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Abstract
Background: The partograph (or partogram) is recommended by the World Health Organisation (WHO), for
monitoring labour wellbeing and progress. Concerns about limitations in the way the partograph is used in the
clinical context and the potential impact on its effectiveness have led to this realist systematic review of
partograph use.
Methods: This review aimed to answer two key questions, 1) What is it about the partograph that works (or does
not work); for whom does it work; and in what circumstances? 2) What are the essential inputs required for the
partograph to work? A comprehensive search strategy encompassed key databases; including papers of varying
methodologies. Papers were selected for inclusion if the focus of the paper was the partograph and related to
context, mechanism or outcome. Ninety five papers were included for data synthesis. Two authors completed data
extraction and synthesis.
Results: The evidence synthesis relates the evidence to identified theories of health worker acceptability, health
system support, effective referral systems, human resources and health worker competence, highlighting barriers
and facilitators.
Conclusions: This first comprehensive realist synthesis of the partograph, provides the international community of
maternity clinicians with a picture of potential issues and solutions related to successful labour recording and
management, which is also translatable to other monitoring approaches.
Keywords: Partograph, Partogram, Labour, Context, Use, Outcomes
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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Bedwell et al. BMC Pregnancy and Childbirth (2017) 17:31 Page 2 of 11
Fig. 1 Types of Partograph. a. Composite partograph [18, 64]. b. Modified partograph [65]
for the tool to be clinically effective. Greater depth of the findings of a review of factors which may impact on
understanding of the context and mechanism of par- partograph efficacy using realist review methodology [12].
tograph use is required in order to determine if and
how it can reach its potential. Methods
Literature suggests that there is widespread support A realistic review approach is appropriate for research
for the partograph, a belief that it works and a profes- synthesis of complex interventions such as health service
sional will for it to succeed [4, 6, 8–10]. However, in delivery [12–14]. Complex interventions are embedded
order to understand the issues facing the partograph and in health or social systems and are therefore influenced
its impact on outcomes, a comprehensive evaluation of by differences in context [12]. The partograph is typical
the evidence is required. The partograph is used as part of a complex health intervention in that its use is af-
of an approach to labour monitoring. As such, the parto- fected by a number of factors related to design, context,
graph by its nature is a complex intervention, relying implementation and management, and because it re-
on a number of factors for effective use, including quires the active input of individuals to be effective [12].
interaction between a number of causal relations, be- Traditional systematic reviews are evaluative, focusing
haviors and outcomes [11]. These complexities require on outcome and whether or not an intervention works.
more than a traditional review and this paper will report The advantage of the realist review approach is that it is
Bedwell et al. BMC Pregnancy and Childbirth (2017) 17:31 Page 3 of 11
explanatory, allowing the researcher to explore why and intervention and the context of its use which may im-
how such interventions may work (or not) and in what pact on its effectiveness. These were situated under an
context [12, 13]. overarching theory of an enabling environment; that is,
The review process itself consists of five steps; clarifying for the intervention to work at all the environment and
the scope of the review, searching for evidence, appraising context in which the intervention occurs must be sup-
primary studies and extracting data, synthesising and portive [15]. Five related theories were identified,
drawing conclusions, dissemination, implementation and consisting of: health worker acceptability, health system
evaluation (outlined in Fig. 2) which will be explained in support, effective referral systems, human resources and
the context of the partograph review. health provider competence (see Fig. 3).
of papers of various methodologies, policy and guidance using specific questions related to each theory. This
documents, audits, grey literature and opinion pieces. The helped to clarify and synthesise the data within each in-
initial search was completed in October 2013 and re- dividual theory.
peated in October 2015. Following removal of duplicates
416 papers were screened on title and abstract by two au- Results
thors. A further 291 full papers were screened, resulting in Ninety five papers were identified for inclusion (see
95 papers for inclusion (see Prisma diagram, Fig. 4). Fig. 4). These included primary research, reviews, guid-
ance documents and opinion papers, in line with the
Appraisal of evidence realist review philosophy. For the purposes of the
Pawson [12] argues that ‘fitness for purpose’ is the most evidence synthesis, only primary research and review pa-
important factor in determining relevance for inclusion pers were included. The majority of included papers re-
of evidence and rejects exclusion of papers on the basis lated to low-resource settings, with very few in medium
of quality alone; the synthesis itself determines the value or high resource settings.
of the evidence. For this reason, all studies with useable The key evidence synthesis is presented below in rela-
data were included, regardless of quality. However, an tion to each relevant theory (Tables 1, 2, 3, 4 and 5) and
understanding of quality is relevant for the ultimate syn- will be discussed in relation to the research questions.
thesis [16]. Therefore, a quality assessment was made
using the MMAT tool (version 11) [17], thus allowing Discussion
for a simple review of quality for studies of varying This review aimed to answer two key guiding questions,
methodologies. which will be discussed below.
Data extraction and synthesis of the evidence What is it about the partograph that works (or does not
A simple data extraction tool was devised and was com- work); for whom does it work (e.g., midwives,
pleted for each paper identifying aspects which related obstetricians, women); and in what circumstances (e.g.,
to the context, mechanism or outcome of the parto- urban/rural setting, country)?
graph. This provided a simple overview of the data, What is it about the partograph that works?
allowing links to be developed and related to the pre- A Cochrane review of the partograph suggests that evi-
defined theories. Pawson et al. [12] suggest that data ex- dence to support improvement of clinical outcomes is
traction is not linear and evidence will continue to limited2. However, evidence from other studies indicates
emerge during the process. This did occur with referral that partograph use may contribute to shorter labours
to the included papers continuing throughout the syn- and some improvement in maternal and fetal outcomes
thesis process as further links were developed and con- [18–21]. Health care workers found the modified parto-
cepts identified. Once extracted, data were interrogated graph the most user-friendly version [3, 22, 23], with the
latent phase of the composite partograph considered dif- Overall completion of the partograph (to pre-defined
ficult to complete. The modified partograph also appears standards) is poor, which is likely to impact on the utility
to improve outcomes including reduced caesarean sec- of the tool in clinical practice. The sections of the parto-
tion rate, augmentation of labour and admission to neo- graph which are most likely to be completed are those
natal unit when compared to the composite partograph relating to progress (cervical dilatation) and fetal well-
in low-resource settings [23]. being (fetal heart rate) [24–27]. Those that were poorly
completed related to maternal wellbeing [24–28]. How- partograph is used, suggestions of fewer vaginal exami-
ever, this may reflect ease of use in completing particular nations, reduced length of labour and referral may indi-
sections, availability of equipment or participants under- cate that women are receiving more appropriate
standing of the partograph, rather than the tool itself [3, treatment and intervention [18–21, 37].
29–31]. Whilst some view the partograph as difficult or Midwives appear to be satisfied with the partograph as
time consuming to complete [30, 32, 33], there is evi- a usable tool for monitoring labour [18, 40]. Positive at-
dence that other, non-professional, cadres of staff can titudes towards the partograph are displayed by both
complete the partograph effectively [34, 35]. midwives and doctors, but less so by other cadres of
The partograph does appear to work as a trigger for health care worker who also use the partograph [32, 36,
referral and transfer [20, 28, 31, 32, 36–38], one of its 40–42]. It is clear that positive attitudes alone do not
primary purposes. However, evidence related to other translate into partograph use in practice. This may be
types of decision-making, for example augmentation of for a number of reasons such as availability, time, work-
labour, based on partograph findings is limited and there load and organisational culture [23, 29–32, 43].
is some suggestion that partograph findings may not al- One advantage of partograph use is that it enables
ways be acted upon [29]. The success of the partograph health workers to take individual responsibility for
as a communication tool at handover of care is limited labour management within their own sphere of prac-
[23, 29] and women who are transferred to tertiary units tice [44]. However, confusion over roles and responsi-
are not always sent with the partograph commenced at bilities for the partograph existed in some settings
the referring facility [39]. [29, 32]. Such role confusion may be an indication of
general poor multi-disciplinary working and commu-
For whom does it work? nication, which may ultimately impact on decision-
In terms of improved outcomes for women and making and outcomes [45]. Similarly, training in
newborns, there is conflicting evidence as to whether partograph use can be an issue where either supervi-
the partograph works, although studies in low-resource sors are not trained [29], or training is not provided
settings suggest that it may have positive impact [18– to those who are using the partograph on a daily
21]. There is no evidence that partograph use is detri- basis [25].
mental to outcomes [2]. Whilst there is no data related Although the partograph is considered a ‘cheap’ inter-
to maternal satisfaction or quality of care when the vention at less than 10 US cents per paper version [46],
there was no evidence of evaluation of the cost- What are the essential inputs required for the partograph
effectiveness of the partograph in the included literature. to work?
Many of the issues relating to partograph use arise from
In what circumstances? the difficulties of putting it into practice effectively. There
The partograph appears widely accepted, but in practice, is limited description of implementation strategies in the
its use varies considerably. Barriers to use include poor reviewed literature. The poor levels of compliance and the
availability of partograph or equipment to complete it, implication that the partograph is not embedded in rou-
high workloads, poor staffing levels, duplication of re- tine care are suggestive that the partograph has not been
cords, lack of available policy or guidance and limited ‘normalised’ into care processes [11]. As such there ap-
knowledge and understanding of the partograph [29, 30, pears to be a lack of overall commitment, resulting in var-
32, 33, 36, 41–43, 47, 48]. ied (at best) acceptability and use of the partograph in
The partograph is most likely to be used in urban, ter- clinical practice. For the partograph to work, it needs to
tiary facilities and by professionally qualified staff or be acceptable to health care workers who provide care to
those trained in partograph use. This is perhaps not sur- women in labour. Currently, although the majority of
prising as tertiary settings are most likely to have fund- health care workers have positive attitudes towards the
ing for training and also employ a greater proportion of partograph, a number of factors need to be overcome to
qualified staff. The partograph is also more likely to be ensure an enabling environment facilitating consistent
used in public facilities. The availability of policy or and effective use of the partograph in practice. These in-
guidance at facility level also appeared to have a positive clude clear health system support and commitment, avail-
impact on partograph use [30, 49]. Much more limited ability of resources, competence in use and monitoring
evidence was available for consistent and accurate parto- and evaluation of the partograph in practice.
graph use in the long term. Studies reintroducing the Health system support and commitment is vital in
partograph or retraining staff suggest problems with promoting a positive culture for partograph use [51].
maintaining consistent partograph use after introduc- The role of the health system itself was not addressed in
tion. Ongoing supervision and support in practice is the literature relating to the partograph, yet the need to
likely to improve partograph use, but current evidence is strengthen such systems is well acknowledged in the
limited to that within study settings [37]. Similarly, wider literature [51, 52]. Current evidence suggests a
repeated audit and feedback contribute to ongoing culture where the partograph is not central to care and
regular and accurate use in practice [50]. where adequate supervision is lacking. Positive validation
Bedwell et al. BMC Pregnancy and Childbirth (2017) 17:31 Page 8 of 11
of the partograph from leaders, managers and supervi- improve partograph use [50, 62]. Such a strategy will en-
sors is required; reinforcement by guidance, audit and able learning, demonstrate continued health system
evaluation of partograph use will assign value to the tool. commitment to the partograph and provide much
‘Buy in’ by supervisors and leaders is important, as they needed data in relation to outcomes. One issue with the
are most likely to be influential in promoting a positive partograph in current use is the failure to evaluate the
environment for partograph use. Furthermore, supervi- tool at facility level in terms of outcomes. This is vital in
sors in the clinical setting can provide guidance and con- determining the level of impact partograph use has on
firm clinical decision making based on partograph care provision and referrals as well as on specific labour
findings. Multidisciplinary working is also crucial in ef- outcomes. Furthermore, if health workers and organisa-
fective use of the partograph and is more likely to be tions can observe positive outcomes from partograph
sustained and effective with health system support [45]. use it is more likely to become embedded into practice.
Facility level guidance should be available and accessible
to health care workers providing care to women in Limitations
labour. This should comprise both guidance on inter- There were some limitations to this review. Few
ventions and the responsibilities of individuals in the included studies considered more than one aspect of
care setting. Support in terms of provision of resources, partograph use, such as mechanism of use, and this was
such as the partograph itself and equipment required for not related to either context or outcomes; although
completion is vital at a basic level to ensure consistent understanding and inferences can be drawn from the
use but which is currently lacking. studies that are available. This limitation is accepted as
Current studies indicate poor health worker compe- part of the realist review process [12]. Furthermore, the
tence in partograph use. Training in partograph use does overall quality of evidence was generally low or very low.
increase knowledge and completion of the partograph in Although quality was not an inclusion criterion for pa-
practice [30, 32, 34, 35, 37, 41, 43, 53–56] and is essen- pers, it must be taken into consideration in interpreting
tial in any facility in which the partograph is used. Fre- the findings. It is also possible that other factors, which
quent and high turnover of staff indicate that this is fall outside of the scope of the review, may impact on
required on a regular basis. Furthermore, in many of the partograph use, such as health workers understanding of
included studies, staff who had already been trained re- the physiology of labour. Finally, whilst some general
quested further training, indicating that consistent recommendations can be made, it is important to ac-
reinforcement is necessary to develop and maintain skills knowledge that the scope of the realist review process is
[23, 25, 30–32, 36, 43]. Although individualised training to provide suggestions and to add depth to established
has been demonstrated to work in improving partograph theories, rather than to provide universal recommenda-
knowledge [55, 56], use of multidisciplinary training tions that may be expected to work in all contexts [12].
strategies may improve understanding of roles and pro-
mote team working [57]. Practical training methods can Recommendations
also enhance learning and may improve patient out- A number of recommendations can be made as a result
comes [58–60]. All staff providing care for women in of this review:
labour should be trained and regularly updated in parto-
graph use. Such training needs to follow established The modified partograph is preferable to the
effective training methods, such as multidisciplinary composite partograph in terms of ‘user friendliness’.
training models [60]. It is essential that the content of The partograph and equipment required to
such training includes both completion and decision complete it need to be available.
making skills, such as when to start the partograph, The partograph should be the main labour record,
when to take action and appropriate referral pathways. reducing unnecessary duplication of documentation.
Health worker training aids the development of com- There should be clear policy/guidance available at
petence in and increases partograph use in the short facility level for healthcare workers’ reference.
term, but long-term maintenance is essential. Indications Effective supervision by healthcare workers/
that organisational culture can negatively affect use [23, managers with training and clinical experience in
29], may require consideration of behavior change strat- partograph use is necessary for sustaining successful
egies for both health workers and supervisors, which are implementation.
suitable for the setting [61]. In order to promote long- Regular training and updating should be provided
term partograph use, ongoing audit, evaluation and feed- for all healthcare workers using the partograph,
back is necessary. Audit and feedback, provided by a using proven effective training techniques, e.g.,
supervisor, can lead to improved performance in terms multi-disciplinary, practical/clinical application.
of professional practice and has also been found to Training should include understanding of when to
Bedwell et al. BMC Pregnancy and Childbirth (2017) 17:31 Page 9 of 11
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