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Partograph Utilization and its Determinant Factors among Healthcare Providers during Childbirth in West Cameroon
*Corresponding author: Armand Duclaire Kemo Djimeli, Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, West Cameroon. armanddjimeli39@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Djimeli AK, Kenfack B, Ateudjieu J. Partograph utilization and its determinant factors among healthcare providers during childbirth in West Cameroon. Int J Matern Child Health AIDS. 2025;14:e021. doi: 10.25259/IJMA_3_2025
Abstract
Background and Objective:
Early detection of abnormal labor progression helps prevent prolonged and stationary labor, which is one of the leading causes of maternal mortality. The objective of this study was to determine the prevalence and predictors of routine partograph use in Western Cameroon.
Methods:
A cross-sectional study was conducted among caregivers in the Western region, from February 1 to June 30, 2024. A self-administered questionnaire was used to collect data. Data were entered into CSPro 7.3 software and exported to R (4.3.3) for analysis. Descriptive statistics and logistic regression analysis were performed. Statistical significance was determined using adjusted odds ratios (AOR) with 95% confidence intervals (CI) and p < 0.05.
Results:
A total of 373 caregivers participated in the study. The prevalence of routine partograph use was 72.1% (95% CI: 67.3; 76.6). Less than two-thirds (59.8%) of healthcare providers had good knowledge of the partograph. On-job-training (AOR = 2.85 [95% CI: 1.45–5.81]) and routine partograph availability (AOR = 390 [95% CI: 75.4–7366]) were significantly associated with partograph use.
Conclusion and Global Health Implications:
Partograph use in this study was moderate. Interventions such as periodic on-job training on the partograph and ensuring its routine availability in maternity wards are recommended.
Keywords
Partograph use
Determinants
Healthcare Providers
West
Cameroon
INTRODUCTION
Approximately 287,000 women died from causes related to pregnancy or childbirth in 2020 worldwide; nearly 87% of these deaths occurred in sub-Saharan Africa and South Asia.[1] In low- and middle-income countries, maternal mortality is a major public health problem.[2] In Cameroon, the maternal mortality rate decreased from 447 to 438 maternal deaths per 100,000 live births from 2015 to 2020,[2] this highlights the need to make significant efforts to achieve a maternal mortality rate of <70 deaths/100,000 live births by 2030.[3] Several interventions can help combat maternal mortality, including refocused prenatal consultations, emergency obstetric and neonatal care, family planning, and assisted childbirth using the partograph.[4]
A multicenter World Health Organization (WHO) study of the partograph found that it reduces inappropriate oxytocic use, labor lasting more than 12 hours, emergency cesarean sections, and perinatal deaths; thus, routine use of the partograph is recommended by the WHO for the monitoring of all women in labor.[5] Despite its proven benefits, partograph use varies widely in Sub-Saharan Africa, with 55.1% in Ethiopia,[6] 38.7% in Tanzania,[7] 44% in Kenya,[8] 47.8% in Nigeria;[9] including within Cameroon, 32.4% in the Northwest and Southwest,[10] 79.3% in the Northwest,[11] and 56.1% in the Center Region,[12] where regional differences highlight the need for localized studies. Unlike the North-West Region’s 79.3% utilization rate,[11] anecdotal evidence suggests lower uptake in the West Region, possibly due to limited training or resources. Studies have found that factors such as partograph availability, supervision, professional experience, continuing education, and knowledge level significantly influence partograph use.[13,14] This study explores whether similar factors influence partograph use in the West Region, where training and attitudes remain underexplored. By assessing partograph utilization and its determinants in the West Region, this study aims to inform strategies that could reduce preventable maternal deaths, bringing Cameroon closer to the Sustainable Development Goals target.
METHODS
Study Design and Period
This was a cross-sectional study conducted from February 1 to June 30, 2024.
Sample Size, Sites, and Study Population
To determine the sample size, the following formula was used: n = (Zα/2)2 P(1-P)/d2, where P = 43%,[15] Zα/2 = 1.96 at 95%, d = 0.05.
n = (1.96)2 0.324 (1-0.324)/(0.05)2 = 377.
Assuming a 5% non-response rate, this resulted in a sample size of 395.
The Western Region has 20 Health Districts, including 8 urban-rural Health Districts and 12 rural Health Districts. Each health district regularly holds a coordination meeting on the activities of health facilities and training centers once a month, and each district health facility manager is required to attend. Using a random sampling technique, 14 health districts, including seven urban-rural health districts: Mifi, Mbouda, Malantouen, Foumban, Dschang, Bangangté, Bafang, and seven rural health districts: Bamendjou, Bangourain, Batcham, Baham, Santchou, Penka-Michel, and Bandja, were selected.
The study population consisted of all healthcare providers: physicians, midwives, nurses, and other healthcare personnel working in the delivery departments of public and private health facilities in the study health districts. All physicians, midwives, nurses, and other healthcare providers involved in the care of women in labor were included in the study. They were interviewed at a monthly health district coordination meeting and provided their informed consent. Obstetriciangynecologists and trainees were excluded.
Data Collection tool and Procedure
Data collection was conducted using a pre-tested, self-administered, and semi-structured questionnaire[10,14] consisting of three sections: Sociodemographic characteristics, knowledge of the partograph, and frequency and other potential factors influencing partograph use.
The prevalence of partograph use was determined using two questions: Do you use the partograph? Yes or no; for those who answered yes, how often do you use it? Always, sometimes, or rarely. Thus, we determined the proportion of healthcare providers who always use the partograph (systematic use) and those who sometimes, rarely, or never use it (non-systematic use).[14]
Regarding the assessment of knowledge about the partograph, a 30-point scoring system was used. A correct answer was worth one point, and a wrong answer was worth zero points. This allowed us to determine the proportion of professionals with a good (21–30), average (11–20), and poor (0–10) knowledge score.[16]
After a brief presentation of the study by the principal investigator to the healthcare providers who met at the site of the monthly coordination meeting of the Health District, the questionnaires designed in French were distributed to the healthcare providers, who completed them immediately for an average of 15 minutes, and then the principal investigator proceeded to collect the questionnaires after verifying their completeness.
Data Entry and Analysis
The collected data were coded and entered into CSPro version 7.3 software, then exported to R version 4.3.3 for analysis. The analysis consisted of descriptive statistics and logistic regression analysis. Statistical significance was determined using Adjusted Odds Ratios (AORs) with 95% confidence intervals (CIs) and p < 0.05.
Ethical Considerations
Ethical approval was obtained from the Regional Ethics Committee for Human Health Research of the West Region, Cameroon. Written informed consent was obtained from study participants after verbal and written summary presentations of the study, in French, the language used during coordination meetings. If necessary, the healthcare provider could call on the principal investigator to read certain questions. Confidentiality was ensured by the de-identification of questionnaires and secure storage. In addition, participants were informed of their right to withdraw from the study at any time without penalty and of the potential benefit of the study, improved maternal healthcare practices. This study adhered to the ethical principles outlined in the Declaration of Helsinki.
RESULTS
Sociodemographic Characteristics of Healthcare Providers
In this study, the response rate was 94.4%. The majority of participants were women 64.6%; the mean age of participants was 39.6 ± 10.6 years, with the 40–49 age group being the most represented 29%. The majority of caregivers were nurses, 64.3%. The majority were Christians, 80.7%, working in a health center, 79.1%, and more than two-thirds of the health facilities, 70.2% were located in urban-rural areas. More than half of the participants, 54.4% had more than 10 years of professional experience [Table 1].
| Variables | Frequency | Percent |
|---|---|---|
| Sex | ||
| Male | 132 | 35.4 |
| Female | 241 | 64.6 |
| Age (years) | ||
| 20–29 | 86 | 23.1 |
| 30–39 | 97 | 26.0 |
| 40–49 | 108 | 29.0 |
| ≥50 | 82 | 22.0 |
| Marital status | ||
| Married | 258 | 69.2 |
| Single | 105 | 28.1 |
| Divorced | 4 | 1.1 |
| Widow | 6 | 1.6 |
| Professional qualification | ||
| Nurse Assistant | 109 | 29.2 |
| Nurse | 240 | 64.3 |
| Midwife | 19 | 5.1 |
| General practitioner | 5 | 1.3 |
| Religion | ||
| Christian | 301 | 80.7 |
| Muslim | 52 | 13.9 |
| Others | 20 | 5.4 |
| Place of work | ||
| Health center | 295 | 79.1 |
| District Hospital/Medical Center | 47 | 12.6 |
| Clinic | 31 | 8.3 |
| Location of health facility | ||
| Urban-Rural | 262 | 70.2 |
| Rural | 111 | 29.8 |
| Years of service | ||
| <1 | 8 | 2.1 |
| 1–5 | 99 | 26.5 |
| 6–10 | 63 | 17.0 |
| >10 | 203 | 54.4 |
Partograph Use
The prevalence of partograph use was 72.1% (95% CI: 67.3– 76.6), meaning that 72.1% (269) used it routinely; 19% (71) used it occasionally, 3.8% (14) used it rarely, and 5.1% (19) of caregivers reported never having used it.
Partograph Knowledge
The mean knowledge score was 20.7 ± 4.6, ranging from 2 to 30. The proportion of providers with a good knowledge score was 59.8% (223), followed by those with an average score of 37.3% (139), and finally, 2.9% (11) recorded a poor knowledge score.
Determinants of Good knowledge on the partograph
The likelihood of having good partograph knowledge was 5.41 times higher among midwives and general practitioners than among nursing assistants (AOR = 5.41 [95% CI: 1.51–26.8]). In addition, healthcare professionals working in a District Hospital/Medical Center had 2.76 times more knowledge than those working in a Health Center (AOR = 2.76 [95% CI: 1.24–6.87]). Furthermore, healthcare providers working in a health facility located in a Rural Health District had 1.71 times more good knowledge than those working in an Urban-Rural Health District (AOR = 1.71 [95% CI: 1.05–2.81]). The probability of having good knowledge of the partograph was six times higher among caregivers with 6–10 years of professional experience compared to those with <1 year (AOR = 6.03 [1.22–35.4]) [Table 2].
| Variables | Overall knowledge | COR (95% CI) | p-value | AOR (95% CI) | p-value | |
|---|---|---|---|---|---|---|
| Poor-to-Fair n(%) | Good n(%) | |||||
| Sex | ||||||
| Female | 106 (44.0) | 135 (56.0) | 1 | 1 | ||
| Male | 44 (33.3) | 88 (66.7) | 1.57 (1.01–2.46) | 0.046 | 1.49 (0.93–2.42) | 0.10 |
| Professional qualification | ||||||
| Nurse-assistant | 54 (49.5) | 55 (50.5) | 1 | 1 | ||
| Nurse | 93 (38.8) | 147 (61.2) | 1.55 (0.98–2.45) | 0.059 | 1.56 (0.95–2.57) | 0.079 |
| Midwife/General practitioner | 3 (12.5) | 21 (87.5) | 6.87 (2.21–30.3) | 0.003 | 5.41 (1.51–26.8)* | 0.018 |
| Type of institution | ||||||
| Health Center | 126 (42.7) | 169 (57.3) | 1 | 1 | ||
| District Hospital/Medical Center | 8 (17.0) | 39 (83.0) | 3.63 (1.72–8.63) | 0.001 | 2.76 (1.24–6.87)* | 0.019 |
| Clinic | 16 (51.6) | 15 (48.4) | 0.70 (0.33–1.47) | 0.3 | 0.66 (0.30–1.44) | 0.3 |
| Location of health facility | ||||||
| Urban-Rural | 112 (42.7) | 150 (57.3) | 1 | 1 | ||
| Rural | 38 (34.2) | 73 (65.8) | 1.43 (0.91–2.29) | 0.13 | 1.71 (1.05–2.81)* | 0.032 |
| Years of service | ||||||
| <1 | 5 (62.5) | 3 (37.5) | 1 | 1 | ||
| 1–5 | 46 (46.5) | 53 (53.5) | 1.92 (0.45–9.77) | 0.4 | 3.03 (0.64–17.0) | 0.2 |
| 6–10 | 18 (28.6) | 45 (71.4) | 4.17 (0.93–22.1) | 0.068 | 6.03 (1.22–35.4)* | 0.031 |
| >10 | 81 (39.9) | 122 (60.1) | 2.51 (0.60–12.5) | 0.2 | 3.91 (0.85–21.6) | 0.088 |
| Routine utilization of partograph | ||||||
| No | 52 (50.0) | 52 (50.0) | 1 | 1 | ||
| Yes | 98 (36.4) | 171 (63.6) | 1.74 (1.10–2.76) | 0.017 | 1.55 (0.95–2.53) | 0.08 |
Determinants of Partograph Use
Partograph use was 390 times higher among healthcare providers working in health facilities where the partograph was continuously available than among those working in health facilities where it was not systematically available (AOR = 390 [95% CI: 75.4–7366]). Furthermore, healthcare providers who had received ongoing training used the partograph 2.85 times more than those who had not yet received it (AOR = 2.85 [95% CI: 1.45–5.81]) [Table 3].
| Variables | Routine utilization | COR (95% CI) | p-value | AOR (95% CI) | p-value | |
|---|---|---|---|---|---|---|
| No (%) | Yes (%) | |||||
| Sex | ||||||
| Male | 41 (31.1) | 91 (68.9) | 1 | 1 | ||
| Female | 63 (26.1) | 178 (73.9) | 1.27 (0.7–2.03) | 0.3 | 1.24 (0.60–2.50) | 0.6 |
| Professional qualification | ||||||
| Nurse Assistant | 32 (29.4) | 77 (70.6) | 1 | 1 | ||
| Nurse | 71 (29.6) | 169 (70.4) | 0.99 (0.60–1.62) | >0.9 | 0.57 (0.25–1.24) | 0.2 |
| Midwife/General practitioner | 1 (4.2) | 23 (95.8) | 9.56 (1.89–175) | 0.030 | 1.72 (0.26–34.2) | 0.6 |
| Type of institution | ||||||
| Health center | 90 (30.5) | 205 (69.5) | 1 | 1 | ||
| District Hospital/Medical Center | 5 (10.6) | 42 (89.4) | 3.69 (1.54–10.9) | 0.008 | 3.51 (0.98–20.2) | 0.092 |
| Clinic | 9 (29.0) | 22 (71.0) | 1.07 (0.49–2.54) | 0.9 | 4.16 (0.95–32.6) | 0.10 |
| Location of health facility | ||||||
| Rural | 36 (32.4) | 75 (67.6) | 1 | 1 | ||
| Urban-Rural | 68 (26.0) | 194 (74.0) | 1.37 (0.84–2.21) | 0.2 | 1.60 (0.79–3.19) | 0.2 |
| Knowledge about partograph | ||||||
| Poor | 7 (63.6) | 4 (36.4) | 1 | 1 | ||
| Fair | 45 (32.4) | 94 (67.6) | 3.66 (1.05–14.6) | 0.047 | 2.14 (0.17–18.0) | 0.5 |
| Good | 52 (23.3) | 171 (76.7) | 5.75 (1.67–22.7) | 0.007 | 2.27 (0.18–18.9) | 0.5 |
| Routine availability of partograph | ||||||
| No | 60 (98.4) | 1 (1.6) | 1 | 1 | ||
| Yes | 44 (14.1) | 268 (85.9) | 365 (77.4–6540) | <0.001 | 390 (75.4–7366)* | <0.001 |
| On job training | ||||||
| No | 75 (38.5) | 120 (61.5) | 1 | 1 | ||
| Yes | 29 (16.3) | 149 (83.7) | 3.21 (1.98–5.31) | <0.001 | 2.85 (1.45–5.81)* | 0.003 |
DISCUSSION
In this study, the partograph utilization rate was 72.1% (95% CI: 67.3; 76.6); this result is lower than those obtained in Nigeria 98.8%,[16] and Ghana, 93.3%.[17] This difference could be explained by the different strategies implemented; in fact, 83.8% of obstetric care providers had received ongoing training on the partograph in Ghana.[17] However, the prevalence obtained was higher than that observed in Ethiopia, 31.1% and 50.7%[14,18] in the North-West and South-West Regions, 32.4% [10] and in the Central Region, 56.1%[12] in Cameroon.
Less than two-thirds of participants, 59.8% had good knowledge of the partograph; our result is similar to that of Agan et al., where the proportion of respondents with a good level of knowledge about the partograph was 58.3%;[19] this proportion was 43.9% in Ethiopia,[18] and 61.8% in Cameroon.[20] On the other hand, a higher proportion, 78% of health care providers in Ghana had good knowledge of the partograph,[17] this difference could be explained by the fact that their study population was composed of 93.3% midwives, unlike our sample of mixed providers.
This study found that midwives and general practitioners had 5.41 times more good knowledge of the partograph than nurse assistants. This result is similar to those obtained in South Africa.[21] This could be explained by the fact that general practitioners have a higher level of education than nurses and nurse assistants. In addition, midwives received more basic training focused on reproductive health than nurse assistants and nurses.
Furthermore, health professionals working in a district hospital or medical center had 2.76 times more good knowledge of the partograph than those working in a health center. This result is similar to that of Mezmur et al.[22] This study also found that healthcare providers in rural health districts were 1.71 times more likely to have optimal knowledge of the partograph than those in urban-rural health districts, this could be due to greater workload in urban-rural Health Districts, where providers face higher client volumes and quicker access to operating rooms for cesarean sections.
Healthcare providers who received ongoing training used the partograph 2.85 times more than those who had not yet received it. Several research studies have found similar results.[17,20,22] This could be due to the fact that healthcare providers who received ongoing training on the partograph had better knowledge and, therefore, felt more confident in using this tool to monitor women during labor. This finding reveals the need to intensify refresher training on the partograph in the West and Cameroon in general. Healthcare workers working in health facilities where the partograph was continuously available used it 390 times more than those working in health facilities where it was not systematically available. Other authors have also found that the availability of the partograph is a determinant that increases its frequency of use.[14,17]
This study was conducted in fourteen health districts, including both urban-rural and rural health districts, selected using a probability sampling strategy. In addition, healthcare providers from various private and public health facilities, including health centers and hospitals, participated in the study. Data collection was done using a self-administered questionnaire, which could lead to social desirability bias, where respondents are more likely to give positive answers. However, to limit this bias, we guaranteed anonymity and specified that the study would help develop strategies to improve the quality of maternal care. These results can be generalized to West Cameroon.
CONCLUSION AND GLOBAL HEALTH IMPLICATIONS
The level of partogram or partograph utilization was 72.1 %, which is lower than WHO recommendation. On-thejob refresher training on partograph and availability of partograph were significantly related to the utilization of the partograph. These results showed the gaps from the optimal partograph utilization and the potential interventions to put in place in order to increase health professional’s knowledge and correct utilization of partograph.
Key Messages
(1) The partograph use rate in the study was 72.1% (95% CI: 67.3; 76.6), which is low compared to WHO recommendations. (2) Less than two-thirds of respondents 59.8% had good knowledge of the partograph, which may affect the quality of its use. (3) Interventions such as periodic refresher training on the partograph and ensuring its continuous availability in delivery services are needed to increase the level of knowledge and frequency of partograph use.
Acknowledgments:
None.
COMPLIANCE WITH ETHICAL STANDARDS
Conflicts of Interest: The authors declare no competing interests; Financial Disclosure: Nothing to declare; Funding/Support: There was no funding for this study; Ethics Approval: Ethical approval for the study was sought and obtained from Regional Ethics Committee for Human Health Research in the West Region, Cameroon, number 1018/27/12/2023/CE/CRERSH-OU/VP, dated December 27, 2023. Declaration of Patient Consent: The authors certify that they have obtained all appropriate patient consent; Use of Artificial Intelligence (AI)-Assisted Technology for Manuscript Preparation: The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI; Disclaimer: None.
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