6. STRATEGY

Despite the fact that the partograph has been described and used since the early 1970s, it is still not used worldwide. One primary reason for this is the lack of conviction felt about its usefulness by decision-makers and some leaders of the profession. Another main obstacle to widespread use is the existence of so many varieties of the partograph; the potential new user is at a loss as to which set of conflicting guidelines to follow.

To overcome these two primary hindrances, the following strategy is recommended:

· Use the simplified partograph developed by WHO. It includes the essential features of most of the partographs currently in use.

· Introduce this partograph to decision-makers at Ministries of Health, as well as to leaders of the profession in each country, especially to those in teaching hospitals.

· Implement this partograph initially in teaching hospitals and referral centres. Its application can then be extended to health centres.

· Encourage medical and midwifery schools to teach the principles and use of the partograph, and to include it in the curriculum.

· Encourage research into all aspects of the application of the partograph. This research should include evaluation of training programmes, as well as investigation of the impact of the partograph on labour management and on adverse outcomes of labour. Particularly needed is research into the use of the partograph as a referral tool in labour. The WHO multicentre trial has emphatically confirmed the value of the partograph in hospital practice.

It is realized that in many developing countries the formal health care system does not look after all pregnant women. If efforts do not go beyond the formal sector, it is unlikely that the existing appalling maternal mortality and morbidity will be influenced very much. Therefore efforts should be made to reach pregnant women outside the formal health care system. This can be done in a variety of ways:

· Traditional birth attendants (TBAs) should be involved as much as possible as agents of change. They should participate in conveying messages to pregnant women and village elders about the need to seek assistance early during pregnancy and labour.

· In those countries where mutual respect exists between trained midwives and TBAs, the latter have been persuaded to refer women in labour not later than 12 hours after they receive them. This experience should be emulated in other countries.

· Other methods of communication should be used as much as possible (e.g. village health committees, the radio, church groups, newspapers) to convey to rural communities the message that delayed labour can lead to problems for the mother and her baby and that help should be sought early (within 12 hours of the onset of labour).

· It is also hoped that the improved results in labour management that should result from the use of the partograph will increase the credibility of the formal health care system and encourage more women to seek assistance early in labour.