Barriers to and incentives for achieving partograph use in obstetric practice in low- and middle-income countries: a systematic review

Background: The partograph is a graphic display of the progress of labour, recommended by the World Health Organization, but often underused in practice in low-and middle-income countries. We were interested in going beyond demonstration of potential efficacy - on which the existing literature concentrates - through a systematic review to identify barriers to and incentives for achieving partograph use. Methods: We searched Ovid MEDLINE, Ovid Maternity and Infant Care, POPLINE, Web of Science, and Scopus, from 1st January 1994 to 30th September 2013, using the term 'partogra*' to include 'partograph', 'partogram', or 'partogramme'. The selection criteria were for primary or secondary research describing barriers to and incentives for partograph use in low-and middle-income countries, in English, reported in peer-reviewed publications since 1994. Thematic analysis of text on partograph use was applied to a commonly used framework for change in clinical practice, with levels describing the innovation, the individual professional, the woman, and social, organisational, economic and political contexts. Results: Reported barriers to and incentives for partograph use related to the partograph itself, professional skills and practice, clinical leadership and quality assurance, and the organisational environment within the wider provision of obstetric care. Neither the evidence base for its effectiveness, nor its credibility, was reported as a barrier to use. Conclusion: Identifying and addressing local barriers and incentives in low-and middle-income countries, based on those in published research, could inform strategies to improve partograph use. Emerging technologies could be used to address some barriers. The thresholds for essential maternity care at which the partograph adds value should be further evaluated.