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Partograph completion is impractical: Why?

The health care systems in low- and middle-income countries (LMICs) still face challenges in adopting the Partograph as the gold standard monitoring tool for expectant mothers in active labour(1). In many of such nations where the forms exist, the existential threat of uncompleted partographs in the patients’ records is real.

Worldwide, approximately 1000 women die from causes related to pregnancy and childbirth every day. 99% of the deaths occur in the LMICs(2). The highest burden is in sub-Saharan Africa and Southeast Asia(3,4). Uganda records about 16 maternal deaths daily. 1 in 53 women in Uganda has a lifetime risk of death due to pregnancy and childbirth(5,6,7).

Because most of the maternal deaths are preventable, the WHO recommends that a skilled or trained birth attendant attends to every expectant mother before, during, and after childbirth(8). Many LMICs don’t have enough skilled birth attendants – yet when such workers are adequate, they extend high-quality care towards the mothers. Quality care also implies a timely referral for an expectant mother who requires specialised care(21).

The Partograph is a record of the progress of labour and relevant details of the mother and the foetus(9). The World Health Organisation (WHO) recommends that health care providers monitor all expectant mothers using Partograph during labour. It is a means of monitoring and recording maternal and foetal well-being. The aim is to identify maternal and foetal distress, as well as disparities in labour progress that warrant extended interventions timely referrals inclusive(10,11,12,13). To seamlessly utilise a partograph is one of the fundamental skills that a skilled or trained birth attendant must exhibit(14).

A partograph has the alert and action lines, with four hours between them(21). They provide an opportunity for the skilled birth attendant to convene more interventions to enhance a seamless labour process. It has both maternal foetal monitoring sections.

A partograph, when used appropriately, prevents the catastrophic effects that arise from prolonged, often obstructed labour toward either the mother, foetus, or both. They include obstetric fistula, uterine rupture, postpartum haemorrhage, and puerperal sepsis. The foetus may suffer anoxia, contract infections, or die(21).

The Ugandan Ministry of Health introduced the partograph in the 1990s, but the utilisation of this tool is still low.  In Rujumba health sub-district and Bwera Hospital, partograph use was at 69.9% and 15.7% respectively(15,16). Similar studies conducted in Ethiopia and Nigeria showed a partograph completion rate of about 34.4%(17,18,19).

In a recent study at Mulago National Referral Hospital, about the level of partograph completion, a staggering 61% of the sampled partographs were incomplete for maternal monitoring, foetal monitoring and labour progress. Furthermore, 79.1% of these had incomplete documentation of age, 52.7% had missing data on gravidity, and 3.2% had no data about parity(21).

The data above shows that despite the proven benefits of partograph use in obstetric care, health care providers don’t utilise the monitoring tool to meet the expected goal of every expectant mother having a partograph plotted for her during labour. Across the continent where the problem exists, there are the same reasons to explain why partograph completion is still a challenge – impractical. We expound on them.

The WHO recommends one nurse for every five patients and one midwife for every four expectant mothers. In Uganda, there’s one nurse for every 11,000 patients and one doctor for every 15,000 patients. On the busiest delivery shift in Mulago National Referral Hospital, there’s one midwife for every 15 expectant mothers in labour(21). The patient load is vast.  It is impractical to feel every partograph of such mothers. In instances where the providers fill the forms to completion, the midwives plotted the graphs retrospectively following delivery. Disaster strikes when such a mother delivers a stillborn, and there’s no graphic representation of the ordeal.

Because patient numbers are abnormally huge, the wards become congested, they occupy all the beds, and more mothers sleep on the floor. It implies that such mothers may miss timely examinations to ascertain the maternal condition and labour progress. So, no examination findings culminate in lack of information to feel the partographs.

A myriad of the birth attendants in the LMICs lacks adequate skills in emergency obstetrics and neonatal care – partograph use inclusive. To make matters worse, many health centres lack on-the-job training through scheduled continuous professional development (CPD) courses. Such birth attendants can neither provide high-quality care nor conduct proper documentation.

Partograph use is impractical.
A complete but erroneously filled partograph. It is due to lack of skills.

In many public facilities where we find the most skilled birth attendants, they lack monitoring tools like the Pinnard stethoscopes, foetal heart rate Doppler. We shall not mention the expensive cardiotocography equipment – many health care workers have never had a glance at such. How can a labour suite that registers about 30 deliveries per day, have only 3 Pinnard stethoscopes, and no foetal Doppler machines? In such scenarios, we must be grateful for any partograph the skilled birth attendants feel, whether complete or incomplete. However, we cannot settle for less. The health care providers cannot complete the partographs: hence the mothers won’t receive high-quality care.

Continue reading:

Obstructed Labour Injury Complex: As complex as it gets.

Understanding Obstetric Fistula using the Haddon Matrix: We can prevent this catastrophe.

Lastly but not least, due to the sorry states of the road and rail network in many LMICs, most expectant mothers reach the health facilities very late. At presentation, the mothers are always in such clinical states that they send the birth attendants into panic modes. The health care providers lack enough time to both attend to the mother and adequately document simultaneously. It is in addition to the low staffing capacity, low-level skillsets, and high patient load.

In a nutshell, the combination of a high patient load, low staffing capacity, ward congestion, inadequate monitoring tools, equipment and supplies, limited skills among the birth attendants, and maternal clinical states at presentation, all explain why partograph completion in low- and middle-income countries impractical(12,15,20). Until we address these bottlenecks, we aren’t about to curb the 1000 maternal deaths that occur daily across the globe every day.


MBChB (MUK), Graduate Fellow, Department of Physiology, Makerere University Founder and Content Creator Peer reviewer, Associate Editor

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