***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE The partogram is a pictorial representation of the progress of labour , used in an effort to enhance early recognition of dystocia and help avoid Caesarean section ( CS ) . The objective of this study was to evaluate the effect of partogram use on the CS and obstetric intervention rates . METHODS We conducted a r and omized controlled trial of use of the partogram in 1932 primiparous women with uncomplicated pregnancies at term . Patients were r and omly assigned to one of two groups : the st and ard group  , who had the progress of labour charted in written notes , or the partogram group  , whose progress in labour was recorded using a bedside graphical partogram as well as in written notes . Outcomes were stratified according to whether labour was spontaneous or induced and whether membranes were initially intact or ruptured . The primary outcome was the rate of CS ; secondary outcome measures were rates of obstetric intervention for dystocia . RESULTS There was no significant difference between the groups in rates of CS ( partogram 24 % , st and ard notes 25 % ) , rates of other interventions , amniotomy , oxytocin use , or the mean cervical dilatation in labour . CONCLUSION In this study , the use of a partogram without a m and atory management of labour protocol had no effect on rates of CS or other intrapartum interventions in healthy primiparous women at term Background The partograph is currently the main tool available to support decision-making of health professionals during labour . However , the rate of appropriate use of the partograph is disappointingly low . Apart from limitations that are associated with partograph use , evidence of positive impact on labour-related health outcomes is lacking . The main goal of this study is to develop a Simplified , Effective , Labour Monitoring-to-Action ( SELMA ) tool . The primary objectives are : to identify the essential elements of intrapartum monitoring that trigger the decision to use interventions aim ed at preventing poor labour outcomes ; to develop a simplified , monitoring-to-action algorithm for labour management ; and to compare the diagnostic performance of SELMA and partograph algorithms as tools to identify women who are likely to develop poor labour-related outcomes . Methods / Design A prospect i ve cohort study will be conducted in eight health facilities in Nigeria and Ug and a ( four facilities from each country ) . All women admitted for vaginal birth will comprise the study population ( estimated sample size : 7,812 women ) . Data will be collected on maternal characteristics on admission , labour events and pregnancy outcomes by trained research assistants at the participating health facilities . Prediction models will be developed to identify women at risk of intrapartum-related perinatal death or morbidity ( primary outcomes ) throughout the course of labour . These predictions models will be used to assemble a decision-support tool that will be able to suggest the best course of action to avert adverse outcomes during the course of labour . To develop this set of prediction models , we will use up-to- date techniques of prognostic research , including identification of important predictors , assigning of relative weights to each predictor , estimation of the predictive performance of the model through calibration and discrimination , and determination of its potential for application using internal validation techniques . Discussion This research offers an opportunity to revisit the theoretical basis of the partograph . It is envisioned that the final product would help providers overcome the challenging tasks of promptly interpreting complex labour information and deriving appropriate clinical actions , and thus increase efficiency of the care process , enhance providers ’ competence and ultimately improve labour outcomes .Please see related articles ‘ http://dx.doi.org/10.1186/s12978-015-0027-6 ’ and ‘ http://dx.doi.org/10.1186/s12978-015-0028-5 ’ Background The Normalization Process Model is a theoretical model that assists in explaining the processes by which complex interventions become routinely embedded in health care practice . It offers a framework for process evaluation and also for comparative studies of complex interventions . It focuses on the factors that promote or inhibit the routine embedding of complex interventions in health care practice . Methods A formal theory structure is used to define the model , and its internal causal relations and mechanisms . The model is broken down to show that it is consistent and adequate in generating accurate description , systematic explanation , and the production of rational knowledge cl aims about the workability and integration of complex interventions . Results The model explains the normalization of complex interventions by reference to four factors demonstrated to promote or inhibit the operationalization and embedding of complex interventions ( interactional workability , relational integration , skill-set workability , and context ual integration ) . Conclusion The model is consistent and adequate . Repeated calls for theoretically sound process evaluations in r and omized controlled trials of complex interventions , and policy-makers who call for a proper underst and ing of implementation processes , emphasize the value of conceptual tools like the Normalization Process Model As part of the Safe Motherhood Initiative , launched in 1987 , the World Health Organization have produced and promoted a partograph with a view to improving labour management and reducing maternal and fetal morbidity and mortality . This partograph has been tested in a multicentre trial in south east Asia involving 35,484 women . Introduction of the partograph with an agreed labour-management protocol reduced both prolonged labour ( from 6.4 % to 3.4 % of labours ) and the proportion of labours requiring augmentation ( from 20.7 % to 9.1 % ) . Emergency caesarean sections fell from 9.9 % to 8.3 % , and intrapartum stillbirths from 0.5 % to 0.3 % . Among singleton pregnancies with no complicating factors , the improved outcome was even more marked , with caesarean sections falling from 6.2 % to 4.5 % . The improvements took place among both nulliparous and multiparous women . The World Health Organisation partograph clearly differentiates normal from abnormal progress in labour and identifies those women likely to require intervention . Its use in all labour wards is recommended Summary In an attempt to evaluate the contributory factors to the high frequency of referred cases in obstructed labour at the State 's referral hospital , a question naire-based survey of 396 maternity care-providers from 66 r and omly selected peripheral delivery units in Ogun State , Nigeria was conducted over a 2-month period , to evaluate their knowledge and use of the partograph .  The majority of the personnel were nurses/midwives ( 45.5 % ) and  community health extension workers  ( CHEW ) ( 42.7 % ) . Of the 216 personnel ( 54.5 % ) who were aware of the partograph , 36 ( 16.7 % ) , 119 ( 55.5 % ) and 61 ( 28.2 % ) demonstrated poor , fair and good levels of knowledge , respectively . No junior CHEW had a satisfactory knowledge of the partograph .  Only 39 ( 9.8 % ) of all the personnel routinely employed the partograph for labour management and almost half of these individuals had a poor level of knowledge . Efforts to limit the frequency of referred cases of established obstructed labour to the State 's referral hospital should include training of care-providers at the peripheral delivery units , especially junior personnel in the effective use of the partograph , in addition to employing quality assurance measures to check inappropriate use OBJECTIVE : To assess the ability of midwives to interpret antenatal cards and partograms correctly following completion of the Maternal Care Manual of the Perinatal Education Programme . STUDY DESIGN : We conducted a prospect i ve , controlled trial in a study town and two control towns in the Eastern Cape Province of South Africa . All 93 midwives caring for pregnant women in the three towns were included in the study . Sample s were compared using the two-tailed Student ’s t-test . RESULTS : The marks achieved by the study group for questions from the antenatal card and the partogram improved by 33.0 % ( p < 0.001 ) and 17.5 % ( p = 0.001 ) , respectively . No changes were observed in the control group . CONCLUSION : Midwives that studied the Maternal Care Manual significantly improved their ability to interpret clinical information and apply knowledge . If this ability is applied in clinical practice , a reduction in maternal and perinatal deaths is possible OBJECTIVE to assess the effectiveness of promoting the use of the World Health Organization ( WHO ) partograph by midwives for labour in a maternity home by comparing outcomes after birth . SETTING Medan city , North Sumatera Province , Indonesia . PARTICIPANTS 20 midwives who regularly conducted births in maternity homes , r and omly allocated into two equal groups . DESIGN cluster r and omised-control trial . INTERVENTION under supervision from a team of obstetricians , midwives in the intervention group were introduced to the WHO partograph , trained in its use and instructed to use it in subsequent labours . MEASUREMENTS AND FINDINGS there were 304 eligible women with vertex presentations among 358 labouring women in the intervention group and 322 among 363 in the control group . Among the intervention group , 304 ( 92.4 % ) partographs were correctly completed . From 71 women with the graph beyond the alert line , 42 ( 65 % ) were referred to hospital . Introducing the partograph significantly increased referral rate , and reduced the number of vaginal examinations , oxytocin use and obstructed labour . The proportions of caesarean sections and prolonged labour were not significantly reduced . Apgar scores of less than 7 at 1min was reduced significantly , whereas Apgar scores at 5mins and requirement for neonatal resuscitation were not significantly different . Fetal death and early neonatal death rates were too low to compare . IMPLICATION S FOR PRACTICE a training programme with follow-up supervision and monitoring may be of use when introducing the WHO partograph in other similar setting s , and the findings of this study suggest that the appropriate time of referral needs more emphasis in continuing education . CONCLUSION the WHO partograph should be promoted for use by midwives who care for labouring women in a maternity home OBJECTIVE To determine the effect of partogram on the frequency of prolonged labour , augmented labour , operative deliveries and whether appropriate interventions based on the partogram will reduce maternal and perinatal complications . METHOD A case controlled , prospect i ve and interventional study on 1000 women in labour was carried out in the obstetric unit of Jinnah Post graduate medical center , Karachi , from 1st July to 30th December , 2002 . Five hundred women were studied before and after the introduction of partogram .  Duration of labour , mode of delivery , number of cases augmented and neonatal outcome were noted RESULTS Labour was shorter than 12 hours in 80.8 % primigravida , 18.4 % had labour shorter than 24 hours and only 0.8 % had labour longer than 24 hours . After introduction of partogram 91.6 % delivered within 12 hours and rest ( 8.4 % ) delivered within 24 hours . Normal vaginal delivery was had in 88 % , 5.6 % had operative vaginal delivery and 6.4 % had caesarean section . Introduction of partogram showed significant impact on duration of labour ( p < 0.001 ) as well as on mode of delivery ( p < 0.01 ) . In multigravidae 94.4 % delivered within 12 hours and rest 5.6 % delivered within 24 hours when partogram was used while 88.4 % delivered within 12 hours and the rest 11.6 % ) within 24 hours before the use of partogram . Partogram showed significant reduction in duration of labour ( p < 0.01 ) . Results also showed significant reduction in number of augmented labour ( p < 0.001 ) and vaginal examinations ( p < 0.001 ) . CONCLUSION By using partogram , frequency of prolonged and augmented labour , postpartum haemorrhage , ruptured uterus , puerperal sepsis and perinatal morbidity and mortality was reduced OBJECTIVE To study the impact of an educational intervention of midwives ' use of the Angolan model of the World Health Organization 's ( WHO ) partograph . SETTING A peripheral delivery unit with approximately 1500 deliveries per year , run by eleven midwives in Lu and a , Angola . DESIGN The quasi-experimental , One-Group Pre-test-Post-test design was used in this study . Fifty partographs plotted with an initial dilatation < 8 cm were r and omly selected from the first period of six month to form sample I , and another fifty from the second six-months period to form sample II . INTERVENTION In-service education ( theory and practice ) performed by a team of midwives and an obstetrician . MEASUREMENTS AND FINDINGS When comparing sample II with sample I , statistically significant improvements were found in seven of 10 measured variables . This indicates a positive effect of the educational intervention on a proper use of the partograph . Due to the small sample size , however , this study can not evaluate action taken in relation to prolonged labour . IMPLICATION S FOR PRACTICE The in-service educational programme may be of use when introducing the WHO partograph in similar setting s , and the findings of this study may indicate which parts of the programme need more emphasis . CONCLUSIONS The midwives improved in general their documentation of the partograph . However , they tended to exceed established criteria for responsibilities at the peripheral delivery unit , a fact supported by an increased number of missed transfers . The study did not , however , answer the question why the midwives acted as they did in the referred cases A 6-week prospect i ve study of women referred to Korle Bu Teaching Hospital during labour and delivery was conducted to determine the sources of and indications for referral , and to assess the adequacy of various aspects of the referral mechanisms . Of 396 women referred , 86 % were referred from polyclinics ( which are state-owned ) and private midwives .  The commonest indications were failure to progress ( 21.5 % ) and hypertensive disease ( 15.7 % ) . A total of 35 ( 8.8 % ) women were referred with third-stage or immediate 
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Results The evidence synthesis relates the evidence to identified theories of health worker acceptability , health system support , effective referral systems , human re sources and health worker competence , highlighting barriers and facilitators .