Department of Midwifery, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
Received Date: June 24, 2020; Accepted Date: July 24, 2020; Published Date: July 31, 2020
Citation: Ayenew AA, Zewudu BF (2020) Estimating partograph utilization and associated factors among health care professionals in Ethiopia: a systematic review and Meta – analysis. Ann Clin Lab Res. Vol.8 No.3:317 doi:10.36648/2386-5188.8.131.527
Copyright: © 2020 Ayenew AA, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Background: Partograph is the prestigious obstetric tool used to monitor labour, predict and follow the progress of labor, maternal and fetal conditions. It allows the health care professionals to increase the frequency of follow up and to prevent prolonged labour, uterine rupture, postpartum hemorrhage, puerperal sepsis, stillbirths, birth asphyxia, and neonatal sepsis. There are various studies on partograph utilization and associated factors in different regions of Ethiopia, they present inconsistent findings and no study was conducted which shows the national estimate of partograph utilization in Ethiopia. Thus, this review was conducted to estimate the national pooled prevalence of partograph utilization and associated factors in Ethiopia.
Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed for this systematic review and meta-analysis. The databases used were; PUBMED, Cochrane Library, Google Scholar, EMBASE, African Journals Online Google scholar, maternity and infant care database and online repositories. A combination of search items: “partograph utilization”, “knowledge and utilization of partograph”, “documentation of partograph”, “partograph and health professionals”, “intrapartum monitoring using partograph” and/or “Ethiopia” were used. Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used for critical appraisal of studies. Descriptive information of studies was presented in narrative form and quantitative results were presented in forest plots. The Cochran Q test and I2 test statistics were used to test heterogeneity across studies.
The meta-analysis was conducted using STATA 11 software. The pooled Meta logistic regression was computed to present the pooled prevalence and relative risks (RRs) of the determinate factors with 95% confidence interval (CI).
Result: A total of 15 studies were included in this meta-analysis with a sample size of 4,553. The national pooled prevalence of partograph utilization was 57.1 %. In subgroup analysis, the highest prevalence of partograph utilization was observed in Oromia (66.10% ) and the lowest in Tigray (50.66% ), increased utilization of partograph was observed after 2016 (62.75% ). Statistically, a significant association was observed between partograph utilization and midwifery profession female health care profession, having short in-service Emergency Obstetric and Newborn Care training, Knowledge of partograph, short Training on partograph.
Conclusion: The pooled prevalence of partograph utilization during labour was low. There was a statistically significant association was between partograph utilization and midwifery profession, female health care profession, having short in-service Emergency Obstetric and Newborn Care training, Knowledge of partograph, short Training on partograph.
The concerned body should intervene on the identified factors to increase the utilization of partograph during labour and delivery.
Partograph utilization, Systematic review, Meta-analysis, Ethiopia.
Partograph is a composite graphical record of key data during labour and delivery. It is a simple, effective, and low coast single paper sheet which has quality-of-care benefits that go beyond effective labour monitoring and management, including increased interaction between health care providers, improved continuity of care and the condition of women [1, 2].
For more than 2 decades now, Maternal and Infant Mortality Reduction have been a goal of several International and National Welfare programs. Although, partograph has been viewed as very helpful to avoid the maternal and neonatal complications related to prolonged and obstructed labour; not being utilized properly to monitor the first stage of labour especially in the resource-limited country [3,4].
Every day, approximately 1000 women die from preventable causes related to pregnancy and childbirth, those are not merely numbers but precious mothers with name and face, who had been a pillar of the family. As of 2015, the Global maternal mortality ratio is 216, of that 99 % of MMR are in developing regions and sub-Saharan Africa alone accounting for roughly 66%, followed by Southern Asia .
In Ethiopia, maternal mortality ratio has been stagnant so far, which is 412 per 100,000 live births. The top five causes of maternal mortality in Ethiopia; hypertension 10-12%, hemorrhage 25%, unsafe abortion 20-40%, infection and Obstructed Labor 10% and uterine rupture cover 9% of maternal deaths. Among those causes of maternal death obstructed labour, infection, uterine rupture and hemorrhage can be prevented by the fortunate utilization of partograph during labour and delivery [6-8].
Thus, the World health organization (WHO) had produced and recommended universal utilization of partograph for its plotting in every birth. Its routine use improves care during labour, increase the frequency of follow up, decrease unnecessary intervention, and reduce prolonged labour and its squeal including obstructed labour, maternal exhaustion, uterine rupture, stillbirths, birth asphyxia, and neonatal sepsis, postpartum hemorrhage, puerperal sepsis, obstetric fistula [5,9-11].
Training on partograph, knowledge of partograph, female health professionals, level of education, health care professional’s level of education, work overload, lack of partograph and health facility difference like heath center and higher institutions were factors that affect partograph utilization. Additionally [12-17].
The Ethiopian government is the first in Africa, rich in publicly stated commitments and has adopted partograph for labour management in the country and the standardized use is recommended for use in all delivery units, aimed at reduction of maternal mortality. Different studies in the country revealed that poor utilization of partograph with poor documentation of components of pantograph in the country, ranging from 6.9% in Oromia and to 92.6% in Dire Dawa [18,19]. These studies showed inconsistent findings and poor documentation of the components of partograph. As a result, this systematic review and meta-analysis were conducted to assess the magnitude of partograph utilization and determinant factors in Ethiopia and this will help program coordinators, policymaker and other responsible stakeholders who are working on maternal and child health issue to have updated data on the status of partograph utilization and associated factors..
The protocol of this systematic review and meta-analysis on Estimating partograph utilization and associated factors among health care professionals in Ethiopia: a systematic review and Meta-analysis were designed according to the Preferred Reporting Items for Systematic Reviews and Meta- Analysis Protocols (PRISMA-P 2015) Guidelines .We used the databases used were; PUBMED, Cochrane Library, Google Scholar, EMBASE, African Journals Online, maternity, and infant care database and online repositories. The search for published studies was not restricted by time, and all published articles up to January 01/2020 were included in the review. A search of the reference list of already identified studies to retrieve additional articles was done. Combination of search items: “partograph utilization”, “knowledge and utilization of partograph”, “documentation of partograph”, “partograph and health professionals”, “intrapartum monitoring using partograph” and/ or “Ethiopia” were used.
First, the title and abstract of the paper were critically reviewed; duplicated data and papers whose titles were irrelevant for this study were excluded here. Then, full documents of the papers read and reread to screen for review. Finally, only 15 [15,16,21- 33] studies conducted in different parts of Ethiopia met the inclusion criteria to this systematic review to assess partograph utilization and determinant factor.
Inclusion and exclusion criteria
• Study design; all study design.
• Time frame: all studies published up to January/01/2020
• Publication type: both published and unpublished studies.
• Language: Published studies only in the English language were included.
• Place of study: studies conducted in Ethiopia, which are institutional-based.
• Outcome: studies that reported the outcome (partograph utilization)
• Studies which did not report the level of partograph utilization
• Studies which had methodological problems.
Data extraction and quality assessment
All authors (AA, BF) extract the data independently form papers included in this study using a standardized data extraction tool adapted from Meta-Analysis of Statistics Assessment and Review Instruments JBI . From each included studies, author’s name, year of study, year of publication, study design, sample size, response rate, odds ratio (OR) and the possible associated factors of partograph utilization was extracted.
The quality of the studies using the Joanna Briggs Institute (JBI) quality appraisal checklist . The disagreement between the reviewers was solved by rereading the articles and by the negotiation of the reviewers.
Publication bias and heterogeneity
Publication bias and heterogeneity were assessed. To check the publication bias, a funnel plot was used. The distribution of studies and a p-value <0.05 were used to declare publication bias. The heterogeneity of studies was checked using the Q test and I2 test statistics. A value of 25%, 50%, and 75% was used to state the heterogeneity test as low, medium and high heterogeneity respectively. The random effect model of analysis was used with the evidence of heterogeneity. Funnel plot and Egger regression asymmetry tests were used to check the existence of publication bias.
To estimate the national pooled prevalence of partograph utilization necessary data from each study were extracted by using the Microsoft Excel spreadsheet. Then Meta-analysis was conducted using State 11 software. Publication bias was assessed using Egger’s test. The percentage of variations between studies due to heterogeneity was tested using I2 test statistics. I2 test statistics result of 25%, 50%, and 75% was declared as low, moderate and high heterogeneity respectively . Subgroup analysis was done by study region and year of study.
Studies included in the meta-analysis
Initially, a total of 820 studies were identified from electronic databases and 200 papers were screened and excluded due to duplication; the remaining 350 articles were excluded by screening the title and abstract of the studies. Additionally, 255 full-text articles were excluded for methodological error and not reporting the outcome variable. Finally, 15 studies were included in this study [15, 16, 21-33] Figure 1.
Characteristics of Included Studies
In this study, a total of 15 studies were included [15, 16, 21- 33] with a sample size of 4,553 were included. Of which, five studies [16, 25, 28, 30, 32] were conducted in southern Nations Nationalities and Peoples Regional State, three [21, 22, 26] in Amhara, three [27, 29, 31] in Oromia, two [15, 33] in Tigray, one  in Addis Ababa and one  in Dire Dawa city administration. All included studies were conducted with a cross-sectional study design. The highest prevalence of partograph utilization was reported in Dire Dawa (92.6 %)  and the lowest in the Oromia region (6.9%)  Table 1.
|Authors||Year of study||Study region||study design||Sample size||Prevalence of Partograph utilization(95% CI)||Quality (JBI check list)|
|Fantu A||2012||Amhara||Cross sectional||381||29.00(24,44,33.68)||Low risk|
|Habtamu R||2017||Oromia||Cross sectional||224||89.10(85.02,93.18)||Low risk|
|Wakeshe W||2015||Oromia||Mixed||266||84.60(80.26,88.94)||Low risk|
|Negash W||2013||Amhara||Cross sectional||403||40.20(35.41,44.9)||Low risk|
|Haymanot M||2015||Dire Dawa||Cross sectional||441||92.60(90.16,95.04)||Low risk|
|Tesfay H||2017||Tigray||Cross sectional||220||73.30(67.45,79.15)||Low risk|
|Desalegne A||2015||Amhara||Cross sectional||273||53.80(47.89,59.71)||Low risk|
|Kidist E||2016||SNNP||Cross sectional||300||51.00(45.34,56.66)||Low risk|
|Kidest G||2016||SNNP||Cross sectional||442||72.60(68.44,76.76)||Low risk|
|D.Markos||2014||SNNP||Cross sectional||401||70.20(65.72,74.68)||Low risk|
|Engida Y||2012||Addis Ababa||Cross sectional||202||57.30(50.48,64.12)||Low risk|
|Sena B||2012||Oromia||Cross sectional||340||6.90(4.21,9.59)||Low risk|
|Gutema C||2015||SNNP||Cross sectional||309||53.90(48.34,59.49)||Low risk|
|Daniel||2016||SNNP||Cross sectional||127||26.00(18.37,33.63)||Low risk|
|Haftom G||2015||Tigray||Cross sectional||233||57.40(51.05,63.75)||Low risk|
Table 1 Descriptive summary of fifteen included studies in the systematic review and meta-analysis of partograph utilization in Ethiopia, 2019 (n=15).
Overall pooled prevalence of partograph utilization in Ethiopia
This Meta-analysis included 15 studies to estimate the national pooled prevalence of partograph utilization. The overall pooled of prevalence of partograph utilization was 57.21 %( 95%CI: 40.77, 73.66%). The heterogeneity among the 15 studies used to estimate the pooled prevalence of prevalence of partograph utilization was marked (I2 = 99.5% and P≤ 0.001). Subgroup Metaanalysis was done by study region and year of study with the evidence of marked heterogeneity. Thus, the pooled prevalence of partograph utilization was high in Oromia (66.10% (95%CI: 26.52, 105.68)) and the least was in Tigray (50.66 %( 95%, CI: 35.34, 65.98)). Similarly, the subgroup analysis by year of study showed that partograph utilization was increased in studies conducted after 2016 (62.57% (95%CI: 43.95, 81.19). Studies conducted before 2015, showed low partograph utilization, 54.59% (95%CI: 32.33, 76.85) Figure 2 and table 2.
|Sub group||Number of studies included||Prevalence (95% CI)||Test of heterogeneity, I2||p-value|
|Amhara region||3||40.89 (27.40, 54.38)||95.3||<0.001|
|Oromia region||5||66.10 (26.52, 105.68)||99.5||<0.001|
|Tigiray||2||65.40 (49.82, 80.98)||92.3||<0.001|
|By publication year|
Table 2 Sub-group analysis of prevalence of partograph utilization in Ethiopia by region and year of publication.
Funnel plot was assessed for asymmetry distribution of prevalence of partograph utilization by visual inspection Figure 3. Egger's regression test showed with a p-value of 0.817 indicated that no publication biase.
This systematic review and meta-analysis showed that the point estimate of its omitted analysis lies within the confidence interval of the combined analysis. Therefore, trim and fill Analysis was no further computed figure 4.
Factors for partograph utilization in Ethiopia
In this systematic review and Meta-analysis; midwifery profession (AOR: 4.9,95%CI:3.38, 7.14), female health professionals (AOR:3.92,95%CI:2.64,4.12), having job related training (AOR:2.7,95%CI:2.26, 3.22), Knowledge about partograph (AOR:3.3,95%CI:1.5, 6.87), Training on partograph (AOR:1.28,95%CI:1.58,33.64) were determinant factors for partograph utilization in Ethiopia.
Midwifery profession and partograph utilization
Seven studies were included in this category of meta-analysis [21, 26, 27, 29, 30, 32, 33]. The pooled Meta regression analysis showed that midwifery profession had statistically significant association with partograph utilization, OR = 4.92 (95% CI=3.38, 7.14).High heterogeneity was observed in this category of metaanalysis, I2 = 92.7%, P-value ≤ 0.001; for this reason, random effect meta-analysis model was computed. Moreover, no possibility of publication bias was detected using the Egger’s tests with a p-value of 0.099 figure 5.
Female health professionals and partograph utilization
This review also assessed the association of female health professionals and partograph utilization. The pooled regression analysis result of four [21, 29, 30, 33]studies showed female health professionals positively associated with partograph utilization OR =3.29 (95%CI=2.64, 4.12). The heterogeneity test of studies and test for publication bias using the Egger’s test showed high heterogeneity (I2 = 82.1%, p-value ≤ 0.001) and no publication bias (p-value = 0.985) respectively (Figure 6).
Emergency Obstetric Care and Neonatal Care training and partograph utilization
Health professionals having short in-service EmOC and NC training was the predictors of partograph utilization. The pooled regression analysis result of studies [15, 21, 22, 24, 26, 32]showed that having Job relating training was positively associated with partograph utilization (OR= 2.7 (95%CI=2.26, 3.22) Figure 7.
There was high heterogeneity (I2=99.4%; p-value ≤0.001) among the included studies. Moreover, no possibility of publication bias was detected using the Egger’s tests with a p-value of (0.282).
Knowledge of partograph and partograph utilization
The pooled regression analysis result of three [22, 26, 27] studies showed that having Health professionals who have good knowledge on partograph were 3.3 times more likely to utilize partograph (OR: 3.30 (95%CI=1.59, 6.87) (Figure 8). Moderate heterogeneity (I2=70.4%; p-value =0.036) was detected among the included studies; for this reason, random effect meta-analysis model was computed. Moreover, no possibility of publication bias was detected using the Egger’s tests with a p-value of (0.341) figure 8.
Training on partograph and partograph utilization
Health professionals who had Training on partograph was positively associated and significant factor for partograph utilization (OR: 7.28 (95%CI: 1.58, 33.64) (Figure 9). High heterogeneity (I2=89.2%; p-value ≤ 0.001) was detected among the included studies and no possibility of publication bias was detected using the Egger’s tests with a p-value of (0.902).
Partograph is a very effective tool to monitor labour and prevent prolonged and obstructed labour , the commonest cause of maternal mortality in resource-limited countries. However, the utilization was not routine, not consistent everywhere and every time and even among those who used the partograph, it was not used according to the recommended standard especially in the resource-limited country [38-40]. In this study, we derived a national estimate of partograph utilization in Ethiopia. As such data are currently unavailable. Using a systematic review and meta-analysis, we derived pooled prevalence partograph utilization of 57.21 %( 95%CI: 40.77, 73.66%).
Partograph utilization in our study was lower than the study report of South Africa , Gambia  and Kenya . These differences might be due to differences in strategies and policies on partograph implementation, socio-economic status of the countries, and the difference in study design, sample size and time gap since, as time elapses, there is a change in strategy, policy, and improvement in the implementation of the partograph.
The second reason might be explained as health care providers might have different levels of knowledge towards partograph, availability of training and number of health professionals distributed to health facility, one factor for utilization was a shortage of staff and work overload.
In the studies of Gambia and South Africa; the participants were only midwives by profession with a great chance to work in labour and delivery unit, to be trained on partograph and might have better knowledge, skill, and commitment to using partograph. But In our study, relatively verities of health professions have participated.
The finding of this study was higher than the studies conducted in Cameroon , Uganda , Analamanga  and Benin . The possible explanation might be the Ethiopian government first in Africa to make a strong commitment to the United Nation’s inspired Millennium Development Goals (MDGs) by making maternal health as of priority health program. Efforts of the Federal ministry of health + Partners (multi-pronged approach) were applied and there were service coverage and utilization improvements. Additionally, the difference might be due to the difference in study design, sample size.
This systematic review and meta-analysis showed that the existence of a significant association between midwifery profession (AOR: 4.9,95%CI:3.38, 7.4) and partograph utilization.
This study finding is supported by the study conducted in Nigeria  and South Africa . This might be due to the fact that midwives might be frequently assigned in labour, delivery unit and might use the partograph daily. The other reason might be Midwives might have a better chance of getting partograph training and in-service obstetric training; they might have a better understanding of partograph than other health professionals. Additionally, midwives might have better knowledge and commitment since obstetric care is a major subject in pre-service education.
In this systematic review and meta-analysis, female health professionals were utilized partograph than male health professionals more (AOR: 3.92, 95%CI: 2.64, 4.12). This study finding is supported by the study conducted in India . This might be due to the fact that female is closer to obstetric information or maybe because female professionals were more committed and optimistic than males to complete the components of partograph.
health professionals having short in-service Emergency Obstetric Care and Newborn care training were 2.7 times more likely to utilize partograph than their counterparts (AOR:2.7,95%CI:2.26, 3.22. This study finding is supported by the study done in Malawi  and Nigeria . This might be due to the fact that the training improves the status of existing health professionals' knowledge on partograph, intern improves utilization of partograph.
The other reason might be as having Emergency Obstetric Care and Newborn care training was able to interpret components of the partograph and increase confidence and motivation to use partograph than those who did not have training. Additionally, the training may support improve the status of existing knowledge and point out those obstetric caregivers should get periodic onjob refresher pieces of training on the obstetric care.
On-job training on partograph had a significant association with partograph utilization. Obstetric care providers who received on the job training on partograph were about 3 times more likely to utilize partograph than those who had not received onjob training. This might be due to the fact that, obstetric care providers who received on-job training had better knowledge about partograph than others13,14,19; that in turn improves their partograph utilization.
Knowledge of the partograph was other significant factors for its utilization and health professional having good knowledge of partograph were 3.3 times (AOR: 3.3, 95%CI: 1.5, 6.87), use partograph. This might be due to the fact that having good knowledge of partograph might enhance caregivers' skill and competency to use it as a decision making tool and interpret it. This was supported by other studies [48,49].
To design more adaptable policies and strategies on partograph utilization to the local context, National estimate and its associated factors need to be generated. Given the importance of such data, there is no published systematic review and metaanalysis on utilization of partograph and associated factors in Ethiopia. As a result, the authors believe that, this systematic review and meta-analysis will generate concrete evidence on the national level of utilization and the result will provide substantial evidence for the government and other stakeholders working on maternal and child health and it will help them in designing intervention and to have strategies on improving the utilization at the national level.
The overall pooled prevalence of Partograph utilization was found to be low. Midwifery profession, female health professionals, having short in-service EmOC and NC training, having Knowledge about partograph, Training on partograph were determinant factors for partograph utilization in Ethiopia.