rj60. g4 g15 bite c.l g379649

RJ60. G4 G15 bite C.l G379649

University of Ghana http://ugspace.ug.edu.gh

THE RELATIONSHIP BETW EEN THE USE OF THE PARTOGRAPH AND BIRTH OUTCOM ES AT KORLE-BU TEACHING HOSPITAL

THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON, IN PARTIAL FULFILM ENT OF THE

REQUIREMENT FOR THE AWARD OF MASTER OF PHILOSOPHY DEGREE IN NURSING

FLORENCE GANS-LARTEY

Co-supervisors:Mrs Faustina Oware-Gyekye Dr Beverley O ’Brien

July, 2007


DECLARATION

I, Florence Gans-Lartey, author o f this thesis “The Relationship between the use o f the

Partograph and Birth Outcomes” do hereby declare that apart from references to past and

current literature duly cited in this thesis, the entire research work presented in this thesis was

done by me as a student o f the School o f Nursing, University o f Ghana, Legon.

This work has never been presented in whole or part for any other degree in this university or

elsewhere.

cz—W ■------------- , ---------------------------

Florence Gans-Lartey (STUDENT)

This thesis has been presented for examination with our approval as supervisors.

Mrs Faustina Oware-Gyekye (MAJOR SUPERVISOR)

(CO-SUPERVISOR)


DEDICATION

This thesis is dedicated to all parents, husbands, children, siblings or friends who have lost

their daughters, wives, mothers, sisters or friends through pregnancy and childbirth.


ACKNOW LEDGEM ENT

Without the support and encouragement o f many people this thesis would not be a reality.

1 am grateful to my supervisors, Mrs. Faustina Owarc-Gyekye and Dr. Beverley O ’Brien for

their direction, suggestions and patience that enabled this research project to reach its

conclusion.

I wish to thank committee members for the time spent and suggestions made in reviewing my

proposal and final thesis.

I would like to thank Mr Annan, the records officer at the Medical Statistics and

Documentation Department o f the Korle-Bu Teaching Flospital M aternity Block, for the

timely pulling o f charts. I am also grateful to all the medical records staff who accommodated

me in coordinating the charts to be reviewed.

I am also indebted to my colleagues, librarians and friends for their support and

encouragement to complete this project.

Finally. I wish to acknowledge my God, my creator and my source o f strength.

I V


DECLARATION

DEDICATION

ACKNOW LEDGEM ENT

TABLE OF CONTENTS

LIST OF TABLES

LIST OF FIGURES

LIST OF ABBREVIATIONS

ABSTRACT

CHAPTER ONE: 1 INTRODUCTION

1.1 Background to the Study

1.2 Statement o f the Problem

1.3 Purpose o f the Study

1.4 Significance o f the Study

1.5 Definition o f Terms

CHAPTER TWO: 2 REVIEW OF LITERATURE

2.1 Maternal M ortality Worldwide

2.2 Maternal Mortality in Ghana

2.3 Programmes to Reduce Maternal Mortality

2.4 The WHO Partograph as a SMI Intervention

2.5 Theoretical Framework

TABLE OF CONTENTS

ii

iii

iv

v

vii

viii

ix

x

1

3

6

8

9

9

11

13

14

17

19

25


CHAPTER THREE: 3 RESEARCH PROCESS 27

3.1 Design 30

3.2 Setting 32

3.3 Sample 34

3.4 Procedure 35

3.5 Assumptions 36

3.6 Analysis 36

3.7 Variables 36

3.8 Ethical Considerations 38

CHAPTER FOUR: 4 RESULTS 40

4.1 Demographic Characteristics 41

4.2 Research Hypotheses 42

4.3 Partograph 43

4.4 Maternal Outcomes 46

4.5 Newborn Outcomes 49

CHAPTER FIVE: 5 DISCUSSION OF RESULTS 52

5.1 Summary of Main Findings 52

5.2 Discussion o f Results 52

5.3 Threats to Validity 55

5.4 Limitations 57

VI


5.5 Implications to Nursing Practice

5.6 Recommendations

5.7 Conclusion

Appendix A

Appendix B

Appendix C

References


Table 1: Components o f Partograph and levels of omission 31

Table 2: Levels of omission resulting in adequate and inadequate partograph 32

Table 3: Parity 41

Table 4: Mode o f delivery 42

Table 5: Components o f partograph 43

Table 5: Various maternal intervention 46

LIST OF FIGURES

Figure 1: Obstetric admission in Korle-Bu maternity block in May and June 2003 40

LIST OF TABLES

v i i i


LIST OF ABBREVIATIONS

APGAR - Appearance, Pulse, Grimace, Activity and Respiration o f the newborn

ARM - Artificial rupture o f membranes

C/S - Caesarean section

F/D - Forceps delivery

FHR - Foetal heart rate

LGA - Large for gestational age

MMR - Maternal mortality rate

N/A Non-applicable

NICU - Neonatal intensive care unit

NSVB - Normal spontaneous vaginal birth

PPH Postpartum haemorrhage

SGA - Small for gestational age

SMI - Safe motherhood initiative

SMP - Safe motherhood programme

UTI - Urinary tract infection

V/E Vacuum extraction

ix


ABSTRACT

The purpose o f this study was to examine the relationship between the use o f the

partograph and maternal interventions as well as maternal and neonatal outcomes. A

retrospective chart review o f 1,845 primiparous and multiparous deliveries which met the

inclusion criteria was conducted. Using pre-established criteria only 472 (25.6%) charts were

adequately completed and on inspection some o f these appeared to be completed

retrospectively. W hether or not timely action was taken if the “action line” was crossed on the

partograph was also assessed. Chi-square analysis showed that when the partograph was

adequately used, there were more interventions to augment labour. There were differences in

maternal outcomes with women being less likely to lose more than 500 millilitres o f blood if

partographs were adequately used. Although there were 13 intra partum deaths only one chart

could be retrieved. While there appeared to be less pyrexia with the group whose partograph

was inadequate, it is possible that this group also had their temperature monitored less

frequently. Decreases in newborn outcomes including Apgar scores, birth injuries, NICU

admissions and mortality were not found.

Recommendations were made to facilitate accurate documentation and completion o f

the partograph to help in taking prompt decisions or interventions. Periodic in-service training

for record officers in health facilities is recommended to improve filing system to ensure easy

retrieval o f patients charts. Recommendations to shorten the length o f time that action is taken

when the action line was crossed.

X


CHAPTER ONE

IN TR O D U C TIO N

Pregnancy and childbirth involve many biological, psychological and social changes

that require a great deal o f adjustment and adaptation on the part o f the mother. Pregnancy is

considered a time o f crisis or transition, although the changes are manifested more clearly in a

w om an's life when the baby is born (Barclay, Everitt and Rogan, 1997; Mercer, 1986; Rubin,

1984). It is a time when w om en’s health can be placed at risk by a host o f factors. For

example, they may be anxious and apprehensive about the outcome o f the pregnancy itself or

about the process of labour and delivery. They may also be apprehensive about being a

mother. However, the outcome of pregnancy, for both mother and baby, is associated with the

health of the mother and the quality of antenatal and intrapartum care. It is affirmed in several

reports from higher income countries that women with uncomplicated pregnancies may be

cared for by midwives, and taken through labour and delivery at home or in birth centres with

no increased risk o f adverse maternal or perinatal outcomes when compared to similarly low-

risk pregnant women who deliver in hospital under the care o f physicians (Ackermann-

Liebrich, Voegeli and Gunter-Witt, 1996; David, Kraker von Schwarzenfeld, Dimer and

Kentenich. 1999; Rooks, Weatherby, Ernst, Stapleton. Rosen and Rosenfield, 1989). The

achievement o f these comparable outcomes, however, can be attributed to early recognition of

complications and prompt intervention or referral and transfer to hospitals for further care. It

may also be attributed to the health status o f the pregnant women (Nkyekyer, 2000).


Labour is seldom a problem if it goes at its proper pace. Most complications start when

labour is delayed or obstructed. To manage such complications it is imperative for the

provider to identify the occurrence o f the problem as early as possible through effective

methods o f monitoring labour. One such method is the partograph. The introduction and use

o f the partograph in labour wards was to help prevent obstructed labour and uterine rupture.

These conditions cause 70 percent o f maternal deaths in lower income countries. The

partograph can be used to monitor all labours in hospital in order to avoid unnecessary

interventions so that maternal and neonatal morbidity are not needlessly increased.

Furthermore, an appropriate use o f the partograph will assist the provider to intervene in a

timely manner so that maternal and neonatal morbidity and mortality can be avoided

(Maternal and Neonatal Health. 2003).

The normal pattern o f labour, including the latent and active phases o f cervical

dilatation, was first documented on a graph in the 1950s. In the 1960s and 1970s. further

research led to improved tools to chart the progression o f labour and to build a scientific basis

for interventions to prevent prolonged labour. Friedman (1975) described a graphic analysis of

labour, correlating the duration of labour with the rate o f cervical dilatation. Philpott and

Castle (1972; 1972b) further developed this tool and added a line to alert providers of

prolonged labours as well as to record other intrapartum details. The partograph provided

health professionals with a continuous pictorial overview o f labour and allowed early

identification and diagnosis o f pathological labour. These early partographs formed the

foundation for the WHO model of the partograph, which was developed as an international

standard in 1988 following the launch of the worldwide safe motherhood initiative.

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1.1 Background to the Study

Many people believed that the dawn o f the 21st century would be associated with the

disappearance o f maternal mortality. Unfortunately, that is not the case, particularly in low-

income countries including Ghana. On the Africa continent, one in 16 childbearing women

will not survive because o f a pregnancy related complication (Gerlus, Moran and Segu, 1999).

Sub-Saharan African women are 175 times more likely to die from complications in

pregnancy and childbirth compared to those in higher income countries. Most maternal deaths

and disabilities result from delays in recognising complications, reaching a medical centre or

receiving quality care (CBC News, 2003).

Although, through the safe motherhood programme, simple interventions were adopted

to improve wom en’s health and reduce maternal mortality and morbidity, maternal deaths still

remain unacceptably high. Maternal mortality is defined as “death o f women while pregnant

or within six weeks o f the termination of a pregnancy, irrespective of the duration and site of

the pregnancy, from any cause related to or aggravated by the pregnancy or its management

but not from accident or incidental causes’1 (WHO, 1997). The World Health Organisation

(WHO) and United Nations International Children’s Emergency Fund (UNICEF) estimate that

each year 585,000 women die from causes related to pregnancy and childbirth.

Every day at least 1,600 women die from complications associated with pregnancy and

childbirth. Almost 90 percent of these deaths occur in Sub-Sahara Africa and Asia. (Maine.

Akalin, Ward and Kamara, 1997). In Ghana, for example, although the maternal mortality rate

has been officially reported to be 214 per 100.000 live births (Ghana Demographic Health

Survey (GDHS), 2003), figures ol'734.4 and 1140 per 100,000 deliveries have been reported


from two teaching hospitals (Lassey and Wilson, 1998; Martey, Djan, Twum, Browne and

Opoku, 1998). Among the national health objectives, health leaders in Ghana stated a goal of

reducing the rate of maternal death to 100 per 100,000 live births by the year 2001 (Annual

Report. Reproductive and Child Health (RCH). 1999). but the institutional maternal mortality

ratio (MMR) increased to 260 per 100,000 live births in 2001 despite efforts to reduce it

(Annual Report. RCH, 2001). The MMR target o f 180 per 100,000 live births for the year

2003 was not achieved. Eight hundred and fifty four institutional maternal deaths were

recorded in 2003. representing a MMR of 205 per 100,000 live births, higher than the 2002

ratio o f 204 per 100,000 (Annual Report, RCH, 2003).

Causes o f maternal deaths are similar all around the world. About 80 percent o f these

deaths have direct causes resulting from obstetric complications o f pregnancy, labour and

puerperium. Deaths may also occur from interventions, omissions, incorrect treatment or a

chain o f events resulting from any o f these complications (Bennett & Brown, 1999). In

Ghana, the direct or major causes o f maternal death are infection/sepsis,

haemorrhage/bleeding, hypertensive disorders of pregnancy, obstructed labour and abortion

complications. These direct causes result in about 80 percent o f all maternal deaths. Other

direct causes include ectopic and molar pregnancies as well as complications associated with

anaesthesia. The indirect causes include anaemia, malaria and heart disease. These conditions

affect the health status o f all women who are o f childbearing and are aggravated by

pregnancy, (WHO, 1997). Indirect causes o f death may arise as a result of previous existing

disease or disease that developed during pregnancy and was aggravated by pregnancy. Other

indirect causes are malnutrition, sickle cell diseases, infectious diseases, diabetes mellitus and

i


hypertension (Network Family Health International, 1999). Most o f the causes o f maternal

mortality and morbidity can be prevented with improved health status and quality o f care

given by health care workers, as well as by access to emergency interventions for most o f the

pregnant women in hospital and in their communities (Starrs, 1998). The issue o f maternal

mortality has raised a lot o f concern among governments and health workers, particularly

those in low-income countries. The concern stems from the fact that proper care during

pregnancy, delivery and puerperium may avert many of these deaths. There is evidence that

adequate care during delivery and the puerperium alone can decrease the number o f maternal

deaths by 50 to 80 percent (Twum-Baah. Nyarko, Quarshie, Caiquo and Amuah, 1994). In

adopting the safe motherhood programme, policy makers in many countries, including Ghana,

hoped to improve w om en’s health in general and especially, to reduce maternal and newborn

morbidity and mortality (RCH Annual Report 2001). The “safe motherhood initiative”

includes a series o f interventions. One of these is the use o f the partograph.

The partograph is a tool that when used appropriately should result in timely

management o f prolonged labour. Labour and delivery is considered a critical time for the

mother and interventions at this time may be essential to reduce maternal morbidity and

mortality. Even with adequate screening during the antenatal period, the intrapartum period

can be complicated, requiring emergency intervention. Delivery must be safe, atraumatic and

clean if maternal mortality is to be reduced. As much as possible delays, such as delay in

deciding to seek care, or in reaching an appropriate care facility because o f difficulties with

transportation and referral system, or in receiving care after arriving at a health facility, should

be reduced (Safe Motherhood Newsletter, 1995).

5


The WHO partograph is an instrument used to improve maternal health care through

early detection o f complications during labour by personnel functioning with or without the

support o f an obstetrician (WHO/MCH. 88.3, 1988). However, more emphasis is being placed

on midwifery notes rather than partographic documentation to the extent that the partograph is

often being completed in retrospectively to correspond with midwifery notes (Groeschel and

Glover, 1998). It is therefore not clear whether the partograph is being used adequately or

inadequately. The question then is “What is the relationship between the appropriate use and

the outcomes o f birth?”

1.2 Statement of the Problem

A parameter to describe the level of care provided by obstetric services is the maternal

mortality ratio (MMR) or the number of maternal deaths per 100,000 deliveries). The MMR

may be the gold standard for obstetric epidemiology but less than 30 percent o f countries

provide reliable maternal mortality data and maternal deaths are frequently underreported in

both higher and lower income countries (Pittrof, 1997). Maternal mortality continues to be a

major problem in sub-Sahara Africa. It is estimated to be about 10 per 1000 live births or

higher in some rural communities in sub-Sahara Africa and these rates are among the highest

in the world. Complications during delivery directly cause about three-quarters o f all maternal

deaths. The remaining deaths are the result o f medical conditions such as viral hepatitis,

anaemia and cardiovascular disease that are aggravated by pregnancy (Herz and Measham.

1987).

Ghanaians, mostly women and children, die each year from preventable causes, and

the official maternal mortality rate was reported as 260 per 100,000 live births (MOH, Ghana.

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1990 and RCH Annual Report, 2002). This trend is unacceptable and calls for all concerned

with issues related to women and children to develop strategies or interventions to prevent or

reduce this horrific toll o f maternal deaths. One such intervention is the introduction o f the

WHO partograph in the labour wards as a tool for early identification and diagnosis of

abnormal progress o f labour. This should lead to timely interventions. The partograph is a

simple chart that is used to guide the health care provider in recording the progress o f labour

as well as monitor the health status o f both the foetus and mother. It is an inexpensive, low

technology tool, which requires basic, though vital, midwifery skills to save lives (WHO,

1994).

The partograph consists o f three components: the foetal condition, the progress of

labour and the maternal condition. It can be used for all labours in hospitals and health centers

and at the domiciliary level where trained nurse/midwives practice midwifery. The purpose o f

the partograph is to reduce maternal and perinatal mortality and morbidity worldwide

(Preventing Prolonged labour: A Practice Guide. The Partograph Part 1.

WHO/FHE/MSM/93.8, 1993). As soon as a woman enters labour, the chart is used to record

the progress of her labour, in particular the rate of cervical dilatation and the pattern o f uterine

contractions. The partograph helps providers ensure that women are carefully monitored

during labour, unnecessary interventions are avoided and complications recognised and

responded to in a timely manner. It gives providers objective data on which to base their

clinical decisions and enhances communication among members o f the team o f providers who

are caring for the woman in labour.

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According to the WHO (1994), the partograph when used appropriately has the

potential not only to reduce foetal and maternal mortality and morbidity but also to reduce the

rising tide o f caesarean deliveries. In projects in Indonesia, Uganda, Nigeria and Ghana where

the use o f the partograph in community obstetrics was examined, it was revealed that its use

was successful in urban community settings. Yet prolonged and difficult labour contributes to

at least a third o f all maternal deaths (Lennox and Kwast, 1995).

The most problematic time in pregnancy is the intrapartum period. The Safe

Motherhood Initiative introduced strategies to address this problem. An important strategy is

the use o f the WHO partograph, which is intended to be used to prevent prolonged labour.

Important questions are: 1) ‘i s the partograph being used properly?” and 2) “When properly

used, does it reduce the M M R?”

The specific research questions were:

1. W'hat is the relationship between outcomes o f labour and appropriate use o f the

partograph.

2. Do health care professionals take action in a timely manner when the action line

is crossed.

1.3 Purpose of the Study

The partograph has been shown to be an efficacious tool for monitoring labour and

identifying women in need o f obstetric intervention. Partographs have been introduced in

many countries and the introduction is supported by guidelines and training workshops but

often with little follow-up and supervision. Moreover, there are concerns that the use of the

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partograph may increase the rate o f unnecessary obstetric interventions. The purpose of this

study is to explore the relationship between the use of the partograph and birth outcomes.

1.4 Significance of the Study

Health care providers/midwives will gain more understanding in the use o f partograph

and this will increase the observation and interpretation skills related to the progress of labour.

Health workers can only use the partograph effectively if they have adequate training. The

results o f the study will help identify the extent to which the partograph is used, determine

whether it is used correctly, identify the relationship between correct use and outcomes, and

identify areas where education or training needs to be strengthened. Utilisation o f the findings

will inform policy makers who make decisions about training programmes o f personnel needs

that will allow them to reach the millions o f women who are delivered with no attendant or

with the assistance only o f a relative or other untrained person. Findings will guide further

research in the area o f safe(r) motherhood in labour and delivery, with the view o f improving

maternity care and reducing maternal morbidity and mortality.

1.5 Definition of Terms

Maternal mortality - is defined as the death o f a woman during childbirth and/or within 2

weeks after delivery.

Maternal morbidity - is any sign or symptom resulting from or made worse by pregnancy or

childbirth. In this study, maternal morbidity is defined as assisted birth, pyrexia and

haemorrhage of 5()0mls or more.

Neonatal morbidity - any complication to the newborn resulting from childbirth. In this

study, neonatal morbidity will be reflected in 1 and 5 minutes APGAR scores of 6 or less.

9


cephal haematoma or other birth injury and admission to the Neonatal Intensive Care Unit

(NICU).

Neonatal mortality - death o f a newborn during birthing and/or within 2 weeks after birth

Appropriate or adequate use of partograph - correctly filled out partograph with no

omission or minor omissions. Adequacy is determined by guides established by the WHO.

10


C H A P TE R TW O

REVIEW OF LITERATURE

I'he purpose o f the review o f the literature is to summarise and critically analyse

existing theoretical and research literature relating to maternal mortality and morbidity, the

Safe Motherhood Initiative and the partograph as a specific intervention for reducing maternal

mortality. Using electronic searches such as Databases (ERIC, EMBASE, CINAHL, Pubmed,

Medline). Internet search engines such as Google and abstracts from dissertations, a wide

range o f articles relevant to the proposed research question were found. References were cited

from 1987 to 2003. However, studies published earlier than 1987 but found to be relevant to

the proposed research study were included. Key words used for the search included safe

motherhood, WHO partograph, maternal mortality and morbidity, quality maternal services,

programme evaluation and pregnancy outcome.

The magnitude o f maternal mortality will be evaluated. Strategies to reduce rates,

particularly in low-income countries, will be discussed and an emphasis will be placed on the

WHO partograph as an intervention. Every minute a woman dies of causes related to

pregnancy or childbirth (Gerlus, Moran and Segu, 1999). She is most likely to be young,

already a mother, and living in a low-income country or within the disadvantaged minority

groups of relatively high-income nations. For each woman who dies, an estimated 100 women

survive childbearing but are afflicted by disease, disability or physical damage caused by

pregnancy-related complications (KobIinsky, 1993). In the late 1980s maternal deaths were

often described as "silent’, because so little had been heard o f the women who died, the

circumstances in which they died, and what may have contributed to their deaths. Because it

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was 'silent' it was not known how many maternal deaths occurred in low-income countries.

“Unheard, unseen, uncounted, unattended, they died" (Peters, 2000 pp 2-7). This is no longer

so. The silence has been cracked, if not broken, by the gaining o f a much better understanding

of why these women die, how many, and in what circumstances.

All pregnant women are at risk of obstetric complications. Most life-threatening

complications occur during labour and delivery, and these cannot all be predicted. Prenatal

screening does not identify all o f the women who will develop complications (Rooks,

W inikoff and Bruce, 1990). Women not identified as ‘high-risk' can and do develop obstetric

complications. Most obstetric complications occur among women with no obvious risk

factors. Similarly, evidence that obstetric complications may occur despite intensive prenatal

care and screening was illustrated in a study of deliveries in out-of-hospital birth centres in the

United States (Weatherby, 1990). One of every 13 women categorized as ‘low-risk’ and

receiving intensive prenatal care developed serious complications. Additionally, maternal

deaths, with all the attendant personal loss a family and nation experience, is only a tip o f the

iceberg because the true incidence o f maternal mortality and morbidity is extremely difficult

to measure, particularly in low-income countries, and has a wide margin o f error. Implications

for economic productivity for the nation, health o f the family and loss o f personal fulfillment

of individual women are incalculable. The difficulty o f measuring maternal mortality has long

proved to be an impediment to progress in alerting health planners and others to the magnitude

and causes of this problem and hence to effective interventions on an appropriate scale (WHO

Maternal Mortality Rates, 1986).

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2.1 Maternal Mortality W orldwide

Profound differences still exist in maternal mortality ratios for women depending on

where they live in the world. Maternal deaths range from less than 10 per 100.000 live births

in Northern European countries to more than 1.000 per 100,000 live births in some low

income countries (WHO, 1992). Women from Southern Asia and Africa are at highest risk. A

community-based study in Bangladesh showed ratios o f approximately 600 maternal deaths

per 100,000 live births. In a rural India a study in Andhra Pradesh, a ratio o f 874 per 100,000

was reported (WHO. Maternal Mortality Rates. 1986).

Northern and Southern Africa report lower mortality rates than the rest of Africa.

However, the very high fertility rate (an average o f eight live births per woman plus foetal

deaths) yields a lifetime risk o f greater than five percent that a woman will die from a

pregnancy related death (WHO. Maternal Mortality Rates, 1986). In rural Africa, ratios of

1,000 per 100.000 live births have been recorded in several studies and in urban studies ratios

of over 500 per 100,000 live births with an overall ratio o f 640 per 100.000. Thus Africa,

while contributing eighteen percent of the world’s live births, contributes thirty percent o f the

world’s maternal mortality. On the other hand, the higher income nations contribute fourteen

percent o f the world’s live births, but only one percent of the maternal mortality (WHO,

Maternal Mortality Rates, 1986).

Latin American mortality rates vary markedly between temperate and tropical areas. It

is estimated that in tropical South America mortality ratios are an average o f 270 per 100.000

live births, with temperate climate ratios somewhat lower. Fifty percent o f the Latin American

maternal deaths are secondary to complications from illegal abortions. Latin American women

13


die in unacceptably high numbers due to lack of access to safe abortions. In contrast to

Southern Asia, Eastern Asia enjoys quite low maternal mortality ratios. China reports rural

ratios o f 59 maternal deaths per 100.000 live births and urban ratios o f 25. Widespread access

to prenatal care and safe abortion are two important contributors to these relatively low ratios.

However, underreporting in China may account for the reduced rates. USSR maternal

mortality data were not available.

Maternal mortality ratios in Northern and Western Europe, Canada, the United States,

Japan, Australia and New Zealand are all in the range o f 10 per 100.000 or lower. Canada in

the year 2000, recorded that 20 women died giving birth, for a rate o f one in 8,700. In the

United States, there were 660 deaths during the same year, for a rate of one in 2,500. Britain

recorded 85 deaths, a risk o f one in 3,300. These deaths include incidental deaths which are

frequently related to low income and this may account for the slightly higher rales in Britain.

In Europe, North America and Australia, the average is one in 2,800. However, the World

Health Organisation, the Children’s Fund and the Population Fund gave no reason for the

higher number o f deaths in the United States or the differences among higher income

countries (CBC News. 2003). The Nordic countries are the lowest with ratios o f 2 to 6 per

100,000. Romania in Eastern Europe has a ratio out o f line with the rest o f the region, i.e.,

more than 30, largely due to abortion related deaths (WHO, Maternal Mortality Rates, 1986).

2.2 Maternal Mortality in Ghana

What is known about maternal mortality in Ghana is fragmented. Ampofo reviewed the

causes of maternal death from 1963 to 67 at Korle-Bu Maternity Hospital in Accra. Korle-Bu

is one of the two teaching hospitals in Ghana and a major referral point for patients within the

14


Greater Accra Region. It is also a referral centre for other parts o f the country and

neighbouring West African countries. During the five-year period reviewed by Ampofo, 238

maternal deaths were recorded for 35,193 births, giving a ratio o f 676 per 100,000 births. Of

the 238 deaths, 63 were attributed to haemorrhage, retained placenta and hypofibrinoginaemia.

Sixty-one deaths were attributed to obstructed labour, including 33 who suffered from

ruptured uteri. Twenty-four died o f puerperal sepsis. Ghana has the additional infection

burden caused by unregistered patients self-treating with herbs and various medicinal potions

applied prior to admission to the vaginal canal in the form o f pessary (Ampofo, 1969).

Seven deaths were attributed to severe anaemia o f pregnancy and 23 deaths were

attributed to sickle cell anaemia. Due to the difficulty in obtaining laboratory confirmation,

these diagnoses were made clinically or from autopsy findings. Twenty-seven o f the deaths

were due to ectopic pregnancy, four o f which were advanced extra-uterine pregnancies.

Within the study period 952 ectopic pregnancies were diagnosed with a mortality rate o f about

3 percent. Abortion accounted for only 33 deaths in this study. Abortion, though a common

practice, was illegal in Ghana during that period. Treatment o f complications o f abortion w'as

the most common condition seen during the study period and this could be due to sepsis

(Ampofo. 1969).

Nine women died from trophoblastic disease, two from hydatidiform mole and seven

from choriocarcinoma. Though it was noted that these women ran a rapid course to death, it is

clear that these deaths were within 42 days of delivery. Thirty-five deaths were due to

eclampsia; 30 of these women died prior to delivery. O f the indirect obstetrical deaths, liver

disease was the leading cause of death claiming 3 1 women (Ampofo, 1969).

15


Korle-Bu teaching hospital was the site for a broader maternal and child health study

conducted by Family Health International, North Carolina. This Maternity Care Monitoring

Project was a multi-site study, which eventually included deliveries of more than half a

million women in 64 countries. Information was collected on a uniform data collection sheet,

which ran one page per mother-child unit. Information was collected at Korle-Bu teaching

hospital on 4.990 deliveries occurring between August 1981 and August 1982. Eleven deaths

were recorded from this study group o f women for a ratio o f 230 per 100,000 live births. Only

in-hospital deaths were recorded. Any of these women who died after discharge but before 42

days postpartum were lost to follow up and not included; therefore the number o f maternal

deaths was underestimated. Although an incomplete ratio, this represents a tremendous change

from the 1.080 deaths per 100,000 live births noted in the previous study. Within the study

group, 5.2 percent of the women delivered by caesarean section and 12.7 percent o f the births

were attended by a physician (Arruda, Covington, Janowitz, Morris and Rodriques, 1985).

The maternal mortality rate remains high in Ghana with estimates ranging from 214

(Ghana Statistical Survey (GSS), 1994) to 740 deaths (WHO/UNICEF, 1996) per 100.000 live

births. Institutional data estimated the Maternal Mortality Ratio (MMR) in 2001 as

260/100,000 live births. Central and Western regions continued to record the highest rates

with 450 deaths per 100,000 live births, fhe Greater Accra region registered the lowest MMR

with 150/100,000 live births (RCH Annual Report, 2001). Other health issues o f specific

concern to women involve a very low level o f knowledge among women about causes,

prevention, risk factors and signs of gynaecological malignancies such as cancer o f the cervix.

16


Cervical cancer deaths are high at 57.8 percent, followed by ovarian cancer at 25.3 percent of

all female genital tract malignancies (W omen's Health Foundation’s Brochure, 2003).

Global experience suggests that the majority of pregnancy-related deaths are

preventable, and a significant body o f research on strategies for reducing maternal mortality

has been generated but there appears to be no decrease in the maternal mortality rate since

1975. Specific attention to wom en’s health is thus warranted and in fact well overdue.

2.3 Programmes to Reduce Maternal Mortality

Since maternal mortality was known to be an important public health problem, there

have been efforts to reduce it. though some strategies have proved to be more effective than

others. To ensure safer motherhood, numerous organisations and groups have introduced

several mechanisms or strategies to help prevent or reduce maternal mortality. Examples of

such organisations include WHO, UNICEF, UNFPA, USAID, JHPIEGO, the World Bank, the

Population Council, IPPF and the Carnegie Corporation of New York. However, efforts to

increase safe motherhood vary among countries depending on the resources available and the

social and cultural environment in which women live. The Safe M otherhood Initiative was

launched in 1987 by international agencies and governments to raise global awareness about

the impact of maternal mortality and morbidity, and to find solutions.

Authors o f safe motherhood programmes assume that maternal health services can

reduce maternal mortality (Campbell, Heichelheim and Koblinsky. 1999; National Research

Council, 1997; Tinker and Koblinsky, 1993). The assumption that services make a difference

is supported by historical data on the timing o f reduction in maternal mortality, which suggests

that such declines have not coincided with socioeconomic gains but with improvements in

17


specific services (Loudon, 1991; Papiernik, 1995). Data supporting the effect o f services is

coming from case-control and experimental studies. For instance, Midhet, Becker and

Berender (1998) linked lower maternal mortality in rural Pakistan to health facility staffing

and the availability o f essential obstetric care. Frankerberg and Thomas (2001) linked the

addition of village midwives in Indonesia, if not to decreases in maternal mortality, at least to

an increase in body mass among women o f reproductive age.

An important question is which maternal health services reduce maternal mortality.

Shiffman (2000) indicates that, in cross-national regressions, having trained attendants at

delivery is strongly associated with lower rates o f maternal mortality. Sloan, W inikoff and

Fikree (2001) counter that the case for any intervention is unprovable from such data, because

of strong interdependence among possible determinants o f maternal mortality. Such ‘single

solutions.’ they argue, do not take into account o f interdependence among services. The Inter

Agency Group for Sale Motherhood (1997) reports that ensuring that a trained attendant is

present at all deliveries has now become the cornerstone o f safe motherhood programmes.

However, having trained attendants at birth or having supervised delivery may not be enough

to reduce maternal deaths. All birth attendants, including midwives, must possess the requisite

skills and competencies, and be knowledgeable in the use o f effective technologies that

monitor mother and foetus during pregnancy and labour, so as to make pregnancy and birthing

safer and less painful for the mother (Smeenk and Ten-Have, 2003).

In lurther research to improve maternal health services, the focus was on indicators

such as socioeconomic development. Hertz, Hebert and Landon (1994), for instance, used the

availability of medical resources as an indicator, and found that maternal mortality across

18


countries was associated with total energy consumption and excess energy consumed as fat.

Other authors explored a variety of socioeconomic variables relating to development and

women’s status, and similarly supported the hypothesis that maternal mortality levels were

dependent on some of them (Shen and Williamson, 1999).

2.4 The WHO partograph as a SMI Intervention

As part of its contribution to the Safe M otherhood Initiative (SMI) which was launched

in 1987. the WHO introduced and promoted the use o f the partograph with a view to

monitoring labour and introducing quick and effective interventions. The magnitude of

maternal/inlant morbidity and mortality to the family, community and the nation cannot be

over emphasized. A mother ’s death greatly influences the health and livelihood o f her

surviving children. When a mother dies, her surviving children are three to ten times more

likely to die within two years than those with both parents living (Tinker, 1997). In addition,

surviving children often do not receive adequate health care and education as they grow up.

The death of a mother has an impact beyond that o f her immediate family. A productive

worker, one who rears and guides the next generation, cares for the elderly, and contributes

stability to the community is lost. As such, the SMI had among its objectives to reduce

maternal mortality by 50 percent by the year 2000, and included supervised delivery as one of

its interventions to achieve this objective. Supervised delivery is defined as the percentage of

deliveries attended by skilled health personnel irrespective o f the outcome. This is one of the

important components of the safe motherhood programme and also an important aspect in

midwifery practice.

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Pregnancy and childbirth have the potential for being intimate and emotionally charged

experiences for all involved. Whether the experience is positive or negative, midwives are

involved in providing support for women and their families, and in dealing with the feelings

that arise. Midwives everywhere arc concerned at the loss o f a wom an’s life at or near the time

o f giving birth and would therefore use every skill they possess and all their expertise to

facilitate the safe delivery o f both mother and infant. All women seem to develop expectations

of childbirth and the kinds o f expectations vary among women, as does how realistic they are.

The pain women expect to feel can provoke anxiety and fear, because the quality and duration

of the potential pain are unknown (Beaton and Gupton 1990). Women also express fears of

loss o f control, abandonment, self-injury, or injury to the baby (Green, 1993; Lowe, 1996;

Sjogren. 1997).

W omen’s satisfaction with maternity services primarily depends on the quality of

communication between the women and their caregivers. This enables these women to

experience an enhanced sense o f recognition and feel more involved in their care as they build

a relationship with a "known midwife” (McCourt and Pierce, 2000). Tarkka and Paunonen

(1996) also reiterated that the midwife was the main source o f emotional support for mothers

during labour and that the mothers attached much importance to the presence o f the midwives,

for the encouragement they offered, and for their individual treatment. The mothers felt safer

if they had their own midwife with them throughout childbirth.

lhe partograph is an instrument used to improve maternal health care through early

detection by any trained birth attendant o f complications during labour. The progress of

labour, especially the rate of cervical dilatation, is recorded in the partograph. It helps to detect

20


abnormal progress in labour so that appropriate interventions can be taken which may save the

lives o f mother(s) and infant(s). The partograph has been in use in many countries for over

25years but adoption in lower income countries has been slower. Research on the use o f this

partograph has taken place mainly in hospital settings. WHO undertook the largest and best-

known study in South East Asia through the SMI, in which 35,000 partographs from eight

hospitals were surveyed (WHO/FHE/MSM/94.4, 1994). Statistically significant differences

were found in numbers o f prolonged labours, caesarean sections and labours requiring

oxytocin augmentation when partographs were used.

There was also a marginal improvement in newborn outcomes as measured by

intrapartum foetal deaths, Apgar scores, resuscitation measures and admission to neonatal

special care facilities. However, the partograph played a minimal role in 47 cases o f maternal

mortality and 55 cases o f uterine rupture, as most o f these occurred as a result o f delayed

presentation of complications. In Ghana, specifically in Accra, the WHO partograph was

introduced in the labour wards in 1990 and by the end of 1991 it was used in almost all the

regional and district hospitals. The partograph was intended to be used routinely for ever)'

delivery attended by midwives and other health care practitioners from all levels o f health

care.

There is increasing awareness of the extent of maternal ill health, and more knowledge

about interventions that can be effective in reducing this burden (Ronsmans et al. 2001). Yet

there has not been enough progress. It is an international disgrace that mothers in poor

countries, at the beginning o f the 21sl century, should be experiencing unimaginable suffering

21


and death, due to a scandalous lack of effective care during pregnancy and childbirth, which is

resulting in approximately 600,000 women dying annually (Walley, 2002).

Unlike higher income countries, birth for most women in Ghana is quite hazardous,

especially in the rural areas where most women give birth in their homes or rural clinics, far

from emergency maternity care. The majority o f the women are delivered by traditional birth

attendants (TBAs) or village women who have minimal or no formal training (Matthews,

1999). The introduction of the use o f the partograph in maternity care is to help reduce

prolonged labour and the sequelae of maternal morbidity and mortality for both women and

infants, to improve the quality o f care for women in labour and to increase the observation and

interpretation skills o f all birth attendants including midwives and other health professionals.

Nakkaki (1998) audited 1000 partographs for patients in Nsambya Hospital, Uganda,

between June 1998 and June 1999. She looked at the use o f the partograph as an indicator for

the quality o f care provided in the hospital. She wanted to know whether partographs were

being used in the labour wards and whether midwives and doctors were using them correctly.

The results revealed that hospital staff used the partograph for the majority o f labours and that

most of the partographs were completed correctly. However, a few partographs had errors,

which might have contributed to poor labour outcomes. Trainees, new doctors and midwives

who had never used a partograph outside the classroom committed these errors.

A prospective population-based study conducted among 20,326 pregnant women in

seven primarily urban areas was used to ascertain whether clinical risk factors for late stillbirth

in West Africa can be detected during antenatal care or only during labour. The investigators

concluded that the principal risk factor for late stillbirth could be detected only in the late

22


antenatal and intrapartum period. The potential benefits o f partograph use are highlighted in

these findings (Bouvier-Colle, Breart and Chalumeau and the MOMA Group, 2001). Seffah

(2002) conducted a study to find out whether the introduction o f the WHO partograph to the

labour wards in Accra, Ghana in 1990 had reduced the incidence o f ruptured uterus, maternal

mortality and perinatal mortality. There were 136 cases o f ruptured uterus diagnosed for

71.067 deliveries between January 1996 and December 2001 (incidence 1 in 523). In 1971

when the partograph had not been introduced in Accra, the incidence was 1 in 257. Other

variables such as improved technology and increased surveillance during labour may have

influenced some of these maternal outcomes.

The quality o f monitoring during labour for routine maternity care after partograph

introduction in three hospitals in southern Tanzania (two governments, one mission) was

assessed. In each hospital, all (62; 65; 69; totalling 196) deliveries were observed and

partographs for each woman were analysed during a 4-week period (Bosse, Massaw'e and

Jahn. 2002). They concluded that the partograph helped to improve delivery' outcomes.

However, its implementation needs continuous reinforcement and quality assurance. Concerns

that the partograph leads to higher rates of caesarean section were not supported by the data.

The sample size may be too small to make any definitive statement. The use o f the partograph

in monitoring labour in a woman who had a caesarean section was studied at Korle-Bu

Teaching Hospital in 1991 1992 (Amaniampong, Seffah, and Wilson, 1994). They analysed

the case notes o f 15,347 deliveries and confirmed that prolonged labour can be prevented

using the partograph as described in the WHO manuscripts.

23


The impact of breech labour management on foetal and maternal outcomes o f labour

was assessed using the WHO partograph (Lennox, Kwast and Parley, 1997). In all 1,740

breech presentations in a larger multicenter hospital-based were studied. The researchers

concluded that the use o f the WHO partograph in the management o f breech labour reduced

prolonged labour and (among multigravida) caesarean section and also improved foetal

outcomes. However, in the study, caesarean section was reported to be a safer method of

delivery for the baby, regardless o f whether or not the partograph was used (International

Federation o f Gynaecology and Obstetrics, 1998). Other studies have shown that using the

partograph can be highly effective in reducing complications for the mother from prolonged

labour for the mother (postpartum haemorrhage, sepsis, uterine rupture) and in preventing

newborn death from anoxia and infections (MSH and UNICEF, 1998).

Some researchers argued that the partograph can be used as a traditional format with

separate pages for the deliver)' summary and midwifery notes, whereas others incorporated the

summary, the partograph and notes into one comprehensive document. Thus, the use o f the

partograph reduces excessive documentation on the part o f the midwife as well as reducing

prolonged labour as asserted by other researchers (Groeschel and Glover, 1998).

In another study, Lavender and Malcolmson (1999) studied midwivcs" views on the

value o f action lines when using the partograph and reported that 83 percent o f midwives

surveyed felt that action lines helps to ‘manage labour’ and ‘diagnose prolonged labour at a

glance’ However, others felt that it takes away autonomy and individual clinical decision

making. I hough the study does not indicate the number o f midwives interviewed, it is worth

24


noting that documenting the information correctly on the partograph can help in early

identification o f the abnormal progress of labour and make timely intervention more likely.

Ghanaians adopted the use o f the WHO partograph in the labour wards in 1 9 9 0 - 1991,

to monitor labour and help to identify women in need (abnormal progress of labour) of an

obstetrical intervention, with a view to reducing the number o f prolonged labours,

appropriately augmenting labour with oxytocin, reducing rates o f caesarean section and

reducing the incidence o f infection, thereby improving maternal health and reducing maternal

and perinatal mortality. Has the introduction o f the WHO partograph helped in making

decisions early enough for women in need o f interventions? Are providers still using the

partograph? Are they using it correctly? Is the correct use associated with changes in

outcomes for mother and baby?

2.5 Theoretical Framework

O f all the health indicators monitored by WHO, maternal mortality rates (MMR)

demonstrate the largest disparity between higher and lower income countries. The disparity of

MMR between countries can largely be attributed to knowledge gap and lack o f human,

financial and material resources available to women o f low socioeconomic status with less

education and living in poorer countries.

To help bridge this gap, series of activities were designed by the WHO under its Safe

Motherhood Programme to update the knowledge and skills o f providers o f maternity

services. I he Life Saving Skill (LSS) training programme for midwives and doctors was

developed to provide clinical training and practice in such areas as use o f the partograph.

25


manual removal ol'lhe placenta, prevention and management o f haemorrhage and post

abortion care including manual vacuum aspiration. It is anticipated by those concerned with

maternal and neonatal health that if the partograph is adequately used and necessary

interventions are promptly initiated, most complications occurring during childbirth will be

prevented. This will reduce maternal and neonatal deaths to a level comparable to those

observed in higher income countries.

This approach is consistent with the theoretical approach taken by the Neumcm Systems

Model (George, 1985), where three levels o f prevention, that is, primary, secondary and

tertiary preventions are descibed. Primary prevention relates to general knowledge applied to

client assessment in an attempt to identify stressors before they occur. Secondary prevention

relates to symptomatology which includes interventions that are initiated after an encounter

with a stressor (George, 1985). Nurses and midwives uniquely use this model to assist

individuals, families and other groups to attain and maintain maximum levels o f total wellness

by purposeful interventions. The use o f the partograph is a secondary prevention strategy. It

enables providers to monitor labour effectively so that timely interventions can be taken as

needed to ensure the safety o f the mother and the newborn.

26


C H A P TE R TH R E E

R ES EA R C H P R O C E S S

Although there have been studies on evaluation of the use o f the WHO partograph in

relation to maternal and neonatal outcomes in other parts of the world, there has not been

adequate assessment o f this tool in monitoring labour and its outcome in Ghana. This is a

retrospective study, which is an example of a non-experimental research design to evaluate the

relationship between the use of the partograph and the outcomes o f birth. Retrospective

studies are almost always cross-sectional and data are collected concurrently with regard to the

independent (partograph) and dependent (maternal and neonatal outcomes and interventions)

variables. The discussion o f the research method includes information about a) sample, b)

instrument, and c) procedure.

Advantages of a Retrospective Study

• It is an efficient and effective means o f collecting a large amount of data about a

problem area.

• It tends to be high in realism and it is seldom criticised for its artificiality.

• It helps in advancing our understanding of what the world around us is like.

Disadvantages of a Retrospective Study

• It is weak in its ability to reveal causal relationship among variables. Manipulation o f

an independent variable and control o f extraneous variables are not possible because

the events occurred prior to data collection.

• It is susceptible to faulty interpretation (Polit and Hungler, 1997).


Three hypotheses each with accompanying sub-hypothesis, were advanced to answer

research questions posed for this study.

Hypothesis 1:

There will be more interventions documented in the partographs that are used adequately

than in those that are used inadequately.

a) There will be more augmentation documented in the charts o f women where the

partograph was used adequately than in those where the partograph was used inadequately.

b) There will be more artificial rupture of membranes (ARM) documented in the charts

of women where the partograph was used adequately than in those where the partograph was

used inadequately.

c) There will be more assisted births (i.e., vacuum extraction, forceps delivery,

Caesarean section) documented in the charts o f women where the partograph was used

adequateh than in those where the partograph was used inadequately.

Hypothesis 2:

There will be less intrapartum and postpartum (within 2 weeks of birth) morbidity

documented in the charts o f women where the partograph was used adequately than in those

where the partograph was used inadequately.

a) There will be less pyrexia at any time during the intrapartum and postpartum period



28


b) There will be less haemorrhage (i.e., blood loss estimated to be more than 500 ml) at

any time during the postpartum period documented in the charts o f women where the


c) There will be fewer readmissions during the first 2 weeks of the postpartum period



d) There will be less mortality at any time during the intrapartum and postpartum period



Hypothesis 3:

There will be less newborn morbidity documented in the charts o f women where the


a) There will be more newborns with Apgar scores o f 7 or more at 1 minute o f age

and 5 minutes of age documented in the charts o f women where the partograph was

used adequately than in those where the partograph was used inadequately.

b) There will be few birth injuries (i.e., cephal haematoma) to newborns documented

in the charts o f women where the partograph was used adequately than in those


c) There will be fewer admissions to the neonatal intensive care unit (NICU)

documented in the charts o f women where the partograph was used adequately

than in those where the partograph was used inadequately.

29


d) There will be fewer neonatal deaths (during the intrapartum and within 2 weeks of

birth) documented in the charts o f women where the partograph was used adequately

than in those where the partograph was used inadequately.

3.1 Design

To assess the relationship between the use o f the partograph and birth

outcomes, a retrospective comparative chart review was used and charts were assigned

to one o f 2 groups depending on whether or not a partograph was used and adequately

completed.

The partograph consists o f three components: foetal condition, progress of labour and

maternal condition.

a Foetal condition consists of foetal heart rate (FHR), status o f membranes and

appearance o f liquor as well as presence o f moulding. During labour the foetal heart rate must

be checked and recorded every hour, but if the foetal heart is irregular then it should be

checked and recorded every fifteen minutes. The state o f the membranes and liquor and

moulding should be checked and recorded every four hours.

b. Progress o f labour comprises cervical dilatation, descent o f the presenting part and

uterine contractions. In labour, dilatation o f the cervix and descent o f the presenting part

should be assessed on admission and repeated at least every four hours. More frequent

examination should be done as the need arises. Uterine contractions should be checked and

recorded every half hour.

c. Maternal condition has the following components: maternal blood pressure, pulse,

temperature and assessment of urine for presence of protein and keynotes. Pulse rale should be

30


assessed and recorded hourly, blood pressure, temperature and urinalysis should be assessed

and recorded every four hours.

A partograph was considered to be adequately or appropriately used if all the three

components: progress o f labour, maternal condition and foetal condition were assessed and the

partograph was filled out in the manner recommended in the WHO guidelines (Appendix B).

Furthermore, if there were no omissions in any of the above areas or if the omissions were

deemed to be minor (1-2 omissions in any of the components) the partograph was considered

adequate or appropriate. A partograph was considered to be inadequate if there were moderate

(3-4 omissions in any o f the components) or major (5 or more) omissions. Definitions of

levels of omissions are presented in the following table.

Table 1: Components of Partograph and levels of omission

Components of Partogragh No omission Omission

a. Foetal condition

I. FHR

II. Moulding

III. Liquor

b. Progress o f labour

IV. Descent of foetal head

V. Cervical dilatation

VI. Uterine contractions

c. Maternal condition

VII. Pulse

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VIII. BP

IX. Temperature

X. Urine (Urinalysis)

A score of 10 was possible for all partographs , one point for each o f the ten variables under

the components o f partograph chosen for this study and classified as adequate or inadequate.

Tabic 2: Levels of Omissions resulting in adequate and inadequate partograph

Adequate Partograph No Omission Minor Omissions, i.e.

1 - 2 omissions

Inadequate Partograph Moderate Omissions, i.e.

3 - 4 omissions

Major Omissions, i.e.

5 and above omissions

3.2 Setting

Korle-Bu Teaching Hospital, the site for the study, is situated on the west part o f Accra

about 0.5 kilometers from the Korle lagoon. Korle-Bu Teaching Hospital is the oldest, largest

and first teaching hospital in the country and serves as the teaching hospital for the College of

Health Sciences, which is comprised of the Medical and Dental School, School of Nursing,

School of Public Health, Noguchi Memorial Institute for Medical Research and Allied Health

Sciences. Currently, it has about 1.560 beds, making it one of the biggest hospitals in the

country. It consists o f the following departments:

• Medicine and Therapeutics

• Surgery, Theatres and Recovery

• Allied Surgery

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• National Cardio-Thoracic Centre

• O bstetrics and G ynaecology

• Child Health

• Reconstructive Plastic Surgery and Burns Centre

• Radiotherapy Centre

• Surgical and M edical Em ergency,

• Accident. Casualty U nit and Central O ut-Patients

• Physiotherapy and Pharm acy

• Polyclinic and A dm inistration

The D epartm ent o f O bstetrics and G ynaecology has two m ain units, that is, the

D epartm ent o f O bstetrics (M aternity Block) and the D epartm ent o f G ynaecology. The setting

for this study was the records departm ent at the M aternity B lock o f the D epartm ent o f

Obstetrics and G ynaecology, w hich handles about 12.000 deliveries annually, w ith an average

o f about 993 deliveries per m onth. The unit serves as referral point for various low er-level

health facilities w ith in m etropolitan A ccra and surrounding areas. The unit is m anaged under 5

team s o f doctors w ith 14 physicians on each team and 253 nursing and m idw ifery staff.

The departm ent has six floors or w ards w ith 54 beds each except the 6Ih floor, which

has 24 beds. It has 2 labour wards and 2 obstetrics theatres, an out-patient unit including 8

consulting room s and an adm ission bay where all patients adm itted to the facility are

registered and exam ined prior to adm ission. The N eonatal Intensive Care U nit (NICU). which

33


is pari o f the D epartm ent o f Child Health, is also housed on the 3rcl floor o f the m aternity

block. There is a laboratory unit, an X-ray, Pharm acy and M edical statistics and

docum entation units.

The departm ent operates 24-hour em ergency services for both antenatal and postnatal

w om en as well as m anagem ent o f labour and delivery and ultrasonologic services. There is

also the Public Health unit w here im m unisations for m others and babies are done, counselling

for family

planning take place and cervical cancer screening m others antenatally and postnatally.

The D epartm ent o f G ynaecology is behind the m ain A dm inistra tion Block o f the

Korle-Bu Teaching H ospital. It has an O ut-Patient unit w ith 7 consulting room s and an

em ergency room. It also has 3 m ain wards, nam ely, W ard E w ith 34 beds, C henard A w ith 50

beds. Chenard A nnex w ith 30 beds and a G ynaecology theatre. The unit handles all

reproductive health cases including early pregnancy care, obstetrics em ergency care, cervical

cancer screening services and fam ily planning services.

3.3 Sample

To avoid selection bias, charts o f w om en who delivered at K orle Bu and m et inclusion

criteria were enrolled as sequentially as possible. The charts w ere from both labour wards

(i.e., 1 & 2). Charts o f m ultiparous and prim iparous w om en at any gestational age greater

than 24 weeks and who w ere deem ed to be in active labour (regular uterine contractions, i.e.. 3

contractions in 10 m inutes) and had a cervical dilation o f least 4 centim etres but not fully

dilated were included.

34


Charts o f w om en treated for hypertension during the index pregnancy or who had been

adm itted to hospital with a blood pressure greater than 140 systolic and/or 100 diastolic were

excluded. Charts o f w om en who arrived at the hospital in second stage o f labour or were

booked for elective C aesarean section or had experienced intrauterine death prior to labour in

the index pregnancy were also excluded.

The sam ple consisted o f charts from the defined cohort o f births occurring at Korle-Bu

teaching hospital during the m onths o f May 1 to June 30, 2003. These m onths had the highest

recorded deliveries. 1.187 and 1,215 respectively. In all. 1,845 charts w ere review ed. About

100 to 150 charts w ere review ed daily and about 24 percent o f these charts did not m eet the

inclusion criteria.

3.4 Procedure

The protocol for data collection was as follows:

a) Data w ere extracted m anually from the m edical records o f the selected

cohort and recorded on the attached data collection sheets (A ppendix B).

b) E ligible charts w ere selected serially as arranged by m edical records

c) For the first 10 charts, the researcher assessed inter-rater consistency in

recording the adequacy o f the partograph. the use o f interventions, and all m aternal and

newborn outcom es by having a colleague w ith about the sam e level o f skill and experience

also com plete data collection forms. An agreem ent o f 90% w as accepted.

d) Data from the data collection sheets were transferred to the com puter database.

e) A colleague checked every 20lh entry for accuracy.

35


3.5 Assumptions

It was assum ed Lhat inform ation recorded on the charts accurately reflected the

characteristics o f the w om en, the interventions that were perform ed, and level o f m aternal and

neonatal m orbidity and mortality.

3.6 Analysis

Data were analysed using a com parative design because the researcher is interested in

assessing the relationship betw een 2 variables [i.e., the adequate use o f the partograph

(independent variable) and birth outcom es (dependent variable)]. A database com patible with

the m ost recent version o f the Statistical Package for the Social Sciences (SPSS) was

developed.

The analyses consisted o f two sections. First, the dem ographic characteristics and

outcom es recorded in the charts were described and relationships am ong selected variables

were evaluated. Categorical variables w ere described using percentages and bar charts.

Numerical variables w ere described using m easures o f central tendency (m eans, m edians)

and variability (ranges, standard deviations). R elationships am ong selected variables were

calculated using sim ple correlations and Chi-square analysis. N ext relationships between

selected outcom es and the use o f the partograph were assessed using non- param etric (i.e.,

Chi-square) statistics.

3.7 Variables

Data were collected for the follow ing dem ographic, m aternal intervention, m aternal and

new born outcom e, and partograph variables.

1. D em ographic

36


a. Age (actual age)

b. Parity (0, 1, 2-5, more than 5)

c. M arital status (m arried, single, divorced, w idow ed)

d. O ccupation (unem ployed, inform al private sector, form al private sector, public

sector)

e. M ode o f last delivery prior to the index pregnancy (N/A, N SV B , C/S, V acuum

extraction, forceps)

f. G estational age at onset o f labour (37 w eeks or less, 38 w eeks or more)

2. M aternal Interventions

a. O xytocin augm entation (yes, no)

b. A rtificial rupture o f m em branes during labour (yes, no)

c. A ssisted delivery (C/S. vacuum extraction, forceps, episiotom y, breech

extraction)

3. M aternal O utcom es

a. Pyrexia above 37.5 C at any tim e (yes, no)

b. M aternal haem orrhage o f 500 ml and above (less than 500m l is no,

5 0 0 -1000ml is m oderate: m ore than 1000ml is severe)

c. R eadm ission to hospital w ithin 2 w eeks o f birth (yes. no)

d. M ortality (yes, no)

4. N ew born O utcom es

A. A pgar Scores (6 or less) or (7 - 10) at one m inute o f birth

b. A pgar Scores (6 or less) or (7 - 10) at five m inutes o f birth

37


c. B irth injury (cephal haem atom a, others)

d. A dm itted to NICU (yes, yes but after operative birth, no)

e. M ortality (yes, no)

5. Partograph adequacy (yes, no)

a. A dequate (1 if no om issions, 2 if m inor om issions)

b. Inadequate (3 if m oderate om issions, 4 if m ajor om issions)

c. Date and tim e action line w as crossed

d. A ction taken in tim ely m anner (yes, no)

A data collection sheet w as developed to reflect values for the above variables (A ppendix C).

3.8 Ethical Considerations

A letter requesting perm ission lo conduct the study was sent to the D eputy D irector o f N ursing

Services (DDNS) o f the K orle-B u Teaching H ospital, the D eputy D irector o f N ursing

Services (DDNS) o f the D epartm ent o f O bstetrics and G ynaecology and the head o f the

M edical Statistics and D ocum entation D epartm ent o f the study area (A ppendix D). This

proposal was subm itted to the Institutional R eview Board o f the N oguchi M em orial Institute

for M edical Research (N M IM R ) and approval obtained before the com m encem ent o f data

collection. All data w ere extracted from the m edical records by the researcher. C onfidentiality

was m aintained since no nam es or identifying inform ation w ere collected w ith the data. A

colleague who does not w ork at the m aternity unit and therefore was unlikely to know the

nam es o f the subjects whose charts were being review ed assisted in exam ining the charts. This

also ensured confidentiality in the charts reviewed. N o consent from subjects was required

because charts rather than individuals were studied. D ata sheets w ere stored in a safe locked

38


cabinet in the School o f Nursing, University o f Ghana and secondary analysis will be done

only with approval o f an appropriate ethics com m ittee.

39


CHAPTER FOUR

RESULTS

The results o f the data analysis are presented in this chapter. First, the dem ographic

characteristics (including age, parity, m arital status, occupational status, m ode o f last delivery

and gestational age o f onset o f labour) are presented. Then the relationship betw een the

independent variable (i.e., adequacy o f the partograph) and the frequency o f m aternal

interventions, m aternal outcom es and new born outcom es are reported. A total o f 1,845 charts

that met inclusion criteria for this study w ere review ed. These included the charts o f 930

w om en adm itted to the M aternity B lock o f the K orle Bu T eaching H ospital in M ay 2003 and

915 in June 2003. A sum m ary o f how eligible charts w ere selected from the 2,622 adm issions

to the M aternity B lock during that tim e is presented in F igure 1.

Figure 1: O bstetric A dm ission in Korle-Bu M aternity B lock in M ay and June2003

Obstctric Adm ission in Korle-Bu Maternity Block2622

M ay1310

June1312

In labour 1187

Not in labciui 123

In labour 1214

Not in labour 98

Included Planned use of Partograph

QfU

ExcludedPartograph not use (Eclampsia,elective C/* 2 stage arrival.IUFD) 223

Included Planned u se o l Partograph

07?i

Excluded Partograph not u se (Eclampsia, Elective C/S, 2 nri stage arrival,It |FD> 7 4 ?

C h a n s found Charts not found Chaits found Charts nol found930 (M issing charts Including deaths)

34915 (M issing charts including deaths)

57

40


4.1 Demographic characteristics

4.1.1 Age

The average age o f the w om en whose charts were included was 27.7 years old (SD

6.09 years). Their ages ranged from 15 to 45 years old. The m ajority o f the w om en were

w ithin the age category o f 21 to 30 years old.

4.1.2 Parity

Out o f the 1,845 w om en w hose charts were review ed, 1,125(61.0% ) w ere m ultiparous

while 717(38.9% ) w ere nulliparous. The modal category for parity w as the 2 to 5 category. A

more detailed description o f parity is presented in Table 3.

Table 3. Parity'

Parity Frequency Percent0 (Prim igravid) 717 38.91 505 27.42 - 5 569 30.8More than 5 51 2.8M issing data oJ 0.2Total 1845 100.0

4.1.3 M arital status

O f the 1,845 charts review ed, marital status was reported for 1,843 wom en. O f these.

1,612 were m arried w om en living with their husbands. The rem ainder reported their m arital

status as single.

4.1.4 Occupation

O f the 1,845 charts review ed, 1,831 w om en reported their occupations. O f these. 1.321

(71.6% ) were em ployed either in the inform al private sector, form al private sector or public

sector. Ih e rem ainder w ere unem ployed. For 14 (1%), their em ploym ent status was not

known.

41


4.1.5 M ode o f last delivery

O f 1.128 m ultiparous w om en whose charts w ere review ed, 989(88% ) had a previous

norm al spontaneous vaginal birth, while the rest delivered either by caesarean section or

vacuum extraction. The previous delivery experience o f m ultiparous w om en is provided in

m ore detail in Table 4.

Table 4: Mode of Last Delivery

M ode o f last delivery Frequency Percent

N orm al spontaneous vaginal birth (NSVB) 974 52.8

Caesarean section (C/S) 132 7.2

Vacuum extraction (V/E) 7 0.4

N on-application (Prim igravid) 705 38.2

M issing data 27 1.5

Total 1845 100.0

4.1.6 G estational age o f onset o f labour

For the m ajority o f the 1,824 w om en w hose gestational ages were included on their

charts, 1,396 (76.5% ) experienced the onset o f labour w hen their gestational age w'as 38 w eeks

or more. For 428 (23.5% ), the onset o f labour occurred prior to 37 com pleted w eeks o f

gestation. Inform ation about gestational age was m issing for 21 charts.

4.2 Research Hypotheses

In the next sections the research hypotheses will be addressed. Each o f the three

hypotheses will be listed with the accom panying sub-hypotheses. The results o f the analysis

o f each individual sub-hypothesis will be reported. Before reporting findings from research

42


hypotheses, guidelines used to establish the adequacy ol the independent variables (i.e.,

partograph and whether or not tim ely action was taken) will be described.

4.3 Partograph

The independent variable is the adequacy o f the partograph. U sing guidelines based

on W orld Health O rganization (W HO) criteria established a priori to determ ine w hether or

not the partograph w as judged to be adequate, m aternal in terventions as well as m aternal and

newborn outcom es w ere com pared w ith respect to w hether or not the partograph was

adequately used.

The levels o f om ission in plotting the partograph as required by W H O guidelines are

presented in Table 4. For the m ajority o f charts that w ere review ed for this study, assessm ents

o f com ponents o f the partograph (i.e., FHR, liquor and m em branes, and presence o f caput or

m oulding, as well as uterine activity, m aternal pulse and urine analysis) w ere not plotted to

specification. There were one or m ore om issions during plotting or charting o f the partograph.

Table 5. Components of Partograph and Levels of Omission

Com ponents o f Partograph No om issions O m issions

a. Foetal conditions i. FHR

Frequency

121

Percent

6.6

Frequency

1724

Percent

93.4ii. M oulding 286 15.5 1559 84.5

iii. Liquor 839 45.5 1006 54.5b. Progress o f labour iv. Descent o f head 1699 92.1 146 7.9v. Cervical dilatation 1759 95.3 86 4.7

vi. Uterine contractions 211 11.4 1634 88.6c. M aternal conditions

vii. Pulse 194 10.5 1651 89.5viii. BP 1568 85.0 277 15.0

xi. Tem perature 1221 66.2 624 33.8x. Urine (Urinalysis) 304 16.5 1541 83.5

•13


O f the 1,845 charts review ed, the partographs w ere correctly filled out in accordance with

W HO guidelines on 472 (25.6% ) charts while 1,373 (74.4% ) partographs w ere incorrectly

filled out.

4.3.1. Action Line on Partograph:

A lthough the use o f the partograph by care providers w as filled on 464 occasions, it

was also noted that w hen the action line was crossed, action w as only taken in a tim ely

m anner on 226 (48.7% ) occasions and was not taken on 238 (51.3% ) occasions. Therefore,

m aternal and new born outcom es w ere com pared on a) w hether or not the partograph was

adequately filled out and b) the charts w ere further analyzed so that those for w hom action

was taken when the action line was crossed w ere com pared w ith those for w hom no action

was taken.

Out o f the 1.845 charts review ed, for 1,381(74.9% ) w om en, labour ended w ithout the

action line being cross. For 464 (25.1% ) the action line w as crossed. O f these, action was not

taken in a tim ely m anner to augm ent labour for 238(51.3% ). T im ely action w as therefore

taken to augm ent labour for only 226(48.7% ) women.

Hypothesis 1:

There will be m ore in terventions docum ented in the partographs that are used adequately than

in those that are used inadequately.

a) There will be m ore augm entation docum ented in the charts o f w om en w here the

partograph was used adequately than in those w here the partograph was used

inadequately.

44


O f the 1,845 records, data were available lor 1,844. O f these, the labour o f 623

w om en was augm ented w ith oxytocin. Those whose partograph was judged to be adequate

were m ore likely to have their labour augm ented than those w hose partographs w ere judged to

be inadequate (X2=175.8, d f 1, p<0.0009). The hypothesis was supported.

b) There will be m ore artificial rupture o f m em branes (A R M ) docum ented in the charts

o f w om en w here the partograph was used adequately than in those w here the

partograph w as used inadequately.

Data were available on 1,835 o f the 1,845 records. O f these, 673 had their labour

augm ented by having their m em branes artificially ruptured during labour. Those whose

partographs were judged to be adequate were more likely to have their m em branes ruptured

(X2=87.3. d f l.p < 0 .0 0 0 9 ). The hypothesis was supported.

c) There will be m ore assisted births (i.e., vacuum extraction, forceps delivery,

Caesarean Section) docum ented in the charts o f w om en w here the partograph was used

adequately than in those where the partograph was used inadequately.

O f the 1,845 records, data with respect to assisted birth w ere available on 1.839. O f

these. 778 w om en had assisted births. These included C aesarean Section (n=235); vacuum

extraction (n=38); forceps extraction (n=5); episiotom y (n=455); and assisted breech birth

(n=44). This hypothesis was also supported as there were m ore assisted births in group whose

partographs were adequately filled out (X2=108.3, d f 1, p<0.0009).

4.4.2 Types o f m aternal interventions

M aternal interventions included oxytocin augm entation, artificial rupture o f

m em branes (ARM ) during labour and assisted deliveries such as C aesarean section, vacuum


extraction, forceps, episiotom y and breech delivery extraction. Six hundred and tw enty-four

(33.8% ) o f the w om en had their labours augm ented w ith oxytocin and 673(36.5% ) had their

m em branes artificially ruptured during labour. Out o f the 778(42.2% ) w om en who were

assisted during delivery, 456(58.6% ) o f them had norm al spontaneous vaginal births with

episiotom y w hile 235(30.2% ) had caesarean sections. I f only Caesarean Section, vacuum

extractions or forceps deliveries w ere considered as assisted birth, there w ere differences

between those w ho had a partograph that was adequately filled out and those w ho d id n ’t

(X 2=5.16, d f 2, p<0.03).

Table 6: Various M aternal Interventions

M aternal Interventions Yes No Totala. Oxytocin augm entation 624 (33.8) 1221 (66.2) 100.0b. ARM during labour 673 (36.5) 1172 (63.5) 100.0c. Assisted delivery 778 (42.2) 1067 (57.8) 100.0

4.4 Maternal Outcomes

Hypothesis 2:

There will be less in trapartum and postpartum (w ithin 2 w eeks o f birth) m orbidity docum ented

in the charts o f w om en w here the partograph was used adequately than in those w here the

partograph was used inadequately.

a) There will be less pyrexia at any tim e during the intrapartum and postpartum period

docum ented in the charts o f w om en where the partograph w as used adequately than in

those w here the partograph was used inadequately.

M aternal tem perature was available for all 1,845 records. O f these, 427 (23.1% ) o f the

wom en had a body tem perature record at or above 37.5 degrees C entigrade (C). at som e time

during their intra partum or postpartum period. Those w hose partographs w ere not adequately

46


com pleted were less likely to have a m aternal tem perature above 37.5 recorded on their

partograph (X2=13.2, d f 1, p<0.0009). The hypothesis was not supported.

However, m aternal tem perature was also com pared betw een those for w hom tim ely

action was taken if the action line was crossed and those w hom tim ely action was not taken.

There were no betw een-group differences (X 2=0.64. d f 1, p=0.44).

b) There will be less haem orrhage (i.e., blood loss o f m ore than 500 m l) at any tim e

during the postpartum period docum ented in the charts o f w om en w here the partograph

w as used adequately than in those where the partograph w as used inadequately.

D ata w ere available on 1,811 o f the 1,845 records. The records o f 1,360(73.7% )

wom en indicated that they had experienced post delivery b lood loss o f less than 500m ls while

485(26.3% ) experienced either m oderate or severe blood loss. The m axim um blood loss was

assessed to be 2500m ls.

There w ere betw een-group differences w ith those w hose partographs were adequately

com pleted being less likely to have a m oderate or severe haem orrhage (X z=81.5, d f 2,

p<0.0009). The hypothesis w as supported .

W hen the presence o f m inim al, m oderate or severe b lood loss w as com pared between

those where action w as taken in a tim ely m anner w hen the action line w as crossed and those

where action was not taken, differences were not found.

d) There will be few er readm issions during the first 2 w eeks o f the postpartum period

docum ented in the charts o f w om en where the partograph was used adequately than in

those where the partograph was used inadequately.

47


O f the 1,845 records, inform ation about w hether or not the m other w as re-adm itted to

hospital during the postpartum period was available in 1,836. It w as indicated in 92 charts

that w om en were readm itted to the m aternity unit. O f these, 26 (27.2% ) o f the w om en were

readm itted w ith pre-eclam psia, 21 (19% ) with puerperal sepsis, 19 (21% ) w ith m alaria or UTI

and 8 (9%) w ith severe anaem ia. The rem aining 18 (20% ) w ere adm itted w ith com plications

such as wound infection, gaping episiotom y, bleeding per vagina (due to secondary PPH) and

sickle cell crisis.

M ore w om en in the group w hose partographs w ere adequately com pleted were

readmitted during the first 2 w eeks postnatally (X2=5.7, d f 1, p=0.01). The hypothesis was not

supported.

W ith respect to w hether or not action was taken in a tim ely m anner, there wrere no

differences betw een groups in rates o f m aternal readm ission to hospital w ithin the first 2

weeks follow ing birth (X2“0.03, d f 1, p=0.87).

There w ill be less m ortality at any tim e during the in trapartum and postpartum period

docum ented in the charts o f w om en w here the partograph w as used adequately than in those

where the partograph w as used inadequately.

Total adm issions and deliveries recorded during the study period M ay and June. 2003

were 2,622 and 2,401. respectively. The unit recorded 29 m aternal deaths during the sam e

period. O f these, it was reported in the log book that there w ere 13 intrapartum m aternal

deaths but only 1 chart was located. The charts o f the rem aining 12 w om en who died during

labour were am ong those that w ere m issing, l he researcher becam e aw are o f the num ber o f

deaths and their causes through scrutiny of records kept by nursing adm inistrators.

48


The num ber o f eligible charts o f wom en who died was insufficient to assess between

group differences w ith respect to the adequacy o f the partograph. Therefore, the hypothesis

was not tested.

4.5 Newborn Outcomes

Hypothesis 3:

There will be less new born m orbidity docum ented in the charts o f w om en w here the

partograph was used adequately than in those w here the partograph w as used inadequately,

a) There will be m ore new borns w ith A pgar scores o f 7 or m ore at 1 m inute o f age and 5

m inutes o f age docum ented in the charts o f w om en w here the partograph was used

adequately than in those w here the partograph was used inadequately.

Out o f the 1,845 charts review ed, A pgar scores at 1-m inute o f age w ere available for

1,843 births. A total o f 1.885 babies including 40 sets o f tw ins w ere delivered during the

study period. For this study only the Apgar scores of the first twin were recorded. O f

these, 704 (38.1% ) babies had A pgar score o f 6 or less at 1 m inute o f age and 1,139(61.9% )

babies had scores o f 7 to 10 w ithin the same period o f time. W hile 1 80 A pgar scores o f less

than 6 were expected, 238 w ere observed in the groups w hose partograph w as adequately

com pleted. Conversely, w hile 524 A pgar scores o f 6 or less w ere expected in the group where

the partograph w as inadequately com pleted, only 466 w ere observed. The differences were

significant, in that A pgar scores were higher in those w hose partographs w ere not filled out

appropriated (X2=40.8. d f 1, p<0.0009). The hypothesis was not supported .

However, when the 226 cases where action was taken in a tim ely m anner was

exam ined, Apgar scores o f 6 or less were expected for 114 o f those w here action w as taken in

49


a tim ely m anner; only 102 w ere observed. Conversely, the 238 w here action was not taken in

a tim ely m anner, 120 cases w ere expected and 133 were observed. In this case, those who

received tim ely action were less likely to have babies w ith low A pgar scores (X2==5.9, d f 1,

p=0.0009)

Apgar scores w ere recorded on all charts for 1,845 births at 5 m inutes o f age. O f

these, 207 babies (11.2% ) had scores o f 6 or less and 1,638 (88.8% ) babies scored 7 to 10 at 5

m inutes after birth. T hose w hose partograph were adequately filled out w ere m ore likely to

have scores o f 6 or less at 5 m inutes o f age (X2= 5 .6 ,d f 1, p=0.01). The hypothesis w as not

supported.

W hen those w here action was taken in a tim ely m anner were com pared w ith those

where action was not taken in a tim ely m anner w ith respect to 5-m inutes A pgar scores, those

where action was not taken w ere significantly higher.

b) There will be few birth injuries (i.e., cephal haem atom a) to new borns docum ented in

the charts o f w om en w here the partograph was used adequately than in those w here the


O f the 1,885 babies delivered from the 1,845 charts, only 17 birth injuries were

recorded. Again, only data for the first o f each o f the 40 sets o f tw ins w ere available. O f these

3(0.2% ) suffered cephal haem atom a w hile 14 w ere born w ith congenital abnorm alities such as

anencephaly, extra digits, haem agiolym phangiom a, ectropion o f left eye. hydrospadias,

exom phalous and supra-um bilical cord. Birth injuries w ere recorded for 6 neonates in the

group whose partographs were adequately com pleted, while 11 occurred in the group whose

partographs were inadequately com pleted. The num ber was sm all but Chi Square analysis

50


was done. No betw een-group differences were found. The hypothesis was not supported (X2

-0 .9 , d f l ,p = 0 .2 5 ) .

l or the 464 charts w here it was recorded that the action line was crossed, there were no

differences between those w here tim ely action was taken and those w here tim ely action was

not taken (X2=0.004. d f 1 p=0.63).

c) There will be fewer adm issions to the neonatal intensive carc unit (NICU) docum ented

in the charts o f w om en w here the partograph was used adequately than in those where

the partograph w as used inadequately.

Inform ation was available on 1,841 records. O f these, 243 new borns, excluding twins

were adm itted to N IC U . O f these, 62 were routinely adm itted because o f C/S and 181 were

adm itted because o f other problem s.

The tim eliness o f intervention after the action line was crossed was evaluated. Again,

there were more adm issions to NICU in the group w here action was not taken in a timely

m anner (X 2=7.8 d f 2. p<0.02).

d) There will be few er neonatal deaths (during the intrapartum and w ithin 2 w eeks o f

birth) docum ented in the charts o f w om en w here the partograph was used adequately

than in those w here the partograph was used inadequately.

There were 29 neonatal deaths. The sam ple size was small but Chi Square analysis was done

and there were no differences in the num ber o f deaths betw een those w hose partograph was

adequate and those w hose partograph was inadequate. The hypothesis was not supported

(X2“0.03, d f - 1, p<0.52)

51


CHAPTER FIVE

DISCUSSION

5.1 Summary of Main Findings

In this study, 1,845 retrospective charts were review ed and the adequate and

inadequate use o f the partograph was analysed using three m ain hypotheses. The study

findings revealed that there w ere m ore m aternal interventions, i.e., augm entation, A R M and

assisted births, recorded in the charts o f w om en w hose partograph was adequately used. There

were slightly m ore w om en w ith pyrexia and others readm itted to hospital docum ented in the

adequately used charts. H ow ever, when the partograph w as adequately used, w om en w ere less

likely to haem orrhage (i.e., experience a blood loss o f m ore than 500 m illilitres). W ith respect

to newborn outcom es, those w hose partographs were adequate w ere less likely to have A pgar

scores o f 7 or m ore at 1 m inute o f age. In those charts w here partographs w ere inadequate,

newborns had few er adm issions to the NICU. N o betw een-group differences in the num ber o f

birth injuries or neonatal deaths were recorded in the charts o f w om en w hose partograph w ere

used adequately. The study also revealed that 472 (25.6% ) out o f the 1,845 charts review ed

were adequately filled out in accordance w ith W HO guidelines.

D ata w ere further explored by com paring w hether or not tim ely action w as taken when

the action line on the partograph was crossed. The action line w as crossed on the partographs

o f 464 charts. In these, action was taken in a tim ely m anner on 238 (48.7% ) occasions. W hen

action was taken in a tim ely m anner, 1-m inute A pgar scores w ere higher.

5.2 Discussion of Results

This study was designed to investigate the relationship betw een the use o f the partograph

and birth outcom es. A retrospective chart review o f both prim iparous and m ultiparous

52


deliveries from May 01 to June 30, 2003 was conductcd. C harts ol 1,845 w om en who m et the

inclusion criteria were assigned to two groups; om issions or no om issions based on W HO

criteria. D ata were analysed and discussed for each o f the three m ain hypotheses that guided

the data collection. Each hypothesis had three or four sub-hypothesis and the d iscussion

covered all these hypotheses.

Hypothesis 1 was highly significant. It clearly revealed that adequate use o f the

partograph indicates m ore interventions, in term s o f oxytocin augm entation, artificial rupture

o f m em branes and assisted deliveries. These findings are com pared w ith a previous m ulti

centre trial conducted by W HO in South East A sia on the use o f the partograph in clinical

practice, w hich revealed that com petent use o f the partograph can save m aternal lives by

ensuring that labour is closely m onitored and that life-threatening com plications such as

obstructed labour are identified and treated (M aternal and N eonatal H ealth, 2002). However,

this was not evident in th is study since only 226(48.7% ) out o f the 464 w om en w hose labour

crossed the action line had interventions taken in a tim ely m anner. Even though action was

taken for the rem aining 238(51.7% ) w om en, they could have been am ong those w om en whose


It was hypothesized (Hypothesis 2) that there will be less in trapartum and postpartum

(within 2 w eeks o f birth) m orbidity docum ented in the charts o f w om en w here the partograph

was used adequately than in those where the partograph w as used inadequately. There were

slightly m ore w om en who had pyrexia as was recorded on the partograph w hich was

adequately used. These w om en may have been m onitored m ore accurately; it is also possible

53


that those whose charts were inadequately m onitored had their charts w ere filled out after

delivery.

W om en w ere less likely to haem orrhage if their partograph was adequately filled out.

However, slightly m ore o f these w om en were readm itted to hospital during the first 2 w eeks

o f the postnatal period. The health status o f a w om an m ay determ ine her ability to survive

pregnancy, labour and delivery as well as puerperium (Royston and A rm strong, 1989). There

were 13 m aternal deaths relating to com plications o f labour and delivery recorded during the

stud)' period but only 1 chart w as retrieved. This num ber w as insufficient to analyze and

therefore the relationship betw een m aternal death and the adequacy o f partograph use cannot

be assessed. W HO (1994) literature suggested that if the partograph w as appropriately used, it

has the potential o f reducing infant and m aternal m orbidity and m ortality.

It was further hypothesized (Hypothesis 3) that there w ill be less new born m orbidity

docum ented in the charts o f w om en where the partograph w as used adequately. There were

more new borns w ith A pgar score o f 7 or m ore and reduced num ber o f adm issions to the N IC U

in those w om en w hose partographs w ere inadequately filled out. No betw een-group

differences w ere observed in the num ber o f birth injuries or neonatal deaths w ith in 2 w eeks o f

birth. This finding differs from that found in a W HO study in South East A sia in w hich 35.000

partographs from eight hospitals were surveyed. They reported a rem arkable im provem ent in

newborn outcom es in the area o f intrapartum foetal deaths, A pgar scores, resuscitation

m easures and adm ission to neonatal spccial care facilities. It w as o f interest that there did not

appear to be an im pact on neonatal health or that it may have even been com prom ised by

adequate use ol the partograph. However, it m ust be noted that there w ere m ore m aternal

54


interventions during labour for the group w hose partographs w ere adequately com pleted.

These assisted births could well have contributed to the higher m orbidity that was observed.

There did not appear to be a “buy-in” for partograph use in G hana since only 26

percent o f the partographs in this study were adequately used. It is possible that partograph

use in South East A sia w as m ore w idespread so that greater opportunities existed to assess its

impact on the outcom es o f m aternal and neonatal health.

5.3 Threats to Validity

In this section, potential threats to the validity o f this study will be addressed and

strategies that w ere used to m inim ize the threats w ill be described. Threats to internal validity

will be identified so that rival explanations for study findings can be considered. H istory is a

m ajor threat to the internal validity o f this study in that data w ere transcribed from the records

o f 1,845 available charts. Som e charts were m issing including all but one o f the 13 w om en

who died during the intrapartum period. B ecause o f this, the num ber o f m aternal deaths

(n=29) is likely underestim ated. It is not possible to know w hether these m issing records

would alter the relationship between the adequacy o f the partograph and m aternal and neonatal

mortality. A nother threat to history and also selection is that data w ere gathered during the

two busiest m onths o f the year (i.e., M ay and June) in that there w ere m ore births and m ore

m aternal m ortality than during other m onths. It is not possible to assess the im pact that

increased w orkload may have had on m aternal and neonatal outcom es in a clim ate where

serious nursing shortages already exist.

The historical threat that is o f greatest concern is always a concern for epidem iologists.

Inform ation on the charts w ould be affected by integrity o f the many individuals who would

55


have recorded the inform ation. Entries w ere m ade by providers in a very large national

hospital as well as by those in sm aller hospitals and polyclinics who m ade a decision to

transfer their patients to K orle Bu Teaching Hospital. On inspection o f several o f the

partographs, it was clear that all inform ation was recorded at the sam e tim e; w e can speculate

that this would have happened at the tim e o f birth, transfer to the tertiary care facility or when

a labouring w o m an 's condition had clearly deteriorated. Since few providers adequately

com pleted the partograph (25.6% ) the “buy-in” by providers has not occurred. Finally, w ith

respect to history, the investigator is not aw are o f m edia reports or other events during the

study period that may have influenced attitudes tow ard the independent variable (i.e.,

partograph). B ecause it w as unclear w hether or not even the adequately com pleted

partographs w ere used to m onitor labour rather than being com pleted retrospectively, the

tim eliness o f in terventions once the action line was crossed w as also assessed.

W hile data entered into patient records was beyond the control o f the researcher, the

criteria for adequacy o f the partograph was established a priori and this criteria w ere applied

to each partograph that was assessed, thus reducing the possib ility in random error when

determ ining the adequacy o f the instrum ent. The researcher w as always present when data

were recorded. W hen she had assistants, inter-rater reliability w as form ally assessed. Any

atypical records w ere d iscussed and consensus was reached. The sam ple size w as large and the

entire population o f eligible charts that could be located w ere included.

It is also im portant to assess the external validity or generalizability o f study findings,

fhe charts o f labouring wom en, including those with atypical pregnancies or m ultiple

gestations that could have a partograph were included. Only those in second stage labour.

56


adm itted for planned instrum ental delivery or where the foetus w as know n to have died in

utero were excluded. W hile a non-probability sam ple was used, it included the entire

population for a specific period o f tim e and was sufficiently large to overcom e selection

effects.

5.4 Limitations

In addition to threats to both internal and external validity w hich have already been

addressed, im portant lim itations will be outlined. The design can be described as an After-

only Non-equivalent Control Group Design (Cam pbell & Stanley. 1966). Ideally, a

prospective study w ould have been conducted so that m ore control could be m aintained.

W om en would have been follow ed from the onset o f labour until 2 w eeks follow ing their

birth. H ow ever, a p rospective design is not feasible for this study because the use o f a tool

(i.e., the partograph) in a real and pre-existing social setting w as being assessed.

N on-param etric tests w ere used in the data analysis as they are based on few er

assum ptions but are less pow erful (W ood & Ross-K err, 2006). The design for this study is

quasi-experim ental in that it was not possible to exert further control by m anipulating the

independent variable or random izing charts to study groups since the condition already existed

in nature. Since full experim ental control was not possible, given the nature o f this study, one

is less confident o f “cause and effect” relationships.

Com puterized patient records w ere not used in the study setting so all data were

recorded by hand from available paper records. D ata from data collection sheets were

transferred to a com puter database. Obviously, errors in both collecting and entering data are

likely. To m inim ize this type o f random error, for the first 10 charts the researcher assessed

57


inter-rater consistency in recording the adequacy o f the partograph, the use o f interventions,

and all m aternal and neonatal outcom es by having a colleague w ith about the sam e level o f

skill and experience also com plete data collection forms. A n agreem ent o f 90 percent was

accepted. Further, a colleague checked every tw entieth entry for accuracy.

5.5 Implications for Nursing Practice

There appears to be an association betw een the appropriate use o f the partograph and

birth outcom es but m ore needs to be done in the tim ing o f interventions to help save the lives

o f m others and their babies. A lthough the providers used the partographs for all w om en in

labour most did not use them adequately or perhaps even prospectively. Som e im portant

com ponents, for instance, uterine contractions, foetal condition and m aternal pulse w ere not

assessed and plo tted correctly. In all, it appeared the partograph w as not correctly filled out as

specified in the W H O guidelines.

The partograph serves as an “early w arning system ” and assists in early referral,

augm entation and term ination. It is therefore im perative that the nurses/m idw ives and

obstetricians be well inform ed or rem inded o f their responsibilities regarding labour

m anagem ent and how they affect birthing outcom es.

5.5.1 Implications for Nursing Education

Periodic in-service education program m es and supervision for all nurses, m idw ives

and other health care w orkers providing m aternity services to pregnant w om en are o f

param ount im portance in order to secure correct use o f the partograph and im prove labour

managem ent.

58


Em phasize the im portance o f m onitoring and appropriate action that is needed w hen

the progress o f labour, m aternal vital signs, and neonatal assessm ent fall outside acceptable

variations.

A priority in providing a high standard o f m aternity care needs to be put in place to

ensure that students are adequately supervised by highly skilled preceptors or m entors who

can serve as m odels w ho provide a high level m aternity care.

5.5.2 Implications for Research

The value o f the partograph as a Safe M otherhood intervention needs to be assessed

since neonates in this study did not appear to have im proved outcom es and in terest am ong

providers appeared low.

Q ualitative study to further understand why health professionals are not com m itted to

using partograph.

Q uantitative studies to further understand why tim ely action w as not taken w hen the

action line w as crossed. A vailability o f intervention? A vailability o f personnel?

5.6 Recommendations

In view o f the extensive literature review s on the use o f the partograph and its effect on

labour, m ost o f the research to date has been on prospective studies. The social, econom ic and

em otional burden that fam ilies face w hen they lose any relative through childbirth cannot be

over-em phasized. The researcher w ishes to m ake the follow ing recom m endations

• O rganize continuous educational program m e to update know ledge and skills o f

nurses/m idw ives in labour m anagem ent and care o f the new born.

59


• D evelop educational m odels that can be delivered to m ore rem ote clinics as well as

be used by nurses/m idw ives in larger tertiary care centres that will address both the

com m itm ent needed and skill level necessary to appropriately docum ent m aternal

progress and m aternal and foetal status using a partograph.

• Develop a sim ilar educational m odel that may be used to assist nurses/m idw ives in

decision m aking once an action line is crossed.

• A protocol for appropriate and tim ely action using recom m ended interventions

needs to be developed and prom inently displayed on the w ards so that attending

m idw ives can apply them prom ptly and effectively.

• D evelop periodic in-service training for personnel at the M edical S tatistics and

D ocum entation U nit (Records departm ent) in the health care facilities to im prove

the filing system and ensure easy retrieval o f patien ts’ charts/folders. M issing

records m ust be located and appropriately filed.

• Lobby the Reproductive and Child Health (RCH) Unit o f the M inistry o f Health to

consider com puterizing m aternal/child records as a priority.

• W ork w ith key representatives in the Maternal and Child Health Unit o f the

M inistry o f Health to evaluate the efficacy o f the use o f the partograph in G hana

and identify barriers to appropriate use.

• P resentation o f findings locally to the tertiary institutions (K orle-B u and Komfo

A nokye Teaching H ospitals), the RCH unit o f the various health care facilities.

N urses’ and M idw ives Council for Ghana and Ghana R egistered N urses/M idw ives

60


A ssociations. Further, to w ider A frican audience and W H O (Safe M otherhood

Project).

5.7 Conclusion

In sum m ary, the study w hich was a retrospective chart review sought to assess the

relationship between the use o f the partograph and birthing outcom es. The m ethod used has

inform ation about sam ple, instrum ent and procedure. The data w ere analysed using sim ple

statistical tools such as percentages, bar charts, m easures o f central tendency (m eans, m edian),

variability (ranges, standard deviations) and chi-square. The results o f the study revealed that

472 (25.6% ) partographs w ere appropriately filled and tim ely in terventions w ere taken for

226(48.7% ) w om en w hose labour crossed the action line. Tw o hundred and fifty-nine (13.7% )

babies were adm itted to N IC U w ith varying conditions. The partograph m ay be o f great value

in clinical practice today if it is accurately used by skilled nurses, m idw ives and obstetricians

to help reduce m aternal and infant m orbidity and m ortality.

61


Af'f'fcN&lX f\mioMomm P A R T O G R A P H

' Page 8N a m e ........................................................................................................................................................

Date o f adm iss ion


PARTOGRAPH

DELIVERY AND C O M PL IC A T IO N S

M E T H O D OF D E L IV E R Y ; . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DATE A N D T I M E O F D EL IV ERY.

D U R A T I O N O F L A B O U R : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

C O M P L I C A T I O N S : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

BABY: S EX : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

C O N D I T I O N OF B ABY: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

A P G A R S C O R E :

IMN________ 5INI INS

A PPEA R A N CE ___________________

PULSE

GRIMACE

ACTIV ITY

RESPIRATION

TOTAL

Delivery By:


APPENDIX B

WHO GUIDELINES IN THE USE OF THE PARTOGRAPH

A. FOETAL CONDITION

I. FHR record FHR every hour but if foetal heart is irregular, check it every 15

m inutes

II. Membranes and liquor - assess and record the state o f m em branes and liquor on

adm ission and every 4 hours

III. M oulding - record degree o f m oulding 4 hourly

B. PROGRESS OF LABOUR

IV. Descent of foetal head - assess level o f presenting part on adm ission and every 4

hours

V. Cervical d ilatation- assess cervical dilatation on adm ission and every 4 hours.

V aginal exam ination m ay done frequently if the need arises

VI. Uterine contractions - plot uterine contractions h a lf hourly

C. MATERNAL CONDITION

VII. Blood pressure - record BP 4 hourly

VIII. Pulse - record pulse hourly

IX. Temperature - record tem perature 4 hourly

X. Urine (urinalysis) - test urine 4 hourly.

63


APPENDIX C

CHECKLIST (Data Collection Sheet)

Participant No.DEMOGRAPHIC CHARACTERISTICS OUTCOMES

1 2 3 41. Dem ographic characteristicsa. Ageb. Parity

0 ’1

2 - 5 More than 5

c. Marital status married single

d Occupation UnemployedSelf-employed (inform al private sector) Formal private sector Public sector

e. Mode o f last delivery Non-applicable (N/A)Normal spontaneous vaginal birth(NSV B) Caesarean section (C/S)Vacuum extraction (V/E)Forceps delivery (F/D)

f. Gestational age on onset o f labour37 weeks or less38 weeks or m ore

2. Maternal Interventionsa. Oxytocin augm entation Yes

Nob. ARM during labour

YesNo

c. A ssisted deliveryC/SV/EF/DFipisiotomyBreech

64


3 M aternal O utcom esa. Pyrexia above 37.5C

YesNo

b. H aem orrhage o f 500ml andaboveNo haem orrhage - less than 500ml M oderate - 5 0 0 - 1000ml Severe - m ore than 1000ml

c. Readm ission to hospital w ithin 2 weeks o f birth

d. M ortality YesNo

4. N ew born O utcom esa. Apgar scores at 1 m inute o f age

6 or less 7 - 1 0

b. Apgar scores at 5 m inutes o f age6 or less 7 - 1 0

c. Birth injuryCephal haem atom a O thers

d. Adm itted to N ICU YesYes but after operative delivery' No

e. M ortality YesNo

5. Partographa. Adequate

No om ission M inor om ission

b. InadequateM oderate om ission M ajor om ission

c. Date and tim e action line was crossed

d. Action taken in tim ely m annerYesNo

65


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