Use of an electronic Partograph: feasibility and acceptability study in Zanzibar, Tanzania

Abstract

Background: The ePartogram is a tablet-based application developed to improve care for women in labor by addressing documented challenges in partograph use. The application is designed to provide real-time decision support, improve data entry, and increase access to information for appropriate labor management. This study's primary objective was to evaluate the feasibility and acceptability of ePartogram use in resource-constrained clinical settings.

Methods: The ePartogram was introduced at three facilities in Zanzibar, Tanzania. Following 3 days of training, skilled birth attendants (SBAs) were observed for 2 weeks using the ePartogram to monitor laboring women. During each observed shift, data collectors used a structured observation form to document SBA comfort, confidence, and ability to use the ePartogram. Results were analyzed by shift. Short interviews, conducted with SBAs (n = 82) after each of their first five ePartogram-monitored labors, detected differences over time. After the observation period, in-depth interviews were conducted (n = 15). A thematic analysis of interview transcripts was completed.

Results: Observations of 23 SBAs using the ePartogram to monitor 103 women over 84 shifts showed that the majority of SBAs (87-91%) completed each of four fundamental ePartogram tasks-registering a client, entering first and subsequent measurements, and navigating between screens-with ease or increasing ease on their first shift; this increased to 100% by the fifth shift. Nearly all SBAs (93%) demonstrated confidence and all SBAs demonstrated comfort in using the ePartogram by the fifth shift. SBAs expressed positive impressions of the ePartogram and found it efficient and easy to use, beginning with first client use. SBAs noted the helpfulness of auditory reminders (indicating that measurements were due) and visual alerts (signaling abnormal measurements). SBAs expressed confidence in their ability to interpret and act on these reminders and alerts.

Conclusions: It is feasible and acceptable for SBAs to use the ePartogram to support labor management and care. With structured training and support during initial use, SBAs quickly became competent and confident in ePartogram use. Qualitative findings revealed that SBAs felt the ePartogram improved timeliness of care and supported decision-making. These findings point to the ePartogram's potential to improve quality of care in resource-constrained labor and delivery settings.

Keywords: Clinical decision support; Labor and delivery; Maternal and newborn health; Mobile data collection; Partogram; Partograph; Quality of care; Real-time monitoring; Zanzibar.

Conflict of interest statement

Authors’ information

LL, MSPH, Program Officer II, Innovations, Jhpiego; CM, MPH, Monitoring and Evaluation Advisor, Jhpiego; AK, Zonal Program Manager - Zanzibar, Jhpiego Tanzania; CH, MHS, Senior Program Officer, Jhpiego; JZ, MS, Country Director, Jhpiego, Tanzania; KM, Zonal Public Health Nursing Officer, Ministry of Health Zanzibar, RN, RM, BsCN, MPH; MD, BSN, RN, MPH, Monitoring, Evaluation and Research Director, Jhpiego, Tanzania; MM, PDME, MSc, Senior Monitoring and Evaluation Officer, Jhpiego, Tanzania; MN, Monitoring, Evaluation and Learning Analyst, Jhpiego, Tanzania; SM, Director, Hospital Services, Ministry of Health, Zanzibar; YK, MSc, Senior Health Informatics Advisor, Jhpiego, Tanzania; PG, CNM, MPH, Senior Maternal and Newborn Health Technical Advisor, Jhpiego.

Ethics approval and consent to participate

The study protocol, study tools, and informed consent forms were approved by the MOH Zanzibar Medical Research and Ethics Committee (IRB00004514) and the Johns Hopkins School of Public Health Institutional Review Board (IRB00000758). Skilled birth attendants (SBAs) provided written informed consent and laboring clients provided oral informed consent to participate in the study. The study team determined that reading a consent form would be unduly burdensome for the laboring woman so oral consent was obtained from women in labor, as has been done in similar IRB approved studies. The oral informed consent script and process were approved by the Zanzibar Medical Research and Ethics Committee and the Johns Hopkins School of Public Health IRB. SBAs who obtained oral consent from laboring women were trained on how to obtain informed oral consent within the context of labor and delivery.

Consent for publication

The study protocol, which included details of data management to maintain confidentiality and anonymity of in-depth interviews, and informed consent forms were approved by both a US-based and the Zanzibar-based ethics committees. Quotes from in-depth interviews with SBAs were taken from anonymized, transcribed and translated audio files of the interviews. Names of skilled birth attendants (SBAs) were not asked during recording, included in digital files, nor written in the interview notes. The study team has reviewed the quotes several times to ensure that an individual participant’s identity could not be derived from the quotes, or from the context of the manuscript along with the quotes. Given these steps to protect study participants anonymity we rely on the IRB approved written informed consent forms obtained from SBAs to include these quotes.

Competing interests

The authors declare that they have no competing interests.

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Figures

Fig. 1

ePartogram

Fig. 2

Facility profiles: 1Mwembeladu Maternity Home: urban, 550 births/month, 12 SBAs enrolled in study. 2Chukwani Primary Health Care Unit (PHCU): urban, 105 births/month, 7 SBAs enrolled in study. 3Makunduchi Health Centre: rural, 136 births/month, 12 SBAs enrolled in study

Fig. 3

ePartogram ease of use by shift. Observed ease of use in completing tasks on the ePartogram: (a) registering a new client; (b) entering the first set of clinical measurements; (c) entering subsequent data; (d) navigating between data entry screens

Fig. 4

Observed SBA comfort and confidence in using the ePartogram

Fig. 5

SBAs taking a measurement after a reminder