BackgroundThe partograph (or partogram) is recommended by the World Health Organisation (WHO), for monitoring labour wellbeing and progress. Concerns about limitations in the way the partograph is used in the clinical context and the potential impact on its effectiveness have led to this realist systematic review of partograph use.MethodsThis review aimed to answer two key questions, 1) What is it about the partograph that works (or does not work); for whom does it work; and in what circumstances? 2) What are the essential inputs required for the partograph to work? A comprehensive search strategy encompassed key databases; including papers of varying methodologies. Papers were selected for inclusion if the focus of the paper was the partograph and related to context, mechanism or outcome. Ninety five papers were included for data synthesis. Two authors completed data extraction and synthesis.ResultsThe evidence synthesis relates the evidence to identified theories of health worker acceptability, health system support, effective referral systems, human resources and health worker competence, highlighting barriers and facilitators.ConclusionsThis first comprehensive realist synthesis of the partograph, provides the international community of maternity clinicians with a picture of potential issues and solutions related to successful labour recording and management, which is also translatable to other monitoring approaches.

Abstractobjectives To analyse the trend of loss to follow-up over time and identify factors associated with women being lost to follow-up after discharge in three fistula repair hospitals in Guinea.methods This retrospective cohort study used data extracted from medical records of fistula repairs conducted from 1 January 2007 to 30 September 2013. A woman was considered lost to follow-up if she did not return within 4 months post-discharge. Factors associated with loss to follow-up were identified using a subsample of the data covering the period 2010-2013.results Over the study period, the proportion of loss to follow-up was 21.5% (448/2080) and varied across repair hospitals and over time with an increase from 2% in 2009 to 52% in 2013.After adjusting for other variables in a multivariate logistic regression model, women who underwent surgery at Labe hospital and at Kissidougou hospital were more likely to be lost to follow-up than women operated at Jean Paul II hospital (OR: 50.6; 95% CI: 24.9-102.8) and (OR: 11.5; 95% CI: 6.1-22.0), respectively. Women with their fistula closed at hospital discharge (OR: 3.2; 95% CI: 2.1-4.8) and women admitted for repair in years 2011-2013 showed higher loss to follow-up as compared to 2010. Finally, loss to follow-up increased by 2& for each additional kilometre of distance a client lived from the repair hospital (OR: 1.002; 95% CI: 1.001-1.003).conclusion Reimbursement of transport was the likely reason for change over time of LTFU. Reducing geographical barriers to care for women with fistula could sustain fistula care positive outcomes.

Norplant is a long-acting contraceptive that has been introduced into family planning programs all over the world. Its efficacy, safety and acceptability in the introductory phases have been widely tested, and most studies point to the need for good provider training in insertion and removal; good client counseling on side effects, suitable client selection to limit early removal, and attention to client access to removal services. Some problems with the method in the developed world, and a belief that it is too costly for developing countries, have led to a waning of support by international donors. Few studies have examined how service delivery expansion in the developing world can minimise and address potential problems as well as maintain Norplant's cost-effective edge against other methods. We examine the expansion of Norplant services in Kenya between 1992 and 1996, specifically in relation to client access to services, removal issues, and cost. Well-supervised and careful expansion has resulted in quality services being provided at more than 70 sites in the country. Early removal is limited, removals seem to have posed few problems, and Norplant offers a welcome and cost-effective addition to the family planning method mix.

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