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.
Keywords: Effectiveness, Training, Midwives, Partograph, Utilisation.
Word Count: 416
TABLE OF CONTENTS
Content Page
Title Page i
Certification ii
Dedication iii
Acknowledgements iv
Abstract v
Table of Contents vi
List of Tables ix
List of Figures xi Appendices
CHAPTER ONE: INTRODUCTION
1.1 Background to the Study 1
1.2 Statement of the Problem 5
1.3 Objective of the Study 5
1.4 Research Questions 6
1.5 Hypotheses 6
1.6 Scope of the Study 6
1.7 Significance of the Study 6
1.8 Justification for the Study 7
1.9 Operational Definition of terms 8
CHAPTER TWO: REVIEW OF LITERATURE
2.0 Introduction 9
2.1 Knowledge and use of the Partograph 10
2.2 Partograph Training and Monitoring/Supervision 15
2.3 Use of the Partograph as a Referral tool 18
2.4 Effect of the partograph on labor and maternal and neonatal outcomes 19
2.5 Use of partograph and incidence of prolonged or
augmented labor and operative delivery 20
2.6 Impact of partograph use on maternal and perinatal complications 22
Content Page
2.7 Providers’ attitudes about the partograph and barriers to use 23
2.8 Lack of access to partograph forms 24
2.9 Partograph improves quality of health care 25
2.10 Partograph is well used for referral, but transport can be inadequate 25
2.11 Lack of emotional consideration 25
2.12 Adaptations to the who partograph 26
2.13 Conceptual Model 29
2.14 Conclusion 31
CHAPTER THREE: METHODOLOGY
- Introduction 32
- Research Design 32
- Population 32
- Sample size and sampling Technique 33
- Instrument for Data Collection 34
- Pilot Study 35
- Method of Data Collection 35
- Method of Data Analysis 36
- Ethical Consideration 37
CHAPTER FOUR: DATA ANALYSIS, RESULTS
AND DISCUSSION OF FINDINGS
4.0 Introduction 38
4.1 Data Presentation 39
4.2 Analysis of Research Questions 41
4.3 Test of Hypotheses 48
4.4 Discussion of Findings 50
CHAPTER FIVE: SUMMARY, CONCLUSION AND
RECOMMENDATIONS
- Summary 55
- Conclusion 56
- Recommendations 57
- Limitation of the Study 58
- Suggestion for further studies 58
REFERENCES 59
APPENDICES 66
LIST OF TABLES
Table Page
- Showing the Categorization of the Midwives in the Study Area 34
- Showing an Outline of the Proposed Training Program 36
- Showing Demographic Characteristics of Participants 39
4.2 Showing Descriptive statistics of midwife’s years of experience and 40
average number of nurse-midwives per shift in labour ward
4.3a Showing Knowledge on utilization of partograph 41
4.3b Showing Definition of partograph 42
4.3c Showing Assessment of midwives skills and knowledge on the utilization 43
of partograph
4.3d Showing Summary of Descriptive and inferential statistics of pre-test 44
knowledge of midwives on the utilization of partograph
4.4a Showing Frequency of usage of the partograph for women in labour ward 45
4.4b Showing Percentage response showing the utilization of partograph 45
by midwives in monitoring the progress of labour
4.5a Showing Training outcome of midwives on the utilization of partograph 47
4.5b Showing Summary of Descriptive and inferential statistics of post-test 48
knowledge of midwives on the utilization of partograph.
- Showing Descriptive statistics of post-test scores and cross tabulation of 49
participants by treatments
- Showing t-test difference in pre-utilization of partograph by trained 49
and untrained midwives
- Showing t-test difference in post-utilization of partograph by trained 50
and untrained midwives
LIST OF FIGURES
Content Page
- Wiedenbach’s model 31
APPENDICES
Appendix Page
- BUHREC Certification
- Informed Consent Form 66
- Questionnaire 67
- Pictures from Field Work 72
CHAPTER ONE
INTRODUCTION
- 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.
- 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;
- 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?
- How well do midwives in selected General hospitals utilise partograph to monitor the progress of labour?
- What is the outcome of training midwives on the use of partograph to enhance its usage on patients care?
- 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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