Analysis of Independent Practice Midwifes in West Pasaman District Using Partograph in Normal Delivery Care

The maternal mortality rate (MMR) and infant mortality rate (IMR) are key performance indicators for a nation. For every Indonesian population, MMR and IMR represent one of the parameters of optimal health status. In an effort to lower the MMR, health professionals are urged to use Partograph to track the progress of labor and make appropriate decisions if pathological conditions are discovered. It has been demonstrated that the Partograph works well for both identifying irregularities in labor and preventing prolonged labor. The purpose of the study is to find out how Partograph are used by midwives at the Independent Midwife Practice in the West Pasaman district. Since the informants for this research are independent practice midwives, the qualitative descriptive research method will be used to collect data through focus group discussions (FGD), in-depth interviews, and observations. Data analysis: By deciphering, writing up, and drawing conclusions from in-depth interviews conducted with key informants and two discussion groups. The research's conclusions are based on the findings of two focus groups and two key informant interviews. Specifically, Partograph are used by independent practice midwives to aid in childbirth; some midwives have also used them to track the progression of labor, particularly for patients with birth insurance so they can claim delivery expenses. The Partograph is filled all the way, but occasionally it is filled after delivery. The only reason partography is applied is to obtain Jampersal fees; independent practical midwives are knowledgeable about partography and have a positive attitude toward it. Organizational policies and leadership for IBI are still lacking.


Introduction
Globally, a total of 13.6 million women have died due to maternal causes from 1990 to 2015.Of all the deaths, 99% were in developing countries with 546 per 100,000 live births, and sub-Saharan Africa only accounts 66% of deaths.Additionally, there is a staggering evidence that peripartum fetal mortality and morbidity are directly related to the labor abnormalities like asphyxia, birth injuries, low Apgar scores (Appearance, Pulse, Grimace, Activity, and Respiration), and intrapartum or postpartum deaths.About 97% of all reported neonatal deaths occur in less developed countries.Of these, majority are a direct consequence of labor complications.In Ethiopia, the tragedy of maternal and neonatal mortality is stagnant so far, in spite of the apparent commitment by stakeholders.In 2016, maternal mortality accounted for 412 per 100,000 live births and neonatal mortality was 29 per 1000 live births.(Ayenew & Zewdu, 2020) The maternal mortality rate is an indicator of women's health status and a component of Indonesia's development and quality of life index.1.The occurrence of labor and delivery complications worldwide ranges from 15% to 20%.Based on these statistics, it has been found that only 5% to 10% of deliveries necessitate a cesarean section.According to the International Conference on Indonesia Family Planning and Reproductive Health, Indonesia's maternal mortality rate remained high at 305 per 100,000 live births as of 2019.The Sustainable Development Goals aim to achieve a maternal mortality rate of 70 per 100,000 live births by 2030.2Problems associated with pregnancy and childbirth, including the elevated maternal mortality rate, cannot be isolated from the various influencing factors (Azhar, 2023).Delivery methods and immediate post-delivery care are among the factors contributing to the high maternal mortality rate.(Anak Agung Ngurah Anantasika et al., 2023) According to (Sanghvi et al., 2020) Globally, it is estimated that there are 2.6 million stillbirths every year, which means almost 7,200 babies are stillborn every day.The World Health Organization (WHO) estimates 303,000 maternal deaths every year, and a global burden of disease study estimates that obstructed labor causes 6.4% of maternal deaths annually, while hypoxia causes 904,000 newborn deaths annually.These deaths can be prevented by identifying and treating intrapartum complications quickly.Fetal death during labor, also known as intrapartum fetal death, is a tragic outcome of pregnancy (Laksmi, 2023).A country's mortality rate reflects the care that mothers and babies receive during childbirth, and there are various areas of improvement that can be determined by carefully reviewing cases like this (McNamara et al., 2018).It is important to monitor maternal and fetal parameters during labor regularly and in a timely manner to ensure their health, support normal delivery, detect complications, and encourage rapid clinical decision making to address them.(Sanghvi et al., 2019) A growing number of women are opting to give birth in medical facilities due to the global push for universal health coverage; nevertheless, until prompt access to services and the quality of "institutional birth" are guaranteed, health outcomes will not improve.The WHO considers labor monitoring as a high-priority quality improvement intervention that should be used to guide appropriate, timely actions (McNamara et al., 2018).To differentiate between "normal" and "abnormal progress" and to plan the next steps, labor monitoring requires skilled birth attendants to record observations of maternal and fetal well-being (Sanghvi et al., 2020).(Sanghvi et al., 2019) The partograph, commonly referred to as the partogram, is a graphical record that has been widely acknowledged and recognized as the foremost labor monitoring instrument across the globe.The World Health Organization (WHO) has recommended partograph usage during the active phase of labor as it aids in the timely detection of abnormal labor progress and facilitates immediate interventions, if necessary.The primary objective of utilizing the partograph is to monitor the maternal and fetal conditions as well as the progress of labor.WHO modified the partograph in 2000, focusing on labor progress, including cervical dilation, head descent, and contractions.The fetal condition is assessed by heart rate, amniotic fluid color, and fetal skull molding.Maternal condition is monitored by vital signs, urine output, urine tests for protein and acetone, drugs, IV fluids, and oxytocin administered during labor.(N & Thayumanavan, 2023) Obstetrician E.A. Friedman (2020) developed the idea of the partograph and labor curve.Later in 1972, R.H. Philpott included alert according to (Rahman et al. 2019), lines upon Friedman's Partograph, which provided access to the partograph as a tool for recording all intrapartum observations and identifying the likelihood of risk.The World Health Organization advises using Partograph, which are low-tech papers that are useful for identifying fetal and maternal problems during childbirth.The WHO partograph is widely accepted as the gold standard for labor monitoring instruments.Using Partograph continuously with cutting-edge technologies can save the lives of expectant mothers and newborns.(Ollerhead & Osrin, 2014) The partograph has been endorsed by World Health Organization (WHO) since 1994 which presents an algorithm for assessing maternal and foetal conditions and labor progression.Monitoring labour with a partograph can reduce adverse pregnancy outcomes such as prolonged labor, emergency C-sections, birth asphyxia and stillbirths.However, partograph use is still very low, particularly in low and middle income countries (LMICs).In Bangladesh the reported partograph user rate varies from 1.4% to 33.0%.Recently, an electronic version of the partograph, with the provision of online data entry and user aid for emergency clinical support, has been tested successfully in different settings.With this proven evidence, we conducted and operations research to test the feasibility and effectiveness of implementing an e-partograph, for the first time, in 2 public hospitals in Bangladesh.(Rahman et al., 2019)

Literature Review
Partograf is a tool used in childbirth that helps clinicians monitor, assess, and manage labor.A partograph can be used to identify issues and complications early in labor, allowing medical professionals to treat the mother under ideal circumstances or handle the issue as soon as possible.Maternal mortality rates can be significantly decreased with the use of Partograph, assisting the health system in moving toward the level of community welfare.Midwives can help prevent complications that could endanger life by regularly using Partograph to ensure that the mother and her child receive safe, appropriate, and timely delivery care.(Sidik & Kusrini, 2015) The partograph has been shown to be an efficacious tool for monitoring labor and identifying women in need of an obstetric intervention.National Partograph have been introduced in many countries supported by guidelines and training workshops but often with little follow-up and supervision.Moreover, there are worries that the use of the partograph may increase the rate of obstetric interventions.(Bosse et al., 2002) The partograph has proven to be a useful instrument for tracking labor and determining which women require obstetric care.Many countries have implemented national Partograph with the support of training workshops and guidelines, but frequently with little oversight and follow-up.Additionally, concerns exist regarding the possibility that the partograph's use will lead to a rise in the number of obstetric procedures.
A partograph, also known as a partogram, is a labor monitoring tool used in many nations to help identify issues early on and allow for referral, intervention, or closer observation.Health professionals around the world have embraced Partograph, but there are worries that they haven't yet realized their full potential in terms of enhancing clinical outcomes.As a result, the tool has undergone multiple iterations, and numerous studies have been conducted to examine the factors that promote and hinder its use.The use of partography as a complex intervention was investigated in the study, suggesting that a variety of contextual factors may influence its effectiveness.(Tina Lavender et al., 2013) The Partograph's labor monitoring program guarantees that the mother and child receive timely and adequate delivery care, and it also helps midwives avoid complications during childbirth.The partograph has not been used during labor to the full extent that is required by procedure.Partograph are not really used by midwives fully, accurately, and on time.It is challenging for midwives to record Partograph, which is a necessary component of the solution, due to situational factors and conditions.Using the system development life cycle (SDLC), which includes requirements and analysis, design, testing, implementation/deployment, and maintenance, he created an Android-based mobile partograph design for monitoring the childbirth process as part of his research.The findings to aid midwives and enable labor monitoring so that documentation is more successful and efficient, a partograph smartphone application has been create.(Wahyuni et al., 2019) Based on (Fawole et al., 2008) research evaluating health workers in southwest Nigeria's partograph knowledge and use.A multistage sampling technique was used to choose respondents from primary, secondary, and tertiary level services.Respondents at the tertiary level reported using Partograph far more frequently than those at the primary or secondary service levels.Although Partograph are mostly used in tertiary healthcare facilities, not many people are aware of them.Partograph are not commonly used to monitor laboring Nigerian women, despite their low cost.
The line of action has been crossed when examining the relationship between partograph use and delivery outcomes.It was found that certain graphs included a complete partograph and that prompt intervention was carried out in less than half the time of partograph generation.By 2015, all hospitals must employ trained birth attendants, according to Millennium Development Goal 5.The "Skills" of birth and thorough intrapartum monitoring are crucial.(Gans-Lartey et al., 2013)

Research Method
In order to gather as much data as possible from informants regarding the use of Partograph in childbirth assistance, this study used a qualitative descriptive design.This study was conducted in the West Pasaman Regency at the Independent Practicing Midwife.In this study, two key informants and two informants served as the sources of informants.Methods for gathering information about partograph filling include focus groups (group discussions), in-depth interviews, and document observation.Three-way triangulation is used to validate data during collection and processing: source triangulation, data triangulation, and data triangulation/analysis method triangulation.The outcomes of the tape recorder data collection, the focus group discussions with informants, and the in-depth interviews with key informants were then documented as research findings through the creation of FGD transcripts, the examination of partograph filling documents, and the interpretation of the data.

Result/Findings
"Results of data analysis of the BPM Focus Group Discussion data collection in West Pasaman Regency regarding the use of Partograph in assisting normal childbirth regarding Knowledge and attitudes, namely: In general, midwives who carry out independent practice have a level of knowledge about Partograph (understanding, objectives, benefits and how to fill out the partograph format)" The majority agreed that a partograph was crucial for tracking the development of labor, but they differed in their implementation particularly when it came to midwives who were required to fulfill an MOU with the local government in order to participate in the birth guarantee program and in their use.The majority of the FGD's findings, including the interpretation of the results, according to a study on BPM, the majority of midwives (BPM) are aware of how to fill out Partograph and have a favorable attitude toward using them to help with childbirth, but in reality, there is still a lack of practice; the only reason Partograph are filled out is to claim delivery costs, which can be time-consuming.

Discussion
When analyzing and interpreting the findings of every investigated facet, we will make connections between the findings and pertinent theoretical frameworks.

Knowledge
Given that they must meet certain requirements before opening a BPM, such as passing a competency test and completing training in normal childbirth care/APN, and having previously received information about Partograph when attending education, midwives possess a thorough understanding of Partograph, from theory to practical application.
As per Notoadmodjo's (2007) theory, the concept of knowledge is the lowest level that can be determined by explicitly defining something as "know".then having the ability to name and understand the familiar objects accurately, as well as to elucidate, provide examples, and draw conclusions knowledge about the subjects under study is referred to as comprehension.According to Aminoto's (2008) study, which described the partography knowledge and skills of 115 midwives at the Adimulyo Kebumen Community Health Center, the findings indicated a deficiency in these areas for 65% of the midwives.The findings of this study support those of Hervina et al.'s (2010) knowledge description study, which found that midwives had good partography knowledge.(Siswanto, 2023)

Attitude
The findings of the research using focus group discussions and interpretation revealed that midwives' attitudes toward the use of Partograph in assisting childbirth were primarily positive and supportive, as evidenced by the statement that Partograph were crucial for tracking the progression of labor and knowing when to take action.According to Allport's theory (1954), as stated in Notoadmodjo ( 2007), knowledge, thoughts, and emotions are the main influencing factors in attitudes.An additional reaction is an attitude.The fact that midwives are knowledgeable about Partograph and have access to stimuli like recommendations and counseling from the IBI.

Action
Observations from the comments indicate that Partograph are still filled after delivery, incomplete partograph filling, and deliveries without the use of a partograph.This is in conflict with the findings of K. Kasiati's study, which described how compliant midwives were with using Partograph with BPS members of the IBI.The majority of them did not fill out the Partograph' front and back sheets.In keeping with Notoatmodjo's (2007) theory that attitudes do not always translate into behavior (Over Behavior) because additional factors or factors that support or strengthen behavior are required for behavior to manifest (Reinforcing Factors).Due to a lack of or insufficient reinforcing factors (reinforcing factors include regulations, policies, and monitoring) pertaining to the partograph's use, midwives in this study did not use the partograph in BPM as required.

Conclusion
1. From 27 BPM, possess partography knowledge for assisting with childbirth.2. The 27 BPM participants viewed the partograph as a helpful tool for assisting in childbirth in a positive light.3. The partograph has not been fully utilized in BPM; it is only used for administrative reasons to claim birth assistance costs; it is not used for regular deliveries (those that do not involve a jamper).4. The usage of Partograph in childbirth assistance by BPM is not governed by any laws, rules, or oversight from pertinent authorities and professional associations.