Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Tina Lavender; Anna Cuthbert; Rebecca MD Smyth

doi:10.1002/14651858.CD005461.pub5

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Figure 1

Modified partograph

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Figure 2

Study flow diagram.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 1 Caesarean section (overall).

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Analysis 1.2

Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 2 Oxytocin augmentation.

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Analysis 1.3

Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 3 Duration of first stage of labour.

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Analysis 1.4

Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 4 Low Apgar score (less than 7 at 5 minutes).

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Analysis 1.5

Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 5 Instrumental vaginal birth.

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Analysis 1.6

Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 6 Regional analgesia ‐ epidural.

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Analysis 1.7

Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 7 Performance of artificial rupture of membranes during labour.

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Analysis 1.8

Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 8 Antibiotic use.

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Analysis 1.9

Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 9 Duration of second stage of labour (hours).

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Analysis 1.10

Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 10 Number of vaginal examinations.

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Analysis 1.11

Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 11 Admission to special care nursery.

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Analysis 2.1

Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 1 Caesarean section (overall).

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Analysis 2.2

Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 2 Oxytocin augmentation.

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Analysis 2.3

Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 3 Duration of first stage of labour (length of labour greater than 18 hours, length of labour greater than 12 hours).

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Analysis 2.4

Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 4 Maternal experience of childbirth ‐ negative childbirth experience.

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Analysis 2.5

Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 5 Low Apgar score (less than 7 at 5 minutes).

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Analysis 2.6

Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 6 Serious maternal morbidity or death.

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Analysis 2.7

Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 7 Caesarean section (distress).

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Analysis 2.8

Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 8 Caesarean section (delay).

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Analysis 2.9

Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 9 Instrumental vaginal delivery.

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Analysis 2.10

Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 10 Postpartum haemorrhage ‐ blood loss > 500 mL.

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Analysis 2.11

Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 11 Regional analgesia ‐ epidural.

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Analysis 2.12

Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 12 Performance of artificial rupture of the membranes during labour.

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Analysis 2.13

Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 13 Number of vaginal examinations in labour.

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Analysis 2.14

Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 14 Serious neonatal morbidity or perinatal death.

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Analysis 2.15

Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 15 Admission to special care nursery.

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Analysis 2.16

Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 16 Cord blood arterial pH less than 7.1.

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Analysis 3.1

Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 1 Caesarean section (overall).

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Analysis 3.2

Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 2 Oxytocin augmentation.

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Analysis 3.3

Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 3 Maternal experience of childbirth ‐ negative childbirth experience.

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Analysis 3.4

Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 4 Low Apgar score (less than 7 at 5 minutes).

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Analysis 3.5

Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 5 Serious maternal morbidity or death.

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Analysis 3.6

Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 6 Caesarean section (distress).

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Analysis 3.7

Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 7 Caesarean section (delay).

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Analysis 3.8

Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 8 Instrumental vaginal delivery.

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Analysis 3.9

Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 9 Postpartum haemorrhage ‐ blood loss > 500 mL.

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Analysis 3.10

Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 10 Regional analgesia ‐ epidural.

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Analysis 3.11

Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 11 Performance of artificial rupture of membranes during labour.

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Analysis 3.12

Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 12 Vaginal examinations.

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Analysis 3.13

Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 13 Serious neonatal morbidity or perinatal death.

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Analysis 3.14

Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 14 Admission to special care nursery.

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Analysis 3.15

Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 15 Cord blood arterial pH less than 7.1.

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Analysis 4.1

Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 1 Caesarean section (overall).

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Analysis 4.2

Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 2 Oxytocin augmentation.

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Analysis 4.3

Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 3 Maternal experience of childbirth ‐ negative childbirth experience.

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Analysis 4.4

Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 4 Low Apgar score (less than 7 at 5 minutes).

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Analysis 4.5

Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 5 Serious maternal morbidity or death.

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Analysis 4.6

Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 6 Caesarean section (distress).

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Analysis 4.7

Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 7 Caesarean section (delay).

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Analysis 4.8

Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 8 Instrumental vaginal delivery.

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Analysis 4.9

Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 9 Postpartum haemorrhage ‐ blood loss > 500 mL.

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Analysis 4.10

Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 10 Regional analgesia ‐ epidural.

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Analysis 4.11

Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 11 Performance of artificial rupture of membranes during labour.

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Analysis 4.12

Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 12 Number of vaginal examinations in labour.

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Analysis 4.13

Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 13 Serious neonatal morbidity or perinatal death.

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Analysis 4.14

Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 14 Admission to special care nursery.

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Analysis 4.15

Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 15 Cord blood arterial pH less than 7.1.

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Analysis 5.1

Comparison 5 Partograph with alert line only versus partograph with alert and action line (study carried out in a low‐resource setting), Outcome 1 Caesarean section (overall).

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Analysis 5.2

Comparison 5 Partograph with alert line only versus partograph with alert and action line (study carried out in a low‐resource setting), Outcome 2 Oxytocin augmentation.

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Analysis 5.3

Comparison 5 Partograph with alert line only versus partograph with alert and action line (study carried out in a low‐resource setting), Outcome 3 Low Apgar score (less than 7 at 5 minutes).

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Analysis 5.4

Comparison 5 Partograph with alert line only versus partograph with alert and action line (study carried out in a low‐resource setting), Outcome 4 Instrumental vaginal delivery.

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Analysis 5.5

Comparison 5 Partograph with alert line only versus partograph with alert and action line (study carried out in a low‐resource setting), Outcome 5 Serious neonatal morbidity or perinatal death.

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Analysis 6.1

Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low‐resource setting), Outcome 1 Caesarean section (overall).

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Analysis 6.2

Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low‐resource setting), Outcome 2 Oxytocin augmentation.

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Analysis 6.3

Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low‐resource setting), Outcome 3 Low Apgar score (less than 7 at 5 minutes).

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Analysis 6.4

Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low‐resource setting), Outcome 4 Caesarean section (distress).

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Analysis 6.5

Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low‐resource setting), Outcome 5 Caesarean section (delay).

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Analysis 6.6

Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low‐resource setting), Outcome 6 Instrumental vaginal delivery.

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Analysis 6.7

Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low‐resource setting), Outcome 7 Admission to special care nursery.

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Analysis 6.8

Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low‐resource setting), Outcome 8 Usability: user‐friendliness score.

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Analysis 7.1

Comparison 7 Partograph with 2‐hour action line versus partograph with stepped dystocia line, Outcome 1 Caesarean section.

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Analysis 7.2

Comparison 7 Partograph with 2‐hour action line versus partograph with stepped dystocia line, Outcome 2 Oxytocin augmentation.

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Analysis 7.3

Comparison 7 Partograph with 2‐hour action line versus partograph with stepped dystocia line, Outcome 3 Duration of first stage of labour (labour longer than 12 hours).

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Analysis 7.4

Comparison 7 Partograph with 2‐hour action line versus partograph with stepped dystocia line, Outcome 4 Maternal experience of childbirth (BSS‐R score).

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Analysis 7.5

Comparison 7 Partograph with 2‐hour action line versus partograph with stepped dystocia line, Outcome 5 Low Apgar score (less than 4 at 4 min).

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Analysis 7.6

Comparison 7 Partograph with 2‐hour action line versus partograph with stepped dystocia line, Outcome 6 Instrumental vaginal birth.

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Analysis 7.7

Comparison 7 Partograph with 2‐hour action line versus partograph with stepped dystocia line, Outcome 7 Postpartum haemorrhage (> 500 mL).

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Analysis 7.8

Comparison 7 Partograph with 2‐hour action line versus partograph with stepped dystocia line, Outcome 8 Regional analgesia.

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Analysis 7.9

Comparison 7 Partograph with 2‐hour action line versus partograph with stepped dystocia line, Outcome 9 Opioid use.

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Analysis 7.10

Comparison 7 Partograph with 2‐hour action line versus partograph with stepped dystocia line, Outcome 10 Need for intubation at birth.

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Analysis 8.1

Comparison 8 Partograph versus labour scale (study carried out in a low‐resource setting), Outcome 1 Caesarean section (overall).

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Analysis 8.2

Comparison 8 Partograph versus labour scale (study carried out in a low‐resource setting), Outcome 2 Oxytocin augmentation.

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Analysis 8.3

Comparison 8 Partograph versus labour scale (study carried out in a low‐resource setting), Outcome 3 Duration of first stage of labour.

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Analysis 8.4

Comparison 8 Partograph versus labour scale (study carried out in a low‐resource setting), Outcome 4 Low Apgar score (less than 7 at 5 minutes).

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Analysis 8.5

Comparison 8 Partograph versus labour scale (study carried out in a low‐resource setting), Outcome 5 Caesarean section (delay).

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Analysis 8.6

Comparison 8 Partograph versus labour scale (study carried out in a low‐resource setting), Outcome 6 Stillbirth, neonatal death or neonatal morbidity.

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Analysis 8.7

Comparison 8 Partograph versus labour scale (study carried out in a low‐resource setting), Outcome 7 Birth injuries and PPH (non‐prespecified outcome).

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Summary of findings for the main comparison. Partograph compared to no partograph (studies carried out in high‐ and low‐resource settings) for women in spontaneous labour at term

Partograph compared to no partograph (studies carried out in high‐ and low‐resource settings) for women in spontaneous labour at term
Patient or population: women in spontaneous labour at term Setting: hospital settings in Canada, India, and Mexico Intervention: partograph Comparison: no partograph (studies carried out in high‐ and low‐resource settings)
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with no partograph (studies carried out in high‐ and low‐resource settings)	Risk with partograph
Caesarean section (overall)	Study population		Average RR 0.77 (0.40 to 1.46)	1813 (3 RCTs)	⊕⊝⊝⊝ VERY LOW ^{a b c}
	214 per 1000	164 per 1000 (85 to 312)
Oxytocin augmentation	Study population		RR 1.02 (0.95 to 1.10)	1156 (1 RCT)	⊕⊕⊕⊝ MODERATE ^d
	715 per 1000	730 per 1000 (680 to 787)
Duration of first stage of labour	The mean duration of first stage of labour was 16 hours (SD 7.6)	The mean duration of first stage of labour was 16.8 hours (SD 7.3)	In the partograph group, mean duration of first stage was 0.80 hours longer (0.06 hours shorter to 1.66 hours longer)	1156 (1 RCT)	⊕⊕⊝⊝ LOW ^{c d}
Maternal experience of childbirth (as defined by trial authors)	Study population		‐	(0 study)	‐	No trials reported this outcome.
	See comment	See comment
Apgar score less than 7 at 5 minutes	Study population		RR 0.76 (0.29 to 2.03)	1596 (2 RCTs)	⊕⊝⊝⊝ VERY LOW ^{e f g}
	11 per 1000	9 per 1000 (3 to 24)
Serious maternal morbidity or death (e.g. ruptured uterus, admission to intensive care unit, septicaemia, organ failure)	Study population		‐	(0 study)	‐	No trials reported this outcome.
	See comment	See comment
Stillbirth or neonatal death or neonatal morbidity, excluding fatal malformations (e.g. seizures, birth asphyxia, neonatal encephalopathy)	Study population		‐	(0 study)	‐	No trials reported this outcome.
	See comment	See comment
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio; SD: standard deviation.
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect
^aTwo out of three studies have design limitations, serious design limitations less than 40% of pooled effect (‐1). ^bSevere heterogeneity > 60% (‐1). ^cWide confidence intervals crossing the line of no effect (‐1). ^dOne trial included which only included low‐risk women (‐1). ^eOne study with serious design limitations but only contributes 17% to pooled analysis (not downgraded). ^fStudies only included term, low risk women (‐1). ^gWide confidence intervals crossing the line of no effect and few events (‐2).

Summary of findings for the main comparison. Partograph compared to no partograph (studies carried out in high‐ and low‐resource settings) for women in spontaneous labour at term

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Comparison 1. Partograph versus no partograph (studies carried out in high‐ and low‐resource settings)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Caesarean section (overall) Show forest plot	3	1813	Risk Ratio (M‐H, Random, 95% CI)	0.77 [0.40, 1.46]

1.1 Low‐resource setting	2	657	Risk Ratio (M‐H, Random, 95% CI)	0.65 [0.22, 1.91]
1.2 High‐resource setting	1	1156	Risk Ratio (M‐H, Random, 95% CI)	1.03 [0.82, 1.28]
2 Oxytocin augmentation Show forest plot	1	1156	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.95, 1.10]

2.1 High‐resource setting	1	1156	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.95, 1.10]
3 Duration of first stage of labour Show forest plot	1	1156	Mean Difference (IV, Fixed, 95% CI)	0.80 [‐0.06, 1.66]

3.1 High‐resource setting	1	1156	Mean Difference (IV, Fixed, 95% CI)	0.80 [‐0.06, 1.66]
4 Low Apgar score (less than 7 at 5 minutes) Show forest plot	2	1596	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.29, 2.03]

4.1 Low‐resource setting	1	440	Risk Ratio (M‐H, Fixed, 95% CI)	0.46 [0.04, 5.00]
4.2 High‐resource setting	1	1156	Risk Ratio (M‐H, Fixed, 95% CI)	0.85 [0.29, 2.52]
5 Instrumental vaginal birth Show forest plot	3	1813	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.84, 1.15]

5.1 Low‐resource setting	2	657	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.75, 1.48]
5.2 High‐resource setting	1	1156	Risk Ratio (M‐H, Fixed, 95% CI)	0.97 [0.81, 1.15]
6 Regional analgesia ‐ epidural Show forest plot	1	1156	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.98, 1.05]

6.1 High‐resource setting	1	1156	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.98, 1.05]
7 Performance of artificial rupture of membranes during labour Show forest plot	1	1156	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.88, 1.11]

7.1 High‐resource setting	1	1156	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.88, 1.11]
8 Antibiotic use Show forest plot	1	1156	Risk Ratio (M‐H, Fixed, 95% CI)	1.23 [0.88, 1.73]

8.1 High‐resource setting	1	1156	Risk Ratio (M‐H, Fixed, 95% CI)	1.23 [0.88, 1.73]
9 Duration of second stage of labour (hours) Show forest plot	1	1156	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.21, 0.21]

9.1 High‐resource setting	1	1156	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.21, 0.21]
10 Number of vaginal examinations Show forest plot	1	1156	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

10.1 High‐resource setting	1	1156	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Admission to special care nursery Show forest plot	1	1156	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.51, 1.75]

11.1 High‐resource setting	1	1156	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.51, 1.75]

Comparison 1. Partograph versus no partograph (studies carried out in high‐ and low‐resource settings)

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Comparison 2. Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Caesarean section (overall) Show forest plot	4	4749	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.88, 1.28]

1.1 Low‐resource setting	2	1148	Risk Ratio (M‐H, Fixed, 95% CI)	1.09 [0.71, 1.68]
1.2 High‐resource setting	2	3601	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.86, 1.30]
2 Oxytocin augmentation Show forest plot	4	4749	Risk Ratio (M‐H, Random, 95% CI)	2.44 [1.36, 4.35]

2.1 Low‐resource setting	2	1148	Risk Ratio (M‐H, Random, 95% CI)	7.22 [2.49, 20.91]
2.2 High‐resource setting	2	3601	Risk Ratio (M‐H, Random, 95% CI)	1.14 [1.05, 1.22]
3 Duration of first stage of labour (length of labour greater than 18 hours, length of labour greater than 12 hours) Show forest plot	1	948	Risk Ratio (M‐H, Fixed, 95% CI)	0.81 [0.32, 2.04]

4 Maternal experience of childbirth ‐ negative childbirth experience Show forest plot	2	2269	Risk Ratio (M‐H, Random, 95% CI)	0.61 [0.28, 1.35]

5 Low Apgar score (less than 7 at 5 minutes) Show forest plot	4	4749	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.61, 1.42]

5.1 Low‐resource setting	2	1148	Risk Ratio (M‐H, Fixed, 95% CI)	1.31 [0.58, 2.96]
5.2 High‐resource setting	2	3601	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.50, 1.35]
6 Serious maternal morbidity or death Show forest plot	2	3601	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

7 Caesarean section (distress) Show forest plot	2	3601	Risk Ratio (M‐H, Fixed, 95% CI)	1.30 [0.86, 1.96]

8 Caesarean section (delay) Show forest plot	2	3601	Risk Ratio (M‐H, Fixed, 95% CI)	0.98 [0.77, 1.25]

9 Instrumental vaginal delivery Show forest plot	3	3801	Risk Ratio (M‐H, Fixed, 95% CI)	0.92 [0.81, 1.04]

10 Postpartum haemorrhage ‐ blood loss > 500 mL Show forest plot	3	4549	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.90, 1.25]

10.1 Low‐resource setting	1	948	Risk Ratio (M‐H, Fixed, 95% CI)	0.85 [0.26, 2.76]
10.2 High‐resource setting	2	3601	Risk Ratio (M‐H, Fixed, 95% CI)	1.07 [0.90, 1.26]
11 Regional analgesia ‐ epidural Show forest plot	2	3601	Risk Ratio (M‐H, Random, 95% CI)	1.06 [0.92, 1.21]

12 Performance of artificial rupture of the membranes during labour Show forest plot	3	3801	Risk Ratio (M‐H, Random, 95% CI)	1.00 [0.84, 1.18]

13 Number of vaginal examinations in labour Show forest plot	2	3601	Mean Difference (IV, Random, 95% CI)	‐0.08 [‐0.37, 0.21]

14 Serious neonatal morbidity or perinatal death Show forest plot	2	3601	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

15 Admission to special care nursery Show forest plot	3	3801	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.51, 1.34]

15.1 Low‐resource setting	1	200	Risk Ratio (M‐H, Fixed, 95% CI)	1.33 [0.31, 5.81]
15.2 High‐resource setting	2	3601	Risk Ratio (M‐H, Fixed, 95% CI)	0.78 [0.46, 1.31]
16 Cord blood arterial pH less than 7.1 Show forest plot	2	3601	Risk Ratio (M‐H, Fixed, 95% CI)	0.73 [0.44, 1.22]

Comparison 2. Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings)

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Comparison 3. Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Caesarean section (overall) Show forest plot	1	617	Risk Ratio (M‐H, Fixed, 95% CI)	0.78 [0.51, 1.18]

2 Oxytocin augmentation Show forest plot	1	617	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.85, 1.21]

3 Maternal experience of childbirth ‐ negative childbirth experience Show forest plot	1	348	Risk Ratio (M‐H, Fixed, 95% CI)	0.49 [0.27, 0.90]

4 Low Apgar score (less than 7 at 5 minutes) Show forest plot	1	617	Risk Ratio (M‐H, Fixed, 95% CI)	1.44 [0.41, 5.05]

5 Serious maternal morbidity or death Show forest plot	1	617	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

6 Caesarean section (distress) Show forest plot	1	617	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.44, 2.10]

7 Caesarean section (delay) Show forest plot	1	617	Risk Ratio (M‐H, Fixed, 95% CI)	0.71 [0.42, 1.19]

8 Instrumental vaginal delivery Show forest plot	1	617	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.69, 1.26]

9 Postpartum haemorrhage ‐ blood loss > 500 mL Show forest plot	1	617	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.63, 1.45]

10 Regional analgesia ‐ epidural Show forest plot	1	617	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.94, 1.44]

11 Performance of artificial rupture of membranes during labour Show forest plot	1	617	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.77, 1.15]

12 Vaginal examinations Show forest plot	1	617	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.29, 0.29]

13 Serious neonatal morbidity or perinatal death Show forest plot	1	617	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

14 Admission to special care nursery Show forest plot	1	617	Risk Ratio (M‐H, Fixed, 95% CI)	3.83 [0.43, 34.12]

15 Cord blood arterial pH less than 7.1 Show forest plot	1	617	Risk Ratio (M‐H, Fixed, 95% CI)	0.38 [0.07, 1.96]

Comparison 3. Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting)

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Comparison 4. Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Caesarean section (overall) Show forest plot	1	613	Risk Ratio (M‐H, Fixed, 95% CI)	1.70 [1.07, 2.70]

2 Oxytocin augmentation Show forest plot	1	613	Risk Ratio (M‐H, Fixed, 95% CI)	1.09 [0.91, 1.30]

3 Maternal experience of childbirth ‐ negative childbirth experience Show forest plot	1	340	Risk Ratio (M‐H, Fixed, 95% CI)	0.80 [0.51, 1.27]

4 Low Apgar score (less than 7 at 5 minutes) Show forest plot	1	613	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.22, 3.04]

5 Serious maternal morbidity or death Show forest plot	1	613	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

6 Caesarean section (distress) Show forest plot	1	613	Risk Ratio (M‐H, Fixed, 95% CI)	1.77 [0.70, 4.42]

7 Caesarean section (delay) Show forest plot	1	613	Risk Ratio (M‐H, Fixed, 95% CI)	1.68 [0.97, 2.91]

8 Instrumental vaginal delivery Show forest plot	1	613	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.72, 1.28]

9 Postpartum haemorrhage ‐ blood loss > 500 mL Show forest plot	1	613	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.68, 1.56]

10 Regional analgesia ‐ epidural Show forest plot	1	613	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.80, 1.27]

11 Performance of artificial rupture of membranes during labour Show forest plot	1	613	Risk Ratio (M‐H, Fixed, 95% CI)	1.04 [0.85, 1.26]

12 Number of vaginal examinations in labour Show forest plot	1	613	Mean Difference (IV, Fixed, 95% CI)	0.10 [‐0.19, 0.39]

13 Serious neonatal morbidity or perinatal death Show forest plot	1	613	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

14 Admission to special care nursery Show forest plot	1	613	Risk Ratio (M‐H, Fixed, 95% CI)	0.51 [0.05, 5.65]

15 Cord blood arterial pH less than 7.1 Show forest plot	1	613	Risk Ratio (M‐H, Fixed, 95% CI)	2.57 [0.50, 13.17]

Comparison 4. Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting)

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Comparison 5. Partograph with alert line only versus partograph with alert and action line (study carried out in a low‐resource setting)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Caesarean section (overall) Show forest plot	1	694	Risk Ratio (M‐H, Fixed, 95% CI)	0.68 [0.50, 0.93]

2 Oxytocin augmentation Show forest plot	1	694	Risk Ratio (M‐H, Fixed, 95% CI)	0.81 [0.62, 1.05]

3 Low Apgar score (less than 7 at 5 minutes) Show forest plot	1	694	Risk Ratio (M‐H, Fixed, 95% CI)	7.12 [0.37, 137.36]

4 Instrumental vaginal delivery Show forest plot	1	694	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.66, 1.15]

5 Serious neonatal morbidity or perinatal death Show forest plot	1	694	Risk Ratio (M‐H, Fixed, 95% CI)	7.12 [0.37, 137.36]

Comparison 5. Partograph with alert line only versus partograph with alert and action line (study carried out in a low‐resource setting)

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Comparison 6. Partograph with latent phase versus partograph without latent phase (study carried out in a low‐resource setting)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Caesarean section (overall) Show forest plot	1	743	Risk Ratio (M‐H, Fixed, 95% CI)	2.45 [1.72, 3.50]

2 Oxytocin augmentation Show forest plot	1	743	Risk Ratio (M‐H, Fixed, 95% CI)	2.18 [1.67, 2.83]

3 Low Apgar score (less than 7 at 5 minutes) Show forest plot	1	743	Risk Ratio (M‐H, Fixed, 95% CI)	0.75 [0.21, 2.63]

4 Caesarean section (distress) Show forest plot	1	743	Risk Ratio (M‐H, Fixed, 95% CI)	4.87 [2.83, 8.37]

5 Caesarean section (delay) Show forest plot	1	743	Risk Ratio (M‐H, Fixed, 95% CI)	1.35 [0.59, 3.08]

6 Instrumental vaginal delivery Show forest plot	1	743	Risk Ratio (M‐H, Fixed, 95% CI)	1.04 [0.61, 1.77]

7 Admission to special care nursery Show forest plot	1	743	Risk Ratio (M‐H, Fixed, 95% CI)	1.84 [1.29, 2.63]

8 Usability: user‐friendliness score Show forest plot	1	743	Mean Difference (IV, Fixed, 95% CI)	‐7.89 [‐8.14, ‐7.64]

Comparison 6. Partograph with latent phase versus partograph without latent phase (study carried out in a low‐resource setting)

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Comparison 7. Partograph with 2‐hour action line versus partograph with stepped dystocia line

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Caesarean section Show forest plot	1	99	Risk Ratio (M‐H, Fixed, 95% CI)	1.10 [0.46, 2.62]

2 Oxytocin augmentation Show forest plot	1	99	Risk Ratio (M‐H, Fixed, 95% CI)	0.62 [0.39, 0.98]

3 Duration of first stage of labour (labour longer than 12 hours) Show forest plot	1	99	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.31, 1.89]

4 Maternal experience of childbirth (BSS‐R score) Show forest plot	1	90	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐3.58, 3.58]

5 Low Apgar score (less than 4 at 4 min) Show forest plot	1	99	Risk Ratio (M‐H, Fixed, 95% CI)	0.98 [0.06, 15.23]

6 Instrumental vaginal birth Show forest plot	1	99	Risk Ratio (M‐H, Fixed, 95% CI)	0.75 [0.37, 1.56]

7 Postpartum haemorrhage (> 500 mL) Show forest plot	1	99	Risk Ratio (M‐H, Fixed, 95% CI)	1.57 [0.55, 4.46]

8 Regional analgesia Show forest plot	1	99	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.56, 1.32]

9 Opioid use Show forest plot	1	99	Risk Ratio (M‐H, Fixed, 95% CI)	0.98 [0.45, 2.14]

10 Need for intubation at birth Show forest plot	1	99	Risk Ratio (M‐H, Fixed, 95% CI)	0.44 [0.14, 1.32]

Comparison 7. Partograph with 2‐hour action line versus partograph with stepped dystocia line

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Comparison 8. Partograph versus labour scale (study carried out in a low‐resource setting)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Caesarean section (overall) Show forest plot	1	122	Risk Ratio (M‐H, Fixed, 95% CI)	0.42 [0.16, 1.11]

2 Oxytocin augmentation Show forest plot	1	122	Risk Ratio (M‐H, Fixed, 95% CI)	0.32 [0.18, 0.54]

3 Duration of first stage of labour Show forest plot	1	110	Mean Difference (IV, Fixed, 95% CI)	0.44 [‐0.40, 1.28]

4 Low Apgar score (less than 7 at 5 minutes) Show forest plot	1	110	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

5 Caesarean section (delay) Show forest plot	1	122	Risk Ratio (M‐H, Fixed, 95% CI)	0.2 [0.05, 0.88]

6 Stillbirth, neonatal death or neonatal morbidity Show forest plot	1	110	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

7 Birth injuries and PPH (non‐prespecified outcome) Show forest plot	1	122	Risk Ratio (M‐H, Fixed, 95% CI)	3.0 [0.32, 28.04]

Comparison 8. Partograph versus labour scale (study carried out in a low‐resource setting)

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