Partograph utilization and associated factors among obstetric care givers in governmental health institutions of Jigjiga and Degehabur towns, Somali region, Ethiopia: A cross-sectional study.

BACKGROUND: Partograph is a simple, inexpensive & economical tool that provides a continuous graphical overview of labour and prevents prolonged and obstructed labor. The purpose of the study is to assess partograph utilization and associated factors among obstetric care givers in governmental health institutions of Jigjiga and Degehabur Towns, Somali Region, Ethiopia.
METHODS: An institution based cross-sectional quantitative study was carried out among obstetric care givers who were working in governmental health institutions. Systematic random sampling with proportional to size allocation was used to recruit a total of 235 study participants. Self-administered questionnaire was used to collect data in this study. Three data collectors and one supervisor were recruited and trained to facilitate the data collection activities. Data were entered into Epi data software and exported into SPSS (23.0) for analysis. Descriptive statistics, bivariate and multivariate logistic regression were computed to determine proportions and significant association with partograph utilization among obstetric care givers. RESULT: Less than half of obstetric care givers, 41% (95%CI: 34.5-46.9) had good partograph utilization to monitor progress of labor. Being female [AOR = 2.36, 95%CI:(1.03-5.44)], availability of partograph [AOR = 4.633, 95%CI: (1.698-12.640)], having good knowledge [AOR = 6.90, 95%CI:(2.62-18.18)], receiving on job training [AOR = 15.46, 95%CI:(6.95-34.42)] and positive attitude towards partograph [AOR = 2.99, 95%CI:(1.25-7.14)] were significantly associated with partograph utilization.
CONCLUSION: Partograph utilization in this study was low. Especial emphasizes and interventions should be given to periodic on job training that improve knowledge and attitude of obstetric care givers to increase partograph utilization.

Background

Women are suffering many health problems during their pregnancy as well as at the time of child birth/delivery; globally, there were an estimated number of 15% expected births that developed life-threatening complications during pregnancy, delivery or the postpartum period [1-4].

In 2017, about 295 000 women died during and following pregnancy and childbirth. Sub-Saharan Africa alone accounted for roughly two-thirds (196 000) of maternal deaths, while Southern Asia accounted for nearly one-fifth (58 000); and both accounted for approximately 86% (254 000) of the estimated global maternal deaths [5]. According to the 2015 Ethiopia Demographic and Health Survey, maternal mortality ratio was 353 per 100,000 live births in Ethiopia [6-9]. Though it was slightly increased to 412 in 2016 [10]. Maternal mortality was still high in 2019 accounted to 412 per 100,000 live births [11].

The major causes of maternal and neonatal death in Ethiopia are obstructed labour and prolonged labour which was account for (13%) of maternal deaths [9, 12]. Obstructed and prolonged labour contribute to series of complication in mothers and newborn infants if it is not managed early [13]. These complications can be prevented by proper utilization of partograph during the progress of labour and providing skill delivery services [14].

The partograph is a graphical presentation of the progress of labour, and of fetal and maternal condition during labour [2, 12, 15–17]. It consists of four sections: the maternal information, the fetal conditions record, the labor progress record, and the maternal conditions record [17-19]. The fetal condition record may track fetal heart rate, amniotic liquor, and molding of the fetal skull. The labor progress record tracks cervical dilatation and descent of the fetus’ head over time, comparing it to a pre-printed “alert” and “action” lines [2, 9, 15, 18]. The maternal conditions record often captures contractions, blood pressure, pulse, urine output, temperature, and drugs administered including drugs to help the uterus contract [12, 17–20].

Universal utilization of the partograph during labour is recommended by world health organization since routine use of partograph is helpful to make better decisions for the diagnosis and management of prolonged and obstructed labour [17]. It is still not broadly used in the developing countries especially in Africa include Ethiopia. Studies done in Baghdad, a metropolitan area in Ghana and Lusaka: in Zambia, showed that58%, 54% and 87.5% of the participants used partograph to monitor progress of labour respectively [21-23]. In Ethiopia, there is no consistent use of the partograph during labour; Studies done in Asella referral and teaching hospital, Sidama zone, Bale zone, East Gojjam zone, Addis Ababa city administration; showed that 26%, 50.7%, 70.2%, 53.85% and 69% of the participants used partograph to monitor progress of labour respectively [1, 9, 14–16]. This inconsistent use of partograph due to different factors such as participant’s sex, age, year of clinical service, health profession, knowledge about partograph, attitude towards partograph, absence of training on partograph, work place and work over load [1, 2, 12, 14, 15, 17, 21, 24].

Assessing obstetric care giver’s practical utilization of partograph and its determinants has great value to design appropriate intervention strategies to provide quality maternity care. Therefore, the purpose of this study was to assess utilization of partograph and associated factors among obstetric care givers working in governmental health institutions of Jigjiga and Degehabur towns, Somali region, Ethiopia.

Methods

Study setting and period

The study was conducted in public health institutions Jigjiga and Degehabur towns from May18/2020 –July 8/2020. Jigjiga town, a capital city of Somali Region, is located 635kms east of Addis Ababa. It has 20 kebeles. The town administration has two hospitals, two health centres and fourteen health posts. In the town there are 1,208 clinical health professional workers (212 midwives, 11 HO, 137 medical doctors and 6 Gynecologist and obstetrician) that work in obstetric care at governmental health institutions. It has 366 total numbers of obstetric care givers.

Degehabur is a town in the Somali Region of Ethiopia, is located 800 &165 kms north of Addis Ababa and Jigjiga town respectively. It is the administrative centre of Degehabur) woreda. The town administration has 1 hospital and 1 health centre of public health institutions. It has also 258 clinical health professional workers. Among those 51 midwives, 9 Health officer, 10 medical doctors, 1 Emergency Surgery and 1 obstetrician that work in obstetric care in the town of public health institutions. It has 72 total numbers of obstetric care givers. Total number of obstetric care givers in two towns is 438 that work public health institutions.

Study design

An institution based cross-sectional study design was conducted to assess utilization of partograph and associated factors.

Study population

All obstetric care providers (midwives, nurses, general practitioners, and health offers working in governmental health institutions) in Jigjiga and Degehabur Towns, Somali Region, Ethiopia included in the study.

Sample size determination

The sample size was estimated using single proportion formula by assuming 5% marginal error and 95% confidence interval (σ = 0.05) and study conducted in central zone, Tigray in which the proportion of utilization of partograph among obstetric care givers were 73.3% [2]. By adding 10% for non-respondents the final sample size was taken as 196. Moreover, the double population proportion formula was used to determine the sample size for factors associated with partograph utilization to get maximum possible sample size. It was calculated for some of the associated factors obtained from different literatures using Epi info statistical software version 7 with the following assumptions: confidence level = 95%, power = 80%, the ratio of unexposed to exposed almost equivalent to 2 and partograph utilization among those do not get additional training is 56.5% with AOR 2.4 [14]. Therefore, the final estimated sample size is 235 after adding 10% non response rate which was higher than the sample size calculated using single population proportion formula.

Sampling procedure

From all health institutions found in Jigjiga and Degehabur towns, six health institutions (Jigjiga university Sheik Hassen Yabare Referal Hospital, Kharamara Hospital, Ablele health center, Ayerdega health center, Degehabour General Hospital, and Degehabour health center) were selected using a simple random sampling technique.

The total number of health professionals found in selected hospitals and health centers in Jigjiga town were 234 and 50 respectively. Additionally, 51 health professionals from the Degehabour General hospital and 21 from Degehabour health center were included. The required number of study subjects was calculated via proportional allocation, with 187 from Jigjiga and 48 from Degehabour. Study subjects were chosen using a simple random sampling procedure (lottery method) after preparing sampling frame.

Data collection instrument and techniques

Semi—structured questionnaire which was developed from different literatures was used [2, 16, 17, 21, 22, 24]. It was prepared in English version. Three Diploma in Midwifery data collectors and one BSc in midwifery supervisor were hired and trained for data collection.

Data processing and analysis

Data was entered, checked, and analyzed using SPSS version 23.0. Descriptive statistics was employed to calculate frequencies, median and percentage. Attitude was measured as follows: there were six (6) attitude determining Likert scale type questions prepared to assess respondents’ attitude towards partograph. The responses of “strongly agree was scored 5, agree was scored 4, uncertain was scored 3, disagree was scored 2 & strongly disagree was scored 1. The scoring was reversed for negative statements. The scores of the items were summed-up and the total was divided by the number of the items, giving a mean score. These score was converted into a percent score and mean were computed. The attitude was considered “positive” if the scored 60% or more and “negative” if less than 60%.

Bivariable logistic regression analysis was made using OR and 95% CI to assess the association of independent variable with the outcome separately. Based on Bivariate analysis variables that showed significant association at (p < 0.2) were entered to multivariable analysis to select Predictor variables of factors affecting partograph utilization. Finally, variables that showed significant association at (p < 0.05) were identified as independent predictors of partograph utilization.

Ethical considerations

The Ethical approval was obtained from Institutional Review Board of College of Health Sciences, Jigjiga University on May 14/2020 with reference number RERC/016/2020. Communications with relevant bodies was made through a formal letter obtained from regional health. The objective and importance of the study was explained to the study participants. Data was collected after full informed written consent was obtained from participants. Confidentiality of the information and privacy is maintained.

Results

Socio-demographic characteristics of study participants

Two hundred twenty eight respondents completed all the questionnaires correctly making a response rate of 97.02%. About 70.6% of obstetric care givers were females. The median ages of the respondents were 26.00 (±3 IQR) years and more than half 56.1% of them were within the age group 25–29 years. Regarding their profession, 66.7% were midwives followed by medical practitioner (MD) 13.6%. Regarding to participant’s working place, 71.1% of them were working at hospitals and the rest 25.0% were working in health centers. More than two third of the respondents 68.4% had ≤4 clinical service years and median year of clinical service of obstetric care givers were 3.00 (±3 IQR) years (Table 1).

Table 1

Socio-demographic characteristics of obstetric care givers in governmental health institutions of Jigjiga and Degehabur Towns, Somali region, Ethiopia, 2020 (n = 228).

Variables	Frequency	Percent
Sex
Male	67	29.4
Female	161	70.6
Age group
20–24	54	23.7
25–29	128	56.1
30 and older	46	20.2
Professional qualification
Nurse	28	12.2
Midwife	152	66.7
HO (health officer)	17	7.5
General practitioner (MD)	31	13.6
Year of service
≤4	156	68.4
5–10	55	24.1
≥11	17	7.5
Place of work
Health center	66	28.9
Hospital	162	71.1

Knowledge of obstetric care givers about partograph

All participants had heard about partograph while 52.6% of them know the exact definition of partograph. Regarding to starting time of plot on partograph, 83.3% of the participants correctly identified the exact time when to start plotting partograph. However, 61.4% of the respondents did not know the component of partograph and also 71.5%, 68%, 76.8% of the respondents did not know the definition of alert line, action line and satisfactory of labour progress respectively. Pertaining to use of partograph, most of the participant 78.9% mentioned that partograph should be used for all women in active first stage of labor. Majority (63.6%) of respondents said they had not received any photographs on the job training (Table 2).

Table 2

Knowledge related responses of obstetric care givers about partograph in governmental health institutions of Jigjiga and Degehabur Towns, Somali region, Ethiopia, 2020 (n = 228).

Variables	Frequency	Percent
Heard about partograph
Yes	228	100.0
Definition of partograph
A tool to be used only in active phase of labor	120	52.6
A graphic method of recording first stage of labor	71	31.2
A salient feature of recording the whole process of labor	37	6.2
Component of the partograph
List all	88	38.6
Not list all	140	61.4
Knowledge about the start time of plotting partograph
At 4cm cervical dilatation	190	83.3
At 3cm cervical dilatation	18	7.9
When labor is diagnosed	20	8.8
Definition of alert line
Define correctly	65	28.5
Not define correctly	163	71.5
Definition of action line
Define correctly	73	32
Not define correctly	155	68
Definition of satisfactory of labor progress
Define correctly	53	23.2
Not define correctly	175	76.8
Detected any complication using a partograph
Yes	196	86
No	32	14
List one complication if you detect using partograph
List	180	91.8
Not list	16	8.2
Type of client that needs partograph use
Primgravid	17	7.5
Multiparious	16	7
Eclamptic patients	15	6.6
All women in active labour	180	78.9
On job training
Yes	83	36.4
No	145	63.6

Regarding respondents’ knowledge about partograph, only less than one third of them 28.5% had good knowledge (Fig 1).

Fig 1

Knowledge of obstetric care givers about pantograph in governmental health institutions of Jigjiga and Degehabur Towns, Somali region, Ethiopia, 2020 (n = 228).

Attitude of obstetric care givers towards partograph utilization

Less than half of them (46%) strongly agreed that the photograph is beneficial. More than one third of participants, 45.2% of them were agreed that partograph is favorable as it alerts obstetric care givers of any deviation from normal and 43.9% of the respondents agreed that health care givers are able to identify problems and recognize complications early. Less than one third (26.3%) of them agreed that skilled birth attendant must use a partograph for every labouring mother. Near to thirty one percent (30.7%) of them were uncertain and 28.5% were strongly disagreed that using partograph enables health care givers perform essential basic interventions. And also 35.1% of them were strongly disagreed that using partograph misleads management as the progress of labour and the partograph alert line are not aligned in most pregnant women (Table 3).

Table 3

Attitude related responses of obstetric care givers towards partograph utilization governmental health institutions of Jigjiga and Degehabur Towns, Somali region, Ethiopia, 2020 (n = 228).

Variables	Frequency	Percent
Partograph is beneficial
Strongly agree	105	46
Agree	95	41.7
Uncertain	13	5.7
Strongly disagree	15	6.6
Partograph is very favorable as it alerts health workers any deviation from normal
Strongly agree	50	22
Agree	113	49.6
Uncertain	45	19.7
Disagree	14	6.1
Strongly disagree	6	2.6
By using partograph, health care providers are able to identify problems and recognize complications early
Strongly agree	31	13.6
Agree	100	43.9
Uncertain	70	30.7
Disagree	14	6.1
Strongly disagree	13	5.7
Skilled birth attendant must use partograph on every laboring mother
Strongly agree	26	11.4
Agree	60	26.3
Uncertain	90	39.5
Disagree	39	17.1
Strongly disagree	13	5.7
Using partograph enables health care givers perform essential basic interventions and make referrals to appropriate levels of care when necessary
Strongly agree	10	4.4
Agree	23	10.1
Uncertain	70	30.7
Disagree	60	26.3
Strongly disagree	65	28.5
Using partograph misleads management as the progress of labour and the partograph alert line are not aligned in most pregnant woman
Strongly agree	16	7
Agree	22	9.7
Uncertain	50	21.9
Disagree	60	26.3
Strongly disagree	80	35.1

Regarding respondents’ attitude towards partograph utilization, only less than one third of them (18%) had positive attitude (Fig 2).

Fig 2

Attitude of obstetric care givers towards partograph utilization governmental health institutions of Jigjiga and Degehabur Towns, Somali region, Ethiopia, 2020 (n = 228).

Reasons for not using the partograph

As indicated in Fig 3, less than half (42.5%) of respondents said that lack of orientation was the reason for not using the partograph when monitoring women in labor.

Fig 3

Reasons for not using the partograph by obstetric care givers in governmental health institutions of Jigjiga and Degehabur Towns, Somali region, Ethiopia, 2020 (n = 228).

Partograph utilization

In this study, majority (74.1%) of the respondents had reported the availability of partograph in the facility. More than half (64%) of the participants were partially recorded parameters of partograph on the tool. Similarly, (26.8%) of the participants were conducted deliveries from 7 to 9 in the institution per shift day. Most (92.1%) of the participants reported that they hadn’t faced any problem to utilize partograph. Majority (68.4%) of participants had work load in their facility. More than three-fourths (76.3%) gave advice for the obstetric care givers to encourage use partograph during labor (Table 4).

Table 4

Partograph utilization related responses of obstetric care givers in governmental health institutions of Jigjiga and Degehabur Towns, Somali region, Ethiopia, 2020 (n = 228).

Variables	Frequency	Percent
Availability of partograph
Yes	169	74.1
No	59	25.9
Partograph use currently
Yes	199	87.3
No	29	12.7
Frequency of partograph utilization
Routinely	71	31.1
Sometimes	128	56.1
Occasionally	29	12.7
Components of partograph plotted
Complete	80	35.1
Incomplete	148	64.9
Number of deliveries conducted per shift day
≤ 3	60	26.3
4 to 6	55	24.1
7 to 9	61	26.8
10 and above	52	22.8
Reasons for not utilizing partograph during labor
Lack of orientation	97	42.5
Availability of other methods	24	10.5
Lack of commitment	61	28.8
Lack of supervisions	46	20.2
Facing any problem to utilize the partograph
Yes	18	7.9
No	210	92.1
Work load
Yes	185	81.1
No	43	18.9
Suggestion in order to encourage partograph utilization
Give suggestion	174	76.3
Not give suggestion	54	23.7

Overall from 228 participants, 93(41%) of the participants were had good partograph utilization (Fig 4).

Fig 4

Utilization of partograph by obstetric care givers in governmental health institutions of Jigjiga and Degehabur Towns, Somali region, Ethiopia, 2020 (n = 228).

Factors associated with partograph utilization

Bivariate analysis was performed to select candidate variables for multivariable analysis. Accordingly, sex of participant (being female) [COR = 2.15, 95%CI: (1.16–3.98)], working in Hospital [COR = 1.71, 95%CI: (0.94–3.14)], having good knowledge [COR = 2.42, 95%CI: (1.24–4.70)], availability of partograph [COR = 6.45, 95%CI: (2.89–14.41)], taking on job training [COR = 12.08, 95%CI: (6.34–22.99)] and positive attitude towards partograph [COR = 2.73, 95%CI: (1.37–5.48)] were among factors showed that candidate variables for multivariate analysis at p value

Multivariate analysis was performed for the purpose of controlling the multiple confounding effects of variables. Accordingly, sex of participant (being female) [AOR = 2.36, 95%CI:(1.03–5.44)], availability of partograph [AOR = 4.63, 95%CI: (1.70–12.64)], having good knowledge [AOR = 6.90, 95%CI:(2.62–18.18)], receiving on job training [AOR = 15.46, 95%CI:(6.95–34.42)] and positive attitude towards partograph [AOR = 2.99, 95%CI:(1.25–7.14)] were factors showing significant association with partograph utilization at p-value

Table 5

Bivariate and multivariable analysis of factors associated with partograph utilization of obstetric care givers in governmental health institutions of Jigjiga and Degehabur Towns, Somali region, Ethiopia, 2020 (n = 228).

Variables	Partograph utilization		COR	AOR (95%CI)	p-value
	Yes	No
	No (%)	No (%)
Sex
Female	70(47.9)	76(52.1)	2.37 (1.32–4.22)	2.37(1.03–5.41)*	0.043
Male	23(28.0)	59(72.0)	1	1
Work place
Hospital	74(45.1)	90(54.9)	1.71(0.94–3.14)	1.35(0.58–3.15)	0.492
Health center	21(31.8)	45(68.2)	1	1
Availability of partograph
Yes	85(50.3)	84(49.7)	6.45 (2.89–14.41)	4.63(1.70–12.64)**	0.003
No	8(13.6)	51(86.4)	1	1
Knowledge about partograph
Good	35(53.8)	30(46.2)	2.42(1.24–4.70)	6.90 (2.62–18.18)***	0.000
Satisfactory	30(39.0)	47(61.0)	1.32(0.70–2.52)	2.67(1.07–6.71)*	0.036
Poor	28(32.6)	58(67.4)	1	1
On job training
Yes	63(75.9)	20(24.1)	12.08(6.34–22.99)	15.46(6.95–34.42)***	0.000
No	30(20.7)	115(79.3)	1	1
Attitude towards partograph utilization
Positive	25(61.0)	16(39.0)	2.73(1.37–5.48)	2.99(1.25–7.14)*	0.014
Negative	68(36.4)	119(63.6)	1	1

Significant at

*p-value<0.05,

**p-value <0.01 and

***p-value <0.001.

Discussion

The proportion of partograph utilization was 41% (95%CI: 34.6–46.9). This finding is inconsistent with study conducted in Baghdad (58%), Metropolitan area in Ghana (54%), Bale zone (70.2%), North Showa Zone (81.1%), West Showa Zone (84.6%) and Central Tigray Zone (73.3%) [2, 12, 16, 17, 21, 22]. The lack of well-designed and integrated programs, such as mentorship and supportive supervision, could be the cause of this difference. Other factors that may contribute to lower partograph utilization include a lack of expertise, a lack of understanding, insufficient partograph training, and a negative attitude among study participants. This finding is higher than the study conducted in Asella, Teaching and Referral Hospital, Ethiopia [1]. These discrepancies may be due to the sample size, different study area and time of study.

Findings of this study also indicated that positively significant association between sex and partograph utilization. Female obstetric care givers were more than two times more likely to good partograph utilization than males. This finding is consistent with a previous study done in Bale zone, Ethiopia [16]. It is understandable that the majority of birth attendants assigned to the labor ward on the study area are female midwives who have had the opportunity to participate in partograph usage trainings, which have increased their knowledge and abilities.

Availability of the partograph in health facility is also associated with its utilization. Those health care givers who had partograph tools in their institution were more than four times more likely to use partograph than had not partograph in their facility. This finding is consistent with a previous study done in Asella, Ethiopia and West Showa Oromia, Ethiopia [1, 12]. This implies that the availability of partograph by itself is essential to motivate obstetrics giver for use of this tools starting from active first stage of labour.

Findings of this study also indicated that significant association between knowledge and partograph utilization. Those obstetric care givers who had good knowledge about partograph were more than six times more likely to good partograph utilization than their counterparts. This finding is consistent with a previous study conducted in Enugu Metropolis, North Showa Zone, Ethiopia, West Showa Zone, Oromia, Ethiopia and Bale zone [12, 16, 17, 24]. The possible reason might be Obstetrics care givers who have knowledge on purpose of partograph may use it more frequently to prevent prolonged labour and related complications.

This research finding showed that on-job training on partograph had a significant association with partograph utilization. Those obstetric care givers who received on job training on partograph were more than fifteen times more likely to utilize partograph than who had not received on- job training. This finding is supported by the study conducted in West Showa zone Oromia Ethiopia, Addis Ababa city administration, Bale zone, East Gojjam zone, central Tigray zone, Easter Ethiopia, North Showa zone and Sidama zone [2, 9, 12, 14–17, 20]. On job trainings enhance knowledge; and improve attitude and skills which in turn increase partograph utilization.

Those obstetric care givers who had positive attitude towards partograph were three times more likely to utilize partograph than to their counterparts. This finding is consistent with a previous study done in North Showa Zone, Ethiopia [17]. The possible reason might be those who had good attitude toward the use of partograph might be committed to improve their skill in use.

Conclusion

This study revealed that the proportion of partograph utilization by the study participants was low according to Modified WHO partograph and previous studies. Being female obstetrics care giver, availability of partograph, having good knowledge about partograph, having on job training and having positive attitude of participants towards partograph were significantly associated with partograph utilization. Therefore, in this study, we suggest to Jigjiga and Degehabur town’s health offices for sustainable and accessible supply of partograph sheets to all institutions to maintain consistency of its utilization Providing periodic on-job training by stakeholders on partograph is also mandatory to improve knowledge and attitude of obstetric care givers towards partograph utilization. Partograph should be also used by obstetric care givers for all laboring women and taken seriously by the care givers and it should be considered as a tool for diagnosing problems, perform essential basic interventions and make referral to appropriate levels of care when necessary, during the progress of labour. Moreover, Further researchers have to be done using qualitative research methodology and on private health institutions to get a comprehensive picture.

Partograph SPSS file.

(RAR)

Click here for additional data file.

25 Aug 2021

PONE-D-21-20057

Partograph utilization and associated factors among obstetric care givers in governmental health institutions of Jigjiga and Degehabur towns, Somali region, Ethiopia: a cross-sectional study

PLOS ONE

Dear Dr. Ayehubizu,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Oct 07 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see:  http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at  https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Nülüfer Erbil, Ph.D, Prof.

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information

3. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

"Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.

We will update your Data Availability statement to reflect the information you provide in your cover letter

4. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

5. Thank you for submitting the above manuscript to PLOS ONE. During our internal evaluation of the manuscript, we found significant text overlap between your submission and the following previously published works, some of which you are an author.

-https://bmcresnotes.biomedcentral.com/articles/10.1186/s13104-018-3814-7

-https://www.hindawi.com/journals/jp/2020/3631808/

We would like to make you aware that copying extracts from previous publications, especially outside the methods section, word-for-word is unacceptable. In addition, the reproduction of text from published reports has implications for the copyright that may apply to the publications.

Please revise the manuscript to rephrase the duplicated text, cite your sources, and provide details as to how the current manuscript advances on previous work. Please note that further consideration is dependent on the submission of a manuscript that addresses these concerns about the overlap in text with published work. We will carefully review your manuscript upon resubmission, so please ensure that your revision is thorough.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This paper examined Partograph utilization and associated factors among obstetric care givers in

governmental health institutions of Jigjiga and Degehabur towns, Somali region,

Ethiopia. The background to the study was elaborated and gave specific reasons why Partograph utilization is important

I also found the approach and conclusions to be robust and useful. I do have little comments and suggestions.

Comments are attached in the manuscript

Reviewer #2: Dear Author,

I think your work will contribute to the literature. However, some corrections are needed. You can find my recommendations below.

I wish you good work…

1. Instead of “We aimed” in the abstract, “the purpose of study is…” should be written in a more academic language.

2. “In 2015 an estimated 303,000 women died because of pregnancy and childbirth-related complications.” If there is a more up-to-date statistic, it would be more appropriate to use it.

3. The problem description is well written.

4. “Study design and” and should be removed

5. study population

… Health professionals (Gynecologist and Obstetrician, students) and who did not attend labor cases were excluded from … this is not an exclusion criterion, it can be removed.

6. It is necessary to explain the sampling method with a more understandable and clear expression. In addition, it should be clearly stated how many people were included in the study in the Study Population.

7. “Semi - structured questionnaire which was developed from different literatures was used.” The sources used should be stated at the end of the sentence.

8. Ethics committee decision number should be attached.

9. Table 1 is in the wrong place in the text.

10. Sociodemographic findings should be Table 1 and the findings should be cited in parentheses accordingly. Table 2 should not be started.

11. Results- Socio-demographic characteristics of study participants –

Out of 235 study participants, 228… This section should be specified in the number of samples in the method.

12. In the findings, the sentence should not be started as “From 228 participants…”, a more academic language should be used.

13. In the findings, it is sufficient to write only the percentages instead of the frequencies. There should be no need to use parentheses.

14. In table 1 “Using partograph misleads management as the progress of labor and the partograph alert line are not aligned in most pregnant woman” percent sum is not 100. It should be corrected.

15. In the discussion section, first the findings of the study and then the findings in the literature should be included. Commentary sentences should be written after the studies are compared. The spelling of some sections is appropriate, but some require editing.

16. Suggestions should also be included in line with the results of the study. Missing suggestions should be added.

17. In Table 2: “List one complication” percent sum is not 100.

18. In the table titles, “N” should be written as “n” in lower case.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Dr. Angelina A. Joho

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: PONE-D-21-20057_reviewer-1.pdf

Click here for additional data file.

23 Sep 2021

Comments raised by both reviewers and editor are important to enrich this research article. Authors have also looked each comments and modified the document accordingly.

Submitted filename: Response to Editor & Reviewers.docx

Click here for additional data file.

8 Nov 2021

Submitted filename: Second review.pdf

Click here for additional data file.

23 Dec 2021

Response to Reviewer 1 comments:

Author should put space between words and also she/he should put all decimal points into two, this should be done in the whole document.

Response: I accepted and modified the document according to your comments.

Response to Reviewer 2 comments:

In the result section: In table 1 “Using partograph misleads management as the progress of labor and the partograph alert line are not aligned in most pregnant woman” percent sum is not 100. It should be corrected.

Response: It is found in table 3 of the manuscript and the percent sum is 100 %( 7+9.7+21.9+26.3+35.1=100)

There are two tables called Table 1.

Response: It was corrected.

Suggestion statements should be added in the recommendation section.

Response: We took some modification

In Table 2: “List one complication” percent sum is not 100.

Response: Corrected based on your comment accordingly

91.8+8.2=100

Table 3 should be written, instead of table 4.

Response: We put table 3 and table 4 based on their logical order.

In the table titles, “N” should be written as “n” in lower case

Response: It was corrected based on previous comment

Submitted filename: Response to Editor & Reviewers.docx

Click here for additional data file.

10 Feb 2022

Partograph utilization and associated factors among obstetric care givers in governmental health institutions of Jigjiga and Degehabur towns, Somali region, Ethiopia: a cross-sectional study

PONE-D-21-20057R2

Dear Dr. Ayehubizu,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Nülüfer Erbil, Ph.D, Prof.

Academic Editor

PLOS ONE

24 Feb 2022

PONE-D-21-20057R2

Partograph utilization and associated factors among obstetric care givers in governmental health institutions of Jigjiga and Degehabur towns, Somali region, Ethiopia: a cross-sectional study

Dear Dr. Ayehubizu:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Nülüfer Erbil

Academic Editor

PLOS ONE