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Revitalizing the Partograph: Does the Evidence Support a Global Call to Action?

Prolonged or obstructed labor contributes to maternal and newborn morbidity and mortality and can lead to postpartum hemorrhage, infection, obstetric fistula, and fetal injury or death. One of the tools used to prevent this problem is the partograph, a preprinted one-page form on which birth attendants record labor observations. This form allows health care providers to record, interpret, analyze, and use data to make decisions on labor management. The form, which is an early warning system, provides a graphic overview of labor. The partograph provides information that alerts health providers to any problems with the mother or baby and to deviations from the normal progress of labor.

The World Health Organization (WHO) recommends universal use of the partograph during childbirth. Fistula Care promotes correct and consistent use of the partograph as one of its key fistula prevention initiatives. However, the findings of a 2011 Fistula Care literature review on partograph use in developing countries indicate that rates of use and health provider skills are low.

In light of these findings, Fistula Care and the Maternal Health Task Force convened a meeting of global experts on November 15 –16, 2011, in New York, with the support of the United States Agency for International Development and the Bill and Melinda Gates Foundation. The objectives of the meeting were to review the evidence base for the partograph’s effectiveness, identify barriers to partograph use and feasible strategies for overcoming them, and determine future research needs. Meeting participants included midwives, physicians, researchers, clinical educators, managers of health services, and representatives of relevant professional associations and partners. The meeting focused primarily on the use of the partograph in low-resource settings.

Participants agreed that the partograph is an essential tool for monitoring and managing labor. However, they identified a number of obstacles that stand in the way of the effective use of the tool. Lack of support from the health system was seen as the most important barrier. To be effective, the partograph requires champions within facilities and at the national level to model its importance and to ensure that the necessary resources (financial, human, and supply-related) are allocated to enable providers to use the tool effectively. For example, in many places, facilities lack the financial resources to train providers, and even the most basic requirements, such as partograph forms and blood pressure machines, may be missing.

Three innovations in partography were presented at the meeting: an electronic partograph on a handheld device, which is under development and field testing by Jhpiego;  a “pictorial partograph” for home births, designed for use by traditional birth attendants, skilled birth attendants, and family members and created by LAMB Hospital in Bangladesh (a Fistula Care–supported site); and the World Health Organization’s Safe Birth Checklist, which highlights partograph use as a key intervention and which is being pilot-tested in India.

There was general agreement that future research should focus on improving implementation of the partograph. Health professionals need to know more about effective methods of training, supervision, and maintenance of providers’ clinical skills.

It was a lively and productive meeting. Participants stressed their desire for the main outcome to be an action plan for revitalizing the partograph, to enable it to achieve its potential. Fistula Care will shortly send out a summary of action points to all meeting participants, to galvanize support in advancing the priorities identified by meeting discussions.