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\begin{document}

\title{WHO next-generation partograph: revolutionary steps towards
individualised labour care?}



\author[1]{nanna  maaloe}%
\author[2]{Jos van Roosmalen}%
\author[3]{brenda dmello}%
\author[4]{barbara kwast}%
\author[5]{Thomas van den Akker}%
\author[6]{Natasha Housseine}%
\author[1]{monica Lauridsen Kujabi}%
\author[7]{Tarek Meguid}%
\author[6]{Hussein Kidanto}%
\affil[1]{University of Copenhagen Faculty of Health and Medical Sciences}%
\affil[2]{Leiden University Medical Centre}%
\affil[3]{Comprehensive Community Based Rehabilitation in Tanzania}%
\affil[4]{international consultant maternal health and safe motherhood}%
\affil[5]{Leiden University Medical Center}%
\affil[6]{The Aga Khan University - Tanzania}%
\affil[7]{Kivunge hospital}%


\vspace{-1em}



  
  \date{May 27, 2024}


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\textbf{Commentary}

\textbf{WHO next-generation partograph: revolutionary steps towards
individualised labour care?}

Nanna Maal\selectlanguage{ngerman}øe\textsuperscript{1,2}, Jos van
Roosmalen\textsuperscript{3,4}, Brenda Sequeira
Dmello\textsuperscript{1,5,7}, Barbara Kwast\textsuperscript{6}, Thomas
van den Akker\textsuperscript{3,4}, Natasha
Housseine\textsuperscript{7}, Monica Lauridsen
Kujabi\textsuperscript{1}, Tarek Meguid\textsuperscript{8}, Hussein
Kidanto\textsuperscript{7}.

\begin{enumerate}
\tightlist
\item
  Global Health Section, Department of Public Health, University of
  Copenhagen, Denmark
\item
  Department of Obstetrics and Gynaecology, Hvidovre University
  Hospital, Hvidovre, Denmark
\item
  Athena Institute, VU University, Amsterdam, the Netherlands
\item
  Department of Obstetrics and Gynaecology, Leiden University Medical
  Centre, Leiden, the Netherlands
\item
  Maternal and Newborn Health, Comprehensive Community Based
  Rehabilitation in Tanzania, Dar es salaam, United Republic of Tanzania
\item
  International Consultant Maternal Health and Safe Motherhood, Leusden,
  the Netherlands
\item
  Medical College East Africa, Aga Khan University, Dar es Salaam,
  United Republic of Tanzania
\item
  Kivunge hospital, Zanzibar, United Republic of Tanzania
\end{enumerate}

Corresponding author: Prof. Jos van Roosmalen,
j.j.m.van\_roosmalen@lumc.nl

Word count: 1172

Hofmeyr et al. anticipate that departure from the familiar partograph
``may provoke anxiety and even antipathy among healthcare
professionals''.\textsuperscript{1} We do concur that change is urgently
needed to reach beyond the co-existence of too little, too late and too
much, too soon care during childbirth.\textsuperscript{2} In particular,
we applaud the World Health Organization (WHO) for their underlying
Better Outcomes in Labour Difficulty (BOLD) project, which has disclosed
the urgency of delaying the onset of the active phase of the first stage
of labour from 3-4 centimeters of cervical dilatation to at least
5.\textsuperscript{3} We do agree that the previously premature
designation was ''a major iatrogenic cause of apparent poor labour
progress and unnecessary interventions'', which has contributed to the
epidemic of caesarean sections in many countries
globally.\textsuperscript{1} For the Labour Care Guide (LCG), however,
to catalyse such change,~we urge WHO to consider three major concerns
before further LCG implementation.

First, any early warning chart only becomes a ``monitoring \emph{and
response} tool'' when applied in combination with clear guidance as to
how to respond.\textsuperscript{2,4} We once again draw attention to
WHO's own multicentre cluster-randomized trial of 35.484 births in
South-East Asia, which indicated that failure to know what to do next
may be more central to suboptimal partograph use than failure to fill it
in. Combining the partograph with clear management guidelines was
associated with reductions in rates of prolonged labour (from 6·4\% to
3·4\%), oxytocin use for labour augmentation (from 20·7\% to 9·1\%),
emergency caesarean section (from 9·9\% to 8·3\%) and intrapartum
stillbirth (from 0·5\% to 0·3\%).\textsuperscript{5} Although the LCG
provides alert values for cervical dilatation, its user's manual is
unclear and leads to confusion with regard to when and which action
should follow. The previous WHO 2018 guidelines were also unspecific in
this respect, and even in disagreement with the 2017

guidelines.\textsuperscript{6} Lack of specific guidance on prolonged
labour is particularly alarming in light of the high rates of oxytocin
augmentation in low-resource hospitals in Nigeria and Uganda, disclosed
in WHO's BOLD project.\textsuperscript{3} Oxytocin augmentation, when
indicated, prevents the risks of prolonged labour, but introduces risks
of perinatal adverse outcomes in low-resource hospitals, if not combined
with appropriate surveillance.

Similar to the aforementioned WHO study of the partograph, the PartoMa
project has co-created clear and comprehensive intrapartum management
guidelines with frontline health providers in
Tanzania.\textsuperscript{6} In case of suboptimal labour progress, the
PartoMa guidelines suggest: 1. Consider underlying causes (power of
contractions, pelvis, position of the baby, urination and anxiety); 2.
Artificial rupture of membranes when these are still intact, caring
support, oral fluid, food and ambulation); 3. When the partographs's
action line is crossed, consider careful augmentation with oxytocin; 4.
Assisted vaginal birth considered in second stage of labour. Only when
these action steps do not apply should the last option of performing
caesarean section be considered.\textsuperscript{6}

Secondly, the LCG is not context-stratified to available resources.
Therefore, one may question the claim that it sets off ``revolutionary
steps towards individualized labour care''.\textsuperscript{1} Maternity
units in low- and lower-middle income countries are increasingly
congested and the human resources crisis is
tremendous.\textsuperscript{7,8} As we have previously disclosed, it is
just impossible to follow the LCG's surveillance regime if caring for
more than two women simultaneously.\textsuperscript{4} Checking fetal
heart rate and assessing contractions, blood pressure, pulse and vaginal
examination every four hours during active labour, would take 110
minutes per woman, excluding extra time for supportive
care.\textsuperscript{6}

Although the different thresholds for every centimetre of dilatation may
provide accurate average progression curves, such complexity hampers
care provision in already overstretched clinical realities. Furthermore,
if a woman remains just below the LCG's threshold at each centimeter of

dilatation, she can be in active labour for over 18 hours without
triggering cervical alerts. At the same time, the
95\textsuperscript{th}centile for cumulative time from 5 to 10cm in the
WHO's Bold study was 11 hours. This adds to the confusion of the LCG and
causes concern for how strong the LCG is informed by the underlying BOLD
evidence.\textsuperscript{3} For anyone who has worked in busy maternity
units amid cries of pain and fear of women labouring alone, such
extended ``watchful waiting'' seems to be a horrifying prospect.
Moreover, it may be good to remember that historically the first
partograph, as designed by Philpott in the 1970s, included the four-hour
time frame between the alert and action lines with the aim of arranging
timely referral from a basic to a comprehensive emergency obstetric care
facility for those women who crossed the alert line. Crossing the alert
line was not intended as an indication for oxytocin
augmentation.\textsuperscript{9} Many women may need earlier alertness
than the new LCG proposes to initiate the aforementioned steps 1 and 2,
and to arrange timely referrals for those giving birth in facilities
without comprehensive emergency obstetric and neonatal care functions.

As the LCG stands now, the new ``partograph'' may work in private
practice with one-to-one care, a birth companion present and pain-relief
available. The presence of a birth companion is an evidence-based
intervention, increasing spontaneous vaginal births and reducing the
need for pain relief.\textsuperscript{10} A birth companion, however, is
often not allowed in the busy labour wards in many countries in
sub-Saharan Africa whilst pain relief is only in place for
post-operative care.

Finally, adaptation and pilot testing of the LCG is paramount, including
assessments of less obvious direct~and indirect (side-)effects. What is
included and how it is prioritized in a universal partograph might frame
priorities of what is done, and what might be
neglected.\textsuperscript{4} For instance, we applaud WHO for placing
additional focus on the second stage of labour. However, neglecting the
latent phase is worrisome as it may cause delay in recognizing
complications or onset of active labour.\textsuperscript{11} Many women
who enter facilities in the latent phase, are those with prolonged
labour in the active phase and need our support also during the latent
phase. Likewise, we applaud WHO for emphasizing compassionate and
supportive care during birth, including advocating for birth companions
and the option of pain relief.\textsuperscript{10} However, to include
for instance posture of the woman higher up on the partograph than the
well-being of her unborn baby, which used to be at the top, seems
disrespectful to women's priorities. Monitoring the baby is an essential
part of caring support, but in many low-resource maternity units still
highly under-prioritized.\textsuperscript{12}

To conclude, our ``anxiety'' is not caused by fear of change, but by
fear of history repeating itself. At global and local levels, we must
intensify the struggle to end root causes of unacceptable intrapartum
care, including the human resources for health crisis and women's unmet
sexual and reproductive rights. Simultaneously, we must assist currently
overburdened and often less well trained midwives and doctors with
clear, realistically achievable and integrated monitoring and response
guidance.\textsuperscript{4} We sincerely hope that the LCG will be
adapted based on our worries. We feel that such adaptation is the only
way to reach ``\emph{the right amount of care at the right time,
delivered in a manner that respects, protects and promotes human
rights''.}

References:

\begin{enumerate}
\tightlist
\item
  Hofmeyr GJ, Bernitz S, Bonet M, et al. WHO next-generation partograph:
  revolutionary steps towards individualized labour care. BJOG 2021;
  doi.org/10.1111/1471-0528.16694.
\item
  Miller S, Abalos E, Chamillard M, et al. Beyond too little, too late
  and too much, too soon: a pathway towards evidence-based, respectful
  maternity care worldwide. \emph{Lancet.} ~2016;~388:~2176-2192
\item
  Oladapo OT, Souza JP, Fawole B, et al. Progression of the first stage
  of spontaneous labour: a prospective cohort study in two sub-Saharan
  African countries. PLoS Med 2018; 15: e1002492.
\item
  Maaløe N, Ørtved AMR, Sørensen JB, et al. The unjustice of unfit
  clinical practice guidelines in low-resource realities. Lancet Glob
  Health 2021; 9: e875-e879.
\item
  Kwast BE, Lennox CE, Farley TMM. World Health Organization partograph
  in management of labour. WHO Organization Maternal Health and Safe
  Motherhood Programme. Lancet 1994; 343: 1399-404.
\item
  Maaløe N, Meguid T, Housseine, N, et al. Local adaptation of
  intrapartum clinical guidelines, United Republic of Tanzania. Bull
  World Health Organ 2019; 97: 365-370.
\item
  Campbell OMR, Calvert C, Testa A, Strehlow M, Benova L, Keyes E, et
  al. The scale, scope, coverage, and capability of childbirth care.
  Lancet. 2016;388(3).
\item
  Sequeira Dmello B, Sellah Z, Magembe G, et al. Learning from changes
  concurrent with implementing a complex and dynamic intervention to
  improve urban maternal and perinatal health in Dar es Salaam,
  Tanzania, 2011-2019. BMJ Glob Health 2021; 6: e004022.
\item
  Philpott RH, Castle WM. Cervicographs in the management of labour in
  primigravidae. I. The alert line for detecting abnormal labour; II.
  The action line and treatment of abormal labour. J Obstet Gynaecol Br
  Commonw 1972; 79: 592-602.
\item
  Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous
  support for women during childbirth. Cochrane Database Syst Rev 2017;
  7: CD003766.
\item
  Kwast BE, Poovan P, Vera E, Kohls E. The modified WHO partograph: do
  we need a latent phase? Afr J Midwifery Women's Health 2008; 2:
  143-148.
\item
  Housseine N, Punt MC, Browne J, et al. Strategies for intrapartum
  foetal surveillance in low- and middle-income countries: A systematic
  review. PLoS One 2018; 13: e0206295.
\end{enumerate}

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