Maternal Deaths and Complications: Documentation of Parameters on the Partographs Used by Health Care Providers in Four Hospitals in West Cameroon

INTRODUCTION

Globally, approximately 800 maternal deaths from preventable causes occurring during pregnancy or childbirth were recorded in 2020; nearly 95% of these deaths occurred in developing countries. The main affected regions are sub-Saharan Africa and South Asia.^[1]

The maternal mortality rate in Cameroon in 2020 was 438/100,000 live births,^[2] highlighting the significant gap that needs to be closed to achieve a maternal death rate of <70/100,000 live births by 2030.^[3] Obstructed labor is one of the leading causes of maternal mortality, with an estimated incidence of 8% of maternal deaths.^[4] Obstetric complications and maternal deaths following obstructed labor could be prevented by inexpensive and effective practices such as the correct and systematic use of the partograph.^[5] The partograph is a graphic record of labor progress and key maternal and fetal parameters over time.^[6] It consists of four sections: identification of the woman, fetal monitoring parameters, labor progress parameters, and maternal parameters.^[7]

Following a multicenter study conducted by the WHO, which demonstrated its effectiveness, the WHO strongly recommended its systematic use for monitoring parturients.^[8] Studies have been conducted in sub-Saharan Africa, particularly in Ghana, where it was found that newborns from births monitored using a partograph had a 4.29-fold lower risk of developing neonatal asphyxia.^[9]

In Uganda, based on 355 partographs, it was found that approximately 61% of parameters were incompletely documented.^[10] In Ethiopia, a study of 420 partographs found that parameters such as fetal heart rate, cervical dilation, and uterine contractions were correctly recorded in <40% of cases each.^[11] In the North West of Cameroon, 58.2% of deliveries were monitored by partogram.^[12] We note through the literature a low number of studies on the partogram in Cameroon in general and in the West in particular; thus, this study aimed to analyze the quality of the partograms completed in four hospitals in West Cameroon with a view to contributing to the achievement of sustainable development objectives.

METHODS

RESULTS

A total of 495 partograph records were analyzed, the majority of which (41.6%, 206/495) came from Bafoussam RH, followed by 39.4% (195/495) from Dschang Regional Annex Hospital, followed by 12.3% (61/495) from Bamendjou DH, and finally 6.7% (33/495) from Batcham DH.

DISCUSSION

The prevalence of partograph use was 62.6%. Our result was higher than those reported by Nyiawung et al. 35%,^[14] Verla et al. 34.8%^[15] and Haile et al. 54.4%;^[16] it was lower than that obtained by Ogwang et al. 69.9%^[17] and Markos et al. 70.2%.^[18] This average prevalence could be due to the unavailability of blank partographs, the lack of refresher training on the use of the partograph, as well as the absence or low number of midwives in certain health facilities.^[15,18,19]

The identification parameters of parturients were relatively well reported in at least 85% of cases; however, the proportions of recording the time of rupture of membranes were low, which constitutes a shortcoming because this parameter will allow a better assessment of the maternal-fetal infection risk.

Cervical dilation was optimally recorded in 85% of cases and more in RHs, while it was <60% in DHs. In Northwest Cameroon, this proportion was 40.5%^[12] and 43.9% in Uganda.^[17] A similar trend was observed for descent, which is a significant gap because these parameters will help detect an abnormality in the progression of labor, for prompt decision-making. This could indicate limited knowledge and skills of health providers in DHs compared to RHs. Periodic refresher training is necessary, as well as strengthening human resources in health facilities to increase the quality of use of the partograph.

The fetal heart rate was correctly recorded in three out of four health facilities in a proportion of ≥77%, except for Batcham DH, where it was correct in 30.3%. This parameter is important in the assessment of fetal well-being; This proportion was 40.5% in the study carried out in North-West Cameroon^[12] and 44.8% in Ethiopia.^[20]

Lower levels of correct recording were observed for the coloration of amniotic fluid; while these parameters are of paramount importance in assessing fetal well-being, in fact, not noticing a possible variation, such as fetal bradycardia, amniotic fluid that has become meconium-stained can lead to missing diagnoses such as acute fetal distress. Regarding the monitoring of maternal parameters, the frequency of adequate recording of blood pressure was between 63.6% at the Batcham DH and 72.8% at the Bafoussam RH; the optimal recording was even lower for the pulse varying between 14.8% at the Bamendjou DH and 27.2% at the Bafoussam RH; this proportion was 12.3% in the Northwest of Cameroon^[12] and 9.6% in Ethiopia.^[20] These results show that although this parameter has been monitored, efforts still need to be made in monitoring blood pressure and pulse, because they allow the detection of the occurrence of preeclampsia or even possible externalized or non-externalized hemorrhage.

The total absence of temperature monitoring ranged from 28.2% at the Annex RH of Dschang to 87.9% at the Batcham DH. This is an important parameter, the elevation of which will allow us to detect or suspect the occurrence of malaria or any other infection. A retrospective design was used to assess the documentation of partographs completed during delivery, which is a limitation because the documentation may not reflect actual clinical practice. Ideally, the quality of partograph completion would have been assessed when the woman was seen and monitored in labor at the maternity ward. We can also note potential observer bias when extracting data from completed partographs. In addition, this study was conducted in 3^rd and 4^th category health facilities, it would be interesting to explore the documentation of partograms in 5^th and 6^th category health facilities; however, the weaknesses observed in the filling of the partogram in DHs (4^th category), makes it possible to understand the possible gaps that could exist in 5^th and 6^th category health facilities concerning the use of the partogram.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

The study showed that there is good partograph documentation in secondary health care facilities. However, it revealed that the partograph documentation in primary health care facilities mostly varies from poor to average based on parameters. It is recommended to support and provide periodic on-the-job training to health professionals on the documentation of the partograph and to conduct regular supportive supervision.