Feasibility and effectiveness of electronic vs. paper partograph on improving birth outcomes: A prospective crossover study design

Abstract

BackgroundThe partograph has been endorsed by World Health Organization (WHO) since 1994 which presents an algorithm for assessing maternal and foetal conditions and labor progression. Monitoring labour with a partograph can reduce adverse pregnancy outcomes such as prolonged labor, emergency C-sections, birth asphyxia and stillbirths. However, partograph use is still very low, particularly in low and middle income countries (LMICs). In Bangladesh the reported partograph user rate varies from 1.4% to 33.0%. Recently, an electronic version of the partograph, with the provision of online data entry and user aid for emergency clinical support, has been tested successfully in different settings. With this proven evidence, we conducted and operations research to test the feasibility and effectiveness of implementing an e-partograph, for the first time, in 2 public hospitals in BangladeshMethodsWe followed a prospective crossover design. Two secondary level referral hospitals, Jessore and Kushtia District Hospital (DH) were the study sites. All pregnant women who delivered in the study hospitals were the study participants. All nurse-midwives working in the labor ward of study hospitals were trained on appropriate use of both types of partograph along with standard labour management guidelines. Collected quantitative data was analyzed using SPSS 23 statistical software. Discrete variables were expressed as percentages and presented as frequency distribution and cross tabulations. Chi square tests were employed to test the association between exposure and outcome variables. Potential confounding factors were adjusted using multivariate binary logistic regression methods. Ethical approval was obtained from the institutional review board of the International Centre for Diarrheal Disease Research, Bangladesh (icddr,b).FindingsIn total 2918 deliveries were conducted at Jessore DH and 2312 at Kushtia DH during one-year study period. Of them, 1012 (506 in each facility) deliveries were monitored using partograph (paper or electronic). The trends of facility based C-section rates was downwards in both the hospitals; 43% to 37% in Jessore and from 36% to 25% in Kushtia Hospital. There was a significant reduction of prolonged labour with e-partograph use. In Kushtia DH, the prolonged labour rate was 42% during phase 1 with the paper version which came down to 29% during phase-2 with the e-partograph use. The similar result was observed in Jessore DH where the prolonged labour rate reduced to 7% with paper partograph from the reported 30% prolonged labour with e-partograph. The e-partograph user rate was higher than the paper partograph during both phases (phase 1: 3.31, CI: 2.04–5.38, p < .001 and in phase 2: 15.20 CI: 6.36–36.33, p < .001) after adjusting for maternal age, parity, gestational age, religion, mother’s education, husband’s education, and fetal sexConclusionThe partograph user rate has significantly improved with the e- partograph and was associated with an overall reduction in cesarean births. Use of the e-partogra...

Need for more evidence in the prevention and management of perinatal asphyxia and neonatal encephalopathy in low and middle-income countries: A call for action

“…The feasibility of electronic partogram (e-partogram) to ensure real-time recording has been studied in various LMICs [ 32 ]. A prospective study from Bangladesh involving 5230 deliveries comparing paper partograph versus the e-partogram reported reduced caesarean section rates (36 %–25 %, p = 0.001) and prolonged labor with the use of e-partogram [ 33 ]. The user rate of e-partogram showed three-fold increase (OR 3.31; 95 % CI, 2.04–5.38; p < 0.001) compared to the user rate with paper partogram.…”

A Tablet-Based Tool for Care During Labor+Attention to System Requirements

“…The evidence from this and similar studies is not yet sufficient to recommend large-scale adoption 8 – 10 . Nevertheless, a strong case can be made for further rigorous study to better characterize what improvements can be achieved in care during labor using such tools and what system requirements must be met to achieve such improvements (such as those identified by Bedwell et al 6 ).…”

Use of mHealth tools to register birth outcomes in low-income and middle-income countries: a scoping review

“…One crossover study comparing the E-partograph with the paper version found higher user rates during the electronic phase in both sites. 12 Another study found that all measurements except fetal heart rate and contractions were recorded more frequently in the ePartogram compared with paper. 11 However, SBAs found that it was more difficult to correct errors in data entry using the ePartogram, which was not an issue with the paper charts.…”

“…11 Improvements in birth outcomes was also seen in studies investigating the E-partograph in Bangladesh. 12 However, a separate study of the E-partograph in Ethiopia found only 46% of care providers would be willing to use a mobile-based E-partograph, despite 65.8% of caregivers reporting they wished to use a partograph routinely. 13 Three other technologies were identified that had a digital partograph as part of their workflow.…”