Every year, 536,000 women and girls die as a result of complications during pregnancy, child birth or puerperium and this account to one death of every woman every minute of every day [1]. Maternal mortality ratio continues to be the major index of the widening discrepancy in the level of care and outcome of reproductive health between the advanced and developing countries [2].

Dzadeyson [3] reported that more than half of women who die every year from pregnancy related causes are in the African region which constitutes only 12% of the world population and 17% of its births. It has also been estimated that 289,000 maternal deaths occurred worldwide in the year 2013 and 99% of this estimate occurred in developing countries [4]. Nigeria accounts for about 13% of the global maternal death rates with an estimated 36,000 women dying in pregnancy or at child birth each year [5].

According to a United Nations Children’s Fund (UNICEF) report, some of the major causes of high maternal mortality rate in Nigeria include: haemorrhage, obstructed labour, puerperal infection, malaria and complicated abortions [4]. The majority of the maternal deaths and complications attributable to obstructed and prolonged labour could be prevented by cost effective and affordable health intervention like the use of partograph [6]. The partograph is a tool developed by Philpott in 1971 and was later modified by the World Health Organization [7]. The partograph is a simple clinical tool which is a graphical record of all the events in labour [8]. It is a tool that have been recommended by World Health Organization and other authorities (maternal and neonatal health, safe motherhood initiative) in maternal health for routine monitoring of labour that helps to detect early warning signs. According to world health organization [9], the partograph is a printed graph representing the progress of labour. It has a 4 hour action line which denotes the timing of intervention for prolonged labour.

Already plotted on the partograph are the alert and action lines. The alert line is plotted to correspond with the active phase of labour once the woman’s dilated cervix reaches 4cm [10]. The cervix is expected to dilate by 1cm per hour at the active phase in a multigravida. The action line is plotted four hours after the alert line [10]. If the woman’s labour is not following the expected pattern within four hours the plotting of her labour will approach the action line, as such signaling the need for special intervention. The appropriate actions when the action line is crossed include the use of oxytocin to augment labour, vacuum assisted birth or caesarean section [10]. A partograph is one of the valuable appropriate technologies in use for improved monitoring of labour progress and maternal and fetal well- being. It is an important tool for managing labour that enables the midwives, nurses and doctors to record their examination findings on a standardized form which generates a pictorial overview of labour progress and allows for early identification and diagnosis of pathological labour [11]. Its’ use is critical in preventing maternal and perinatal morbidity and mortality and therefore has applicability in developed and developing world settings [2].

A partograph has clear demarcations which if arrived at or exceeded clearly, indicates the need to address existing or imminent complications like poor progress of labour, prolonged labour, fetal distress and in the worst cases, obstructed labour and ruptured uterus. It also aids early detection of obstructed labour and other related complications such as post- partum haemorrhage, ruptured uterus, puerperal sepsis and obstetric fistula [12]. Oladakpo, Daniel and Olatunji [13] reported poor knowledge of the partograph and recommended training of care providers especially junior personnel at the peripheral delivery units in the effective use of the partograph. Also Opiah, Bola, Ekere and Monjok [14] inferred that despite midwives knowledge of the partograph, there was poor utilization in labour monitoring in both centers. Likewise Fawole, Adekanle and Hunyinbo [2] reported that Partograph use was significantly more frequently by respondents in tertiary level compared with respondents from primary/secondary levels of care. The same study found out that non – availability of partograph charts in labour wards and poor knowledge of the partograph were factors affecting its use. Ollerhead and Osri [15] included clinical leadership and quality assurance, as well as organizational environment as part of the barriers to use of partograph.

Despite the World Health Organization advocating and recommending that the partograph be compulsorily used in monitoring all labour process since 1994, it was and is still reported to be in a limited extent in the developing countries like Nigeria [16]. This is especially so in primary and secondary health care facilities where most of the deliveries take place [17]. This study aimed at evaluating Nurses’ perceived factors that impede/facilitate the utilization of partograph. The result of the study provide information on the factors that are responsible for non- utilization of the partograph among nurses and midwives.

Descriptive survey design was used for this study. The health institutions selected by convenience sampling method due to the fact that most of the other hospitals refused to allow their staff to participate. Those that were use include Poly Sub-District hospital Asata, St Patrick’s hospital Asata, Mother of Christ Specialist hospital Ogui, Balm of Gilead hospital Maryland, Redeemer Maternity Abakpa, Iji Nike cottage hospital and Uwani cottage hospital. The subjects of study comprise of 134 nurses/ midwives working in the labour wards of these seven selected health care facilities in Enugu urban. It is not surprising that only 134 nurses/midwives were working in seven hospitals in Enugu metropolis as most hospitals in Nigeria are short staffed. Due to the small population of the nurses/ midwives working in labour wards of the selected health care facilities, the whole population was used for the study. No sampling procedure therefore was carried out. However, involvement in the study was dependent on the following inclusion criteria of registered nurses/midwives practicing midwifery in labour wards of the selected health facilities and willingness to participate in the study. The instrument for data collection was a self-structured questionnaire drawn strictly based on extensive literature search on partograph in order to fit the objectives of the study by the researchers. The instrument was validated by 3 lecturers from University of Nigeria, Enugu Campus that were skilled in test construction.

Pilot study was conducted for the reliability of the instrument using test- retest method using registered nurses/ midwives working in labour wards at Good Shepherd Hospital Uwani. This hospital had similar characteristics set up as the selected health care facilities of study. The test-retest reliability using the Cronbach’s alpha coefficient obtained was 0.773. This coefficient being greater than 0.7 indicate that the reliability of the test instrument is very strong. Thus the reliability of the research instrument was established. Permission to carry out the study in the selected health care facilities was obtained from the heads of the selected health care facilities in Enugu urban, since they did not have ethical committees. The researchers then approached the subjects, and obtained verbal informed consents from them. The copies of the questionnaire were distributed to each nurse/midwife in the selected health care facilities through by the researchers at the beginning of the shift and collected back before the end of the shift. A total of 132 copies were distributed and 126 copies (95.5%) recovered. Data collected were presented in tables and charts. The responses to each question were tallied and analyzed using descriptive statistics ranging from meanscores to standard deviation. They were grouped according to study objectives. The data were analyzed using the IBM Statistical Package for Social Sciences (SPSS) version 20.

Table 1 above shows that out of the 10-item statements that were designed for objective one, 68(54%) of the respondents strongly agreed that lack of knowledge of the partograph impede their utilization of the partograph, 57(45.2%) agreed, 1(0.8%) disagreed. The results also show that 28(22.2%) of the respondents strongly agreed while 93(73.8%) agreed and only 5(4%) disagreed that skill incompetency in the use of partograph impede the use of the partograph. 27(21.4%) of the respondents strongly agreed and 77(61.1%) agreed while 22(17.5%) disagreed that inability to interpret findings correctly after assessment with the partograph hinders their utilization of the partograph. 71(56.3%) of the respondents strongly agreed and 33(26.2%) agreed while 11(8.7%) disagreed that filling the partograph is an additional time consuming task for the inadequate staff thus, impede their utilization of the partograph. 39(31%) of the respondents strongly agreed and 21(16.7%) agreed while 25(19.8%) disagreed and 41(32.5%) strongly disagreed that partograph has no benefit if used to monitor progress of labour. 57(45.2%) of the respondents strongly agreed and 43(34.1%) agreed, 24(19%) disagreed while 2(1.6%) strongly disagreed that lack of adequate orientation to partograph use hinders their utilization of partograph. 13(10.3%) of the respondents strongly agreed, 10(7.9%) agreed , 64(50.8%) disagreed and 39(31%) strongly disagreed that negligence of duty impede their utilization partograph. 43(33.3%) of the respondents strongly agreed, 23(18.3%) agreed, 49(38.9%) disagreed while 12(9.5%) strongly disagreed that nurses /midwives exhibit laziness generally in the use of the partograph hence, impeding their utilization of partograph. 11(8.7%) of the respondents strongly agreed, 66(52.4%) agreed, 36(28.6%) disagreed while 13(10.3%) strongly disagreed that lack of interest hinders the utilization partograph. 32(25.4%) of the respondents strongly agreed, 43(34.1%) agreed, 26(20.6%) disagreed, while 25(19.8%) strongly disagreed that partograph involves much responsibility.

Table 1: Nurse/midwives perception of factors that impede utilization of the Partograph(n=126).

Table 2 above revealed the factors that can facilitate the use of the partograph. 105(83.3%) of the respondents strongly agreed that provision of necessary resources such as observation tools like sphygmomanometer, fetoscope, etc. will facilitate their use of the partograph. 20(15.9%) agreed that this factor will facilitate their use of the partograph, 1(0.8%) disagreed to this factor will facilitate their use of the partograph while none (0%) strongly disagreed to this. The mean response of this factor was 3.83(0.40). 87(69%) of the respondents strongly agreed that provision/ availability of partograph charts in the labour wards will facilitate their use of the partograph, 18(14.3%) agreed, 2(1.6%) disagreed that this factor will facilitate their use of the partograph while none (0%) strongly disagreed. The mean response of this factor was 3.52(0.77). 99(78.6%) of the respondents strongly agreed that employment of adequate staff will facilitate their use of the partograph, 20(15.9%) agreed to this factor 7(5.5%) disagreed that this factor will facilitate their use of the partograph while none (0%) strongly disagreed. The mean response of this factor was 3.73(0.56). 102(81%) of the respondents strongly agreed that in-service training of nurses / midwives through seminars on partograph use will facilitate their use of the partograph, 23(18.3%) agreed that this factor will facilitate their use of the partograph, 1(0.8%) disagreed while none (0%) strongly disagreed. The mean response of this factor was 3.80(0.42). 60(47.6%) of the respondents strongly agreed that adequate supervision of nurses /midwives will facilitate their use of the partograph, 52(41.3%) agreed to this factor while 7(5.6%) each disagreed and strongly disagreed that this factor will facilitate their use of the partograph. The mean response of this factor was 3.31(0.81). 77(61.1%) of the respondents strongly agreed that integration of management policy and guidelines will facilitate their use of the partograph, 30(23.8%) agreed that this factor will facilitate their use of the partograph, 12(9.5%) disagreed while 7(5.6%) strongly disagreed that this factor will facilitate their use of the partograph. The mean response of this factor was 3.40(0.88). 86(68.3%) of the respondents strongly agreed that routine/ mandatory use of the partograph in handing over or taking over of women in labour will facilitate their use of the partograph, 33(26.2%) agreed to this factor, 7(5.6%) disagreed that this factor will facilitate their use of the partograph while none (0%) strongly disagreed. The mean response of this factor was 3.63(0.59). 77(61.1%) of the respondents strongly agreed that elimination of non-professional task in order to create time for partograph use will facilitate their use of the partograph, 42(33.3%) agreed that this factor will facilitate their use of the partograph, 7(5.6%) disagreed while none (0%) strongly disagreed that this factor will facilitate their use of the partograph. The mean response of this factor was 3.56(0.60).

Table 2 Nurses’ perception of Factors that facilitate the use of Partograph (n = 126).

The findings of this study revealed that majority of the nurses/midwives face a lot of challenges in utilizing the partograph. Some of the major factors indicated are lack of knowledge of the partograph and inability to interpret findings correctly after assessment with the partograph. This is not surprising as majority of the respondents indicated that they have not received any in-service training on partograph use. This is in line with the study carried out by Oladakpo, Daniel and Olatunji [13] in their study on knowledge and use of the partograph in Ogun state, Nigeria who reported poor knowledge of the partograph and recommended training of care providers. Also, the finding is in line with the study carried out by Yisma, Dessalegn, Astatkie and Fesseha [18] on knowledge and utilization of the partograph in Ethiopia; which revealed lack of knowledge, lack of training of obstetric care givers on the use of the partograph and lack of positive attitude towards the use of the partograph as factors affecting the use of the partograph.

Another major factor that determines non utilization of the partograph is that filling the partograph is an additional time consuming task for the inadequate staff. The probable reason for this factor is shortage of staff and consequent work overload. Also, ignorance of the importance/benefit of the partograph as seen in their responses may be a contributory factor. This finding is in accordance with the studies by Sarah and Alice, their study showed that some midwives often think that completing the partograph is an additional time consuming task and as such have no understanding of how it can save a woman’s life.

Also, lack of adequate orientation of the nurse/midwife to partograph use and none availability of monitoring instrument were reported by nurses as factors that determine the non- utilization of the partograph.

Furthermore, nurses/midwives exhibit laziness generally in the use of the partograph, lack of interest, partograph has no benefit and partograph involves much responsibility were implicated as factors that hinder their utilization of partograph. This explains why the nurses see the partograph as an additional time consuming task. However, nurses/ midwives do not think that non utilization of the partograph is as a result of negligence of duty. The probable reason for their not using of the partograph is lack of training which made them not to know the benefits of using the partograph and thus, lack interest on its use. This is in contrast with the findings of Khonje [19] in his study on use and documentation of partograph and factors that prevent optimal utilization of the partograph in Lilongwe-Malawi; which revealed negligence, inadequate supervision and lack of motivation as factors that influences utilization of the partograph. This finding corresponds with the findings of Umezulike, Onah and Okaro [20] in their studies on use of the partograph among medical personnels in Enugu which reported that midwives knowledge about the partograph is a significant factor in its utilization.

The findings of this study showed that one of the major factors that can facilitate the use of the partograph in monitoring labour progress is provision of necessary resources such as observation tools like sphygmomanometer, fetoscope and provision/ availability of partograph charts in the labour wards. This implies that provision of enabling environment such as provision of partograph chart and observation tools may make the nurses /midwives to use the partograph if they are skilled as they implicated non availability of resources as determinant of their non- utilization of the partograph. This agreed with Ollerhead and Osrin [15] who included clinical leadership and quality assurance, as well as organizational environment as part of the barriers to use of partograph.

Also, employment of adequate staff was reported by the respondents as a factor that will facilitate their use of the partograph. This is because increase in number of workers will bring about decrease in work overload and thus, their provision of quality care. The finding is supported by the studies of Azendegbe, Testa & Makoutode, which found that more staff on duty was associated with high utilization of the partograph and there were more partograph completed where more staff was on duty. This finding is also in line with the finding of Saviola, Arez, Raddi, Sudha and Metgu [21], who inferred that the planned teaching program was effective to improve knowledge and skills on partograph.

Integration of management policy and guidelines, routine/ mandatory use of the partograph in handing over or taking over of women in labour and elimination of non-professional task in order to create time for partograph use were also reported by the respondents as a factor that will facilitate their use of the partograph. The findings revealed that the respondents know the proper measures to put in place to improve utilization of the partograph but they lack the knowledge, skill and necessary resources needed for utilization of the partograph [22,23].

Based on the findings of this study, it was concluded that the major factors in the nurses/midwives that impede the utilization of partograph includes lack of knowledge, inability to interpret findings correctly after assessment with the partograph and that partograph is an additional time consuming task for the inadequate staff. Majority of the nurses/ midwives opined that the major factors that facilitate their utilization of the partograph among others in monitoring the progress of labour includes provision of necessary resources such as partograph in the labour wards, employment of adequate staff and in-service training of nurses /midwives through seminars. It is recommended that all nurses/midwives should work towards self-development through education to increase knowledge and skill on partograph use. Management should stand up for their responsibility to encourage and sponsor seminars/ workshops as well as conferences on partograph use for quality client care. More nurses should be employed to combat the manpower shortage that is biting the nursing workforce especially public health nurses who are better prepared to work in both primary and secondary health institutions. Management should provide the necessary resources needed for the utilization of the partograph such as the charts, observation tools etc.

The limitations of this study include the few number of hospital and nurses used in the study and the variations in the hospitals in the use of partograph was not studied. Yet this study form a base for further study in use of partograph in Enugu metropolis.