Practice and Factors Inuencing Partograph Utilization on the Delivery of nursing care: An analytical Cross – Sectional Study among Nurses in Singida, Tanzania

Background Partograph is the graphic recording for labour management and monitoring of pregnant women in labour pain. The well-plotted data allow the nurse to recognize any abnormal conditions earlier and decide to employ proper actions to the particular pregnant mother in labour pain during the delivery of nursing care. However, its uses have been recommended by WHO among nurses around the globe but it is not fully utilized. This study aimed to determine the level of practice and factors inuencing partograph utilization among nurses in Singida, Tanzania. Methods Analytical cross sectional study was conducted involving 150 nurses randomly selected from Sokoine health center and Singida Regional Referral Hospital in Singida municipality, Tanzania from January to February 2020. A self-administered structured questionnaire on partograph use to deliver maternal care among pregnant women was the main data collection tool. The Statistical Package for Social Science (SPSS) software program version 23 was used for data entry, screening, processing, and analysis. Both descriptive and inferential statistics were employed in which ndings were presented in tables. Concerning the relationship between age category of study respondents and level of practice on partograph usage, results depicted that there is a signicant relationship between age group and level of practice among nurses as proven by ( X 2 = 7.427; p < 0.05). Among 150 study respondents, nurses whose age were between 20 to 32 years, 46.1% (n = 47) had a high level of practice while 53.9% (n = 55) had a low level of practice on partograph utilization, age group between 33 to 45years, 21.9% (n = 7) had a high level of practice and 78.1% (n = 25) had a low level of practice on partograph utilization and nurses with the age category of 46 to 58 years, 25.0%(n = 4) had a high level of practice while 75.0% (n = 12) had a low level of practice on partograph utilization. In light of the research among 150 respondents, results indicated that nurse and midwife ocers 81.8% (n = 36) had a high level of practice while 18.2% (n = 8) had a low level of practice on partograph usage. Between the assistant nurse ocers, 20.3% (n = 13) had a high level of practice while 79.7% (n = 51) had a low level of practice on the partograph usage and among the enrolled nurses, 21.4% (n = 9) had a high level of practice while 78.6% (n = 33) had a low level of practice on partograph usage. The chi-squared test indicated that there is a signicant relationship between professional qualications and level of practice on the partograph usage among nurses (X 2 = 49.835; p < 0.05). Concerning level of education between nurses who the level, 83.3% (n = 35) a high level of practice while only 16.7% (n


Results
Out of 150 nurse midwives 58.7% (n = 88) were females. Only 38.7% (n = 58) of the study respondents had a high level of practice on the utilization of partograph during labour monitoring. Their levels of education were identi ed to be a protective factor because those who had University education were more times likely to practice using partograph when delivering care compared to other lower education levels (AOR = 16.757; 95%CI: 6.394; 43.915; p < 0.01). Also, their professional quali cations were discovered to be a protective factor because nurse o cers and midwives o cers were more times likely to practice using partograph as compared to other professional quali cations (AOR = 8.323; p = 0.004; 95%CI: 0.098; 0.642).

Conclusion
This study found that many nurses in Singida municipality had a low level of practice in utilizing partograph when delivering of health care among patients. Continuous and formal supportive supervisions and on job training at national and health facilities need to be emphasized and adhered to promote quality of health services by use of partograph and cost-effective maternal and newborns health.

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Background Many women who become pregnant globally suffer much during the perinatal period. Pregnant women in the world who die due to pregnancy-induced complications were estimated to be 303,000 deaths yielding a maternal mortality ratio (MMR) of 2016 deaths per 100,000 live births (1). According to WHO which reported that these deaths decreased worldwide to estimate of 44 percent from 1990 to 2015 (2).
Approximately 289,000 deaths occurred in 2013 and 99% of deaths occurred in Asian and African countries which are not developed and more than half happened in the African continent. Furthermore, data showed that African countries had 179 000 (62%) of global deaths and southern part of Asia had 69 000(24%) maternal mortality (3).
Philpott and Castle initiated uses of partograph in 1972 and later on in 1988 were modi ed and initiated to be used globally in the health care setting for labour monitoring and management (4).The WHO emphasized the uses of partograph for monitoring progress of labour, fetal and maternal conditions as well as reducing labour complications which were a signi cant strategy to reduce both maternal and fetal mortality in the globe (5). Although WHO recommended the uses of the partograph to monitor progress of labour, fetal and maternal conditions in all settings routinely but it is not implemented as it should be to aid in guiding in early decision making (6).
The African countries still face the same problem because studies done by (7)data showed that maternal complications were estimated to be 0.34% and neonatal deaths approximated to be 2.1% in Rwanda.
Data uncovered that 36.6% of health care providers were not trained on labour management by using partograph during delivery. Although, partograph is not a complex and expensive tool which can be used to reduce fetal and maternal mortality as well as complications due to prolonged labour or obstructed labour it is not used accordingly. Caregivers may not use the partograph only if they have inadequate knowledge and cannot know the reasons for utilizing it properly (5).
According to (8) ndings showed that nurses who had an average understanding of the use of partograph were about 57.5% and 25% were knowledgeable while17.5% were not knowledgeable, ultimately they commented that they had low knowledge regarding the use of partograph. So there was a need for ongoing training and close supervision among nurses to increase the quality use of partograph in hospitals. According to (9), he recommended that a lack of detailed knowledge of the partograph use, inadequate training, and poor policy cause poor ineffective use of partograph. To solve this problem periodic training and mandatory institutional policy should be considered on partograph utilization.
Furthermore, results from a study done by (5)showed that nurses who were at maternity department perceived that partograph use consumes much time and needs on-going training because some did not receive any training on partograph utilization since they were employed. He recommended that policymakers and nursing administrators should ensure that all quali ed nurses use the partograph in the care of women in labour (5). Tanzania faces the same challenge of using partograph because data showed that poor utilization of partograph was observed at Mbeya Regional Referral Hospital, Geita Regional Referral Hospital, and Kitete Regional Referral Hospital (10).
Despite the strategies of the ministry of health to emphasize on wisely use of partograph on the delivery of health care among pregnant women, there is persistent of maternal and fetal complications such as prolonged labour, uterine rupture, hemorrhage, birth asphyxia, and neonatal sepsis respectively in Tanzania (10).
Therefore, this study aimed to investigate the level of practice and factors in uencing partograph utilization to raise the provision of health care among nurses. The signi cance of this study is that the data should be used as the baseline data for conducting large scale research on partograph utilization in the Singida region. Also, the results would help to decrease the number of deaths in pregnant women because proper use of partograph would help to detect abnormal markers in the progress of labour earlier and proper management to be initiated to save the life of the patient.

Study design and Setting
The analytical cross sectional study was conducted from January to June 2020 in Singida Municipality,

Study population
The population understudy were 150 nurses who were working in maternity wards in Singida region after providing informed consent to participate in the study

Inclusion criteria
These are the criteria that characterize who is included in the study population (11). The study inclusion criteria were; quali ed nurses who had worked in maternity at least six months, the nurses who gave informed consent to take part in the study, nurses with a valid license (licensed nurse), and nurses who were working in maternity wards.
Exclusion criteria or avoidance criteria Exclusion criteria of the study were; nurses who were sick during the data gathering period, nurses who failed to give informed consent during the study, nurses who have working experience of less than six months, and nurses' students as well as intern nurses.

Sample Size and Sampling Technique
The sample was computed by using the formulae as structured by Fisher in 1965, n=Z 2 P(1-P)/E 2 Where,Zis the Z value for the con dence level of 95%, d is the standard error of 5%, pis the value for the extent of 26.6% (12).
Subsequently, the sample size increased by 10% of study dropouts which gave a total of 150 Sampling technique Singida region was purposively selected to be the area understudy in Tanzania. One district (Singida urban) was selected by simple random sampling from the seven districts of Singida Region. Three staged multi-stage cluster sampling technique was used to obtain study participants. In rst stage random sampling, all wards (16 wards) in Singida urban (municipality) were listed and by the use of purposive random sampling three wards (Ipembe, Mandewa, and Misuna) were picked since are the only wards with two big health facilities in Singida municipality.
During second stage sampling two health facilities (Singida Region Referral Hospital and Sokoine Health Center) were conveniently selected from six health facilities because had large number of nurses compared to other health facilities found in Singida municipality. The third stage sampling was simple random sampling technique used to obtain study participants. At each health facility nurses were interviewed for working experience, those who were worked for at least six months and gave consent to participate in the study were enrolled.

Data analysis
The data analysis employed both descriptive and inferential statistical analysis. Descriptive data analysis was used to determine frequencies and percentages of Sociodemographic characteristics of the study respondents. Chi-square and cross-tabulation were adopted to determine the relationship between categorical variables. Inferential data analysis served to determine the extent of association between variables. A con dence interval (CI) was set at 95% with a signi cance level of 5%. Statistical Package for Social Sciences (SPSS) software program version 23 was used for data entry, processing, and analysis. Findings were presented in tables by frequencies (n), percentages (%), Odds Ratio (OR), Adjusted Odds Ratio (ARO), and p-values at 95%CI of demonstrating signi cance relationship and or association between variables.

Sociodemographic Characteristics of the Study Respondents
The results uncovered that most of the respondents' ages from 20 to 32 years which was 68.7% (n = 103). Furthermore, study ndings showed that most of the respondents'58.7% (n = 88) were female and the mean age range of the study respondents was 26 years and 68.7% (n = 103) were within the age group of 20-32 years. The study respondents 42.7% (n = 64) were assistant nurse o cers (diploma holders) and 29.3% (n = 44) were nurse and midwife o cers, as well as 28% (n = 42) had a certi cate in nursing. Also, 61.3% (n = 92) works at Singida Regional Referral Hospital; notwithstanding that, further Sociodemographic qualities are depicted in Table 1.

Factors In uencing Levels Of Practice On Partograph Utilization
Among 150 nurses, nurses whose age were between 20 to 32 years, 46.1% (n = 47) had a high level of practice while 53.9%(n = 55) had a low level of practice on partograph utilization, age group between 33 to 45years, 21.9% (n = 7) had a high level of practice while 78.1% (n = 25) had a low level of practice on partograph utilization and those with the age category of 46 to 58 years, 25.0% (n = 4) had a high level of practice while 75.0% (n = 12) had a low degree of practice on partograph utilization this implied that age has in uences on partograph use among nurses in Singida municipality. It was evident that gender had an in uence on the level of practice on partograph usage among nurses in Singida municipality as results uncovered that among male 48.4% (n = 30) had a high level of practice while 51.6% (n = 32) had a low level of practice on partograph use on the provision of nursing services. Likewise, among female results depicted that 31.8% (n = 28) had a high level of practice on the partograph use while 68.2% (n = 60) had a low level of practice on partograph usage among nurses in Singida municipality. Other factors in uencing the utilization of partograph have been summarized in Table 3.  showed that there is a statistically signi cant relationship between residence and level of practice on partograph usage among nurses in Singida municipality (X 2 = 6.034; p < 0.05).
It was evident that gender had an in uence on the level of practice on partograph usage among nurses in Singida region as results uncovered that 48.4% (n = 30) males had a high level of practice and 51.6% (n = 32) had a low level of practice on partograph use on the provision of nursing services. Additionally, among females results depicted that 31.8% (n = 28) had a high level of practice on the partograph utilization while 68.2% (n = 60) had a low level of practice on the usage of partograph in Singida municipality. Results showed that there is a statistical signi cance (X 2 = 4.211; p < 0.05). Furthermore; other independent variables such as religion, marital status, and working health facility had no statistical signi cant relationship with the level of practice on the usage of the partograph among nurses in Singida municipality.  Table 5.

Discussion
This study entailed at assessing the level of practice and factors in uencing partograph utilization.

Level of Practice on Partograph Utilization Among Nurses
The ndings found that most of the study respondents 61.3% (n = 92) had a low level of practice on using partograph to deliver health care among nurses in Singida municipality. This implied that even if they learned about the usage of partograph in classrooms, health institutions and workshops or seminars data discovered that there is a gap between knowledge and practice on the utilization of partograph for monitoring the progress of labour as well as maternal and fetal condition. The probable cause could be discussed in this study to be due to residence, education level, age, gender, and professional quali cations among nurses in the Singida municipality.
These ndings differ with those found by Bazirete (13) whereas data depicted that 58.8% of the study respondents were found to have low level practice in utilizing partograph. The difference in ndings in these two studies is probably due to different study areas. Moreover, the results of this study were different from those conducted in Kenya whereas data showed that 55.5%of study respondents had a lower level of practice on partograph utilization (5). Furthermore, ndings from this study were low compared to the results of a study which was conducted in India of which data depicted that majority of the study respondents (86.67%)had a low level of practice on partograph utilization (14).
Factors in uencing the level of practice on the utilization of the partograph The study results show that there is a statistically signi cant relationship between age group and level of practice among nurses p = 0.024. This implied that the age of the respondents in uenced the level of practice on the partograph usage in Singida municipality. The probable reason to be discussed in this study is due to forgetfulness because the majority of respondents with age group between 20 to 30 years had a high level of practice on partograph utilization compared to other age groups. Also, this kind of results is similar to the study conducted in Ethiopia of which data showed that age was statistically signi cantly associated with the level of partograph use p < 0.05 (15).
The ndings discovered that there is a statistically signi cant relationship between professional quali cations and level of practice on partograph use among nurses p > 0.01. The majority of study respondents who had a high level of practice were nurse o cers followed by nurse o cer midwives compared to other professional quali cations. The probable reason behind to be discussed in this study is due to the level of education and knowledge on partograph utilization. This kind of statistical relationship is similar to that found by (12)who studied the level of partograph usage and its related factors among obstetrics care workers at health facility northwest Ethiopia p > 0.01.
The study's ndings have revealed that the majority of nurses who had university education had a high level of practice on partograph use in Singida municipality p > 0.01. This implied that the nurse o cers and nurse o cer midwives learned about the utilization of partograph in the university were knowledgeable and had enough skills on partograph utilization. The probable cause could be discussed in this study to be due to the level of education as well as competence and skills on the utilization of partograph for monitoring and managing labour progress, fetal and maternal conditions. These kinds of results are similar to the study done at Ethiopia on level of partograph usage and its related elements among obstetricians in northwest Ethiopia which showed that professional quali cation was signi cantly associated with the level of practice on the utilization of partograph p < 0.05 (12).

Conclusion
The vast majority of the study respondents had a low level of practice on partograph usage on the provision of health services among nurses in Singida municipality; this could endanger both maternal and fetal health. The probable causes to be discussed are due to educational level, professional quali cations, residence, and age in Singida municipality. Moreover, close supervision, on the job training, seminar, and staff motivation should be reviewed to ensure the quality of health care services by proper utilization of partograph among nurses in Singida municipality.

Limitations
Basing on this study, the limitation to be highlighted are such as the cause -effect relationship is di cult to establish, the data was gathered by using a self-administered questionnaire and it could be subjected to social desirability bias and the ndings are from Singida municipality hence cannot be generalized to the whole population in Tanzania. O cer, and Hospital Medical in charges. Written informed consent was asked from every study respondent. Privacy and con dentiality were guaranteed as well as autonomy was watched plainly because neither the study respondents' names nor of those health facilities involved were requested on the questionnaire.