Electronic Partograph: A Way of Improving Partograph Use During Labour Monitoring Process in Selected District Hospitals in Bangladesh
Electronic Partograph: A Way of Improving Partograph Use During Labour Monitoring Process in Selected District Hospitals in Bangladesh
Background (brief):

 1. Burden: Abnormal prolonged labour and its effects are important contributors to maternal
 and perinatal mortality and morbidity worldwide. Although the partograph has been shown
 to be an efficacious tool for monitoring labor and identifying women in need of an
 comprehensive emergency obstetric intervention, it's appropriate use is questionable
 throughout the world. Evidence suggests that very few service provider use partograph
 despite recognizing its usefulness.

 2. Knowledge gap: In Bangladesh partograph is hardly used by the concern person though its
 importance and positive outcome is acknowledged at the national level. To introduce a
 digital partograph Johns Hopkins Program for International Education in Gynecology and
 Obstetrics (Jhpiego) developed an ePartogram device and WHO created partograph
 e-Learning tool. Jhpiego is currently testing three ePartogram implementations. However,
 till today, no data has been collected or analysed for any of these ePartogram models.
 The WHO e-Learning tool has been distributed to facilities like Kenyatta National
 Hospital via CD-ROM. In Kenya, a study also being conducted using a digital partograph
 (partopen) and results are yet to come.

 3. Relevance: The use of the paper partograph is found to be complex and too much
 time-consuming for effective use in low-resource settings where there has been
 inadequate health care staffing. These challenges highlight a need for strengthening
 providers' skills and/or developing new technologies that are suitable for low-resource
 countries and promote consistent, correct use of the partograph as well as, a labour
 monitoring system for the peripheral level health facilities. The benefits of this
 device are: ease of use, minimal training requirements, improved data quality and
 capture, and seamless integration into current local practice.

 Objectives: The current study aims-

 1. To explore the feasibility, acceptability of digital partograph use among health service
 providers in selected district hospitals in Bangladesh;

 2. To compare the user rate between paper and digital partograph during labour monitoring
 process in district hospitals in Bangladesh;

 3. To compare the outcome of paper and digital partograph use in respect to the birth
 asphyxia and prolonged labour rate after introducing digital partograph in selected
 district hospitals in Bangladesh;

 4. To determine the barriers and facilitating factors of introducing electronic partograph
 in district hospital in Bangladesh.

 Methods: A mixed-method prospective follow-up study with crossover design will be conducted
 in two DHs. One DH will serve as intervention (electronic partograph) hospital and another as
 control hospital (paper-based partograph). After applying the crossover design this
 allocation will be reversed. The total study will be completed within 18 months period.
 Nurse-midwives posted in obstetric wards will be the study participants. The sample size in
 each DH will be 506 mothers who will deliver their baby during the study period.

 Outcome measures/variables:

 -  Feasibility and acceptability of digital partograph use will be assessed among health
 service providers in selected DH in Bangladesh;

 -  The user rate of digital partograph will be estimated during labour monitoring process
 in DHs in Bangladesh;

 -  The birth asphyxia and prolonged labour rate will be estimated after introducing digital
 partograph in selected DHs in Bangladesh;

 -  The barriers and facilitating factors of introducing electronic partograph will be
 determined in DHs in Bangladesh.
Study design, site and duration:

 A prospective, follow-up crossover study design was used. Two secondary level referral
 hospitals in Jessore and Kushtia districts were selected as study sites. The selected
 facilities were similar in terms of infrastructure, human resources, and service delivery
 scenarios to typical district hospitals and were thus representative of public hospitals in
 Bangladesh. However, there were a few differences in the number of c-section and stillbirth
 rates in between two study hospitals. The crossover study design adopted under this study was
 designed to minimize the impact of this non-similarity on the study outcomes. The same
 facility was served as its own control at different time point in time. The study was
 conducted in two phases with an intervening pause period. During the first phase, an
 electronic partograph was used in Kushtia district hospital and a paper based partograph was
 used in Jessore district hospital. Both of these hospitals were being crossed to alternate
 partograph tool after the pause period.

 The nurse-midwives from each hospital posted in obstetric wards were the user who observed
 the calculated deliveries (N=506 for each facility) during the study period. Each participant
 attended a two-day long training to become acquainted with the respective partograph that
 they would be utilizing in the first phase of the study. Another training session was also
 arranged during the pause period. Clinical parameters recorded in the partograph were
 validated by the project appointed research assistants with midwifery qualifications who
 observed labor progression and deliveries.

 Sample selection:

 Sample size calculations were completed on the basis of existing prevalence of partograph use
 (17.1 %), and delivery outcome data related to paragraph use such as incidence of birth
 asphyxia (22%) and prolonged labour (7%) . Sample size calculations also took into account
 the refusal rate (10%) and design effects. Thus to observe the 50% improvement for all three
 mentioned clinical parameters (increased use of partograph, decreased level of birth
 asphyxia, and prolonged labour), the number of deliveries that needed to be observed were as
 follows, 105, 216 and 506 respectively at 80% power and 5% significance level. Thus the final
 sample size in each district hospital was taken as 506; half of the sample (253) before and
 the other half (253) after applying the crossover design. Field data collection continued for
 12 months and the data collectors tried to capture all deliveries until the required minimum
 sample size was achieved.

 Inclusion criteria Inclusion criteria for the study were women with spontaneous labour in the
 first stage of labour with cervical dilatation in between 4-7 centimeters, singleton
 pregnancy, gestation of at least 37 completed weeks, cephalic presentations, and no
 additional complications.

 Exclusion criteria Exclusion criteria for the study were women with ante partum hemorrhage,
 breech presentation, multiple pregnancies, premature labour (before 37 weeks), eclampsia,
 elective caesarean section, and induced labour.

 Study procedure and data collection:

 An expert obstetrician, who was also a study investigator, provided training to the nurses
 and midwives. The basics for the paper and electronic partographs were essentially the same,
 so the training methods were not vastly different. For the e-partograph, a junior programmer
 was available by mobile phone, around-the-clock, to provide any instant trouble shooting or
 feedback. In addition, the Android Tablet was used for implementing the digital partograph
 study. Participants were also introduced to varying inconsistencies and errors they might
 face when utilizing the e-partograph. The research assistants became expert users of the
 e-partograph and facilitated the usage for the weak users.

 e-partograph: The electronic version of the partograph was a state-of-the-art application
 that is accessed through smart phone or tablet pc or computer device. The application's user
 interface (UI) is segmented; users will have to concentrate only on a single portion at a
 time that would lessen the existing complexity of using paper-based partograph.

 e-partograph application's user interface in Android programming language for smart tabs, and
 in ASP.net with C# language for personal computers. The application has options to save the
 data in local storage and in a remote central database storage concurrently. Local storage
 contains data for temporarility; the remote server contains the data permanently which makes
 the partograph information searchable at any time and place. This application allows
 partograph data to be monitored remotely.

 The existing knowledge on how to use the paper and e-partograph was assessed for each
 participant before the start of the training to understand the skill status of the
 individuals. The training consisted of two days of intensive hands on training as well as a
 refresher course that was organized six months after the first training to ensure that
 participants would not forget the information. In order to measure user rates, rates of birth
 asphyxia, and prolonged labour, record reviews generated by the partographs were collected
 and analyzed.

 Data Analysis:

 Quantitative data was analyzed using SPSS 23 statistical software. The outcome variables were
 use of the partograph and delivery outcomes (prolonged labour and birth asphyxia). The
 independent variables covered maternal demographic and obstetric variables along with fetal
 characteristics as well as partograph type and facility. Partograph was considered done when
 it was correctly used for labour monitoring among the delivered women who fall under
 inclusion criteria. Prolonged labour was defined as labour extending more than 12 hours and
 birth asphyxia was defined as an APGAR score less than 7 on the 5th minute after delivery.
 Discrete variables were expressed as percentages and presented as frequency tables and cross
 tabulations. Chi square (χ2) tests were employed to test the association between proportions
 of respondents and type of partograph. Statistical significance was defined as p-values of
 <0.05. The data collected between the two groups was analyzed in such a way that a clear
 comparison could be made between the user rate of different periods (before and after
 applying the crossover design). Potential confounding factors were adjusted using binary
 logistic regression.

 Ethical Assurance:

 The Research Review Committee (RRC) of the International Centre for Diarrheal Disease
 Research, Bangladesh (icddr, b) approved the technical part of the proposed study. Then the
 Ethical Review Committee (ERC) of icddr, b who oversees the protection of human rights,
 approved the study. In addition, informed consent was obtained from the hospital
 administration, health workers, and the laboring mothers.
Inclusion Criteria:

 -  women with spontaneous labour in the first stage of labour

 -  cervical dilatation in between 4-7 centimeters

 -  singleton pregnancy

 -  gestation of at least 37 completed weeks

 -  cephalic presentations

 -  no additional complications

 Exclusion Criteria:

 -  women with ante partum hemorrhage

 -  breech presentation,

 -  multiple pregnancy,

 -  premature labour (before 37 weeks)

 -  Eclampsia,

 -  elective caesarean section

 -  induced labour