborns (830) having the time recorded. APGAR scores at 1 minute and 5 minutes were also recorded for a majority of newborns, with 80.54% (902) and 78.57% (880) recorded, respectively.Regarding the newborn's sex, 86.88% (973) were recorded. Similarly, weight was well-documented for most newborns, with 85.63% (959) recorded. Figure 4 presents data on the recording status of various delivery-related parameters childbirths. The data reveals the percentages of recorded instances for each parameter. Notably, the time of decision to intervene was recorded for 6.79% of deliveries (76). Other details, such as the date of delivery (83.21%, 932), time of delivery of membranes and placenta (82.59%, 925), and type of delivery (83.13%, 931), were relatively well-documented. However, some parameters, like the duration of the first stage of labour (6.43%, 72) and post-delivery temperature (5.09%, 57), had lower recording rates. The duration of the second stage of labour (18.04%, 202), post-delivery blood pressure (18.93%, 212), post-delivery pulse (14.64%, 164), and comments on delivery (79.91%, 895) were recorded to varying degrees. Regarding specific medical interventions, oxytocin given was recorded for 80% of deliveries (896),.The amount of blood lost during delivery (62.41%, 699), episiotomy (53.84%, 603), and tears (55.80%, 625) also showed varying recording rates. Figure 5 represents a comprehensive analysis of utilization rates and they range from 2% to 78%. Prominent concentration of utilization rates are between 30% and 50% (75% of data points fall within this range), Utilization rates below 50% are more prevalent than rates above 50%. Qualitative findings Five participants were approached and they all agreed to participate as key informants. These included nurses and midwives. The data obtained was then broken down into two themes focusing on factors associated with partograph utilization and the recommendations and three sub themes including hospital related factors, staff/health worker related factors and policy related factors. Results Theme 1 : FACTORS ASSOCIATED WITH PARTOGRAPH UTILISATION Sub theme 1 : HOSPITAL RELATED FACTORS Heavy workload The health workers attributed their not filling of the partographs to heavy workload due to inadequate human resources. They claimed that the mothers come in very large numbers hence making it challenging for one midwife on duty to fill partographs for all the mothers. “… Overwhelming workload due to inadequate human resource –Many mothers compared to the present midwives…” (MRMM 5) Shortage of partographs Some of the health workers reported that they didn’t fill the partographs because they were not there. They reported that sometimes they make requests for partographs from ministry of health but the delivery is delayed hence preventing them from filling the partographs. “...Shortage of partographs and MOH delays to bring more…” (MRNL 1) Knowledge gap regarding filling the partograph Some health reported a knowledge gap in regards to filling the partograph. They reported this mainly among students as well as some health workers. They claimed that they feared to ask for help while filling the partograph. “...Knowledge gap about filling the partograph but fear to ask for help...” (MRANP 2) Sub theme 2 : STAFF/ HEALTHWORKER RELATED FACTORS Negative attitudes towards filling partographs Some health workers report saying that some of their colleagues have a negative attitude towards filling the partographs because of the strict steps taken to fill it and its time consuming nature. “...some of us have a poor attitudes towards filling the partograph...” (MRANP 2) Knowledge gap Some health workers reported that some of the students who go to the hospital do not know how to fill the partographs and because of their large numbers, supervising them becomes complicated. “...their is knowledge gap about filling the partograph especially among students…” (MRSANG 3) Sub theme 3 : POLICY RELATED FACTORS Partograph lacks some parameters Some health workers reported that the partograph lacked very many important parameters such as presenting complaints at that very time hence making some of the health workers prefer to write. “...Partograph is a summary not having some parameters therefore some people prefer to write...” (MRMM 5) Few labor ward beds There was an issue of limited beds on the wards and in instances where the number of mothers is overwhelming, filling of the partographs becomes hard as mothers are in and out of the wards. “…There are few labor ward beds and this makes follow up hard because emergencies come in all the time…” (MRSANG 3) Limited spaces Some health workers reported that there was limited space in the wards which affected privacy and service delivery hence making it difficult to fill the partograph. “…There’s a problem of limited spaces in the wards…” (MRSANG 3) Theme 2 : RECOMMENDATIONS Sub theme 1 : RECOMMENDATIONS TOWARDS HOSPITAL RELATED FACTORS Increase the human resource Respondents suggested an increase in manpower so as to ensure better utilization. It was pointed out that one or two midwives follow over 20 mothers and it is hard to plot a partograph for all these. “…sometimes I am on the shift alone with over 20 mothers , I cannot plot a partograph for each of them but if more people are employed and I have fewer mothers to follow I belief I can fill the partograph more completely…” (MRSANG 3) Increase stationary for printing more partographs Most respondents pointed out that if partographs are availed it would be easy to fill since this ensures that a partograph is opened for the mother on admission but sometimes due to stockouts we are unable to fill in partographs. “…initially the supply of partographs was limited and we would get stockouts plus no supplies at all, but when seed global health started supplying us with printed partographs that are available all the time, it became easier to use them to monitor mothers hence if this supply is continued it would help us fully utilize them…” (MRANP 2) Sub theme 2 : RECOMMENDATIONS FOR HEALTH WORKER-RELATED FACTORS Teach health workers how to plot the partographs Most respondents suggested training and retraining of health care workers on the use of the partograph so as to ensure increased utilization. They pointed out that this will ensure more complete and accurate filling of the partograph. “ …when seed global health came on board and trained us on how to use the partograph we used them more because we were confident on how to use them and not scared to make mistakes…” (MRMM3) Medical officers should also be screened in regards to filling the partograph as a key component Respondents pointed out that most medical officers do not fill the partograph and as thus they believed that they sometimes make wrong decisions because of failure to interpret the partograph. “…I think medical officers do not know how to use the partograph because each time we ask some of them to guide us they just quarrel and just point at our mistakes; I think it would be better to organize a training for them…” (MRSANG3) Partograph should also be an assessment tool for students Most respondents agreed that due to the heavy workload, it is hard for them to fully utilize the partograph due to the workload. As such they suggested that training of students would help cover this gap since each student can be assigned one or two patients hence ensuring more complete utilization. “…the work here is too much and we are few, but we have students that can help us. All is needed is training them so that they know how to fill the partograph and they can be of great help in following up the mothers using the partograph…” (MRANP) Sub theme 3 : ROCOMMENDATIONS TOWARDS POLICY RELATED FACTORS Three codes were got under this subtheme including Increase the number of beds in the wards, Improve the hospital spaces, Improve the partographs by adding some more parameters Most respondents said that increasing the space and beds in labour suit would aid in better follow up. “…each bed is used by more that 10 mothers, even after delivery we have to transfer the mother there and then to create space for more mothers, if we had more beds and space, a lot would be solved so that each mother or two mothers os allocated a bed…” MRMM 5 Discussion The results of our study shed light on the current level of partograph utilization and the challenges faced in Mbale Regional Referral Hospital, Uganda. The quantitative findings revealed that while certain mothers’ particulars, such as inpatient number, date of admission, and age, were well-documented, critical information like LNMP, EDD, weeks of gestation, and risk factors showed higher rates of missing data. Showing an overall low initial utilization of the partogram. Utilisation of the partogram is low in most countries as highlighted out by 13 , 14 . From our Study: trainings, supervision, provision of the partographs and QI projects improved partograph utilization from 3% to 80% in one year, these interventions were also found to improve partograph utilization in other parts of the country 15 Regarding monitoring during the progression of labour, the study highlighted a concerning trend of decreasing monitoring rates with subsequent monitoring times. Proper monitoring of fetal heart rate, membranes and liquor color, cervical dilation, uterine contractions, blood pressure, and other vital parameters is essential for timely intervention and decision-making during labor 16 . The relatively low monitoring rates for blood pressure and other parameters underscore the importance of continuous monitoring to ensure the well-being of both mother and baby and this can lead to increased possibility of failing to recognize disorders such as pre eclampsia which can lead to an increase in maternal morbidity 17 . Notably, on overall utilization clustering was observed around 30% and 50%, suggesting potential common utilization patterns, with few extreme values representing outliers at both low and high utilization rates with an average level of utilization of 39%, this is relatable to Ethiopia were the level of utilization was found to be 32.8% 18 The qualitative findings provided valuable insights into the challenges faced by healthcare workers in utilizing the partograph. Heavy workload and inadequate human resources emerged as significant factors hindering partograph utilization. This factors are in tandem with what was found out in other countries for example in Ethiopia Working facility, supportive supervision, mentoring, training on partograph, number of midwives working per shift, and knowledge were factors affecting partograph utilization 19 This points to the need for increased staffing and better workload management to improve the quality of care provided to expectant mothers. Negative attitudes towards filling the partograph and knowledge gaps among healthcare workers and students were also identified as barriers. The poor attitude was also found as a barrier in other countries including Ethiopia 13 Addressing these issues requires targeted educational programs and training to enhance knowledge and foster a positive attitude towards utilizing the partograph as a valuable tool in labor management. Trainngs and menorship improved partograph utilization in different parts of Uganda 15 Policy-related factors, such as the lack of certain parameters in the partograph and limited labour ward beds and space, were also identified. Enhancing the partograph by adding missing parameters and improving hospital infrastructure could contribute to better partograph utilization and overall maternal care. This is the aim of the LCG, to fill this gap. However there is need for localization of this LCG so as to fit within the local picture 20 . Key informants identified several challenges in partograph utilization. Hospital-related factors included heavy workload due to inadequate human resources and shortages of partographs. Staff-related challenges encompassed knowledge gaps among some health workers and students and negative attitudes towards partograph filling. Policy-related issues involved missing parameters in the partograph and limited labor ward beds and space. Conclusion In conclusion, our study points out the fact the partograph utilization is generally sub optimal and offers evidence-based approaches and recommendations to enhance partograph utilization. These are key aspects to follow and ensure successful rolling out of the labour care guide at Mbale Regional Referral Hospital and making appropriate targeted changes for a smoother implementation. By addressing the identified challenges and implementing targeted interventions, healthcare administrators, policymakers, and frontline providers can improve maternal and newborn care practices, ultimately leading to better health outcomes for expectant mothers and their infants. The integration of evidence-based guidelines into routine clinical practices is crucial for reducing maternal and neonatal morbidity and mortality and advancing safe and effective labor management in Mbale and beyond. As a team with support from Seed global health and from the lessons and insights learn from a QI project to improve utilization of the partogram, we are now set to roll out the labour care guide Declarations Ethical Consideration: Ethical approval and a waiver of consent was sought and obtained from the Research Ethics Committees (REC) of Mbale Regional Referral Hospital No. MRRH-2023-300 Conflict of interest The corresponding author and all co-authors declare no conflict of interest. Availability of Data and Materials The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. References WHO. WHO Labour Care Guide User’s ManUal .; 2020. Vogel JP, Comrie-Thomson L, Pingray V, et al. Usability, acceptability, and feasibility of the World Health Organization Labour Care Guide: A mixed-methods, multicountry evaluation. Birth . 2021;48(1):66-75. doi:10.1111/birt.12511 Pingray V, Bonet M, Berrueta M, et al. The development of the WHO Labour Care Guide: an international survey of maternity care providers. Reprod Health . 2021;18(1):1-15. doi:10.1186/s12978-021-01074-2 Vogel JP, Pingray V, Althabe F, et al. Implementing the WHO Labour Care Guide to reduce the use of Caesarean section in four hospitals in India: protocol and statistical analysis plan for a pragmatic, stepped-wedge, cluster-randomized pilot trial. Reprod Health . 2023;20(1):1-15. doi:10.1186/s12978-022-01525-4 Khalil MR, Guldberg R, Nørgård BM, Uldbjerg N, Wehberg S. Child-Mother Index: a new risk factor for selected adverse maternal birth outcomes. AJOG Glob Reports . 2022;2(4). doi:10.1016/j.xagr.2022.100090 MSF. https://medicalguidelines.msf.org/en/viewport/ONC/english/5-2-monitoring-labour-and-delivery-51416957.html. Published online 2023. Ghulaxe Y, Tayade S, Huse S, Chavada J. Advancement in Partograph: WHO’s Labor Care Guide. Cureus . 2022;14(10). doi:10.7759/cureus.30238 WHO. WHO_FHE_MSM_93.8.pdf. Published online 1994. Mukisa J, Grant I, Magala J, Ssemata AS, Lumala PZ, Byamugisha J. Level of Partograph completion and healthcare workers ’ perspectives on its use in Mulago National Referral and teaching hospital , Kampala , Uganda. 2019;3:1-8. Greene JW. Maternal mortality. J Ky Med Assoc . 2020;74(9):474-475. Say L, Chou D, Gemmill A, et al. Global causes of maternal death: A WHO systematic analysis. Lancet Glob Heal . 2014;2(6):323-333. doi:10.1016/S2214-109X(14)70227-X WHO. Maternal mortality Evidence brief. 2020;(1):1-4. Wakgari N, Amano A, Berta M, Tessema GA. Partograph utilization and associated factors among obstetric care providers in north shoa zone, central ethiopia: A cross sectional study. Afr Health Sci . 2015;15(2):552-559. doi:10.4314/ahs.v15i2.30 Ayenew AA, Zewdu BF. Partograph utilization as a decision-making tool and associated factors among obstetric care providers in Ethiopia : a systematic review and meta-analysis. Published online 2020:1-11. Aluka N and K. Improving Partograph Use in Uganda Through Coaching and Mentoring. Usaid . Published online 2017:2-7. US Agency for International Development, Office of Health and Nutrition, Bureau for Global Health. Graphic Space The Partograph: An Essential Tool for Decision-Making during Labor Graphic Space History of the WHO Partograph. Published online 2011. http://pdf.usaid.gov/pdf_docs/Pnact388.pdf Nakimuli A, Nakubulwa S, Kakaire O, et al. The burden of maternal morbidity and mortality attributable to hypertensive disorders in pregnancy: A prospective cohort study from Uganda. BMC Pregnancy Childbirth . 2016;16(1):1-8. doi:10.1186/s12884-016-1001-1 Tesfaye GA, Chanie FT, Gemechu EN. Level of partograph utilization and its predictors among obstetrics care givers in Ilu Aba Bor Zone, Southwest Ethiopia: a cross-sectional study. 2023;09(8):316-327. Hagos AA, Teka EC. Utilization of Partograph and its associated factors among midwives working in public health institutions , Addis Ababa City. BMC Pregnancy Childbirth . 2020;20(49):1-9. https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-2734-4 Shafti V, Haghollahi F. The World Health Organization Labor Care Guide. Fertil Gynecol Androl . 2023;In Press(In Press):10-12. doi:10.5812/fga-136218 Additional Declarations No competing interests reported. Supplementary Files Appendix.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3776078","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":263808509,"identity":"98454d75-8f17-451e-bdb7-4f5c390a2cfd","order_by":0,"name":"RONALD KIBUUKA","email":"data:image/png;base64,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","orcid":"","institution":"Busitema University, Faculty of Health Sciences, P.O Box 1460 Mbale","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"RONALD","middleName":"","lastName":"KIBUUKA","suffix":""},{"id":263808510,"identity":"f4dfd44f-ae64-4e6a-8887-283c27784258","order_by":1,"name":"Jill Apoya","email":"","orcid":"","institution":"Busitema University, Faculty of Health Sciences, P.O Box 1460 Mbale","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jill","middleName":"","lastName":"Apoya","suffix":""},{"id":263808511,"identity":"5dd5158c-2260-4eb6-a702-14dd80d12e83","order_by":2,"name":"Allan. G. Nsubuga","email":"","orcid":"","institution":"Seed Global Health, P.O Box 12491, Kampala","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Allan.","middleName":"G.","lastName":"Nsubuga","suffix":""},{"id":263808512,"identity":"dfdf2083-159e-4b2d-9c95-df067b0fc552","order_by":3,"name":"Enid Kawala Kagoya","email":"","orcid":"","institution":"Busitema University, Faculty of Health Sciences, P.O Box 1460 Mbale","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Enid","middleName":"Kawala","lastName":"Kagoya","suffix":""},{"id":263808513,"identity":"2632f11f-03ca-498e-9cd9-4be8d3d99e79","order_by":4,"name":"Irene Atuhairwe","email":"","orcid":"","institution":"Seed Global Health, P.O Box 12491, Kampala","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Irene","middleName":"","lastName":"Atuhairwe","suffix":""},{"id":263808515,"identity":"0e0b3591-9d9c-45f4-9b6c-a4131555377f","order_by":5,"name":"Prossy Nakattudde","email":"","orcid":"","institution":"Seed Global Health, P.O Box 12491, Kampala","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Prossy","middleName":"","lastName":"Nakattudde","suffix":""},{"id":263808517,"identity":"7df86395-4692-4e76-babe-6636411f96f4","order_by":6,"name":"Atugonza Jesca","email":"","orcid":"","institution":"Busitema University, Faculty of Health Sciences, P.O Box 1460 Mbale","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Atugonza","middleName":"","lastName":"Jesca","suffix":""},{"id":263808519,"identity":"c338868f-c140-4cf3-a458-689d359b0bcc","order_by":7,"name":"Ambrose Okibure","email":"","orcid":"","institution":"Busitema University, Faculty of Health Sciences, P.O Box 1460 Mbale","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ambrose","middleName":"","lastName":"Okibure","suffix":""},{"id":263808520,"identity":"95bf8f40-98cd-4312-8698-7c774a5d34fe","order_by":8,"name":"Nakawuka betty","email":"","orcid":"","institution":"Busitema University, Faculty of Health Sciences, P.O Box 1460 Mbale","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nakawuka","middleName":"","lastName":"betty","suffix":""},{"id":263808521,"identity":"f9fbc56b-b055-4755-a28c-ab0380a3425c","order_by":9,"name":"Agnes Namaganda","email":"","orcid":"","institution":"Busitema University, Faculty of Health Sciences, P.O Box 1460 Mbale","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Agnes","middleName":"","lastName":"Namaganda","suffix":""},{"id":263808525,"identity":"f6268664-4e7f-4a81-9671-fe04e3389be7","order_by":10,"name":"Kenneth Mugabe","email":"","orcid":"","institution":"Mbale Regional Referral Hospital, Mbale – Eastern","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kenneth","middleName":"","lastName":"Mugabe","suffix":""},{"id":263808527,"identity":"dd992e10-86d0-4d9a-bdcb-35d910bf74a9","order_by":11,"name":"Patience Auma","email":"","orcid":"","institution":"Busitema University, Faculty of Health Sciences, P.O Box 1460 Mbale","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Patience","middleName":"","lastName":"Auma","suffix":""},{"id":263808529,"identity":"8b983deb-1870-4fbe-8e1d-e4215d3ec46b","order_by":12,"name":"Olga Ariga Olaki","email":"","orcid":"","institution":"Busitema University, Faculty of Health Sciences, P.O Box 1460 Mbale","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Olga","middleName":"Ariga","lastName":"Olaki","suffix":""},{"id":263808530,"identity":"30cd1051-c2c9-4e28-bedb-96bf2018394f","order_by":13,"name":"Barbara Rachael Adokon","email":"","orcid":"","institution":"Busitema University, Faculty of Health Sciences, P.O Box 1460 Mbale","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Barbara","middleName":"Rachael","lastName":"Adokon","suffix":""},{"id":263808532,"identity":"00bdcaa0-422a-4fe7-95f4-3a740375a456","order_by":14,"name":"Ernest Wandera","email":"","orcid":"","institution":"Busitema University, Faculty of Health Sciences, P.O Box 1460 Mbale","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ernest","middleName":"","lastName":"Wandera","suffix":""},{"id":263808534,"identity":"78fb5ac8-f75f-4f7b-9d2e-a4447ddea874","order_by":15,"name":"Francis Okello","email":"","orcid":"","institution":"Busitema University, Faculty of Health Sciences, P.O Box 1460 Mbale","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Francis","middleName":"","lastName":"Okello","suffix":""},{"id":263808535,"identity":"81628aea-3d42-42f5-87d1-9e989f27de37","order_by":16,"name":"Ashley Nakawuki","email":"","orcid":"","institution":"Busitema University, Faculty of Health Sciences, P.O Box 1460 Mbale","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ashley","middleName":"","lastName":"Nakawuki","suffix":""},{"id":263808536,"identity":"524a9920-98dd-495c-9213-4c08e92b5298","order_by":17,"name":"Rebecca Nekaka","email":"","orcid":"","institution":"Busitema University, Faculty of Health Sciences, P.O Box 1460 Mbale","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rebecca","middleName":"","lastName":"Nekaka","suffix":""},{"id":263808537,"identity":"2ab14fda-f519-4f52-890a-1daa97a9f8f8","order_by":18,"name":"Lawrence Arach","email":"","orcid":"","institution":"Mbale College of Health Sciences, P.O Box 1672, Mbale","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lawrence","middleName":"","lastName":"Arach","suffix":""},{"id":263808538,"identity":"1a8a3fec-1e23-4f4f-b2c1-2f344c382ad8","order_by":19,"name":"Milton Musaba","email":"","orcid":"","institution":"Busitema University, Faculty of Health Sciences, P.O Box 1460 Mbale","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Milton","middleName":"","lastName":"Musaba","suffix":""},{"id":263808539,"identity":"2efa5877-1b8d-4ad1-9cca-1e5089a895ca","order_by":20,"name":"Paul Waako","email":"","orcid":"","institution":"Busitema University, Faculty of Health Sciences, P.O Box 1460 Mbale","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Paul","middleName":"","lastName":"Waako","suffix":""},{"id":263808540,"identity":"372c0aba-aded-4376-8aa4-c81631ab5e0e","order_by":21,"name":"julius wandabwa","email":"","orcid":"","institution":"Busitema University, Faculty of Health Sciences, P.O Box 1460 Mbale","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"julius","middleName":"","lastName":"wandabwa","suffix":""}],"badges":[],"createdAt":"2023-12-19 09:29:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3776078/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3776078/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":48971701,"identity":"6a1da3b7-9138-4df2-ac06-5510b775a208","added_by":"auto","created_at":"2023-12-29 14:19:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":43727,"visible":true,"origin":"","legend":"\u003cp\u003elevel of recording social demographic details on the partograph\u003c/p\u003e\n\u003cp\u003eSocial Demographic details recorded\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3776078/v1/60b5bc8dd2ea228afa1fb897.png"},{"id":48971705,"identity":"5d1d7f91-d6d2-4259-b71b-e57cada0f4c5","added_by":"auto","created_at":"2023-12-29 14:19:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":41770,"visible":true,"origin":"","legend":"\u003cp\u003emonitoring of the mother and fetus\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3776078/v1/e09792d7f7959260d0262776.png"},{"id":48972235,"identity":"6a68f1a1-71b6-4cce-b684-d33daba50283","added_by":"auto","created_at":"2023-12-29 14:27:29","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":36162,"visible":true,"origin":"","legend":"\u003cp\u003enew borne details\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-3776078/v1/e6d7bcc6e4bcdcadb52a2856.png"},{"id":48971702,"identity":"51a71729-f6a1-46c5-a178-5824ddeccf20","added_by":"auto","created_at":"2023-12-29 14:19:29","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":58946,"visible":true,"origin":"","legend":"\u003cp\u003edetails regarding delivery\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-3776078/v1/5ed2fffbf2b97934d68b0afc.png"},{"id":48971703,"identity":"d2be0b6b-f8d7-4bc8-bba8-7a261328fc5b","added_by":"auto","created_at":"2023-12-29 14:19:29","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":17519,"visible":true,"origin":"","legend":"\u003cp\u003eoverall level of utilization\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-3776078/v1/a7dca1650eb4e82c1dee7d1d.png"},{"id":50779100,"identity":"e2a27ff7-0dd0-4096-b706-ec4adf24ba53","added_by":"auto","created_at":"2024-02-07 07:17:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":661275,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3776078/v1/4cc47606-fc9a-4460-868e-e60b77e3e443.pdf"},{"id":48971706,"identity":"6f5dadbf-4206-4525-9c1d-6c0fb4fb9f7c","added_by":"auto","created_at":"2023-12-29 14:19:29","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":25083,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-3776078/v1/2b761c54c3d335c05911b6d0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Bridging the Gap: Leveraging Partograph Utilization Insights to Facilitate the Smooth Implementation of the Labour Care Guide at Mbale Regional Referral Hospital, Eastern, Uganda","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn recent years, healthcare practices have made significant strides in improving maternal and newborn care, with a specific focus on enhancing safe and effective labour progress monitoring and management. One such advancement is the introduction of the next-generation partograph, the Labour Care Guide by the WHO in 2020, which is intended to replace the partograph\u0026nbsp;\u003csup\u003e1\u003c/sup\u003e. The labour care guide is clear, relevant and appropriate, and has the potential to positively impact clinical decision-making and respectful maternity\u0026nbsp;\u003csup\u003e2,3\u003c/sup\u003e. The aims of the labour care guide include guiding the monitoring and documentation of the well-being of women and babies and the progress of labour, guiding skilled health personnel to offer supportive care throughout labour to ensure a positive childbirth experience for women, assisting skilled health personnel to promptly identify and address emerging labour complications, by providing reference thresholds for labour observations that are intended to trigger reflection and specific action(s) if an abnormal observation is identified, prevent unnecessary use of interventions in labour and support audit and quality improvement of labour management, reducing primary cesarean delivery rate without increasing the duration of hospital stay and fetomaternal complications .\u0026nbsp;\u003csup\u003e1,4,5\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe partogram has been valuable in monitoring maternal and fetal well-being during active labour and aiding healthcare professionals in making timely decisions when abnormalities are detected\u0026nbsp;\u003csup\u003e6\u003c/sup\u003e,\u0026nbsp;thereby reducing maternal and neonatal morbidity and mortality.\u0026nbsp;Worldwide, the partogram, has been used as a labor monitoring tool to detect difficulties early, allowing for referral, intervention, or closer observations\u0026nbsp;\u003csup\u003e7\u003c/sup\u003e.\u0026nbsp;The WHO model of the partogram was devised by an informal working group, in 1954 when E. A Friedman described the normal cervical dilatation amongst women in USA\u0026nbsp;\u003csup\u003e8\u003c/sup\u003e. As healthcare systems strive to enhance the quality of care provided to expectant mothers, the adoption and utilization of evidence-based guidelines play a crucial role in achieving successful outcomes. However, despite proven effectiveness, the level of utilization of the partogram varies significantly across healthcare facilities and regions. For example at Mulago National Hospital\u0026nbsp;79.1% of the partographs reviewed had incomplete documentation of age, 52.7% gravidity, and 3.2% parity. In about 61%, the specific parameters for fetal monitoring, maternal monitoring and labour progress were incomplete\u0026nbsp;\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe maternal mortality ratio in developing countries in 2015 was 239 per 100 000 live births versus 12 per 100,000 live births in developed countries, with large disparities between countries, within countries, and between women within high and low income and those women living in rural and urban areas\u0026nbsp;\u003csup\u003e10\u003c/sup\u003e.\u0026nbsp;More than one-third of maternal deaths, half of stillbirths and a quarter of neonatal deaths result from complications during labour and childbirth\u0026nbsp;\u003csup\u003e11\u003c/sup\u003e 94% of all maternal deaths occur in low and lower-middle income countries, Appropriate care provided by skilled health professionals competent in sexual and reproductive health care, before, during and after childbirth can save the lives of women and newborn babies\u0026nbsp;\u003csup\u003e12\u003c/sup\u003e. \u0026nbsp;To curb this, WHO devised a more comprehensive monitoring tool to replace the partogram\u0026nbsp;\u003csup\u003e1\u003c/sup\u003e. However in order to ensure its successful implementation it is prudent to have an insight into the level of utilization of the partograph plus factors contributing to this level of utilization.\u003c/p\u003e\n\u003cp\u003eWith support from SEED GLOBAL HEALTH we carried out an anecdotal research in March 2021 to identify the level of partograph use and of the 200 files sampled, only 3% of the files sampled had a partograph inserted, various interventions were then put in place to aid improvement of partograph utilization and these included trainings on correct filling of the partogram, printing partograms and ensuring that they are always available on ward and carrying out QI programs to continuously remind the different health workers to utilize the partogram,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo ensure the successful implementation of the labour care guide and enhance maternal care, it is essential to understand the factors that influenced the utilization of the partogram. Targeted interventions can be designed to improve compliance and efficiency during labour management by identifying potential barriers and challenges hindering its widespread use.\u0026nbsp;In response to this imperative, this study is aimed at identifying the effects of these interventions, determine the extensive level of utilisation of the partogram and make better planning for the effective rollingout of the labour care guide. The construction of the modified partogram in utilizing the new instrument would not compromise but rather advance the objectives of the earlier partogram\u0026nbsp;\u003csup\u003e7\u003c/sup\u003e. By analyzing this data, we seek to understand the prevailing challenges and explore how these insights can facilitate the smooth rollingout of the labour care guide into existing clinical practices. This will Bridge the gap between research findings and practical implementation, our work aims to make a meaningful contribution to maternal and newborn healthcare. By offering evidence-based approaches, our study intends to guide policymakers, healthcare administrators, and frontline providers in improving maternal and newborn care, ultimately leading to better health outcomes for both mothers and infants.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe carried out a retrospective study at Mbale Regional referral hospital, were partographs were reviewed and Key informants interviewed, the study combined quantitative and qualitative methods of data collection. 6 key informant interviews were carried out. The quantitative component used a retrospective selective cluster randomized review of Partographs used in deliveries during April 2022 to December 2022, this was the second cohort and 1120 files were sampled and analyzed for presence or absence of a partograph, data from these partograph was captured using a predesigned questionnaire in form of google form, an excel sheet was then extracted cleaned and analyzed using STATA version 15 to determine the level of utilization under each section and then the overall level of utilization for those files that had a partograph,. Two cohorts were considered in the study one year apart. The first cohort of files was reviewed in March 2021 and in these 200 files were sampled and checked for presence or absence of a partograph\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained for each participant during the key informant interview. The interviews were moderated by trained research assistants and audio recorded. We used an interview guide that had been developed by the multidisciplinary team of a public health specialist, an epidemiologist and social scientist. It was written in English and administered by trained research assistants (in qualitative research methods), under the supervision of the Principal Investigator to elicit data. We explored specific factors or reasons that affected utilization of the partograph through examining their experiences and identifying issues that confronted them collectively as well as individually plus asking for possible recommendations. All interviews were conducted in English, the commonly spoken language by the interviewees.\u003c/p\u003e\n\u003cp\u003eThe Key informant interviews were transcribed and analyzed thematically by an experienced social scientist using standard principles. The field team, together with the authors of the paper under the leadership of the principal investigator read through the transcripts and notes from the discussions several times, identifying meaning units. The meaning units were then condensed, coded and put into categories, from which themes emerged.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eQuantitative findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a retrospective review of 1120 partographs for the period noted from records office of Mbale Regional Referral Hospital. In a retrospective survey in March 2021 200 files were randomly sampled and checked for presence or absence of a partograph.\u003c/p\u003e\n\u003cp\u003eTable 1 baseline vs current partograph use\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"621\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.47826086956522%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"56.52173913043478%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003epresence or absence of a partograph in the file\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.40836012861736%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"28.617363344051448%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ebaseline N=200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.974276527331188%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ecurrent N=1120\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.54838709677419%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"15.483870967741936%\" valign=\"top\"\u003e\n \u003cp\u003eFiles without a partograph\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.064516129032258%\" valign=\"top\"\u003e\n \u003cp\u003eFiles with a partograph\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.064516129032258%\" valign=\"top\"\u003e\n \u003cp\u003eFiles with a partograph\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.838709677419354%\" valign=\"top\"\u003e\n \u003cp\u003eFiles without a partograph\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.54838709677419%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003enumber\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.483870967741936%\" valign=\"top\"\u003e\n \u003cp\u003e194\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.064516129032258%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.064516129032258%\" valign=\"top\"\u003e\n \u003cp\u003e896\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.838709677419354%\" valign=\"top\"\u003e\n \u003cp\u003e224\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.54838709677419%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003epercentage\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.483870967741936%\" valign=\"top\"\u003e\n \u003cp\u003e97%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.064516129032258%\" valign=\"top\"\u003e\n \u003cp\u003e3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.064516129032258%\" valign=\"top\"\u003e\n \u003cp\u003e80%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.838709677419354%\" valign=\"top\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.54838709677419%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAverage level of utilisation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.483870967741936%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.064516129032258%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.064516129032258%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.838709677419354%\" valign=\"top\"\u003e\n \u003cp\u003e39%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFrom table 1 above, two cohorts: a baseline cohort consisting of 200 cases and a current cohort of 1120 cases. The cases are divided into two categories: those with a partograph in the file and those without. For the baseline cohort, 97% of cases (n=194) had no partograph in the file, while 3% (n=6) had a partograph. In the current cohort, 80% of cases (n=896) had a partograph in the file, and 20% (n=224) did not.\u003c/p\u003e\n\u003cp\u003eFigure 1 above presents a comprehensive overview of the recorded and not recorded mothers\u0026rsquo; particulars for a sample of N = 1120. The graph displays the percentages of mothers\u0026rsquo; particulars that were documented. The recorded mothers\u0026rsquo; particulars, such as inpatient number, date of admission, and age, were well-documented in over 80% of cases., indicating a high level of data completeness in these areas. However, certain critical mothers\u0026rsquo; particulars, such as weeks of gestation, risk factors, and time of membrane rupture, showed a being recorded in less than 50% of the partographs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFigure 2 above provides figures on the monitoring status of 1120 mothers during pregnancy and childbirth across various parameters. Monitoring rates displayed a decreasing trend with subsequent monitoring times. Fetal heart rate was monitored in 55.25% (619) of cases once, and this figure decreased to 26.61% (298), 12.05% (135), 7.05% (79), and 5% (56) for two, three, four, and five times, respectively. Only 13.75% (154) of mothers were monitored once for blood pressure and \u0026lt;1% of mothers had their blood pressures recorded for more than two times.\u003c/p\u003e\n\u003cp\u003eData in Figure 3 reveals the percentages of recorded details of the new borne baby. Notably, life status was recorded for 55.08% of newborns (625). The course of death was recorded for only 0.18% of cases (2), Time of delivery was relatively well-documented, with 74.11% of newborns (830) having the time recorded. APGAR scores at 1 minute and 5 minutes were also recorded for a majority of newborns, with 80.54% (902) and 78.57% (880) recorded, respectively.Regarding the newborn\u0026apos;s sex, 86.88% (973) were recorded. Similarly, weight was well-documented for most newborns, with 85.63% (959) recorded.\u003c/p\u003e\n\u003cp\u003eFigure 4 presents data on the recording status of various delivery-related parameters childbirths. The data reveals the percentages of recorded instances for each parameter. Notably, the time of decision to intervene was recorded for 6.79% of deliveries (76). Other details, such as the date of delivery (83.21%, 932), time of delivery of membranes and placenta (82.59%, 925), and type of delivery (83.13%, 931), were relatively well-documented. However, some parameters, like the duration of the first stage of labour (6.43%, 72) and post-delivery temperature (5.09%, 57), had lower recording rates. The duration of the second stage of labour (18.04%, 202), post-delivery blood pressure (18.93%, 212), post-delivery pulse (14.64%, 164), and comments on delivery (79.91%, 895) were recorded to varying degrees. Regarding specific medical interventions, oxytocin given was recorded for 80% of deliveries (896),.The amount of blood lost during delivery (62.41%, 699), episiotomy (53.84%, 603), and tears (55.80%, 625) also showed varying recording rates.\u003c/p\u003e\n\u003cp\u003eFigure 5 represents a comprehensive analysis of utilization rates and they range from 2% to 78%. Prominent concentration of utilization rates are between 30% and 50% (75% of data points fall within this range), Utilization rates below 50% are more prevalent than rates above 50%.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFive participants were approached and they all agreed to participate as key informants. These included nurses and midwives. The data obtained was then broken down into two themes focusing on factors associated with partograph utilization and the recommendations and three sub themes including hospital related factors, staff/health worker related factors and policy related factors.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1 : FACTORS ASSOCIATED WITH PARTOGRAPH UTILISATION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSub theme 1 : HOSPITAL RELATED FACTORS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHeavy workload\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe health workers attributed their not filling of the partographs to heavy workload due to inadequate human resources. They claimed that the mothers come in very large numbers hence making it challenging for one midwife on duty to fill partographs for all the mothers.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u0026hellip;\u003cem\u003eOverwhelming workload due to inadequate human resource \u0026ndash;Many mothers compared to the present midwives\u0026hellip;\u0026rdquo; (MRMM 5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eShortage of partographs\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome of the health workers reported that they didn\u0026rsquo;t fill the partographs because they were not there. They reported that sometimes they make requests for partographs from ministry of health but the delivery is delayed hence preventing them from filling the partographs.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;...Shortage of partographs and MOH delays to bring more\u0026hellip;\u0026rdquo; (MRNL 1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge gap regarding filling the partograph\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome health reported a knowledge gap in regards to filling the partograph. They reported this mainly among students as well as some health workers. They claimed that they feared to ask for help while filling the partograph.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;...Knowledge gap about filling the partograph but fear to ask for help...\u0026rdquo; (MRANP 2)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSub theme 2 : STAFF/ HEALTHWORKER RELATED FACTORS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNegative attitudes towards filling partographs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome health workers report saying that some of their colleagues have a negative attitude towards filling the partographs because of the strict steps taken to fill it and its time consuming nature.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;...some of us have a poor attitudes towards filling the partograph...\u0026rdquo; (MRANP 2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge gap\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome health workers reported that some of the students who go to the hospital do not know how to fill the partographs and because of their large numbers, supervising them becomes complicated.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;...their is knowledge gap about filling the partograph especially among students\u0026hellip;\u0026rdquo; (MRSANG 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSub theme 3 : POLICY RELATED FACTORS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePartograph lacks some parameters\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome health workers reported that the partograph lacked very many important parameters such as presenting complaints at that very time hence making some of the health workers prefer to write.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;...Partograph is a summary not having some parameters therefore some people prefer to write...\u0026rdquo; (MRMM 5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFew labor ward beds\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was an issue of limited beds on the wards and in instances where the number of mothers is overwhelming, filling of the partographs becomes hard as mothers are in and out of the wards.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;There are few labor ward beds and this makes follow up hard because emergencies come in all the time\u0026hellip;\u0026rdquo; (MRSANG 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimited spaces\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome health workers reported that there was limited space in the wards which affected privacy and service delivery hence making it difficult to fill the partograph.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;There\u0026rsquo;s a problem of limited spaces in the wards\u0026hellip;\u0026rdquo; (MRSANG 3)\u0026nbsp;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2 : RECOMMENDATIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSub theme 1 : RECOMMENDATIONS TOWARDS\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eHOSPITAL RELATED FACTORS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIncrease the human resource\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRespondents suggested an increase in manpower so as to ensure better utilization. It was pointed out that one or two midwives follow over 20 mothers and it is hard to plot a partograph for all these.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;sometimes I am on the shift alone with over 20 mothers , I cannot plot a partograph for each of them but if more people are employed and I have fewer mothers to follow I belief I can fill the partograph more completely\u0026hellip;\u0026rdquo; (MRSANG 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIncrease stationary for printing more partographs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost respondents pointed out that if partographs are availed it would be easy to fill since this ensures that a partograph is opened for the mother on admission but sometimes due to stockouts we are unable to fill in partographs.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;initially the supply of partographs was limited and we would get stockouts plus no supplies at all, but when seed global health started supplying us with printed partographs that are available all the time, it became easier to use them to monitor mothers hence if this supply is continued it would help us fully utilize them\u0026hellip;\u0026rdquo;\u003c/em\u003e\u0026nbsp; (MRANP 2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSub theme 2 : RECOMMENDATIONS FOR\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eHEALTH WORKER-RELATED FACTORS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTeach health workers how to plot the partographs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost respondents suggested training and retraining of health care workers on the use of the partograph so as to ensure increased utilization. They pointed out that this will ensure more complete and accurate filling of the partograph.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003e\u0026hellip;when seed global health came on board and trained us on how to use the partograph we used them more because we were confident on how to use them and not scared to make mistakes\u0026hellip;\u0026rdquo; (MRMM3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMedical officers should also be screened in regards to filling the partograph as a key component\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRespondents pointed out that most medical officers do not fill the partograph and as thus they believed that they sometimes make wrong decisions because of failure to interpret the partograph.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;I think medical officers do not know how to use the partograph because each time we ask some of them to guide us they just quarrel and just point at our mistakes; I think it would be better to organize a training for them\u0026hellip;\u0026rdquo; (MRSANG3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePartograph should also be an assessment tool for students\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost respondents agreed that due to the heavy workload, it is hard for them to fully utilize the partograph due to the workload. As such they suggested that training of students would help cover this gap since each student can be assigned one or two patients hence ensuring more complete utilization.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;the work here is too much and we are few, but we have students that can help us. All is needed is training them so that they know how to fill the partograph and they can be of great help in following up the mothers using the partograph\u0026hellip;\u0026rdquo; (MRANP)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSub theme 3 : ROCOMMENDATIONS TOWARDS\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePOLICY RELATED FACTORS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree codes were got under this subtheme including\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIncrease the number of beds in the wards, Improve the hospital spaces, Improve the partographs by adding some more parameters\u003c/p\u003e\n\u003cp\u003eMost respondents said that increasing the space and beds in labour suit would aid in better follow up.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;each bed is used by more that 10 mothers, even after delivery we have to transfer the mother there and then to create space for more mothers, if we had \u0026nbsp; more beds and space, a lot would be solved so that each mother or two mothers os allocated a bed\u0026hellip;\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cem\u003eMRMM 5\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of our study shed light on the current level of partograph utilization and the challenges faced in Mbale Regional Referral Hospital, Uganda. The quantitative findings revealed that while certain mothers\u0026rsquo; particulars, such as inpatient number, date of admission, and age, were well-documented, critical information like LNMP, EDD, weeks of gestation, and risk factors showed higher rates of missing data. Showing an overall low initial utilization of the partogram. Utilisation of the partogram is low in most countries as highlighted out by\u0026nbsp;\u003csup\u003e13\u003c/sup\u003e ,\u0026nbsp;\u003csup\u003e14\u003c/sup\u003e. From our Study: trainings, supervision, provision of the partographs and QI projects improved partograph utilization from 3% to 80% in one year, these interventions were also found to improve partograph utilization in other parts of the country\u0026nbsp;\u003csup\u003e15\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding monitoring during the progression of labour, the study highlighted a concerning trend of decreasing monitoring rates with subsequent monitoring times. Proper monitoring of fetal heart rate, membranes and liquor color, cervical dilation, uterine contractions, blood pressure, and other vital parameters is essential for timely intervention and decision-making during labor\u0026nbsp;\u003csup\u003e16\u003c/sup\u003e. The relatively low monitoring rates for blood pressure and other parameters underscore the importance of continuous monitoring to ensure the well-being of both mother and baby and this can lead to increased possibility of failing to recognize disorders such as pre eclampsia which can lead to an increase in maternal morbidity\u0026nbsp;\u003csup\u003e17\u003c/sup\u003e.\u0026nbsp;Notably, on overall utilization clustering was observed around 30% and 50%, suggesting potential common utilization patterns, with few extreme values representing outliers at both low and high utilization rates with an average level of utilization of 39%, this is relatable to Ethiopia were the level of utilization was found to be 32.8%\u0026nbsp;\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe qualitative findings provided valuable insights into the challenges faced by healthcare workers in utilizing the partograph. Heavy workload and inadequate human resources emerged as significant factors hindering partograph utilization. This factors are in tandem with what was found out in other countries for example in Ethiopia Working facility, supportive supervision, mentoring, training on partograph, number of midwives working per shift, and knowledge were factors affecting partograph utilization\u0026nbsp;\u003csup\u003e19\u003c/sup\u003e This points to the need for increased staffing and better workload management to improve the quality of care provided to expectant mothers.\u003c/p\u003e\n\u003cp\u003eNegative attitudes towards filling the partograph and knowledge gaps among healthcare workers and students were also identified as barriers. The poor attitude was also found as a barrier in other countries including Ethiopia\u0026nbsp;\u003csup\u003e13\u003c/sup\u003e Addressing these issues requires targeted educational programs and training to enhance knowledge and foster a positive attitude towards utilizing the partograph as a valuable tool in labor management. Trainngs and menorship improved partograph utilization in different parts of Uganda\u0026nbsp;\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003ePolicy-related factors, such as the lack of certain parameters in the partograph and limited labour ward beds and space, were also identified. Enhancing the partograph by adding missing parameters and improving hospital infrastructure could contribute to better partograph utilization and overall maternal care. This is the aim of the LCG, to fill this gap. However there is need for localization of this LCG so as to fit within the local picture\u0026nbsp;\u003csup\u003e20\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eKey informants identified several challenges in partograph utilization. Hospital-related factors included heavy workload due to inadequate human resources and shortages of partographs. Staff-related challenges encompassed knowledge gaps among some health workers and students and negative attitudes towards partograph filling. Policy-related issues involved missing parameters in the partograph and limited labor ward beds and space.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, our study points out the fact the partograph utilization is generally sub optimal and offers evidence-based approaches and recommendations to enhance partograph utilization. These are key aspects to follow and ensure successful rolling out of the labour care guide at Mbale Regional Referral Hospital and making appropriate targeted changes for a smoother implementation. By addressing the identified challenges and implementing targeted interventions, healthcare administrators, policymakers, and frontline providers can improve maternal and newborn care practices, ultimately leading to better health outcomes for expectant mothers and their infants. The integration of evidence-based guidelines into routine clinical practices is crucial for reducing maternal and neonatal morbidity and mortality and advancing safe and effective labor management in Mbale and beyond. As a team with support from Seed global health and from the lessons and insights learn from a QI project to improve utilization of the partogram, we are now set to roll out the labour care guide\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Consideration:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval and a waiver of consent was sought and obtained from the Research Ethics Committees (REC) of Mbale Regional Referral Hospital No. MRRH-2023-300\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe corresponding author and all co-authors declare no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO. \u003cem\u003eWHO Labour Care Guide User\u0026rsquo;s ManUal\u003c/em\u003e.; 2020.\u003c/li\u003e\n\u003cli\u003eVogel JP, Comrie-Thomson L, Pingray V, et al. Usability, acceptability, and feasibility of the World Health Organization Labour Care Guide: A mixed-methods, multicountry evaluation. \u003cem\u003eBirth\u003c/em\u003e. 2021;48(1):66-75. doi:10.1111/birt.12511\u003c/li\u003e\n\u003cli\u003ePingray V, Bonet M, Berrueta M, et al. The development of the WHO Labour Care Guide: an international survey of maternity care providers. \u003cem\u003eReprod Health\u003c/em\u003e. 2021;18(1):1-15. doi:10.1186/s12978-021-01074-2\u003c/li\u003e\n\u003cli\u003eVogel JP, Pingray V, Althabe F, et al. Implementing the WHO Labour Care Guide to reduce the use of Caesarean section in four hospitals in India: protocol and statistical analysis plan for a pragmatic, stepped-wedge, cluster-randomized pilot trial. \u003cem\u003eReprod Health\u003c/em\u003e. 2023;20(1):1-15. doi:10.1186/s12978-022-01525-4\u003c/li\u003e\n\u003cli\u003eKhalil MR, Guldberg R, N\u0026oslash;rg\u0026aring;rd BM, Uldbjerg N, Wehberg S. Child-Mother Index: a new risk factor for selected adverse maternal birth outcomes. \u003cem\u003eAJOG Glob Reports\u003c/em\u003e. 2022;2(4). doi:10.1016/j.xagr.2022.100090\u003c/li\u003e\n\u003cli\u003eMSF. https://medicalguidelines.msf.org/en/viewport/ONC/english/5-2-monitoring-labour-and-delivery-51416957.html. Published online 2023.\u003c/li\u003e\n\u003cli\u003eGhulaxe Y, Tayade S, Huse S, Chavada J. Advancement in Partograph: WHO\u0026rsquo;s Labor Care Guide. \u003cem\u003eCureus\u003c/em\u003e. 2022;14(10). doi:10.7759/cureus.30238\u003c/li\u003e\n\u003cli\u003eWHO. WHO_FHE_MSM_93.8.pdf. Published online 1994.\u003c/li\u003e\n\u003cli\u003eMukisa J, Grant I, Magala J, Ssemata AS, Lumala PZ, Byamugisha J. Level of Partograph completion and healthcare workers \u0026rsquo; perspectives on its use in Mulago National Referral and teaching hospital , Kampala , Uganda. 2019;3:1-8.\u003c/li\u003e\n\u003cli\u003eGreene JW. Maternal mortality. \u003cem\u003eJ Ky Med Assoc\u003c/em\u003e. 2020;74(9):474-475.\u003c/li\u003e\n\u003cli\u003eSay L, Chou D, Gemmill A, et al. Global causes of maternal death: A WHO systematic analysis. \u003cem\u003eLancet Glob Heal\u003c/em\u003e. 2014;2(6):323-333. doi:10.1016/S2214-109X(14)70227-X\u003c/li\u003e\n\u003cli\u003eWHO. Maternal mortality Evidence brief. 2020;(1):1-4.\u003c/li\u003e\n\u003cli\u003eWakgari N, Amano A, Berta M, Tessema GA. Partograph utilization and associated factors among obstetric care providers in north shoa zone, central ethiopia: A cross sectional study. \u003cem\u003eAfr Health Sci\u003c/em\u003e. 2015;15(2):552-559. doi:10.4314/ahs.v15i2.30\u003c/li\u003e\n\u003cli\u003eAyenew AA, Zewdu BF. Partograph utilization as a decision-making tool and associated factors among obstetric care providers in Ethiopia : a systematic review and meta-analysis. Published online 2020:1-11.\u003c/li\u003e\n\u003cli\u003eAluka N and K. Improving Partograph Use in Uganda Through Coaching and Mentoring. \u003cem\u003eUsaid\u003c/em\u003e. Published online 2017:2-7.\u003c/li\u003e\n\u003cli\u003eUS Agency for International Development, Office of Health and Nutrition, Bureau for Global Health. Graphic Space The Partograph: An Essential Tool for Decision-Making during Labor Graphic Space History of the WHO Partograph. Published online 2011. http://pdf.usaid.gov/pdf_docs/Pnact388.pdf\u003c/li\u003e\n\u003cli\u003eNakimuli A, Nakubulwa S, Kakaire O, et al. The burden of maternal morbidity and mortality attributable to hypertensive disorders in pregnancy: A prospective cohort study from Uganda. \u003cem\u003eBMC Pregnancy Childbirth\u003c/em\u003e. 2016;16(1):1-8. doi:10.1186/s12884-016-1001-1\u003c/li\u003e\n\u003cli\u003eTesfaye GA, Chanie FT, Gemechu EN. Level of partograph utilization and its predictors among obstetrics care givers in Ilu Aba Bor Zone, Southwest Ethiopia: a cross-sectional study. 2023;09(8):316-327.\u003c/li\u003e\n\u003cli\u003eHagos AA, Teka EC. Utilization of Partograph and its associated factors among midwives working in public health institutions , Addis Ababa City. \u003cem\u003eBMC Pregnancy Childbirth\u003c/em\u003e. 2020;20(49):1-9. https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-2734-4\u003c/li\u003e\n\u003cli\u003eShafti V, Haghollahi F. The World Health Organization Labor Care Guide. \u003cem\u003eFertil Gynecol Androl\u003c/em\u003e. 2023;In Press(In Press):10-12. doi:10.5812/fga-136218\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Partogram, Partograph, labour care guide, maternal and newborn care, Partograph utilization, implementation insights, healthcare workers, barriers, Mbale Regional Referral Hospital, Uganda","lastPublishedDoi":"10.21203/rs.3.rs-3776078/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3776078/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction: \u003c/strong\u003eMaternal and newborn care has seen significant advancements through evidence-based guidelines, including the labour care guide introduced by the World Health Organization (WHO). However, the successful implementation of these guidelines relies on analysing the level of effective utilization of tools such as the partogram. In this study, we aim to assess the effects of a QI project aimed at improving the utilization of the partogram, and the current level of its utilization at Mbale Regional Referral Hospital, Uganda, and identify the possible challenges in its use and design effective procedures in rolling out of the labour care guide into existing clinical practices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology:\u003c/strong\u003e A retrospective study combining quantitative and qualitative approaches was conducted. In March 2021 200 files were randomly sampled and checked for presence or absence of a partograph and this formed the baseline data before starting a QI project to improve utilization of a partograph to improve partograph utilization. In March 2023, 1120 patient files were reviewed from deliveries that happened between April to December 2022, these were analyzed to determine the presence or absence of a partogram in the file and the level of utilization. 6 key informant interviews were also conducted with healthcare workers to explore factors influencing partograph utilization and recommendations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e While certain mothers’ particulars were well-documented, critical information such as LNMP, EDD, and risk factors displayed higher rates of missing data. Monitoring rates decreased with subsequent times with an average level of partograph utilization of 39%. The presence of a partograph in patients’ files improved from 3% in March 2021 to 80% from April to December 2022. Key informant interviews revealed challenges related to heavy workload, inadequate human resources, poor attitudes towards partograph utilization, knowledge gaps, and policy-related issues.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The level of partograph utilization at Mbale Regional Referral Hospital remains suboptimal (\u0026lt;50%), Which could hinder the successful rolling out of the LCG. Addressing the identified challenges is essential for improving maternal and newborn care practices. With the above insights in mind and with support from Seed Global Health, the team is set to effectively change its goal from improving the level of utilization, which improved from 3% to 80%, towards rolling out the LCG.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations:\u003c/strong\u003e To enhance partograph utilization and facilitate the smooth implementation of the labour care guide, we recommend increasing human resources, providing targeted training and education, improving hospital infrastructure, fostering positive attitudes among healthcare workers, and implementing continuous quality improvement programs.\u003c/p\u003e","manuscriptTitle":"Bridging the Gap: Leveraging Partograph Utilization Insights to Facilitate the Smooth Implementation of the Labour Care Guide at Mbale Regional Referral Hospital, Eastern, Uganda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-12-29 14:19:24","doi":"10.21203/rs.3.rs-3776078/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f1b4af59-e5e7-4709-bc26-514ded71e695","owner":[],"postedDate":"December 29th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-07T07:16:12+00:00","versionOfRecord":[],"versionCreatedAt":"2023-12-29 14:19:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3776078","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3776078","identity":"rs-3776078","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}