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A. Jagau*, S Fawcus**, S Crede*, D Woods*, J Wyatt*, R. Maughan-Brown*, JE Lawn*, ***

*Powerfree Education and Technology

** Associate Professor, Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Cape Town

*** Save the Children

Background The fourth Millennium Development Goal (MDG) aims to reduce the number of children who die under the age of five. Currently, 43% (3.1 million) of all child deaths worldwide occur under 28 days of age. The most common cause of neonatal death is complications of preterm birth. Intrapartum related events (“birth asphyxia”) in term infants is ranked second. Good intrapartum care, with partograph use and correct fetal heart rate monitoring (FHRM) can reduce both intrapartum and neonatal mortality and morbidity. This study aimed to investigate midwives’ knowledge, attitudes and current practises regarding fetal heart rate monitoring and partograph use.


The study took place at Mowbray Maternity Hospital (MMH) which is a referral hospital providing public maternal and neonatal services to a designated drainage region. Each month there are over 800 births at MMH of which 300 are by Caesarean section. Interviews were done in February 2013. All midwives who work in a labour ward in MMH were eligible for inclusion in the study. Midwives who had never worked at a labour ward were understandably excluded. All midwives who met the inclusion criteria had the option to decline participation.

The study was approved by the ethics committees of the University of Cape Town and of MMH (approval number HREC 555/2012). All midwives who participated in interviews, focus groups and knowledge assessments signed an informed consent form.

In depth interviews and a knowledge assessment were used. After completion of the in-depth interview, the midwives were asked to fill out a theory assessment. This consisted of a case study and 15 multiple choice questions on FHRM.

A questionnaire with open-ended questions was prepared to investigate the FHRM knowledge, attitudes and reported practises of experienced midwives and junior midwives. This knowledge is crucial in order to better understand the enablers and barriers to optimal fetal monitoring. The midwives that participated in these interviews also completed a knowledge assessment that was comprised of a case study and multiple choice questions. One trained counsellor midwife conducted and facilitated all of the interviews and focus groups.

The in-depth interviews and focus group conversations were recorded and transcribed. Themes and patterns in the transcripts were identified and organised into categories. Patterns within and between the different categories were found and these findings were used to reach an overall interpretation of the results. The written theory assessments were marked, and the participants’ scores were compared.


In depth interviews

Fourteen midwives from MMH were interviewed individually and 14 midwives participated in two separate focus groups. The midwives were randomly assigned for individual interviews or focus groups. Some were interviewed both individually and in the focus groups. In total 24 different midwives took part in the interviews. The focus group midwives were divided in two groups: midwives with several years of work experience, and junior midwives who had started working a month before recruitment took place.

Attitude towards fetal monitoring

Midwives were asked for their thoughts on fetal heart rate monitoring. All participants viewed it as a necessary and important part of their responsibility:

“…I feel that it is something that should be done, you can save a baby’s life. It is not just the baby that dies, if the baby dies it also affects the mom and the family. So it is very important…”

Most answers showed an understanding of the urgency of fetal heart rate monitoring due to the tenuous nature of labour and delivery. A mother can be low-risk the one moment and high-risk and in need of special care the next moment:

“… If we don’t look after the fetal heart and it goes in distress and you don’t pick it up, the baby will die. It is irresponsible to not look after the fetal heart. Basically the most important thing you need to do is monitoring because you want a good outcome from labour. A healthy baby and happy mother…”

Feeling capable

Training regarding fetal heart rate monitoring does not get the attention it deserves according to the junior midwives. As a result, our sample of junior midwives indicated that they do not feel confident when they need to monitor a fetus:

“…I feel that I am not very confident. It is because I do not really want to ask, when there is someone higher I will ask but I am scared. I feel that we need more training. Now I know what can go wrong, but I do not know how to respond to it…”

The experienced midwives said that their knowledge was not really a problem; they felt confident. However, they indicated that they did not always use their knowledge and relied on the CTG too much. They acknowledged that it is not just about picking up abnormalities but also responding to them:

“…I think that is the problem, it is not that the people can’t interpret in my opinion, I just think we don’t do it because of the CTG, it gives you this sense of security. If you are busy with a delivery… lots of things may have happened but you were just not there to do something. It is not that you cannot pick it up, it is just that you did not get to it… Then continues CTG does not make sense, you need to be able to respond…”

Partograph use

A partograph is supposed to be used in every labour according to standard practise procedures to safeguard healthy labour outcomes for both mother and child. The midwives in our sample agreed that it is important:

“…if you did not write it down, that means you did not do it. Even if you actually did it, there is no proof. You need to record it somewhere....”

However, our partograph assessment showed that not all the labours were monitored with a partograph. When a partograph was used, it often was not used correctly. Most midwives, especially the junior midwives, confessed that they do not always know how to use the partograph correctly:

“…It looks to me as if everybody does a little bit of their own thing and it makes it more confusing. I think the staff must be taught more on how to use the program, more training. Students and staff, the new staff so that everybody does the same…”

The junior midwives said that the midwifery training did not prepare them to do fetal heart rate monitoring and to use the partograph well:

“…When I started here in the hospital it was actually the first time that I got to know it step by step. As a student I made up my own stuff and I just went along as I saw other people doing it. I feel a bit more confident now because of the lectures we got when we started here…”

Even the experienced midwives admitted that they do not always feel confident using the partograph:

“…The partograph has always been the dark horse in maternity. I think many people feel insecure about it, not confident to fill it out, it has always been there but I think there are people who never properly got trained. It was just assumed that they worked with it. You know, they are actually a bit scared because if I damage the patient you need to examine well, if your name is on there, you are responsible, so the nurses wait for the doctors to fill it out when things are not all that well…”

The midwives all agree that they are very busy and often do not have time to write down their observations:

“… Time is an issue, you make the observations but you don’t record it. It is sad because a well filled out partograph can be a very good tool to help you monitor progression of labour. But it could be more useful if we had more staff and time… “


The biggest barrier to good monitoring was reported to be inadequate staffing. Nearly every midwife said that there needs to be more staff in order to monitor better:

“…Staffing is an issue. Every patient should get every half an hour. We compromise, try to do every hour… It makes you feel guilty because things you are supposed to do, do not happen… Nobody gets the care they deserve…”

“…You can’t just listen to everybody in half an hour and then you feel bad. I think sometimes people get a CS or get advised to have one because we are not sure about the FHR and we know we can only check again in an hour. So it would be better if we had more staff and more time per patient…”

Preferred device

Most of the interviewed midwives had experience with all the three different devices that can be used for FHRM; the PFS, the dFHRM, and the CTG. The majority of the midwives said that they preferred the CTG, but that the dFHRM was a good alternative. They explained their preference for the CTG on the fact that it is very busy at the labour ward so the midwives often do not have time to go to a patient. At least they have a trace of what happened when the mother is connected to the CTG:

“… I prefer CTG, because at least it is there if you are not there. After that the Doptone (dFHRM)... Mobilization is a good thing, it is better for the mothers. CTG is easy for the midwife, but not best practice I think in the way we use it. In low risk we should do intermittent monitoring…”

However, midwives all agreed on which device the mothers preferred. They say that the mothers would choose the dFHRM because it is more gentle than the PFS, and the intermittent monitoring gives the mothers the freedom to be mobile during labour, which they do not have when monitored with a CTG:

“…Mothers prefer the doptone, with the intermittent monitoring. They do not want to be strapped to their bed. Some mothers also believe that the straps from the CTG causes the pains they have. They also like hearing the (baby’s) heart, it encourages them…”

Knowledge assessment

Twenty-four midwives participated in the knowledge assessment. Eleven of them were junior midwives, who had graduated within the last six months and only had one month work experience. The 13 other midwives had between three and 26 years of experience. The junior midwives had a median score of 45% correct, while the experienced midwives scored 75% correct.

Table 1 Results of the knowledge assessment

Multiple choice

Case study


Junior midwives

median score




Experienced midwives

median score




In the multiple choice section of the knowledge assessment, eight questions were related to theory and seven questions were about responding to observations and practise. The junior midwives scored reasonably well (60%) for the theory but were lacking in practical knowledge (48%) compared to the experience midwives (76% for theory knowledge, 72% for practical knowledge).

Discussion and conclusion

Midwives are motivated to provide good intrapartum care. However, they feel that time, lack of staff and inadequate equipment are barriers that stand in the way of doing this well. Junior midwives feel that the pre-service training does not prepare them for the work they are supposed to do while their knowledge of care in labour was often lacking. Partograph use was not optimal while the CTG was often not closely monitored. These findings indicate that changes need to be made to both pre-service and in-service training to enable midwives to provide quality care.


We thank the midwives and support staff of Mowbray Maternity Hospital for their helpfulness in the data collecting process.

We thank the Laerdal Foundation for providing financial support for this study. The funding agency was independent from the study design, data collection, and data analysis

William P. Fifer (Columbia University), Lisa Ecklund-Flores (Mercy College), Hein Odendaal (Stellenbosch University), Julia Zavala Columbia University), Albany Perez (Columbia University)
Maternal depression during pregnancy has a significant impact on perinatal development. Growing numbers of studies document the prevalence of depression during pregnancy among disparity groups.  In this study, the relationship between maternal depression during pregnancy, resting maternal heart rate and heart rate variability, and neonatal birth weight was compared, and the role of SES (income) in these relationships was explored.  

197 pregnant women were recruited from Columbia University Medical Center. These women met exclusion criteria of no gestational diabetes, hypertension, or other related medical conditions, and no cigarette, alcohol, illicit or prescription drug use during pregnancy.  Testing took place at 36 weeks gestation. Mean age of mothers was 26.3 years (±6.3 SD ).  All were low risk, full term pregnancies.  Neonatal birth weight was adjusted for gestational age and gender.  Subsequently, adjusted heart rate, adjusted heart rate variability and adjusted birth weight values, as well as income, were analysed to determine the nature of the relationships. 


34% of pregnant mothers measured depressed on the CES-D (CESD≥16).  Mean resting heart rate for all pregnant mothers was 89.95 bpm (±10.83).  When depressed vs. non-depressed were compared, depressed pregnant mothers had significantly higher heart rate (93.17 bpm±10.54 vs. 88.16 bpm±10.78) [p=.002].  Beat-to-beat heart rate variability (RMSSD) for all pregnant mothers was 23.09 (±14.69).  When depressed vs. non-depressed pregnant women were compared, those meeting the criteria for depression had significantly lower heart rate variability (19.16±12.48 vs. 25.22±15.31) [p=.005].  Comparison of birth weight revealed that the babies from the group with higher levels of depressive symptoms had higher birth weights (3810g±404 vs. 3193g± 440) [p<.001].

Mediation procedures (Baron and Kenny, 1986; Preacher & Hayes, 2004) were used to explore the relationships between these variables in a series of regression analyses.  Maternal heart rate was found to be the strongest predictor of neonatal birth weight [p=.004].  Higher heart rates resulted in higher birth weights.  Maternal heart rate variability was found to have the strongest direct effect on maternal heart rate [p<.0001].  Lower heart rate variability resulted in higher heart rates.  Income [p=.002] and depression [p=.05] were both found to be significant mediators of maternal heart rate variability.  Lower levels of income and higher levels of depression resulted in lower heart rate variability and higher heart rate.  Income was a significant predictor of depression [p=.005].  Lower income resulted in significantly greater depression.

Economic disparity has a significant impact on mood and physiology.  In the case of pregnant women, the physiological effects of depression impact the neonate.  While higher birth weight may serve as a protective mechanism during labour and delivery, it puts the infant at higher risk for SIDS and other neurodevelopmental disorders.

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