Effectiveness of the modified WHO labour care guide to detect prolonged and obstructed labour among women admitted at publicly funded facilities in rural Mbarara district, Southwestern Uganda: an ambispective cohort study
Authors: Godfrey Mugyenyi R , Wilson Tumuhimbise , Esther Atukunda C , Leevan Tibaijuka , Joseph Ngonzi , Musa Kayondo , Micheal Kanyesigye , Angella Musimenta , Fajardo Yarine T , Josaphat Byamugisha K 
Published: September 2024

Background

Obstructed labour, a sequel of prolonged labour, remains a significant contributor to maternal and perinatal deaths in low- and middle-income countries.

Objective

We evaluated the modified World Health Organization (WHO) Labour Care Guide (LCG) in detecting prolonged and or obstructed labour, and other delivery outcomes compared with a traditional partograph at publicly-funded maternity centers of rural Mbarara district and City, Southwestern Uganda.

Methods

Since November 2023, we deployed the LCG for use in monitoring labour by trained healthcare providers across all maternity centers in Mbarara district/City. We systematically randomized a total of six health center IIIs (HCIIIs) out of 11, and all health center IVs (HCIVs), reviewed all their patient labour monitoring records for their first quarter of 2024 (LCG-intervention) and 2023 (partograph-before LCG introduction). Our primary outcome was the proportion of women diagnosed with prolonged and or obstructed labour. Our secondary outcomes included; tool completion, mode of delivery, labour augmentation, stillbirths, maternal deaths, Apgar score, uterine rupture, postpartum haemorrhage (PPH). Data was collected in RedCap and analyzed using STATA version 17. Statistical significance was considered at p<0.05.

Results

A total of 2,011 women were registered; 991 (49.3%) monitored using the LCG, and 1,020 (50.7%) using a partograph, 87% (1,741/2011) delivered from HCIVs and 270/2011 (13%) from HCIIIs. Mean maternal age (25.9; SD=5.6) and mean gestation age (39.4; SD=1.8) were similar between the two groups. A total of 120 (12.4%) cases of prolonged/obstructed labour were diagnosed (100 for LCG versus 20 for partograph), with the LCG having six times higher odds to detect/diagnose prolonged/obstructed labour compared to the partograph (aOR=5.94; CI 95% 3.63-9.73, P<0.001). Detection of obstructed labour alone increased to 12-fold with the LCG compared to the partograph (aOR=11.74; CI 95% 3.55-38.74, P<0.001). We also observed increased Caesarean section rates (aOR=6.12; CI 4.32-8.67, P<0.001), augmentation of labour (aOR=3.11; CI 95% 1.81-5.35, P<0.001), and better Apgar Score at 5 minutes (aOR=2.29; CI 95% 1.11-5.77, P=0.025). The tool completion rate was better for LCG compared to (58.5% versus 46.3%), aOR=2.11; CI 95% 1.08-5.44, P<0.001. We observed no differences in stillbirths, maternal deaths, post-partum haemorrhage (PPH) and uterine rupture.

Conclusions

Our data shows that LCG diagnosed more cases of prolonged and or obstructed labour compared to the partograph among women delivering at rural publicly funded facilities in Mbarara city/district. We also observed increased C-sections, labour augmentation, and 5-minute Apgar scores. There were no differences in stillbirths, maternal deaths, PPH and uterine rupture. More controlled and powered studies should evaluate the two tools for other delivery outcomes, in different sub-populations.

Trial registration numberNCT05979194clinical trials.gov.

Article Summary

This manuscript presents novel results from a before-and-after (ambispective cohort study) that utilized retrospective historical data from records of women monitored in labour using an old partograph before introduction of the new modified WHO LCG in South western Uganda. We compared the ability of these labour monitoring tools in detecting cases of prolonged and or obstructed labour and other delivery outcomes at two different times, one year apart. Our data shows that the LCG diagnosed more cases of prolonged and or obstructed labour compared to the partograph, with observed increase in C-section and labour augmentation rates, and no differences in stillbirths, maternal deaths, PPH and uterine rupture. We recommend the LCG as a decision-making tool for use in routine labour in Uganda and similar settings

Strengths and limitations of this study

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Our study utilized record reviews which generally represent routine practice and removes the Hawthorne effect where people change/modify or improve their behaviour or practice because they know they are being observed or researched on.

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Our retrospective cohort utilized historical partograph records before introduction of LCG in Uganda, while the prospective cohort utilized LCG data at two different times, one year apart, avoiding contamination and observer bias. No known study has reported results comparing clinical outcomes from patients monitored using the old partograph and the new WHO LCG.

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Before-and-after designs, also referred to as ambispective cohorts increase statistical power by combining data from multiple sources in a short period of time. Our study presents retrospective partograph data and prospective LCG data.

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A small number of records were excluded due to missing critical data on time of onset of labour and time of delivery necessary to robustly define the primary outcome

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Due to our preferred study design, we were not able to obtain data on prolonged/obstructed labour detection using the two tools administered to the same mother while monitoring same labour for direct comparison and diagnostic validation.

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We were also not powered enough to detect significant differences in maternal deaths, post-partum haemorrhage, uterine rupture and other maternal-foetal outcomes/complications, especially in different maternal demographic or clinical Caesarean section subgroups.

Implications for implementation and policy

Our results provide local contextualized data to guide implementation and use of the LCG as an effective decision-making tool in monitoring labor in rural south western Uganda, and similar settings. Health care provider competences in tool use coupled with good implementation strategies in a responsive health care system with good referral networks and LCG champions will improve obstetric outcomes. The results from our study should guide customization of WHO LCG user’s and training manuals to guide roll out of the LCG in Uganda and similar settings to improve intrapartum care for a positive pregnancy and childbirth experience.