Effective labor management is crucial for improving maternal and neonatal outcomes. This is more important in low- and middle-income countries where the burden of maternal mortality is high. Globally it is estimated that 295,000 women died during pregnancy or following pregnancy complications arising during labor or delivery [1].  Timely identification of labor abnormalities is critical, and the partograph has long been recommended by the World Health Organization (WHO) as a vital tool in this regard [2]. Early detection of labor abnormalities is important and the partograph has been recommended by the World Health Organization (WHO) as an essential tool in this regard [2]. The WHO partograph is a graphical record of key labor parameters. This includes cervical dilatation, fetal heart rate, uterine contractions, and maternal vital signs. The WHO partograph was first introduced in 1970 and was then revised in 2000 to the so-called modified version. This tool assists healthcare workers in tracking the progress of labor and identifying complicated cases of long and obstructed labor in time and, therefore, refer or handle the issue in a timely manner [3]. Although its effectiveness in decreasing maternal and perinatal morbidity has been demonstrated, research has identified issues related to its practical application such as time-consuming, lack of training, documentation failure, and non-compliance particularly where there is an overburden [4, 5].

To overcome these challenges and support digital health initiatives, a paperless partograph, which is an electronic version integrated into mobile devices and hospital information systems, has been developed. This innovation was developed to overcome the limitations of the traditional paper-based partograph. It provides real-time monitoring, accuracy, ease of use, and timely alerts for deviations in labor progression [6]. Mobile-based applications have demonstrated promising results in initial studies by increasing partograph completeness, compliance, and early decision-making [7]. Few studies comparing electronic and manual partograph systems have reported increased consistency of data entry and accurate assessment of labor and response by users of digital sensors [8]. In addition, the implementation of the paperless partograph supports the international trend of the digitalization of health processes included in the Global Strategy on Digital Health 2020-2025 developed by the WHO [9]. Nevertheless, there is little clinical evidence of the empirical comparison between the paperless partograph and the modified WHO partograph regarding clinical outcomes, user efficiency, and acceptability despite its potential. Hence, this study aimed to conduct a comparative analysis of the paperless partograph and modified WHO partograph in the management of labor.

This was a prospective, comparative study conducted in the Department of Obstetrics and Gynecology at a tertiary care teaching hospital over a period of 12 months. Institutional Ethical approval was obtained for the study. Written consent was obtained from all the participants of the study after explaining the nature of the study in vernacular language.

Inclusion criteria

1. Pregnant females in active labor (≥4 cm cervical dilatation) with singleton term pregnancies and cephalic presentation.
2. Low-risk parturients
3. Aged between 18–35 years with spontaneous onset of labor.
4. Voluntarily willing to participate in the study

Exclusion criteria

1. Women with known obstetric complications such as preeclampsia,
2. eclampsia,
3. antepartum hemorrhage, or
4. multiple gestations were excluded.

Sample Size: A total of 200 women were recruited and randomly allocated into two equal groups:

• Group A: Labor monitored using the paperless partograph (n = 100)
• Group B: Labor monitored using the modified WHO partograph (n = 100)
• Randomization was done using a computer-generated random number table.

In Group A, labor was monitored using a validated mobile/tablet-based paperless partograph application that automatically plotted cervical dilatation, fetal heart rate, uterine contractions, and maternal vitals, and provided real-time alerts for deviation from expected labor progress. In Group B, monitoring was performed using the traditional WHO-modified partograph with manual entries at regular intervals.

Data collected included maternal demographic details, obstetric history, time of onset of active labor, frequency of monitoring, mode of delivery, duration of labor, and neonatal outcomes (Apgar scores at 1 and 5 minutes, NICU admission). User-related parameters such as time taken for documentation, completeness of entries, and ease of use were also recorded through feedback questionnaires completed by trained staff.

Primary outcomes:

1. Duration of the active phase of labor
2. Mode of delivery (spontaneous vaginal delivery, instrumental, or cesarean section)
3. Neonatal outcomes (Apgar score, NICU admission)

Secondary outcomes:

1. Completeness and accuracy of documentation
2. Time taken per entry
3. User satisfaction and ease of use (assessed via a 5-point Likert scale)

Statistical Analysis: All the available data was segregated, refined, and uploaded to an MS Excel spreadsheet and analyzed by SPSS version 25 in Windows format. The continuous data was represented as mean, standard deviation, frequency, and percentage. Categorical variables were analyzed using the student’s t-test for comparison of mean values. The chi-square test was used to compare the differences between the two groups. A p-value of <0.05 was considered statistically significant.

The baseline characteristics of the study participants in depicted in Table 1. The analysis of the table shows that the mean maternal age of 26.4 ± 4.2 years in the paperless group and 27.1 ± 4.5 years in the modified WHO partograph group and the p values were not significant (p=0.28). Similarly, the gestational age, parity status, and cervical dilatation on enrolment including BMI were distributed between the two groups. Although the incidence of nulliparous women in the paperless group was 62% and in the WHO group was 58% the p values were not found to be significant. These findings show that the two groups were homogeneous in maternal profiles, therefore, minimizing confounding variables.

The labor outcomes and mode of delivery are depicted in Table 2. The active labor was considerably shortened in the paperless partograph group (5.2 ± 1.4 hrs) than in the modified WHO group (6.8 ± 1.9 hrs p<0.001). Spontaneous vaginal birth was more common in the paperless group (78%) than in the WHO group (65%, p=0.04). The rates of cesarean sections were considerably reduced in the paperless group (14 %) than in the WHO group (23%, p=0.03). The number of instrumental births was also lower in the paper-free group but had no statistically significant differences between the groups. These results show that the digital tool contributed significantly to improving labor efficiency and decreasing surgical interventions.

            *Significant

The neonatal outcome in the cases of the study is given in Table 3. Minute and 5-minute Apgar scores were significantly higher among newborns of the paperless partograph group (7.9 vs. 7.5, p=0.001 and 8.8 vs. 8.6, p=0.02, respectively). Fewer neonates in this group showed an Apgar score of less than 7 at the 5-minute mark (2% vs. 7%) which was not significant (p=0.09). Admissions to NICU were reduced greatly in the paperless group (5%) than in the WHO group (11%, p=0.046). There were similar birth weights in the groups. This result indicates that the neonatal outcomes are better under the use of the paperless system; this is probably because labor complications are detected earlier and this labor problem is intervened early.

                           *Significant

Table 4 shows the comparison quality of documentation and efficiency in two groups of the study. The quality of documentation was found to be significantly better in the paperless partograph, with 98.7% of documentation completeness compared with 85.2% in the modified WHO group (p<0.001). Digital group spent less time on individual entry (1.5 vs. 3.8 minutes, p<0.001) and much faster alerts were identified (8.2 vs. 22.5 minutes, p<0.001). Major omission was much lower in paper less group (3% vs. 17% p=0.001). These findings imply that the electronic system improves the reliability of data and response time in monitoring labor.

            *Significant

The estimation of user satisfaction on the Likert Scale is presented in Table 5. A critical analysis of the table shows that there was significantly higher satisfaction with the paperless partograph. Ease of use (4.6 vs. 3.2), time efficiency (4.7 vs. 2.8), alert effectiveness (4.5 vs. 3.5), and overall satisfaction (4.6 vs. 3.3) were all significantly higher in the digital group (p<0.001 for all). Additionally, 97% of users would recommend the paperless system compared to 68% in the traditional group (p<0.001). This reflects high usability, efficiency, and acceptance of the digital tool among healthcare providers.

  *Significant

In this study, the paperless partograph was compared with the modified partograph of the WHO for monitoring labor, resulting in considerable clinical, operational, and user-oriented benefits of the digital solution. The results of this study prove that the paperless partograph not only enhanced the outcomes of labor but also the quality of documentation, lessened time pressure, and increased provider satisfaction. The duration of active labor was considerably decreased in the paperless group (5.2 vs. 6.8 hours), probably due to on-time alerts and interventions provided by the digital system. This corresponds to the findings of other studies that demonstrated that electronic partographs helped in early labor anomaly recognition and an early applied clinical decision-making process [6, 8].

Moreover, the digital group had a higher number of spontaneous vaginal births (78% vs. 65%) and a lower incidence of cesarean sections (14% vs. 23%), indicating that effective monitoring led to better control of the labor process, avoiding unnecessary surgical interventions. These results concur with the findings of the global recommendations that improving intrapartum care processes can directly reduce cesarean delivery rates and their associated risks [10, 11]. The digital group also had a positive trend in neonatal outcomes. The higher 1- and 5-minute Apgar outcomes coupled with a decrease in NICU admissions indicate improved fetal monitoring and prompt obstetrical interventions. Although the difference in the number of neonates with Apgar <7 at 5 min was not significant, the general trend favors the paperless system. These results are in line with those readings that indicate better neonatal outcomes as a result of the effective use of electronic partographs [7, 12].

Operationally, the paperless partograph displayed remarkable advancements in documentation quality and effectiveness. The rate of entries entered was more efficient and complete (98.7% to 85.2%), spent less time per entry (1.5 to 3.8 minutes), and had fewer vital omissions. These metrics are important in overburdened labor wards, where documentation errors and delays can compromise care. Studies in this field have shown that digital partographs enhance compliance and accuracy compared to manual methods [4, 5]. In addition to this, real-time alerting (shorter times of recognition 8.2 vs. 22.5 minutes) also highlights the usefulness of the digital form in enhancing clinical responsiveness.

The paperless system also justified the overall user satisfaction scores. The digital group scored higher than the WHO group in terms of ease of usage, time efficiency, effectiveness of the alert, and satisfaction. It was notable that the digital system was also rated highly among the users with 97 percent saying they would recommend it. This evidence brings out expanded awareness and adoption of digital health tools by healthcare professionals in cases where tools are easy to adopt and integrated into the workflow [13].

Despite these favorable results, the implementation remains a challenge because of its initial setup costs, training requirements as well as infrastructure limitations in low-resource settings. However, as the WHO's Global strategy on digital health 2020-2025 emphasizes digital innovations are a must for harnessing and strengthening healthcare systems and this could lead to improvement in maternal and neonatal outcomes [9, 14, 15]. In the end, the paperless partograph demonstrated its superiority over the modified WHO partograph in labor monitoring. These were apparent from improved labor outcomes, better neonatal indicators, and higher user satisfaction.

The study showed that there are major benefits of the paperless partograph over those of the modified WHO partograph in the management of labor. The digital tool was associated with a reduced length of labor, higher prevalence of spontaneous vaginal birth, better neonatal outcomes, and fewer posts throughout the cesarean deliveries. It also improved documentation quality, decreased the time spent on an entry, and increased satisfaction ratings among healthcare providers. These results justify the integration of digital partographs as an effective, efficient, and convenient substitute for paper-based tools. Widespread adoption with appropriate training and infrastructure can significantly improve intrapartum care and maternal-neonatal health outcomes.

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