Abstract:

One of the most important quality thematic areas incentivized in PBF is maternity services which among other aspects include the use and completion of partographs when monitoring women in labor. Use f partographs during labor is a key intervention but it is not widely used due to various factors. Thus, the PBF program in Jimma sought to strengthen its use and completion since Q4 2019. A quasi-experimental design was used to review 7,260 mothers’ records from 2018, 2019 and 2021 from both Buno-Bedele (control) and Jimma (intervention) zones. Impact of the PBF program on partograph utilization and completeness was estimated using difference-in-differences (DiD) models in STATA 15. In 2019, partograph utilization was estimated to be 29.2% (CI: 26.6% - 31.8%) in Jimma and 23.5% (CI: 21.1% - 25.9%) in Buno-Bedele. In 2021, utilization increased to 87.2% (CI: 85.3% - 89.2%) in Jimma and 41.4% (CI: 38.7% - 44.2%) in Buno-Bedele. Out of the labor cases monitored with partographs, the completeness was 60.2% (CI: 58.1% - 62.4%) in Jimma and 51.6% (CI: 49.5% - 53.6%) in Buno-Bedele in 2019. In 2021, the completeness increased to 83.2% (CI: 82.3% - 84.2%) in Jimma and but remained the same in Buno-Bedele, 51.3% (CI: 49.7% - 52.8%). PBF accelerated the rate of improvement for both utilization (DiD: 30.8%, p-value < 0.001) and completion (DiD: 24.9%, p-value < 0.001) of partographs. Incentivizing facilities to improve quality of care coupled with coaching and mentorship of health workers is effective in improving quality of service for pregnant women in labor and delivery.

Keywords: Labor and delivery, Maternity, Partographs, Performance based financing, Pregnancy.

References:

[1] WHO. Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization, 2019.

[2] Countdown to 2015-decade report (2000–10): taking stock of maternal, newborn, and child survival. Bhutta, Z. A., Chopra, M., Axelson, H., Berman, P., Boerma, T., Bryce, J, & Wardlaw, T. 2015, The lancet, 375(9730), pp. 2032-2044.

[3] Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Kassebaum, N. J., Barber, R. M., Bhutta, Z. A., Dandona, L., Gething, P. W., Hay, S. I., & Ding, E. L. 2016, The Lancet, 388(10053)., pp. 1775-1812.

[4] The use and perceived barriers of the partograph at public health institutions in East Gojjam Zone, Northwest Ethiopia. Zelellw, D., Tegegne, T. 1, s.l.: Annals of global health, 2018, Vol. 84. 198.

[5] Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. Alkema, L., Chou, D., Hogan, D., Zhang, S., Moller, A. B., Gemmill, A., ... & Inter, U. N. M. M. E. 10017, s.l.: The lancet, 2016, Vol. 387. 462-474.

[6] FMOH, EPHI. National maternal death surveillance and response annual report 2008 EFY. s.l.: Federal Democratic Republic of Ethiopia Ministry of Health (FMOH) EPHI, 2017.

[7] Indicators, K. Mini Demographic and Health Survey. s.l.: EPHI and ICF, 2019.

[8] Level of partograph utilization and its associated factors among obstetric caregivers at public health facilities in East Gojam Zone, Northwest Ethiopia. Zelellw, D. A., & Tegegne, T. K. 2018, PloS one, 13(7).

[9] Magnitude of partograph use and factors that affecting its utilization among obstetric caregivers in public health institutions of West Showa Zone. Oromia Regional state, Ethiopia. Willi, W. 2015.

[10] Effect of partograph use on outcomes for women in spontaneous labour at term and their babies. Lavender, T., Cuthbert, A., & Smyth, R. M. 2018, Cochrane Database of Systematic Reviews, (8).

[11] Maternal mortality from obstructed labor: a MANDATE analysis of the ability of technology to save lives in sub-Saharan Africa. Harrison, M. S., Griffin, J. B., McClure, E. M., Jones, B., Moran, K., & Goldenberg, R. L. 09, s.l.: American Journal of Perinatology., 2016, Vol. 33. 873-881.

[12] The use of the partograph in labor monitoring: a cross-sectional study among obstetric caregivers in General Hospital, Calabar, Cross River State, Nigeria. Asibong, U., Okokon, I. B., Agan, T. U., Oku, A., Opiah, M., Essien, E. J., & Monjok, E. s.l.: International Journal of Women’s Health, 2014, Vol. 6. 873.

[13] Partograph utilization as a decision-making tool and associated factors among obstetric care providers in Ethiopia: a systematic review and meta-analysis. Ayenew, A. A., & Zewdu, B. F. 1, s.l.: Systematic Reviews., 2020, Vol. 9. 251.

[14] Health professional’s knowledge and use of the partograph in public health institutions in eastern Ethiopia: a cross-sectional study. Mezmur, H., Semahegn, A., Tegegne, B. S. 1, s.l.: BMC Pregnancy and Childbirth., 2017, Vol. 17. 1-7.

[15] A cross-sectional study of partograph utilization as a decision-making tool for referral of abnormal labour in primary health care facilities of Bangladesh. Khan, A. N. S., Billah, S. M., Mannan, I., Mannan, I. I., Begum, T., Khan, M. A., & Graft-Johnson, J. D. 2018, PloS one, 13(9).

[16] Knowledge and utilization of the partograph: A cross-sectional survey among obstetric care providers in urban referral public health institutions in northwe and southwest Cameroon. Sama, C. B., Takah, N. F., Danwe, V. K., Melo, U. F., Dingana, T. N., & Angwafo III, F. F. 2017, PloS one 12(2).

[17] Knowledge and utilization of the partograph among obstetric care givers in southwest Nigeria. African journal of reproductive health. Fawole, A. O., Hunyinbo, K. I., & Adekanle, D. A. 2008, African Journal of Reproductive Health, 12(1), pp. 22-29.

[18] Knowledge and utilization of the partograph among midwives in the Niger Delta Region of Nigeria. Opiah, M. M., Ofi, A. B., Essien, E. J., & Monjok, E. 2012, African Journal of Reproductive Health, 16(1), pp. 125-132.

[19] Assessment of knowledge and utilization of the partograph among health professionals in Amhara region. Abebe, F., Birhanu, D., Awoke, W., Ejigu, T. 2, 2013, Ethiopia Science Journal of Clinical Medicine, Vol. 2, pp. 26 - 42.

[20] Low utilization of partograph and its associated factors among obstetric care providers in governmental health facilities at West Shoa Zone, Central Ethiopia. Bedada, K. E., Huluka, T. K., & Bulto, G. A. 2020, International Journal of Reproductive Medicine.

[21] Utilization of the partograph and its associated factors among obstetric care providers in the Eastern zone of Tigray, Northern Ethiopia. Gebreslassie, G. W., Weldegeorges, D. A., Assefa, N. E., Gebrehiwot, B. G., Gebremeskel, S. G., Tafere, B. B., & Welesamuel, T. G. 2019, The Pan African Medical Journal (34).

[22] Utilization of Partograph and its associated factors among midwives working in public health institutions, Addis Ababa City Administration, Ethiopia. Hagos, A. A., Teka, E. C., & Degu, G. 2017, BMC Pregnancy and Childbirth, 20(1), pp. 1-9.

[23] Assessment of partograph utilization and associated factors among obstetric care givers at public health institutions in central zone, Tigray, Ethiopia. Hailu, T., Nigus, K., Gidey, G., Hailu, B., & Moges, Y. 2018, BMC Research Notes, 11(1)., pp. 1-6.

[24] Partograph utilization and associated factors among obstetric care providers in North Shoa Zone, Central Ethiopia: a cross sectional study. Wakgari, N., Amano, A., Berta, M., & Tessema, G. A. 2015, African Health Sciences, 15(2), pp. 552-559.

[25] Partograph Utilization and Associated Factors among Obstetric Care Providers Working in Public Health Facilities of Wolaita Zone. Markos, M., Arba, A., & Paulos, K. 2020, Journal of Pregnancy.

[26] Partograph utilization and associated factors among obstetric care providers at public health facilities in Hadiya Zone, Southern Ethiopia. Haile, Y., Tafese, F., Weldemarium, T. D., & Rad, M. H. 2020, Journal of Pregnancy 2020.

[27] Knowledge and utilization of partograph among health care professionals in public health institutions of Bale zone, Southeast Ethiopia. Markos, D., & Bogale, D. 2016, Public health (137), pp. 162-168.

[28] Knowledge and utilization of partograph among obstetric care givers in public health institutions of Addis Ababa, Ethiopia. Yisma, E., Dessalegn, B., Astatkie, A., & Fesseha, N. 2013, BMC Pregnancy and Childbirth, 13(1), pp. 1-9.

[29] Partograph utilization as a decision-making tool and associated factors among obstetric care providers in Ethiopia: a systematic review and meta-analysis. Ayenew, A. A., & Zewdu, B. F. 2020, Systematic Reviews, 9(1), pp. 1-11.

[30] Magnitude of partograph use and associated factors among obstetric care givers in public health institution in Sidama Zone, Southern Ethiopia. Eshetu, K., Hussen, E., & Dulla, D. 6, s.l.: Diversity and Equality in Health and Care., 2017, Vol. 14.

[31] Effect of partogram use on outcomes for women in spontaneous labour at term. Lavender, T., Hart, A., Smyth, R.M. s.l.: Cochrane Database Syst Rev., 2013, Vol. 7.

[32] Effect of Partogram Use on Outcomes for Women in Spontaneous Labour at Term: RHL Commentary. Soni, B. L. Geneva: World Health Organization, 2009, The WHO Reproductive Health Library.

[33] Partograph revisited. N., Magon. 1, 2011, Int J Clin Cases Investig, Vol. 3.

[34] Partograph Utilization and Factors Associated with Poor Perinatal Outcomes in Wolaita Sodo University Referral Hospital, Southern Ethiopia. Chemeda, G., Teklewold, B., & Daka, K. s.l.: Journal of Health, Medicine, and Nursing., 2019, Vol. 63.

[35] Partograph in management of labour. World Health Organization maternal health and safe motherhood programme. WHO. s.l.: Lancet, 1994, Vol. 343. 1399-1404.

[36] Obstetric care in low-resource settings: what, who, and how to overcome challenges to scale up? Hofmeyr, G. J., Haws, R. A., Bergström, S., Lee, A. C., Okong, P., Darmstadt, G. L., & Lawn, J. E. 2009, International Journal of Gynecology & Obstetric (107)., pp. 21-45.

[37] Contemporary patterns of spontaneous labor with normal neonatal outcomes. Zhang, J., Landy, H. J., Branch, D. W., Burkman, R., Haberman, S., Gregory, K. D., ... & Reddy, U. M. 2010, Obstetrics, and gynecology,116(6)., p. 1281.

[38] Labour, W. P. P. (1994). A Practical Guide: The Partograph Part I, Principles and Strategy WHO. World Health Organisation. Division of Family Health. Maternal Health and Safe Motherhood Programme. Safe Motherhood Practical Guide: WHO/FHE/MSM/93.8. Labour, W. P. P. s.l.: A Practical Guide: The Partograph Part I, Principles and Strategy WHO. World Health Organisation. Division of Family Health. Maternal Health and Safe Motherhood Programme. Safe Motherhood Practical Guide: WHO/FHE/MSM/93.8., 1994, Safe Motherhood Practical Guide: WHO/FHE/MSM/93.8.

[39] Incidence causes and outcome of obstructed labor in jimma university specialized hospital. Fantu, S., Segni, H., & Alemseged, F. 2010, Ethiopian Journal of Health Sciences, 20(3).

[40] The partograph for the prevention of obstructed labor. Clinical obstetrics and gynecology, 52(2), 256-269. Mathai, M. 2009, Clinical obstetrics, and gynecology, 52(2)., pp. 256-269.

[41] Assessment of knowledge and utilization of the partograph among health professionals in Amhara region. Abebe, F., Birhanu, D., Awoke, W., Ejigu, T. 2, 2013, Ethiopia Science Journal of Clinical Medicine, Vol. 2, pp. 26 - 42.

[42] Partograph utilization and associated factors among obstetric care providers in North Shoa Zone, Central Ethiopia: a cross sectional study. Wakgari, N., Amano, A., Berta, M., & Tessema, G. A. 2, s.l.: African Health Sciences, 2015, Vol. 15. 552-559.

[43] Looking into the performance-based financing black box: evidence from an impact evaluation in the health sector in Cameroon. de Walque, Damien, et al. 6, 2021, Health Policy and Planning, Vol. 36.

[44] Communities of practice: the missing link for knowledge management on implementation issues in low-income countries? Meessen, Bruno, et al. 8, 2011, Vol. 16.

[45] Performance-based financing: the same is different. Meessen, Bruno, et al. 2017, Health Policy and Planning.

[46] Output-based payment to boost staff productivity in public health centres: contracting in Kabutare District, Rwanda. Meessen, Bruno, Kashala, Jean-Pierre I and Musango, Laurent. 2007, Bulletin of the World Health Organization, pp. 108-115.

[47] Effects of pay for performance in health care: A systematic review of systematic reviews. Eijkenaar, Frank, et al. 2-3, 2013, Health Policy, Vol. 110.

[48] Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation. Basinga, P., et al. 2011, The Lancet, pp. 1421-1428.

[49] Paying for performance’ in Rwanda: Does it pay off? Kalk, A., Paul, F. A. and Grabosch, E. 2010, Tropical Medicine & International Health, pp. 182-190.

[50] Performance-based financing for better quality of services in Rwandan health centres: 3-year experience. Rusa, Louis, et al. 7, 2009, Tropical Medicine & International Health, Vol. 14.

[51] A Conditional Cash Transfer Program in the Philippines Reduces Severe Stunting. Kandpal, Eeshani, et al. 9, 2016, The Journal of Nutrition, Vol. 146.

[52] Can performance-based financing be used to reform health systems in developing countries? Ireland, Megan, Paul, Elisabeth and Dujardin, Bruno. 9, 2011, Bulletin of the World Health Organization, Vol. 89.

[53] Taking Results-Based Financing from Scheme to System. Shroff, Zubin Cyrus, et al. 2, 2017, Health Systems & Reform, Vol. 3.

[54] Why there is so much enthusiasm for performance-based financing, particularly in developing countries. Soeters, Robert and Vroeg, Piet. 9, 2011, Bulletin of the World Health Organization, Vol. 89.

[55] The national free delivery policy in Nepal: early evidence of its effects on health facilities. Witter, S., et al. 2, 2011, Health Policy and Planning, Vol. 26.

[56] Studying the link between institutions and health system performance: a framework and an illustration with the analysis of two performance-based financing schemes in Burundi. Bertone, M. P. and Meessen, B. 8, 2013, Health Policy and Planning, Vol. 28.

[57] Does training on performance-based financing make a difference in performance and quality of health care delivery? Health care provider’s perspective in Rungwe Tanzania. Manongi, Rachel, et al. 1, 2014, BMC Health Services Research, Vol. 14.

[58] Performance-based financing with GAVI health system strengthening funding in rural Cambodia: a brief assessment of the impact. Matsuoka, S., et al. 4, 2014, Vol. 29.

[59] A realist review to assess for whom, under what conditions and how pay for performance programmes work in low- and middle-income countries. Singh, Neha S., et al. 2021, Social Science & Medicine, Vol. 270.

[60] Didq: A Command for Treatment-effect Estimation under Alternative Assumptions. Mora, Ricardo and Reggio, Iliana. 3, 2015, The Stata Journal: Promoting Communications on Statistics and Stata, Vol. 15.

[61] Use of the partogram by doctors and midwives at Odi District Hospital, Gauteng, South Africa. Maphashaa, O. M., Govender, I., Motloba, D. P., & Barua, C. 2017, South African Family Practice, 59(2)., pp. 82-86.

[62] Use and completion of partograph during labour is associated with a reduced incidence of birth asphyxia: a retrospective study at a peri-urban setting in Ghana. Anokye, R., Acheampong, E., Anokye, J., Budu-Ainooson, A., Amekudzie, E., Owusu, I., & Mprah, W. K. 2019, Journal of Health, Population and Nutrition, 38(1)., pp. 1-8.

[63] Partograph use among Midwives in the Gambia. Badjie, B., Kao, C. H., Gua, M. L., & Lin, K. C. 2013, African Journal of Midwifery and Women’s Health, 7(2), pp. 65-69.

[64] Assessment of partogram use during labour in rujumbura health Sub district, Rukungiri district, Uganda. Ogwang, S., Karyabakabo, Z., & Rutebemberwa, E. 2009, African Health Sciences, 9(2).

[65] Use of the partogram by doctors and midwives at Odi District Hospital, Gauteng, South Africa. Maphashaa, O. M., Govender, I., Motloba, D. P., & Barua, C. 2017, South African Family Practice, 59(2), pp. 82-86.

[66] Helping midwives in Ghana to reduce maternal mortality. Floyd, L. 2013, African Journal of Midwifery and Women’s Health, 7(1), pp. 34-38.

[67] Care/Engender Health, Fistula. Improving partograph use in Uganda through coaching and mentoring. New York: Fistula Care., 2013.

[68] An exploration of the unintended consequences of performance-based financing in 6 primary healthcare facilities in Burkina Faso. Turcotte-Tremblay, A.M., Gali Gali, I.A., Ridde, V. 2, 2022, International Journal Health Policy Management., Vol. 11. 145–159.

[69] Partograph utilization as a decision-making tool and associated factors among obstetric care providers in Ethiopia: a systematic review and meta-analysis. Ayenew, A. A., & Zewdu, B. F. 2020, Systematic reviews, 9(1)., p. 251.

[70] Partograph utilization and associated factors among graduating health professional students in Asella Referal and Teaching Hospital, Ethiopia, 2016. Bekele, D., Beyene, K., Hinkosa, L., & Shemsu, M. N. 2, s.l.: STM Journal., 2016, Vol. 6.

[71] Partograph utilization and associated factors among obstetric care givers in governmental health institutions of Jigjiga and Degehabur towns, Somali region, Ethiopia: A cross-sectional study. Ayehubizu, L.M., Tibebeu, A.T., Fetene, M.T., Yohannes, S.H., Yadita, Z.S. 3, s.l.: PLoS ONE, 2022, Vol. 17.

[72] An evaluation of the knowledge and utilization of the partogragh in primary, secondary, and tertiary care settings in Calabar, South-South Nigeria. Okokon, I. B., Oku, A. O., Agan, T. U., Asibong, U. E., Essien, E. J., & Monjok, E. 2014, International Journal of Family Medicine 2014.

[73] De Walque, D., Robyn, P. J., Saidou, H., Sorgho, G., Steenland, M. “de Walque, Damien; Robyn, Paul Jacob; Saidou, Looking into the Performance-Based Financing Black Box: Evidence
from an Impact Evaluation in the Health Sector in Cameroon. Policy Research Working Paper; No.8162. Washington D.C: World Bank, 2017.

[74] Local stakeholders’ perceptions about the introduction of performance-based financing in Benin: a case study in two health districts. Paul, Elisabeth, Sossouhounto, Nadine and Eclou, Dieudonné Sèdjro. 4, 2014, International Journal of Health Policy and Management, Vol. 3.

[75] The effects of performance-based financing on neonatal health outcomes in Burundi, Lesotho, Senegal, Zambia, and Zimbabwe. Gage, Anna and Bauhoff, Sebastian. 3, 2021, Health Policy and Planning, Vol. 36.