Knowledge, Attitude and Practice of nurse-midwives on the use of partograph in health care centres of Bhutan

Childbirth is a natural phenomenon. Yet, everyday women die from preventable causes related to pregnancy and childbirth. In 2017, the global point estimate of maternal death was 211 and 9.2% of which was due to direct obstetric causes1. Maternal and neonatal deaths were found to be highly associated with prolonged and obstructed labor2,3. The reported causes of maternal deaths in Bhutan were postpartum hemorrhage (43%), sepsis (11%), and obstructed labor (4%)4. These complications can be reduced through close monitoring of women in labor using partograph5–7. Partograph, instituted by the WHO in 1987, especially for underdeveloped and developing countries, serves as an early warning system. The partograph provides a pictorial presentation of fetal and maternal wellbeing, and the progress of labor7. Despite Knowledge, Attitude and Practice of nurse-midwives on the use of partograph in health care centres of Bhutan Karma Choden1, Nidup Dorji2


INTRODUCTION
Childbirth is a natural phenomenon. Yet, everyday women die from preventable causes related to pregnancy and childbirth. In study sites were selected based on the volume of deliveries and shorter travel distance. We included seven hospitals and one BHU-I. Hence, non-probability sampling technique was used.
All the nurse-midwives who attended deliveries were surveyed using self-administered semi-structured questionnaires. There were a total of 96 nurse-midwives at the time of data collection. Nursing students, nurses on attachment duties and those who did not attend deliveries were not included in the study. The already validated data collection tool was adapted before data collection 10 . Retrospective review of partographs filled up three months before the survey was done. The partographs were assessed for its completeness using a checklist based on four components: Personal information of laboring woman, fetal wellbeing, the progress of labor and maternal wellbeing.
Each variable of interest was scored on the 'yes' and 'no" scales. Each correct knowledge question (18 in total) earned one point, while incomplete, incorrect, or not attempted were scored zero. Respondents who scored 0-6 were categorized as having poor knowledge, whereas those that scored 7-12 and 13-18 score as having fair and good knowledge, respectively. 12 questions on attitude were assessed on a 5-point Likert scale and the overall attitude was scored using median. The attitude was scored as favourable if the total scores ranged between 30-48 (indicating positive attitude towards the usage of partograph). An unfavourable attitude was considered if the scores ranged between 12-30, minimum score being 12. Variables on practice (17 in total) were dichotomized and counted for their frequency. The questions on practice were what the participants reported on the usage of the partograph. The completeness of the partograph using the completeness checklist was reported in terms of its completeness in counts and percentages. Data entry and analysis were performed using SPSS for Windows (V22.0: IBM Corporation, Armonk, NY, USA).
The Research Ethics Board of Health, Ministry of Health, approved the conduct of this study (vide no. REBH/ Approval/2017/030). Table 1 shows that 68.8% of the participants were females and 70.8% of them were in the age range of 25-35 years. Sixty-three (65.6%) had the professional qualification of General Nurse Midwife. Regarding clinical experiences, 80(83.3%) had a clinical experience of fewer than 10 years while 10 (10.4%) of them had clinical experience ranging from 15-20 years.

Knowledge on Partograph
The knowledge about the partograph was assessed through 18 items measured on the 'yes' and 'no' scale. Among 96 nursemidwives, 95 (99.0%) knew what was a partograph while 95.8% reported that a partograph should be used during labour. As evident from Table 2, they lacked knowledge on desired frequency (61.1%) and duration of uterine contractions (33.3%) for normal labour and the function of the alert line. Although 100% of the participants reported that the progress of labour is assessed by the degree of cervical dilatation and descent of the presenting part, 13.6% of participants reported not knowing if prolonged labour refers to more than 12 hours of labour. Overall, 50% of them had a good knowledge on partograph with a median score of 12.5 (Min-Max: 10-16), while 50% scored fair. There was no difference between the knowledge on partograph among males and females as shown in Table 2.

Attitude on the utilization of partograph
All the participants (100%) had a favorable attitude towards the partograph with a median score of 42 (Min-Max: 32 -48). 87.5% strongly agreed that they used partograph daily in their practice, as evident from Table 3. However, only 49 % reported being very confident in the use of the partograph. Although the majority (80.2%) knew the importance of using a partograph, 76% reported that a partograph is not necessary to monitor the progress of labor.

Utilization of partograph
As illustrated in Table 4, all the participants reaffirmed the availability of partograph at all times in their ward/unit. Although 97.9% reported using partograph to monitor women in labour, 2.1% (2 participants) felt that it was not necessary to use   Total knowledge score  partographs; the components that were missed or incomplete included fetal heart rate, amniotic fluid status and fetal head moulding. Labor progress was better recorded as compared to other components with 58.5% of the assessed partographs being complete. The components that received less attention were the record of uterine contractions every 30 minutes and descent of the presenting part at every vaginal examination. Although 33.6% of the partographs had complete maternal wellbeing components, maternal pulse and the body temperature recordings were not paid much attention to. Overall, the completeness of the partographs was found to be only 16.0%.

DISCUSSION
A total of 96 nurse-midwives attending deliveries were recruited for the survey on knowledge, attitude and practice of partograph. In addition, a total of 426 partographs were reviewed for its completeness.
The findings on knowledge in this study suggest that overall, nurse-midwives have a good knowledge regarding the partograph. Out of 96 nurse-midwives, 50% of them had 'good knowledge' and 50% had 'fair knowledge' which is significantly higher than what was reported in Addis Ababa (39.0%) 10 , Cameroon (29.6%) 9 , and Samdrup Jongkhar (7.1%) 11 although, slightly lower than the ones reported by a study carried out in Northwest Ethiopia (56.1%) 13 . These differences in knowledge could be due to study settings, knowledge assessment tools that were used, level of training on partographs that were received, extent of knowledge gained during their education, number of years in service and their qualifications. This may also imply that having 'fair to good knowledge' does not ensure adequate knowledge on the partograph and its completeness. For instance, 100% of the participants in this study knew that the progress of labour was determined by cervical dilatation and descent of the presenting part, however it is concerning to note that they are not able to correctly report the desired frequency and duration of uterine contractions, function of the alert line and the definition of prolonged labour.
Attitude is another factor that enhances knowledge and usage of the partograph. Although attitude towards using partograph was found to be favourable (Score of 42), 76% of them reported that partograph is not necessary to monitor the progress of labour and only 49% reported being confident in the use of partograph. Favourable attitude towards using partograph is comparable to the study in Ethiopia 13 . Utilization of partograph was reported as high (89.7%) by the participants which is in line with the study done in Ethiopia 10,15 . However, some participants (2.1%) expressed that a partograph is not necessary to be used in all the women in labour. With only 10.4% receiving in-service training on partograph, this could have had an impact on its utilization in Bhutan 11 . Majority of the participants (89.7%) reported utilizing partograph to monitor women during labour and start plotting partograph once the cervical dilatation is 4 cm and above (97.9%), yet inconsistency in actual utilization could be noticed from the review of the filled partographs, similar to the findings of a study carried out in Nigeria 15 . The factors responsible for the mismatch between what is reported and what is done in actual practice needs to be explored further. Out of 426 partographs assessed, 16.0% was found to be complete, 77.5% was incomplete, 1.8% was referred to higher centers and 4.7% were left empty. This finding is consistent with the findings of the study carried out in 2017 in Bhutan 11 and could be attributed to trainings they have received during their professional career and the knowledge they have on the partograph. This study has some limitations.There may be many factors such as knowledge, attitude, years of service and the participant's place/county of pre-service education which may be associated with proper utilization, which is not explored in this study. The other important limitation of this study was the fact that it was not able to establish the relationship between the participants' knowledge and attitude to the completeness of the partograph and the relationship between the reported utilization of partograph and actual completeness of the partograph.

CONCLUSIONS
This study implicates that despite having fair to good knowledge, a favourable attitude and highly reported utilization of partograph, a gap remains when it comes to actual practice as evidenced by the low completeness of partographs. Taking into consideration the various limitations of the study, we recommend a further detailed study on the factors associated with incompleteness of the partograph. Nonetheless, the results from this study can be used to reinforce the use of partograph through continuous medical education, auditing of the partographs and taking up the utilization of partograph as a point of care quality improvement (POCQI) projects in their respective units or hospitals.