Use of the partogram in a private hospital in South Africa
Introduction
The maternal mortality ratio (MMR) in South Africa is 269 per 100,000 live births (Pettifor, 2015). South Africa has not been able to reverse its maternal mortality ratio possibly because deaths in the community is under-reported (Mmusi-Phetoe, 2016). Of note is that the reported MMR for South Africa consists only of the facility-based maternal deaths. The institutional maternal mortality ratio (iMMR) in South Africa decreased from 176.22 per 100,000 live births in 2008–2010 to 154.06 per 100,000 live births in 2011–2013 (Saving Mothers 2011–2013) and 134.3 per 100,000 live births in 2014–2015 (Bhardwaj et al., 2018).
The iMMR for private hospitals is approximately 45 per 100,000 live births (Saving Mothers 2011–2013). This may be due to early intervention and the high caesarean section rate in the private sector. Approximately 67% of births in the private sector of South Africa are conducted by caesarean section, similar to studies conducted in Mexico. Caesarean birth in the private sector in South Africa has become standard practice, with no clear medical indication. As in Mexico, most caesarean sections performed are either elective or due to obstetric convenience and the practice of admitting women to labour wards before they are in active labour (Aranda-Neri et al., 2017). Although the number of maternal deaths are much lower in the private sector, the pattern of disease resulting in maternal deaths is similar. Haemorrhage associated with caesarean section occurred in 17% of private cases, compared to one third of cases in the public sector (Saving Mothers 2011–2013, Saving Mothers 2014–2016). It is reported that all women in the high resource private sector in South Africa are monitored with the partogram during the intrapartum period as recommended by the World Health Organisation (WHO, 2016). It also appears however, that this does not necessarily bear a direct relationship to mode of birth.
Intrapartum monitoring and early detection of abnormal labour progress can significantly improve the outcome of labour (Tayade and Jadhao, 2012). There appears to be conflicting evidence in terms of routine partogram use and improved outcomes for women and newborns (Bedwell et al., 2017). Two Cochrane reviews (Lavender et al., 2013; Lavender et al., 2018) concluded that routine use of the partogram for labour surveillance did not improve the clinical results for the mother and infant. Midwives find partogram use to have practical benefits in terms of ease of use, time resourcefulness, continuity of care and educational assistance, but routine use may reduce midwife autonomy and limit the flexibility to treat each woman as an individual (Weerasekara, 2014). Quality-of-care audits of 163 South African facilities identified a reduction of perinatal mortality rates in some facilities and an increase in others (Allanson and Pattinson, 2015). The contributing factors identified in the audit included foetal distress not detected with monitoring and poor progress of labour with incorrect interpretation of the partogram. The partogram provides healthcare professionals a pictorial overview of the foetal condition, progress of labour and maternal condition to allow early identification and diagnosis of pathological labour (Salama et al., 2010). South Africa adopted a partogram with 2 h action line that represents the extreme of poor progress where ‘action’ such as transferring the woman from a clinic to hospital, oxytocin infusion or caesarean section is mandatory (National Department of Health, Guidelines for Maternity Care, 2015).
Despite the use of the partogram, it has been observed in South African tertiary, district and private hospital, that midwives do not record appropriately on the partogram when monitoring women in labour. Midwives either do not plot the partogram, plot inaccurately and then do not analyse or interpret the findings correctly, or only plot after delivery of the baby. An unpublished audit of 38 files at a district hospital in 2013 by a community of practice group to determine completion of the partogram during the active phase of labour revealed the foetal heart rate was recorded half-hourly on 10 of the 38 partograms and contractions and the maternal condition on 14 of the 38 partograms.
In a study conducted by Shokane et al. (2013) in Limpopo Province of South Africa, most of the midwives indicated that they failed to monitor and plot their finding of the latent and active phase of labour correctly as the partogram had too many details to complete. The study also found that the majority of the participants knew to examine and assess progress of the women during labour, but lacked knowledge in terms of cervical dilatation. Konlan et al. (2016) reported similar findings in Ghana. Findings overall suggest inadequate knowledge and skills on partogram use.
It is likely that there is a number of contributory knowledge factors associated with inappropriate use of the partogram. Insight into maternal care providers’ perceptions and use of the partogram could identify those factors related to partogram use in the clinical environment. Inappropriate use of the partogram is a complex problem as it involves doctors, midwives and their respective students as users. As there may be differences in partogram recording between the private and public sectors, a large baseline study that included private, tertiary and district hospital sites was undertaken to identify areas for improvement. Of interest in particular is that no previous studies on the use of the partogram in private hospitals in South Africa could be found. The aim of this paper is therefore to present the findings related to the use of the partogram in a private maternity hospital context, where patterns of mode of birth are particularly skewed.
Section snippets
Methods
The study adopted a pragmatic approach where the research question drove the inquiry, and both deduction and induction could be accomplished (Cresswell and Plano Clark, 2007). An explanatory mixed method design was followed to integrate data derived both quantitatively and qualitatively in two phases (Polit and Beck, 2017). The qualitative data of the interviews were used to explicate the significance of the initial quantitative results from a questionnaire. Ethical approval was granted by the
Findings
Of the 14 midwives who participated in the study, six had two to five years of experience, five had more than 5 years of experience and the three midwife specialists had more than 5 years of experience. Interviews were conducted with all the midwives who completed the questionnaire.
The quantitative and qualitative data were integrated and Table 1 summarises the six knowledge themes addressed in the questionnaire. Given the nature of sampling and sample size, the analysis was descriptive.
All
Discussion
The aim of the study was to explore and describe the use of the partogram in a private maternity hospital using interviews to explicate the significance of the quantitative questionnaire findings. No South African studies could be found on partogram use in private hospitals. As there is a much higher incidence of caesarean sections in the private sector, the researchers suspected that the partogram was not used for the purpose it is intended. Knowledge of the partogram among the midwives in
Conclusion
This study revealed an understanding of the use of the partogram. A lack of use of the partogram is often associated with poorer maternal and foetal outcomes in low income countries. Literature report mainly on studies conducted in high-income settings and may not have included all relevant outcomes or were not used in practice effectively. Although the use of the partogram is compulsory in all obstetric settings in South Africa, completion of the partogram in the selected private hospital was
Authors’ contributions
Authors’ contributions MY JJ Research concept and design √ √ Collection and/or assembly of data √ Data analysis and interpretation √ √ Writing the article √ √ Critical review of the article √ Final approval of the article √ √
Conflict of interest
The authors have no conflicts of interest to disclose.
Ethical approval
Ethical approval was granted by the Ethics Committees of the Faculty of Health Sciences, University of Pretoria (313/2013) and a private hospital (UNIV-2014-0032).
Funding sources
Not applicable.
Acknowledgements
The authors are grateful to the midwives of the private hospital who participated in the study. All personal identifiers have been removed.
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