ABSTRACT
Maternal
mortality continues to be a global burden worldwide. Each year, more than 200
million women become pregnant and a large number of mothers die as a result of
complications of pregnancy or childbirth. Nigeria is still one of those
developing countries with high maternal mortality ratio and child mortality
rate, estimated at 340/100,000 and 21/1000 live births respectively. The World
Health Organisation (WHO) has recommended the use of partograph to monitor
labour and delivery, in order to improve healthcare and reduce maternal and
foetal mortality rate.
The
study examined the effect of training midwives on the utilisation of
panrtograph in general hospitals in Ogun east senatorial districts;
quasi-experimental design was used for the study. The study used two groups-
intervention and control groups using right inclusion and exclusion criteria.
The entire population comprised of 45 midwives providing obstetric care in the
labour ward. A structured questionnaire which contained close ended questions was
used to elicit information from the participants. Face and content validity of
the instrument were determined while their reliability indices of 0.75 and 0.86
respectively were established using split-half test and spearmen brown’s
formula. Statistical package for the social sciences (SPSS) version 22.0 was
used for the statistical analysis and a coding of variables in this
quantitative research was utilised for better interpretation of results.
Descriptive analysis (frequency, percentage, mean and standard deviation) was
used to analyze the demographic characteristics of the participants. t-test was
used to determine the difference in mean score of pre and post-test of the
sampled midwives in the selected general hospitals.
The
study showed that 45(100.0%) of the participants where all female midwives,
(82.2%) of the participants where within the ages of 30 and 49, 27(60.0%) of
the participants where registered midwives. The t-test result indicate that
there is no statistically significant difference between intervention group and
control group prior to partograph training intervention (t=-2.375; p>.05).
It also indicate that there is a statistically significant difference between
intervention group and control group immediately after partograph training intervention
(t=-1.5.46; p<.0.5).
It
was concluded that intervention training enhanced the knowledge and skills
midwives in the use of partograph. Therefore it was recommended that midwives
should be exposed to regular in-service training on the use of partograph to
monitor the progress of labour. Hence, it is important that nurses and midwives
are empowered with necessary knowledge and skills that are linked to job
responsibilities and roles.
CHAPTER
ONE
INTRODUCTION
1.1
Background
to the Study
Globally, labour has
been defined as a physiological process characterized by an increase in
myometrial activity resulting in cervical effacement and dilatation; followed
by the expulsion of the foetus from the uterus to the outside world. It is
therefore imperative for midwives to monitor the woman in labour utilising a
partograph in order to have a safe delivery; and to avoid obstructed and
prolonged labour (Ratchliffe, 2010).
A partograph is an
effective clinical tool used during labour surveillance for early diagnosis of
complications. The partograph is a
simple chart that, when used routinely for every birth, aids the monitoring of
labour and provides early warning of the need for intervention so health
workers can provide prompt, appropriate care (World Health Organisation, 2014).
Partograph was developed by an obstetrician named Friedman, which he tagged as
cervicograph as a result of its usefulness to monitor cervical dilatations.
Furthermore, cervicograph was adopted by Philpott in 1972 and he redesigned it
as partograph to serve as a practical device in the documentation of all
intrapartum observations and not only to monitor cervical dilatation, hence,
the phrase “Philpott’s partograph”. This new document contains action lines and
alert lines which are used to determine cases of prolonged labour.
In 1988, Safe
Motherhood Initiative established the adoption of partograph as a global
practical device that is of high quality to monitor labour and avert prolonged
labour. Furthermore, extensive examination was conducted in 2014 by WHO and the
organisation established a scientific based rationale for the use of partograph
as the aversion of maternal morbidity and prolonged labour. However, when
correctly implemented, partograph minimize cases of obstructed and prolonged
labour as well assist in identifying heart abnormalities which can have
intrapartum foetal hypoxia as its consequences.
(Cronje and Grobler,
2012; Dangal, 2011) described the partograph as a graphical representation of
progressive stages of labour, related situations or parameters on pregnant
mother and foetus, displaying all investigation made during the first stage of
labour in a manner that will enable midwives and medical practitioners to
analyse, interpret and recognise if the pregnant woman has moved into a high
risk category and to respond decisively to the identified problems.
With reference to the
World Health Organisation (2014), the utility of partograph to observe pregnant
women in labour does not serve as an alternative for proper assessment of
conditions that needs instant reference of pregnant women on the arrival at the
labour unit. World Health Organisation
(2014) further states that the partograph is developed for timely
identification of abnormal progress of labour and the aversion of prolonged
labour which would significantly reduce the risk of postpartum hemorrhage and
sepsis as well eradicate obstructed labour, prolonged labour, uterine rupture
and its sequelae. The organisation further affirm that the purpose of the use of
partograph to examine pregnant women in labour is to lessen morbidity and
mortality rate of pregnant women globally, to develop the level of care of
pregnant women during labour session, to develop the observational abilities
and skills of the midwives, to assist in the advancement of team work in a bid
to ease the referral to specialist units and promote timely referral from the
primary health units.
A randomized study was
conducted on 434 women in Mexico in 1966 to test for the effectiveness of the utilisation
of the partograph during labour using Friedman’s partograph and a non-graphical
descriptive chart. The women were randomized to either Friedman’s partograph or
a non-graphical descriptive chart. The study revealed that those who were not
put on the partograph had more operative deliveries and more babies with low
Apgar scores at 5 minutes. Another study
conducted in Karachi by Bhutta, Javed, and
Shoaib, (2010) tested the role of the partograph in preventing prolonged
labour, the objective of the study was to determine the effect of the
partograph on the frequency of prolonged labour, augmentation of labour,
operative deliveries and appropriate interventions based on the partograph to
reduce maternal and perinatal complications.
A case-controlled prospective and interventional study on 1000 women in
labour was carried out in the obstetric units of Jinna Postgraduate Medical
Centre, Karachi. Five hundred (500)
women were studied before and after the introduction of the partograph. The
results showed that there was a reduction in both the duration of labour and
the number of augmented labour and vaginal examinations. It was concluded that by using the partograph
to monitor pregnant women in labour reduced the frequency of prolonged labour,
augmented labour, postpartum hemorrhage, ruptured uterus, puerperal sepsis and
perinatal morbidity and mortality rates.
In spite of the
continual use of the partograph in the health care industry; and wide record
keeping of its effectiveness (Chongsuvivatwong & Fahdhy 2015; Fawole &
Fadare, 2010)
recorded variation attainable with the use of
partograph across health care facilities in Nigeria. It was revealed that in
two separate tertiary hospitals, 84% of midwives had good knowledge on
partograph and average of 31% of partograph graphs was correctly filled.
Hindrances in the effective utilisation of partograph were discovered by Opiah
on cases such as absence on the use of partograph charts (30.3%), and
under-staff (19.4%). The absence of knowledge and the use of partograph were
discovered by (Fawole et al. (2010); Daniel, Oladapo, & Olatunji, 2016)
among different levels of maternity health providers in all three levels of
health care. A report was also submitted showing that previous training
significantly improved the knowledge and accurate use of partograph.
Researchers also
indicated that tertiary health workers employs partograph unlike their
counterparts in secondary and primary level health workers. Furthermore,
research also indicates that just 33.7% cases of 1,319 deliveries were
monitored with the effective use of partograph which influenced decision making
as well as associated positive labour result available among low and high risk
cases. However the extent of which partograph is being employed neither
attitude of midwives as a means to attainment of effective or non-utilisation
of partograph is not available in literature. The aim of the utilisation of
partograph is to empower midwives with plotting, analysis and interpretation
skills when monitoring pregnant women in labour.
In the study conducted
by Chongsuvivatwong & Fahdhy (2015), it is stated that the partograph was
introduced in Indonesia in 1998, and the new version of the World Health
Organisation (WHO) partograph was brought into Indonesia in 2000. The aim of the study was to assess the
effectiveness of promoting the utilisation of the partograph by midwives caring
for women in labour. Previously, before
research, it was however discovered that utilisation of partograph was not
carried out by midwives because complains were given that partograph’s
completion is highly complicating. It was however observed that utilisation of
partograph was as a result of midwives education, training and supervision
which led to notable reduction in the number of vaginal assessment,
augmentation of labour, obstructed labour, poor Apgar score and increased
transfer to mention but a few. Furthermore Alfirevic, Lavendor and Walkinshaw
(2016) support that if progress of labour crossed the action line; a diagnosis
of prolonged labour was made and managed according to protocol. The results of
this study showed that the use of the 4 hour action line partograph improved
the maternal and neonatal outcomes.
The use of partograph
as a device for intrapartum assessment by midwives in sub-Saharan Africa is
still a challenge, a notion supported by the study conducted in South West
Nigeria by Adekanle, Fawole and Hunyinbo (2008) who found that a partograph is
commonly not employed to monitor pregnant women in Nigerian as a result of
insufficient idea about partograph.
Furthermore, the
authors concluded that the maternal mortality rate in Nigeria is a major public
health issue and continues to rise since a partograph is not effectively used
as a tool for monitoring labour. Nakkazi (2010) indicates that midwives often
feel that completing the partograph is an additional time-consuming task, and
they do not always understand how the utilisation of the partograph to monitor
pregnant women in labour can be life-saving. Thus, some midwives take the
partograph lightly as they plot the partograph when pregnant women who were in
labour have already delivered. Midwives often argue that they do not have time
to plot the partograph during the monitoring of pregnant women in labour. The
National Department of Health (2010) further states that all midwives should
employ the partograph when assessing pregnant women in labour so that problems
identified during monitoring of labour can be attended to promptly by both the
midwife and the attending doctor. Therefore, utilisation of the partograph
increases the analysis and interpretation skills of midwives, the monitoring of
pregnant women in labour and thus aids in providing standardized fetal and
maternal care, and accordingly improves midwifery care.
Researchers ascertained
that to effectively use the partograph, requires knowledge and skills.
Therefore, education, training and supervision of the midwives will results in
a higher rate of the utilisation of the partograph which will reduce the number
of virginal examinations, prolonged labour, augmented labour, poor apgar score
at first minute, obstructed labour and increased referral.
The focus of this
research therefore is to identify midwives’ knowledge on the use of the
partograph as a tool to monitor labor, comparatively assess the use of the
partograph among midwives in the hospital, assess level of deployment of
partograph as a device in each center, identify barriers to its use, determine
the existing relationship with the length of years of experience and knowledge
of the use of the partograph in the hospitals.
1.2 Statement of the Problem
A
number of research studies revealed that there are challenges associated with
the correct and consistent use of the partograph (Lester, 2010; Magon, 2011;
Mathibe-Neke, 2009; Opiah, 2011). The
findings from these studies reveal that there is poor utilisation of the
partograph, which were largely related to the midwives’ lack of competence and
knowledge on the use of the partograph. They submit further that non-
availability of the partograph, shortage of staff, lack of in-service training
and the number of years of experience in intrapartum care are also some of the
contributory factors associated with the poor utilisation of the partograph.
(Magon,
2011; Ogwang et al. (2009); Opiah, 2011) argued that caregivers may regard
filling of the partograph as an additional chore. The study conducted by Lavender, Lee, Mathai,
Omoni and Wakasiaka (2011) also revealed that partographs were filled in
retrospectively, and done only as a defensive practice to avoid being
reprimanded by the matrons. The researcher has also observed from clinical
practice that midwives do not utilise the partograph appropriately when
monitoring pregnant women in labour either by not plotting or incompletely
plotting the activities and also not interpreting the findings as appropriate.
Consequently, labour cases which carry impending dangers to both mother and the
foetus are not usually discovered and managed accordingly. These have often led
to an increase maternal/foetal mortality, morbidity and irreversible damages on
their lives. The purpose of this study, therefore, is to examine the Effect of
training midwives on the utilisation of partograph in General Hospitals in Ogun
East Senatorial District.
1.3 Objective of the study
The
main objective of this study is to evaluate the effectiveness of training
midwives on the utilisation of partograph in General Hospitals in Ogun East
Senatorial District. The specific objectives are to:
- assess
the knowledge of partograph among midwives in general hospitals in ogun
east senatorial district.
- determine
the utilisation of the partograph by midwives when monitoring progress of
labour in general hospitals in Ogun east senatorial district.
3. assess
the effect of training midwives on the usage of partograph.
1.4 Research Questions
The
research questions focus on providing answers to the following concerns;
1.
What skills and knowledge do midwives
have on the utilisation of partograph for monitoring pregnant women in labour
in General Hospitals in Ogun East Senatorial District?
2.
How well do midwives in selected General
hospitals utilise partograph to monitor the progress of labour?
3.
What is the outcome of training midwives
on the use of partograph to enhance its usage on patients care?
1.5 Hypotheses
Ho1
There is no significant difference in pre-test utilisation of partograph of
trained and untrained midwives.
Ho2
There is no significant difference in post-test utilisation of partograph of
trained and untrained midwives.
1.6 Scope of the Study
This
study evaluated the effect of training midwives to improve their knowledge
on utilization
of partograph in general hospitals in Ogun east senatorial district.
1.7 Significance of the Study
This
research is essential to influence the reduction of maternal and neonatal
mortality and morbidity rates, which are on the increase in Nigeria. By creating innovative and other methods on
how to use the partograph, it can increase confidence and facilitate
supervision of junior and learner midwives working in the labour ward so that
the partograph is used correctly and consistently and thus benefit these
categories of staff (Fistula Care and Maternal Health Task Force, 2012). This
could contribute to lifelong learning for all practitioners working in a labour
ward. The barriers and challenges identified in the study could influence
policy making and create an enabling environment for midwife practitioners in
the operational field. Managers have knowledge from the research on how to plan
pre and in-service training of the clinical staff, making them confident and
competent. The most significant benefit would be the improved health care
provided to the mother and child by improved support for the practitioner at
the grassroots level. Confidence and competence in rendering care to the mother
during labour would boost the confidence of the client in the health care
system, and thus also improve its reputation.
1.8 Justification for the Study
The
major determinant to the expansive inconsistency level in care and the outcome
of reproductive health between the advanced and developing countries is based
on maternal mortality ratio. This observation is supported by the global
maternal mortality pattern in which annual loss of more than 515,000 maternal
deaths from complications of pregnancy and childbirth occurring in developing
countries. Among those who survive childbirth at least 8 million develop
serious morbidities and a further 50 million suffer minor complications.
Therefore, the partograph should be used for all women admitted in established
labour as it serves as an “early warning system” and assists in early decision
on transfer, augmentation and termination of labour. It also increases the
quality and regularity of all observations on the fetus and the mother in
labour and aids early recognition of problems.
Maternal
morbidity rate increases because of insufficient facilities in the health care
settings, inadequate attitude and knowledge of plotting the interventions in
the partograph. Therefore, midwives need adequate knowledge regarding the
partograph and its use to reduce the maternal mortality and morbidity rate.
Partograph knowledge helps to improve good attitude and practice in the
clinical performance. Hence, there is a need to assess the knowledge, attitude
and practice of partograph among midwives.
1.9 Operational Definition of Terms
Operational
definition was used to describe the following terms:
Utilisation -
To put to use especially to make profitable or effective use of an approach, in
this study utilisation refers to plotting the partograph correctly and making
appropriate decisions.
Partograph - in
this study a partograph refers to the labour graph provided by Ogun State
Ministry of Health.
Midwife -in
this study, midwife refers to a person trained to assess, monitor, analyse and
interpret labour and conduct delivery of pregnant women.
Effect - it
refers to the extent to which the structured teaching program on partograph has
achieved the desire effect in improving the knowledge of midwives as an
evidenced by gain in knowledge scores.
Training- it
refers to planned teaching programme regarding proper use of Partograph.
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