Feasibility and effectiveness of electronic vs. paper partograph on improving birth outcomes: A prospective crossover study design

Autoři: Aminur Rahman aff001;  Tahmina Begum aff001;  Fatema Ashraf aff002;  Sadika Akhter aff001;  Dewan Md. Emdadul Hoque aff003;  Tarun Kanti Ghosh aff004;  Monjur Rahman aff001;  Jelle Stekelenburg aff005;  Sumon Kumar Das aff007;  Parveen Fatima aff008;  Iqbal Anwar aff001
Působiště autorů: Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh aff001;  Department of Obstetrics and Gynaecology, Shaheed Suhrawardi Medical College & Hospital, Dhaka, Bangladesh aff002;  Maternal and Child Health Division, icddr,b, Dhaka, Bangladesh aff003;  Department of Obstetrics and Gynaecology, Kushtia Medical College & Hospital, Kushtia, Bangladesh aff004;  Department of Health Sciences, Global Health, University Medical Centre/University of Groningen, Groningen, The Netherlands aff005;  Department of Obstetrics and Gynaecology, Leeuwarden Medical Centre, Leeuwarden, The Netherlands aff006;  Clinical and Nutrition Sciences Division, icddr,b, Dhaka, Bangladesh aff007;  Department of Obstetrics and Gynaecology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh aff008
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: https://doi.org/10.1371/journal.pone.0222314



The partograph has been endorsed by World Health Organization (WHO) since 1994 which presents an algorithm for assessing maternal and foetal conditions and labor progression. Monitoring labour with a partograph can reduce adverse pregnancy outcomes such as prolonged labor, emergency C-sections, birth asphyxia and stillbirths. However, partograph use is still very low, particularly in low and middle income countries (LMICs). In Bangladesh the reported partograph user rate varies from 1.4% to 33.0%. Recently, an electronic version of the partograph, with the provision of online data entry and user aid for emergency clinical support, has been tested successfully in different settings. With this proven evidence, we conducted and operations research to test the feasibility and effectiveness of implementing an e-partograph, for the first time, in 2 public hospitals in Bangladesh


We followed a prospective crossover design. Two secondary level referral hospitals, Jessore and Kushtia District Hospital (DH) were the study sites. All pregnant women who delivered in the study hospitals were the study participants. All nurse-midwives working in the labor ward of study hospitals were trained on appropriate use of both types of partograph along with standard labour management guidelines. Collected quantitative data was analyzed using SPSS 23 statistical software. Discrete variables were expressed as percentages and presented as frequency distribution and cross tabulations. Chi square tests were employed to test the association between exposure and outcome variables. Potential confounding factors were adjusted using multivariate binary logistic regression methods. Ethical approval was obtained from the institutional review board of the International Centre for Diarrheal Disease Research, Bangladesh (icddr,b).


In total 2918 deliveries were conducted at Jessore DH and 2312 at Kushtia DH during one-year study period. Of them, 1012 (506 in each facility) deliveries were monitored using partograph (paper or electronic). The trends of facility based C-section rates was downwards in both the hospitals; 43% to 37% in Jessore and from 36% to 25% in Kushtia Hospital. There was a significant reduction of prolonged labour with e-partograph use. In Kushtia DH, the prolonged labour rate was 42% during phase 1 with the paper version which came down to 29% during phase-2 with the e-partograph use. The similar result was observed in Jessore DH where the prolonged labour rate reduced to 7% with paper partograph from the reported 30% prolonged labour with e-partograph. The e-partograph user rate was higher than the paper partograph during both phases (phase 1: 3.31, CI: 2.04–5.38, p < .001 and in phase 2: 15.20 CI: 6.36–36.33, p < .001) after adjusting for maternal age, parity, gestational age, religion, mother’s education, husband’s education, and fetal sex


The partograph user rate has significantly improved with the e- partograph and was associated with an overall reduction in cesarean births. Use of the e-partograph was also associated with reduced rates of prolonged labour. This study has added to the growing body of evidence on the positive impact of e-partograph use. We recommend implementing e-partograph intervention at scale in both public and private hospitals in Bangladesh.

Trial registration

ClinicalTrials.gov NCT03509103.

Klíčová slova:

Asphyxia – Bangladesh – Cesarean section – Hospitals – Labor and delivery – Obstetrics and gynecology – Pregnancy – Religion


1. Lawn JE, Blencowe H, Kinney MV, Bianchi F, Graham WJ. Evidence to inform the future for maternal and newborn health. Best Pract Res Clin Obstet Gynaecol. 2016;36:169–83. Epub 2016/10/07. doi: 10.1016/j.bpobgyn.2016.07.004 27707540.

2. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010;375(9726):1609–23. doi: 10.1016/S0140-6736(10)60518-1 20382417

3. Bongaarts J. WHO, UNICEF, UNFPA, World Bank Group, and United Nations Population Division Trends in Maternal Mortality: 1990 to 2015 Geneva: World Health Organization, 2015. Population and Development Review. 2016;42(4):726–.

4. Say L, Chou D, Gemmill A, Tuncalp O, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Global Health. 2014;2(6):e323–33. Epub 2014/08/12. doi: 10.1016/S2214-109X(14)70227-X 25103301.

5. Halim A, Dewez JE, Biswas A, Rahman F, White S, van den Broek N. When, where, and why are babies dying? Neonatal death surveillance and review in Bangladesh. PloS one. 2016;11(8):e0159388. doi: 10.1371/journal.pone.0159388 27478900

6. World Health organization. Preventing prolonged labour: A practical guide. Maternal health And safe Motherhood programme. Geneva: Division of family health, World Health organization, 1994.

7. Underwood HM. The PartoPen: Using Digital Pen Technology to Improve Maternal Labor Monitoring in the Developing World: University of Colorado Boulder; 2013.

8. Friedman EA. Primigravid labor; a graphicostatistical analysis. Obstet Gynecol. 1955;6(6):567–89. Epub 1955/12/01. doi: 10.1097/00006250-195512000-00001 13272981.

9. Philpott R, Castle W. Cervicographs in the management of labour in primigravidae. BJOG: An International Journal of Obstetrics & Gynaecology. 1972;79(7):592–8.

10. World Health Organization. Safe Motherhood Initiative; Nairobi Conference. Nairobi: World Health Organization, 1987.

11. World Health Organization partograph in management of labour. World Health Organization Maternal Health and Safe Motherhood Programme. Lancet. 1994;343(8910):1399–404. doi: 10.1016/s0140-6736(94)92528-3 7910888

12. Yisma E, Dessalegn B, Astatkie A, Fesseha N. Knowledge and utilization of partograph among obstetric care givers in public health institutions of Addis Ababa, Ethiopia. Bmc Pregnancy Childb. 2013;13(1):17. Artn 17 doi: 10.1186/1471-2393-13-17 WOS:000314290700001. 23331626

13. Sama CB, Takah NF, Danwe VK, Melo UF, Dingana TN, Angwafo FF. Knowledge and utilization of the partograph: A cross-sectional survey among obstetric care providers in urban referral public health institutions in northwest and southwest Cameroon. Plos One. 2017;12(2):e0172860. doi: 10.1371/journal.pone.0172860 WOS:000394688200155. 28234990

14. Wakgari N, Tessema GA, Amano A. Knowledge of partograph and its associated factors among obstetric care providers in North Shoa Zone, Central Ethiopia: a cross sectional study. BMC research notes. 2015;8(1):407.

15. Anwar I, Kalim N, Koblinsky M. Quality of obstetric care in public-sector facilities and constraints to implementing emergency obstetric care services: evidence from high- and low-performing districts of Bangladesh. J Health Popul Nutr. 2009;27(2):139–55. Epub 2009/06/06. doi: 10.3329/jhpn.v27i2.3327 19489412; PubMed Central PMCID: PMC2761772.

16. Chowdhury ME, Roy L, Biswas TK, Rahman M, Akhter S, Al-Sabir A. A Needs Assessment Study for Emergency Obstetric and Newborn Care (EmONC) Services in 24 Districts of Bangladesh. Dhaka: icddr,b, 2014.

17. Bogren MU. Saving Lives of Mothers and Babies: An Assessment on Nurse-Midwives´ Knowledge in Bangladesh. 2010.

18. Orhue A, Ande A, Aziken M. Barriers to the universal application of the portograph for labour managent: A review of the issues and proposed solution. Tropical Journal of Obstetrics and Gynaecology. 2013;28(1):32–42.

19. Pett C, Ruminjo J, Levin K. Revitalizing the partograph in low resource settings: Does the evidence support a global call to action? International Journal of Gynecology & Obstetrics. 2012;119:S235.

20. Vangeenderhuysen C, Renaudin P, Vall MI. The delivery record: a help to make the right decision Sante. 2001;11(4):259–63.

21. Singh S, Khalid A, Paul K, Haider Y, Prasad S, editors. prasavGraph: An Android-based e-Partograph. Systems in Medicine and Biology (ICSMB), 2016 International Conference on; 2016: IEEE.

22. Hadi SPI, Kuntjoro T, Sumarni S, Anwar MC, Widyawati MN, Pujiastuti RSE. THE DEVELOPMENT OF E-PARTOGRAPH MODULE AS A LEARNING PLATFORM FOR MIDWIFERY STUDENTS: THE ADDIE MODEL. Belitung Nursing Journal. 2017;3(2):148–56.

23. E-Parto Digital WHO Partograph: An effective use of technology to identify and manage labor complications in Kenya–Bungoma County [Internet]. Hyderabad India, Conference Presentation: ICT4D Conference,; 2017

24. Vangeenderhuysen C, Renaudin P, Vall MI. The delivery record: a help to make the right decision. Sante. 2001;11(4):259–63. 11861204

25. Louis TA, Lavori PW, Bailar JC, 3rd, Polansky M. Crossover and self-controlled designs in clinical research. N Engl J Med. 1984;310(1):24–31. Epub 1984/01/05. doi: 10.1056/NEJM198401053100106 6689736.

26. Maclure M. The case-crossover design: a method for studying transient effects on the risk of acute events. Am J Epidemiol. 1991;133(2):144–53. Epub 1991/01/15. doi: 10.1093/oxfordjournals.aje.a115853 1985444.

27. Islam MN. Situation of Neonatal Health in Bangladesh. The Orion. 2000;6.

28. Aliyu I, Lawal TO, Onankpa B. Prevalence and outcome of perinatal asphyxia: Our experience in a semi-urban setting. Tropical Journal of Medical Research. 2017;20(2):161.

29. Rather SY, Qadir A, Parveen S, Jabeen F. Use of condom to control intractable PPH. JK Science. 2010;12(3):127–9.

30. INNOVATION PROJECT PROFILE: Electronic partograph [Internet]. 2017. Available from: http://www.mnhcicf.org/portfolio/project/electronic-partograph.

31. Lennox CE, Kwast BE. The partograph in community obstetrics. Trop Doct. 1995;25(2):56–63. Epub 1995/04/01. doi: 10.1177/004947559502500204 7778195.

32. World Health organization. The Parograph. Guideline for operation research on the application of partograph. Geneva: World Health Organization, 1988 (WHO/MCH/88.3).

33. Gitanjali D, Rajashree S, Chandra DG. Role of Paperless Partograph in Monitoring Primiparous and Multiparous Labour. Age (years). 2014;17(36):23–3.6.

34. Deka G, Sharma R, Das GC. The paperless partograph: can it be effective to replace the WHO modified partograph. International Journal of Reproduction, Contraception, Obstetrics and Gynecology. 2015:452–5.

35. World Health Organization. Indicators to monitor maternal health goals. Geneva: World Health Organization, 1994.

36. Molina G, Weiser TG, Lipsitz SR, Esquivel MM, Uribe-Leitz T, Azad T, et al. Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality. Jama-J Am Med Assoc. 2015;314(21):2263–70. doi: 10.1001/jama.2015.15553 WOS:000365515700018. 26624825

37. Begum T, Rahman A, Nababan H, Hoque DME, Khan AF, Ali T, et al. Indications and determinants of caesarean section delivery: Evidence from a population-based study in Matlab, Bangladesh. PLoS One. 2017;12(11):e0188074. Epub 2017/11/21. doi: 10.1371/journal.pone.0188074 29155840; PubMed Central PMCID: PMC5695799.

38. National Institute of Population Research and Training (NIPORT). Bangladesh Demographic and Health Survey 2014: Key Indicators. Dhaka, Bangladesh, and Rockville, Maryland, USA: NIPORT, Mitra and Associates, and ICF International. Dhaka: National Institute of Population Research and Training, 2015.

39. National Institute of Population Research and Training (NIPORT). Bangladesh Maternal Mortality and Health Care Survey 2016: Summary. Dhaka: National Institute of Population Research and Training, 2016.

40. Boerma T, Wilson K. Quiet Revolution Strengthening the Routine Health Information System in Bangladesh. Eschborn: 2014.

41. World Health Organization. Bangladesh health system review. Manila: WHO Regional Office for the Western Pacific, World Health Organization; 2015.

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