Assessment of partograph knowledge and associated factors among obstetric care providers in West Cameroon: a cross-sectional study

¹Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon, ²Department of Obstetrics and Gynecology and Mother Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon

^&Corresponding author
Armand Duclaire Kemo Djimeli, Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon

Introduction    

In 2023, approximately 260,000 maternal deaths occurred worldwide, with the highest maternal mortality ratio recorded in sub-Saharan Africa, at 454 maternal deaths per 100,000 live births, compared to 11 maternal deaths per 100,000 live births in Europe and North America [1]. In Cameroon, the maternal mortality ratio fell from 678 deaths per 100,000 live births in 2000 to 258 maternal deaths per 100,000 live births in 2023, a reduction of approximately 62% [1]; however, efforts are still needed to achieve the sustainable development goal set by the World Health Organization, which aims for a maternal mortality rate of less than 70 maternal deaths per 100,000 live births by 2030 [2].

A study conducted by the World Health Organization in South Asia found that the partograph is necessary for labour management and that its proper use reduces the proportion of labour requiring increased contractions (from 20.7% to 9.1%), prolonged labour (from 6.4% to 3.4%), emergency Cesarian section rates (from 9.9% to 8.3%), and stillbirths (from 0.5% to 0.3%) [3,4]. In Ethiopia, the partograph allows early detection of abnormalities in labour progression, such as obstructed labour, which was responsible for 8.3% of maternal deaths and 39.7% of stillbirths [5]. His utilization remain sub-optimal, a systematic review and meta-analysis revealed that the pooled prevalence of systematic use of the partograph in sub-Saharan Africa was 51.17% [6]. Studies conducted on the partograph have found that the proportion of obstetric care providers with a good level of knowledge about the partograph was: 49.1% in Ethiopia [7]; 59% in Nigeria [8]; 60% in Kenya [9].

A limited number of studies have been conducted on the partograph in Cameroon, showing that 21.3% to 62% of obstetric care providers in the North-West and South-West regions [10-12] and 35% in the Central region [13] had a good level of knowledge about the partograph. Thus, this study aimed to determine the level of knowledge and factors associated with good partograph knowledge among obstetric care providers in West Cameroon in order to provide appropriate strategies for optimal labour management and monitoring and to ensure safe maternity practices.

Methods     

Study design, period and setting: this was a cross-sectional study conducted from February 1^st to June 30^th, 2024 in the West, which is one of Cameroon's ten regions. The West Region has Bafoussam as its capital and comprises 20 Health Districts, including eight urban-rural Health Districts: Foumban, Mifi, Dschang, Mbouda, Malantouen, Bafang, Bangangte, and Foumbot, as well as 12 rural Health Districts: Penka-Michel, Batcham, Baham, Bandja, Santchou, Bamendjou, Bangourain, Bandjoun, Galim, Massangam, Kekem, and Kouoptamo.

Study population: the study population consisted of all obstetric care providers working part-time or full-time in maternity wards in public or private health facilities in 14 Health Districts selected using a stratified random sampling technique among the 20 Health Districts in the West, including seven urban-rural Health Districts: Foumban, Mifi, Dschang, Mbouda, Malantouen, Bafang, Bangangte, and seven rural Health Districts: Penka-Michel, Batcham, Baham, Bandja, Santchou, Bamendjou, and Bangourain.

Inclusion and exclusion criteria: all general practitioners, midwives, nurses, and other healthcare providers offering care to women in labour who attended a monthly district coordination meeting of the study health districts were included in the study. Obstetric care providers who did not give their informed consent were excluded from the study.

Sample size estimation: to calculate the sample size, we used a single population proportion formula, n = (Ζα/2)² P(1-P)/d² [14]; considering that the proportion of obstetric care providers with a good level of knowledge about the partograph is P=44.8% according to the study conducted by Wakeshi and Molla [15]; with a 95% confidence interval, Z=1.96 and a margin of error d= 5%. N=(1.96)² x (0.448)x(1-0.448)/(0.05)²=0.247296x3.8416/0.0025=380. Furthermore, considering a non-response rate of 5%, we obtain a sample size of 399.

Data collection: data were collected using a semi-structured, self-administered questionnaire developed on the basis of previous studies [10,14]. This questionnaire was pre-tested by administering it to obstetric care providers in a Health District not included in the study, then adopted without modification. The data collected covered several variables, including the dependent variable: partograph knowledge and independent variables: socio-demographic characteristics, factors related to obstetric care providers and factors related to health facilities.

Operational Definitions

Partograph knowledge: level of knowledge of obstetric care providers on the partogram assessed using a questionnaire scored out of 30 points in total. A correct answer corresponds to 1 point and an incorrect answer corresponds to 0 points.

Good partograph knowledge: proportion of obstetric care providers with a partograph knowledge score between 21-30.

Fair partograph knowledge: proportion of obstetric care providers with a partograph knowledge score between 11-20.

Poor partograph knowledge: proportion of obstetric care providers with a partograph knowledge score between 0-10.

Partograph utilisation: systematic use of the partograph by obstetric care providers to monitor women in labour. To determine the proportion of obstetric care providers who systematically use the partograph, two questions were asked: Have you used the partograph in the six months before the study? Yes or No; for those who answered yes, how often do you use the partograph: always, sometimes, or rarely. We thus determined the proportion of obstetrics care providers who use the partograph systematically (always) and the proportion of those who do not use the partograph systematically (sometimes, rarely, or never).

Obstetric care providers: healthcare providers such as general practitioners, nurses, midwives, and other healthcare providers who monitor labour progress and offer delivery service.

Statistical analysis: the collected data were entered into CsPro software version 7.3, then exported to R software version 4.3.3 for analysis. Descriptive statistical analysis was performed, consisting of calculating the mean with standard deviation and frequency; univariable and multivariable logistic regression analysis were also performed to determine the association between the dependent variable and the independent variables; the results were presented in tables and figure. Variables with a p-value less than 0.2 in the univariable logistic regression analysis were included in the multivariable logistic regression analysis model. The odds ratio with a 95% confidence interval was calculated to determine the existence and strength of the association, and a p-value less than 0.05 was considered statistically significant.

Ethical considerations: authorization from the Regional Delegate for Public Health in the West was obtained before the implementation of this study. In addition, ethical clearance was issued by the Regional Ethics Committee for Human Health Research in West Cameroon, number 1018/27/12/2023/CE/CRERSH-OU/VP, dated December 27, 2023, before the study began. The informed consent of the participants was obtained before distributing the questionnaires. Confidentiality was ensured by the anonymity of the questionnaire forms. The study adhered to the principles of the Declaration of Helsinki.

Results     

Socio-demographic characteristics of obstetric care providers: a total of 373 obstetric care providers were enrolled in the study, making a response rate of 93.5%. Table 1 presents the socio-demographic characteristics of the study participants; the average age of participants was 39.6 ± 10.6 years. More than half of the obstetric care providers (64.6%) were women, and 64.3% were nurses. Two hundred and fifty-eight (69.2%) obstetric care providers were married; two hundred and ninety-five (79.1%) worked in health centers and almost three-quarters (71.4%) had been practising for six years or more.

Detailed knowledge of the partograph: Table 2 shows obstetric care providers' knowledge of the partograph in West Cameroon. Almost all (95.7%) participants identified the correct definition of the partograph, noting that it is a tool for graphically recording the progress of labour and the main maternal and fetal parameters over time in hours. Knowledge of the partograph as a prevention tool showed that 81.2% and 71.8% of obstetric care providers stated that the use of the partograph reduces maternal morbidity and mortality, and neonatal morbidity and mortality, respectively. Only 25.2% of participants responded that the first recording of cervical dilation should be made on the alert line. Obstetric care providers' knowledge of the graphical representation of normal labour progression was low, with only 41.3% correctly stating that, in normal labour progression, the graph of labour progress should fall to the left of the alert line. Less than three-quarters (69.7%) agreed that it takes 10 minutes to assess the adequacy of uterine contractions, and only 60.6% correctly stated that prolonged labour is labour that lasts more than 12 hours. Regarding the different diagnoses that can be made using a partograph, only 50.7% recognized that it can be used to assess the need to increase uterine contractions.

Overall knowledge of the partograph: overall, obstetric care providers' knowledge scores on the partograph ranged from 2 to 30, with an average score of 20.7 ± 4.6. Figure 1 shows that 59.8% of obstetric care providers had a good level of knowledge about the partograph.

Utilization of partograph: the magnitude of partograph use was 72.1%, 95% CI: 67.3 - 76.6; that is, 269 (72.1%) of obstetric care providers systematically used the partograph, while 71 (19%) used it sometimes, 14 (3.8%) rarely used the partograph, and 19 (5.1%) reported never using the partograph.

Factors associated with good knowledge on the partograph: Table 3 explores factors associated with a good level of knowledge of the partograph. Thus, the probability of having good knowledge of the partograph was 5.41 times higher among midwives and general practitioners than among nursing assistants aOR: 5.41, 95% CI 1.51- 26.8; p = 0.018. In addition, the probability of having good knowledge of the partograph was 2.76 times higher among obstetric care providers working at the District Hospital/Medical Center compared to those working at the Health Center aOR: 2.76, 95% CI 1.24-6.87; p = 0.019. The probability of having good knowledge of the partograph was 1.71 times higher among obstetric care providers working in a healthcare facility located in a rural Health District compared to those working in a healthcare facility located in an urban-rural Health District aOR: 1.71, 95% CI 1.05-2.81; p = 0.032. In addition, the probability of having good knowledge of the partograph was six times higher among obstetric care providers with 6-10 years of professional experience compared to those who had been practising for less than a year aOR: 6.03, 95% CI 1.22-35.4; p = 0.031. In addition, 94.1% (351) of obstetric care providers expressed the need for additional training on the partograph.

Discussion     

The objective of this study was to determine the level of knowledge and factors associated with a good level of knowledge of the partograph among obstetric care providers in West Cameroon; the results show that that 59.8% of obstetric care providers had good knowledge about the partograph in West Region, Cameroon. In addition, professional qualification aOR: 5.41, 95% CI 1.51- 26.8; p = 0.018, type of institution aOR: 2.76, 95% CI 1.24-6.87; p = 0.019, location of health facility aOR: 1.71, 95% CI 1.05-2.81; p = 0.032 and number of years´ service aOR: 6.03, 95% CI 1.22-35.4; p = 0.031 were significantly associated with good knowledge of the partograph. In addition, the level of systematic partograph utilisation was 72.1%.

Our study revealed that less than two-thirds of obstetric care providers (59.8%) had overall good knowledge of the partograph; our result fall in line with the study conducted by Agan et al. who found that 58.3% of obstetric care providers had a good level of knowledge about the partograph [16]; 53.7% according to Mezmur et al. in Ethiopia [14]; 61.8% in the study conducted by Verla et al. in Cameroon [12]; however, the proportion of obstetric care providers with a good level of knowledge about the partograph was higher (78%) in the study conducted in Ghana [17], this can be explained by the fact that their study population consisted only of midwives, who have received basic training in obstetric care. In addition, detailed knowledge of partograph among obstetrics care providers revealed that only 25.2% of our study participants knew that the first measurement of cervical dilation should be taken at the alert line. Furthermore, less than half of obstetric care providers, 41.3% stated that the graph of labour progress should ideally fall to the left of the alert line; this result is similar to that obtained by Sama et al. 42.3% in Northwest and Southwest Cameroon [10], revealing that some obstetric care providers may be filling out the partograph with limited ability to interpret it; Agan et al. found that only 30% of obstetric care providers were able to correctly explain the function of the action line [16]; these authors reported that it could contribute to an increase in the incidence of prolonged labour, as the action line generally serves as the basis for intervention during labour. Our study also revealed that less than two-thirds of respondents (60.6%) answered that labour is prolonged when it lasts more than 12 hours; this proportion was 62% in the study conducted in Northwest and Southwest Cameroon [10]. Regarding knowledge of the characteristics of normal labour, approximately one-third (30.3%) did not know that 10 minutes are needed to assess the adequacy of uterine contractions, and 34.3% did not know that the minimum duration of a strong contraction is 40 seconds; in the study conducted by Agan et al. 50% of respondents did not know that 10 minutes are needed to assess the adequacy of contractions, and 59.8% of obstetric care providers did not recognize that the minimum duration of a strong contraction is 40 seconds [16]. Although 76.7% of respondents acknowledged knowing how to identify ineffective uterine contractions using a partograph, only 50.7% of respondents reported being able to use a partograph to assess the need to increase labour. These results highlight the need to implement strategies that will raise the level of knowledge of obstetric care providers regarding the partograph. This is how 94.1% (351) obstetric care providers expressed the need for additional training on the partograph.

The proportion of obstetric care providers who systematically use the partograph was 72.1%, which is higher than the pooled prevalence of systematic use of the partograph in sub-Saharan Africa, 51.17% [6]; however, further efforts are needed, as the World Health Organization recommends the use of the partograph for monitoring all women in labour for a safe motherhood [3]. This therefore, highlights the need to implement interventions that will encourage obstetric care providers to systematically use the partograph to monitor women in labour.

Our study revealed that midwives and general practitioners had 5.41 times more knowledge of the partograph than nursing assistants; this result is similar to those of studies conducted in Nigeria and South Africa [18,19]. Our result could be explained by the fact that midwives have received basic training that is more focused on reproductive health compared to nurses and nursing assistants during pre-service; thus, they are better equipped to use the partograph to monitor women in labour. This result calls on health authorities to advocate for and/or recruit more midwives in different health facilities to improve the effectiveness of labour monitoring using the partograph. Also, obstetric care providers who have been working at District Hospital/Medical Center were 2.76 times more likely to have good knowledge on partograph compared to those who have been working at health centers; this result could be explained by the presence of doctors in District Hospitals and Medical Centers, unlike Health Centers, which do not have them. This implies the need for more intensive capacity building for obstetric care providers working in health centers on the partograph. This result relates to a study conducted by Mezmur et al. which shows that the place of work was significantly associated with a good level of knowledge on partograph [14]. In addition, obstetric care providers who have been working in health facility located rural Health District were 1.71 times more likely to have good knowledge on partograph compared to those who have been working at urban-rural Health District; this result could be explained by the fact that there are probably more Health Centers in urban-rural Health Districts than in rural Health Districts; in addition, we observed above that obstetric care providers working in District Hospitals and Medical Centers had 2.76 times more knowledge about the partograph than those working in Health Centers. Obstetric care providers who had 6-10 years of service were 6 times more likely to have good knowledge on partograph than obstetric care providers with less than one year of service. This result implies that when forming work teams in health facilities, a less experienced obstetric care provider should be paired with a more experienced obstetric care providers to optimally monitor labour using the partograph, which is a decision-making tool, enabling early detection of abnormalities in labour progression, such as obstructed labour, which was responsible for 8.3% of maternal deaths and 39.7% of stillbirths in a study conducted in sub-Saharan African country [5].

Since information was obtained from respondents through self-administered questionnaires, rather than observation, there is a tendency to social desirability bias, whereby respondents may be inclined to give answers that they consider desirable in the eyes of researchers. To reduce the response bias, the aim of the study was discussed with respondents in order to obtain a genuine response. This study was conducted in 14 Health Districts, including both urban-rural and rural Health Districts, randomly selected among the 20 Health Districts in the West, which is a strength of the study. In addition, the sample size was large, which made it possible to explore the determinants of a good level of knowledge about the partograph; furthermore, the study participants were obstetric care providers from both public and private healthcare facilities; thus, the findings can be generalised to the West region of Cameroon. It would be relevant to explore obstetric care providers' knowledge of the partograph in other regions of the country.

Conclusion     

This study revealed that less than two-thirds of obstetrics care providers had an overall good knowledge about the partograph in the West region of Cameroon. Professional qualification, type of institution, location of health facility and year of service were the variables found to be significantly associated with good knowledge of the partograph. The level of partograph utilisation was 72.1%, which is lower than WHO recommendations. We recommend conducting interventions aimed at capacity building and the systematic use of partograph by obstetric care providers in general, and those working in health centres in particular; ensure that work teams are formed by pairing less experienced obstetric care providers with those who have more years of service and increase the recruitment of midwives in different health facilities.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Conception and study design: Armand Duclaire Kemo Djimeli, Bruno Kenfack and Jerome Ateudjieu. Data collection: Armand Duclaire Kemo Djimeli. Data analysis and interpretation: Armand Duclaire Kemo Djimeli and Bruno Kenfack. Manuscript drafting: Armand Duclaire Kemo Djimeli. Manuscript revision: Armand Duclaire Kemo Djimeli, Bruno Kenfack and Jerome Ateudjieu. Guarantor of the study: Armand Duclaire Kemo Djimeli. All authors approved final version of the manuscript.

Tables and figure     

Table 1: socio-demographic characteristics of obstetric care providers, 2024 (N=373)

Table 2: detailed knowledge of obstetric care providers about the partograph, 2024 (N=373)

Table 3: factors associated with good partograph knowledge among obstetric care providers, 2024 (N=373)

Figure 1: overall knowledge of obstetric care providers about the partograph, 2024 (N=373)

References