Implementation of the partograph in India's JS']JSY cash transfer programme for facility births: a mixed methods study in Madhya Pradesh province

Objectives: To study implementation of partograph use to monitor labour in facilities providing the JSY (Janani Suraksha Yojana) cash transfer programme for facility births in India by determining (1) adherence to partograph use, (2) staff abilities at partograph use and (3) staff responsiveness to the policy on partograph use. Design: A mixed methods study using Carroll's framework for implementation fidelity. Methods include (1) obstetric case record review, (2) a vignette-based survey among nurse midwives and (3) interviews with staff. Setting: Routine use of the partograph is recommended to monitor progress of labour in most low-and middle-income countries (LMICs), including India, although currently available evidence in this regard is insufficient. This study was conducted in the context of the highly successful JSY programme in three districts of Madhya Pradesh province. Participants: 73 different level JSY programme facilities participated in the record review, 233 nurse midwives at these facilities participated in the vignette survey and a total of 11 doctors and midwives participated in the interviews. Results: The partograph was used in 6% of the 1466 records reviewed. The staff obtained a median score of 1.08 (maximum of 10) at competence in plotting a partograph. Three themes emerged from the qualitative data: (1) partographs are used rarely and retrospectively; (2) training does not support correct use of the partograph; and (3) partographs can be useful but are not feasible. Conclusions: Implementation fidelity of partograph use in the JSY programme is low. Successful implementation of the partograph can result in improved quality of care in the JSY programme only if potential moderators to its adherence, such as training, supervision, staff 'buy in' and practice environment are addressed so that staff find a conducive practice environment in which to use the partograph and women find it beneficial to present early in labour.