Partograph utilization as a decision-making tool and associated factors among obstetric care providers in Ethiopia: a systematic review and meta-analysis
Background: Globally, a total of 13.6 million women have died due to maternal causes from 1990 to 2015. Majority of these deaths occurred in resource-limited countries. Among the causes of these deaths, obstructed and prolonged labor covers the highest percentage, which could be prevented by cost-effective and affordable health interventions like partograph use. Therefore, this systematic review and meta-analysis aimed to assess the level of partograph utilization among obstetric care providers and its associated factors in Ethiopia. Method: For this review, we used the standard PRISMA checklist guideline. Different online databases were used for the review: PubMed/Medline, Google Scholar, EMBASE, Cochrane Library, HINARI, WHO Afro Library Databases, and African Online Journals. Based on the adapted PICO principles, different search terms were applied to achieve and access all the essential articles. Microsoft Excel was used for data entry and Stata version 11.0 (Stata Corporation, College Station, TX, USA) for data analysis. Result: Nineteen studies were included in this systematic review and meta-analysis with a total of 6237 obstetric care providers. The overall pooled prevalence of partograph utilization was 59.95% (95% CI 46.8–73.09, I2 = 99.4%, P < 0.001). Being in midwifery profession (adjusted odds ratio (AOR) 3.97; 95% confidence interval (CI) 2.63–5.99, I2 = 28.8%, P = 0.198), presence of supervision (AOR = 3.21; 95% CI 2.22–4.66, I2 = 0.0%, P = 0.742), Basic Emergency Obstetric and Newborn Care (BEmONC) training (AOR = 2.90; 95% CI 2.19–3.84, I2 = 36.9%, P = 0.13), knowledge of partograph (AOR = 2.5; 95% CI 1.6–3.8, I2 = 64.58%, P = 0.024), on-the-job refresher training on partograph (AOR = 5.7; 95% CI 2.5–12.9, I2 = 87.8%, P < 0.001), favorable attitude (AOR = 2.12; 95% CI 1.48–3.04, I2 = 0.0%, P = 0.58), and working at health center (AOR = 3.50; 95% CI 2.49–4.92, I2 = 49.1%, P = 0.08) were the determinant factors for partograph use among obstetric care providers in Ethiopia. Conclusion: The overall pooled prevalence of partograph utilization among obstetric care providers was low. Therefore, supportive supervision, providing Basic Emergency Obstetric and Newborn Care training, on-the-job refresher training on partograph, and promoting midwifery profession are strongly recommended to increase the use of partograph.
This systematic review and meta-analysis was conducted to estimate the national use of partograph and its associated factors among obstetric care providers in Ethiopia. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist guideline [22] (Additional file 1). First, the PROSPERO database and Database of Abstracts of Reviews of Effects (DARE) (http://www.library.UCSF.edu) were searched to check whether published or ongoing projects exist related to the topic. The literature search strategy, selection of studies, data extraction, and result reporting were done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [23]. We searched PubMed, Google Scholar, EMBASE, Cochrane Library, HINARI, WHO Afro Library Databases, and African Online Journal databases for all available studies using the following terms: “Partograph utilization,” “knowledge on partograph,” “labor,” “on-the-job refresher training on partograph,” “obstetric care providers,” “midwives,” “decision making tool,” “attitude towards partograph,” “labor monitoring,” “first stage of labor,” “health care providers,” “health institutions,” “childbirth,” “factors,” “determinants,” “health institutions,” “intrapartum monitoring,” “components,” “partograph,” and “Ethiopia.” The search string was developed using “AND” and “OR” Boolean operators. Searching terms were based on adapted PICO principles to search through the above-listed databases to access all the relevant articles. For unpublished studies, the official websites of Ethiopian’s university research repository online library (University of Gondar and Addis Ababa University) were used. In this systematic review and meta-analysis, we included all observational studies (cross-sectional, case-control, and cohort studies) conducted in Ethiopia and only in English language. Additionally, studies that reported prevalence and/or risk factors, the outcome was partograph utilization as a decision-making tool, and participants of obstetric care providers and both published and unpublished studies at any time were included. However, studies available only as abstract with unclear outcomes, commentaries, editorials, reviews, and qualitative studies were excluded. After collecting the findings from all databases, the articles were exported to Microsoft Excel spreadsheet. Two authors (AAA and BFZ) independently extracted the data and reviewed the screened and eligible articles. Any disagreement was handled by the two reviewers (AAA and BFZ). Finally, a consensus was reached between the two authors through discussion. The methodological quality of each study (sampling strategy, response rate, and representativeness of the study), comparability, and outcome were checked using the NOS tool. Newcastle-Ottawa Quality Assessment Scale (NOS) for cross-sectional and case-control studies was used to assess the methodological quality of a study and to determine the extent to which a study has addressed the possibility of bias in its design, conduct, and analysis [24]. All the included articles scored (NOS) 7, and more can be considered as “good” studies with low risk (Additional file 2). This review has two main outcomes. Partograph utilization among obstetric care providers to monitor the progress of labor and feto-maternal condition was the primary outcome of the study, whereas associated factors for partograph utilization among obstetric care providers were the second outcome variables. The odds ratio was calculated for the common risk factors of the reported studies. The most common associated factors included in this systematic review and meta-analysis were midwifery profession, presence of supervision, Basic Emergency Obstetric and Newborn Care (BEmONC) training, knowledge of partograph, on-the-job refresher training on partograph, favorable attitude towards partograph, and working at the health center. Microsoft Excel (2016) and Stata version 11.0 (Stata Corporation, College Station, TX, USA) software were used for data entry and analysis, respectively. Two authors (AAA and BFZ) independently extracted all the important data using a standardized JBI data extraction format. The inter-rater agreement between authors for study inclusion, data extraction, and methodological quality will be assessed using Cohen’s kappa coefficient (values ≤ 0 as indicating no agreement and 0.01–0.20 as none to slight, 0.21–0.40 as fair, 0.41– 0.60 as moderate, 0.61–0.80 as substantial, and 0.81–1.00 as almost perfect agreement) [25]. Substantial agreement between reviewers, i.e., Cohen’s kappa coefficient > 0.60, was accepted. Any disagreement between reviewers was resolved through discussion, and then, consensus was reached. During data extraction, name of the author, sample size, publication year, study design, prevalence, response rate, population outcome, study site, and different contributing factors were included. Moreover, prevalence of partograph use with 95% CI and associated factors were collected [26]. As the test statistic showed significant heterogeneity among studies (I2 = 99.4%, P < 0.05), the random-effects model was used to estimate the DerSimonian and Laird pooled effect [27]. Cochran’s Q chi-square statistics and I2 statistical test were conducted to assess the random variations between primary studies [28]. In this study, heterogeneity was interpreted as an I2 value of 0% = no heterogeneity, 25% = low, 50% = moderate, and 75% = high [29]. In case of high heterogeneity, subgroup analysis and sensitivity analyses were run to identify possible moderators of this heterogeneity. Potential publication bias was assessed by visually inspecting funnel plots and objectively using Egger’s test (i.e., P < 0.05) [30]. To account for any publication bias, we used the trim-and-fill method, based on the assumption that the effect sizes of all the studies are normally distributed around the center of a funnel plot. The meta-analysis was performed using the Stata version 11.0 (Stata Corporation, College Station, TX, USA) software. Finally, for all analyses, P < 0.05 was considered statistically significant.
– Maternal mortality is a significant global issue, with a high number of deaths occurring in resource-limited countries.
– Obstructed and prolonged labor is a major cause of maternal deaths that can be prevented with cost-effective interventions like partograph use.
– This systematic review and meta-analysis aimed to assess the level of partograph utilization among obstetric care providers in Ethiopia and identify associated factors.
Highlights:
– Nineteen studies with a total of 6237 obstetric care providers were included in the review.
– The overall pooled prevalence of partograph utilization among obstetric care providers in Ethiopia was found to be 59.95%.
– Factors associated with partograph use included being in the midwifery profession, presence of supervision, Basic Emergency Obstetric and Newborn Care (BEmONC) training, knowledge of partograph, on-the-job refresher training on partograph, favorable attitude towards partograph, and working at a health center.
Recommendations:
– Supportive supervision should be provided to obstetric care providers to increase partograph utilization.
– Basic Emergency Obstetric and Newborn Care (BEmONC) training should be provided to enhance knowledge and skills related to partograph use.
– On-the-job refresher training on partograph should be conducted to reinforce knowledge and ensure consistent use.
– Promoting the midwifery profession can contribute to increased partograph utilization.
Key Role Players:
– Obstetric care providers (midwives, nurses, doctors)
– Supervisors and managers in healthcare facilities
– Trainers and educators in obstetric care
– Policy makers and government officials in the healthcare sector
Cost Items for Planning Recommendations:
– Training materials and resources for Basic Emergency Obstetric and Newborn Care (BEmONC) training and on-the-job refresher training
– Personnel costs for trainers and educators
– Monitoring and evaluation costs for supportive supervision
– Promotional activities and campaigns to promote the midwifery profession
Please note that the provided cost items are general suggestions and may vary depending on the specific context and implementation strategy.
The strength of evidence for this abstract is 7 out of 10. The evidence in the abstract is strong, but there are some areas for improvement. The study used a systematic review and meta-analysis methodology, which is a rigorous approach to synthesizing evidence. The authors followed the PRISMA guidelines and conducted a comprehensive search of multiple databases. They included a total of 19 studies with a large sample size of 6237 obstetric care providers. The overall pooled prevalence of partograph utilization was reported with a 95% confidence interval. The study also identified several associated factors for partograph use among obstetric care providers in Ethiopia. However, there are a few areas for improvement. The abstract could provide more details on the specific search terms used and the inclusion/exclusion criteria. Additionally, the abstract could mention the quality assessment of the included studies and any potential limitations. Overall, the evidence in the abstract is strong, but these suggestions can further enhance its clarity and completeness.
Background: Globally, a total of 13.6 million women have died due to maternal causes from 1990 to 2015. Majority of these deaths occurred in resource-limited countries. Among the causes of these deaths, obstructed and prolonged labor covers the highest percentage, which could be prevented by cost-effective and affordable health interventions like partograph use. Therefore, this systematic review and meta-analysis aimed to assess the level of partograph utilization among obstetric care providers and its associated factors in Ethiopia. Method: For this review, we used the standard PRISMA checklist guideline. Different online databases were used for the review: PubMed/Medline, Google Scholar, EMBASE, Cochrane Library, HINARI, WHO Afro Library Databases, and African Online Journals. Based on the adapted PICO principles, different search terms were applied to achieve and access all the essential articles. Microsoft Excel was used for data entry and Stata version 11.0 (Stata Corporation, College Station, TX, USA) for data analysis. Result: Nineteen studies were included in this systematic review and meta-analysis with a total of 6237 obstetric care providers. The overall pooled prevalence of partograph utilization was 59.95% (95% CI 46.8–73.09, I2 = 99.4%, P < 0.001). Being in midwifery profession (adjusted odds ratio (AOR) 3.97; 95% confidence interval (CI) 2.63–5.99, I2 = 28.8%, P = 0.198), presence of supervision (AOR = 3.21; 95% CI 2.22–4.66, I2 = 0.0%, P = 0.742), Basic Emergency Obstetric and Newborn Care (BEmONC) training (AOR = 2.90; 95% CI 2.19–3.84, I2 = 36.9%, P = 0.13), knowledge of partograph (AOR = 2.5; 95% CI 1.6–3.8, I2 = 64.58%, P = 0.024), on-the-job refresher training on partograph (AOR = 5.7; 95% CI 2.5–12.9, I2 = 87.8%, P 0.60, was accepted. Any disagreement between reviewers was resolved through discussion, and then, consensus was reached. During data extraction, name of the author, sample size, publication year, study design, prevalence, response rate, population outcome, study site, and different contributing factors were included. Moreover, prevalence of partograph use with 95% CI and associated factors were collected [26]. As the test statistic showed significant heterogeneity among studies (I2 = 99.4%, P < 0.05), the random-effects model was used to estimate the DerSimonian and Laird pooled effect [27]. Cochran’s Q chi-square statistics and I2 statistical test were conducted to assess the random variations between primary studies [28]. In this study, heterogeneity was interpreted as an I2 value of 0% = no heterogeneity, 25% = low, 50% = moderate, and 75% = high [29]. In case of high heterogeneity, subgroup analysis and sensitivity analyses were run to identify possible moderators of this heterogeneity. Potential publication bias was assessed by visually inspecting funnel plots and objectively using Egger’s test (i.e., P < 0.05) [30]. To account for any publication bias, we used the trim-and-fill method, based on the assumption that the effect sizes of all the studies are normally distributed around the center of a funnel plot. The meta-analysis was performed using the Stata version 11.0 (Stata Corporation, College Station, TX, USA) software. Finally, for all analyses, P < 0.05 was considered statistically significant.
The systematic review and meta-analysis conducted in Ethiopia found that the utilization of the partograph as a decision-making tool among obstetric care providers was low. Based on the findings, the following recommendations are suggested to improve its utilization:
1. Supportive supervision: Regular and supportive supervision should be provided to obstetric care providers to enhance their knowledge and skills in using the partograph. This can be done through on-site visits, mentoring, and feedback sessions.
2. Basic Emergency Obstetric and Newborn Care (BEmONC) training: Training programs on BEmONC should include comprehensive instruction on the use of the partograph. This can help improve obstetric care providers’ understanding and utilization of this tool.
3. On-the-job refresher training on the partograph: Regular refresher training sessions specifically focused on the partograph should be conducted to reinforce obstetric care providers’ knowledge and skills. This will ensure that they stay updated on best practices.
4. Promoting the midwifery profession: Encouraging and promoting the midwifery profession can contribute to increased partograph utilization. Midwives are trained in maternal health care and have a strong understanding of the importance of using the partograph in monitoring labor progress.
Implementing these recommendations is expected to improve the utilization of the partograph as a decision-making tool among obstetric care providers in Ethiopia. This, in turn, can lead to better access to maternal health care and a reduction in maternal mortality and morbidity rates.
AI Innovations Description
The recommendation from the systematic review and meta-analysis is to improve the utilization of the partograph as a decision-making tool among obstetric care providers in Ethiopia. The study found that the overall pooled prevalence of partograph utilization was low, indicating a need for interventions to increase its use.
Based on the findings, the following recommendations are suggested:
1. Supportive supervision: Providing regular and supportive supervision to obstetric care providers can help improve their knowledge and skills in using the partograph. This can be done through on-site visits, mentoring, and feedback sessions.
2. Basic Emergency Obstetric and Newborn Care (BEmONC) training: Offering training programs on BEmONC that include comprehensive instruction on the use of the partograph can enhance obstetric care providers’ understanding and utilization of this tool.
3. On-the-job refresher training on the partograph: Conducting regular refresher training sessions specifically focused on the partograph can reinforce obstetric care providers’ knowledge and skills, ensuring that they stay updated on best practices.
4. Promoting midwifery profession: Encouraging and promoting the midwifery profession can contribute to increased partograph utilization. Midwives are trained in maternal health care and have a strong understanding of the importance of using the partograph in monitoring labor progress.
By implementing these recommendations, it is expected that the utilization of the partograph as a decision-making tool will improve among obstetric care providers in Ethiopia. This, in turn, can lead to better access to maternal health care and a reduction in maternal mortality and morbidity rates.
AI Innovations Methodology
To simulate the impact of the main recommendations on improving access to maternal health, a multi-faceted approach can be implemented. Here is a brief description of the methodology:
1. Supportive supervision: Implement a program that includes regular on-site visits, mentoring, and feedback sessions for obstetric care providers. Measure the frequency and quality of supervision provided and assess the impact on their knowledge and skills in using the partograph.
2. Basic Emergency Obstetric and Newborn Care (BEmONC) training: Develop and deliver training programs on BEmONC that include comprehensive instruction on the use of the partograph. Measure the knowledge and utilization of the partograph before and after the training to evaluate its effectiveness.
3. On-the-job refresher training on the partograph: Conduct regular refresher training sessions specifically focused on the partograph for obstetric care providers. Measure the impact of these sessions on their knowledge and skills in using the partograph.
4. Promoting midwifery profession: Implement initiatives to encourage and promote the midwifery profession, such as scholarships, career advancement opportunities, and public awareness campaigns. Measure the increase in the number of midwives and their utilization of the partograph.
To assess the impact of these interventions, the following data collection methods can be used:
1. Pre- and post-intervention surveys: Administer surveys to obstetric care providers before and after implementing the interventions to measure changes in their knowledge, skills, and utilization of the partograph.
2. Direct observation: Conduct direct observations of obstetric care providers during labor and delivery to assess their adherence to partograph utilization and identify any barriers or challenges they may face.
3. Record review: Analyze medical records and partographs to assess the frequency and quality of partograph utilization before and after implementing the interventions.
4. Key informant interviews: Conduct interviews with key stakeholders, such as obstetric care providers, supervisors, and midwives, to gather qualitative data on their experiences, perceptions, and attitudes towards the interventions and the use of the partograph.
5. Quantitative analysis: Analyze the collected data using appropriate statistical methods to determine the impact of the interventions on the utilization of the partograph and access to maternal health care.
By implementing this methodology, it will be possible to evaluate the effectiveness of the recommendations in improving access to maternal health care through increased utilization of the partograph among obstetric care providers in Ethiopia.
