Dr. Christine Bukenya, study PI, and co-PI Dr. Richard Mangwi together with the study team at the dissemination event in Kololo.
Kampala —Wednesday 10/02/2021: Researchers have urged government to fast-track the use of the electronic partograph, a smart and lifesaving tool for improving quality and health outcomes in maternity care.
This is according to the results of their study titled; “Scale-up of the electronic partograph (e-partograph) to improve skilled delivery and emergency referral among refugees and host communities in the West Nile region of Uganda".
A partograph (labor progress chart) is a lifesaving tool designed and recommended by the World Health Organisation (WHO), to monitor the progress of labor and wellbeing of the mother and baby.
In this study, the researchers evaluated its usability, feasibility, and acceptability for maternity care providers in Adjumani district, at Pagirinya and Ayilo Health Centre IIIs between March - September 2020.
Dr. Richard Mangwi Ayiasi, a research fellow in the Department of Community Health and Behavioural Sciences at Makerere University School of Public Health says they chose to conduct the study in Adjumani district because of its uniqueness.
He argues that being a refugee setting made it unique and that it also had well-established systems in place including a referral system as well as adequate staff.
“When you are trying out something, you want to try it out in a place where they have support systems. Otherwise, you have to provide these systems yourself as a researcher and we couldn’t afford for instance the transport system. For example, in this area, they had already standby ambulances which is not common in many other areas,” says Dr. Mangwi.
He observes that they went to Adjumani not because of the problems it had, but as an opportunity since it already had pre-existing systems. “We have done work there before and therefore we knew what was happening,” adds Dr. Mangwi.
Dr. Justine Bukenya, a Principal Investigator of the study and lecturer at Makerere University School of Public Health says they wanted to assess differences in quality of care given to women during labor by comparing proportions of maternal examinations conducted using e-partograph and paper partograph.
“Health workers monitor labor by recording progress on a labor progress chart known as partograph, which has several printed parameters. The health workers keep piles and piles of partographs at the facility ready for use when they get mother in active labor. We transferred the details on paper partograph onto an electronic tool,” says Dr. Bukenya.
A total of 382 mothers were monitored in both facilities from March –September 2020. A paper partograph was used on 201 mothers while electronic partographs were used for 181.
Among mothers monitored using paper partograph, three (3) were not monitored for the heart rate of unborn, and seven (7) missed blood pressure measurements, while six (6) missed temperature recordings. On the other hand, those monitored using e-partographs had all maternal measurements recorded. Regarding the APGAR score, a scoring system doctors and nurses use to assess new-borns one minute and five minutes after they’re born, a total of 13 babies scored below seven of which mothers of 11 were monitored using paper partographs.
According to researchers, regular and timely monitoring of maternal and unborn parameters during labor is critical to assessing maternal and unborn well-being, supporting normal labor, identifying complications, and spurring clinical decision-making to address them in a timely manner.
They contend that the e-partograph is an efficacious intervention in close monitoring of labor as it facilitates complete filling of the partograph and timely action.
In Uganda, 27 babies in every 1000 die in the first 28 days of life according to the Uganda Demographic Health Survey, 2016. Statistics also show that 375 women in every 100,000 die from health problems related to pregnancy. For the last four decades, the WHO has recommended that, during labor, skilled birth attendants use the partograph as a tool to improve documentation of intrapartum maternal and the unborn measurements, identify abnormalities, and inform appropriate labor management.
Whereas the introduction of electronic decision-support tools has the potential to improve health service delivery in resource-constrained settings, researchers warn that before scaling up the tool, there is need to address power shortages especially for rural health centers, poor network coverage as well as addressing the low computer knowledge among health workers.
The researchers also note that there is a need to address the sustainability issues, internet data, and airtime, security of the gadgets, maintenance of the tablets as well as ensuring the availability of resident IT staff to rectify issues
Government especially, the Ministry of Health has been urged to assess its effect on a larger scale including non-refugee settings since evidence suggests its efficiency in improving monitoring of labor.
According to Dr. Bukenya, up to 50% of women assessed using both tools missed urine tests and yet this test is important in detecting whether the mother will progress into eclampsia through detecting protein in their urine. She says this is an area for further investigation, to ascertain why assessment of pregnant mothers especially in health facilities such as those in the study miss out an important element of carrying out urine tests.
How the ePartograph works
Joshua Businge Muleesi, Co-Investigator and a Computer Scientist with Think IT Company says the innovation has been designed to digitize the paper-based tool that is currently used to enable monitoring of pregnant mothers’ vital signs easy and more efficient since it creates alerts/reminders of when to take the next reading.
“The application enables sharing of the partographs among health workers which make referral easy especially in remote communities. We have tested this system in Ayilo, Pagirinya, Dzaipi Health centers which all refer their patients to Adjumani Hospital,” says Businge.
This is a new innovation system that has been developed by ThinkIT Limited, a company led by Joshua Businge in partnership with Makerere University School of Public Health.
Researchers are optimistic that with the roll-out of the internet and electricity across the country, the use of this tool will be inevitable for better health outcomes. They also want to explore the feasibility of having this app configured for smartphones as opposed to the current mode that supports tablets.
“Five or so years ago, the internet was concentrated here in Kampala. But today, someone can be in position to access the internet even in the remotest area in the country. This means that something is changing in the background,” says Dr. Mangwi.
“While it appears that it is costly now, in the next ten years, the internet will be a necessity in Uganda. Tablets are not going to be an exclusion for a few. So, the wave of digital technologies cannot be resisted. Each health facility can have one tablet and this can support this goal and it is feasible,” he adds.
By Davidson Ndyabahika