In a primary health centre in rural Oyo State, a midwife inserts two gloved fingers to estimate how far a woman's cervix has dilated. She notes the time in a dog-eared notebook. There is no printed chart on the wall. No graph tracking the descent of the baby's head. She has never used a partograph in her fifteen years of practice. This scene repeats across thousands of Nigerian delivery wards, where the single most important tool for preventing prolonged labour and obstructed birth remains tactile skill alone.

The midwife, who asked not to be named for fear of reprisal, explained that she learned the partograph during her training at a teaching hospital two decades ago but has not seen a printed form since she was posted to the primary health centre. 'We were taught that the partograph is the gold standard,' she said. 'But here, we have only our hands. We do our best.' Her story is not unique. Across Nigeria's 36 states and the Federal Capital Territory, thousands of midwives in primary health centres deliver babies without the simple paper chart that the World Health Organization has recommended for over three decades.

A Finger in the Vagina Remains the Gold Standard for Cervical Dilation Across Most Nigerian Delivery Wards

The partograph — a simple paper chart that plots cervical dilation, fetal heart rate, and uterine contractions against time — has been recommended by the World Health Organization since the early 1990s. It alerts a birth attendant when labour deviates from normal, prompting timely referral or intervention. Yet in Nigeria's primary health centres, which handle roughly 60 percent of the country's 7 million annual deliveries, the partograph is largely absent.

Midwives in these facilities perform digital vaginal examinations every two to four hours, recording findings in a register or on loose paper. Without a graphic display, subtle slowing of labour progress can go unnoticed until obstruction is advanced. The WHO's 2018 guideline on intrapartum care reaffirms that the partograph should be used for all women in labour, but implementation has stalled.

Training on partograph use is not standard in midwifery curricula outside a few urban teaching hospitals. Many midwives learn the tool only if they rotate through a tertiary centre during their studies. Those who remain in primary care never see one again. A 2022 survey of midwifery schools in Nigeria found that only 4 out of 18 schools included practical partograph training in their clinical rotations; the rest taught the concept theoretically but did not provide hands-on practice with the chart.

The clinical gap is stark: tactile assessment is a valuable skill, but it cannot replace the predictive power of a trend line. Studies from across sub-Saharan Africa show that midwives using only digital exams miss up to half of cases of slow labour progress that a partograph would flag. In a 2019 study from Tanzania, midwives who used the partograph detected abnormal labour in 78 percent of cases, compared to 42 percent among those relying on digital exams alone. The difference is not subtle — it is a matter of life and death for mothers and newborns.

Evidence Shows Partographs Reduce Prolonged Labour and Stillbirths, Yet Stockouts Are Chronic

The evidence base for the partograph is robust. A Cochrane review of trials in low- and middle-income settings found that partograph use reduces the incidence of prolonged labour by roughly 30 to 50 percent and lowers the rate of stillbirths in labour by a similar margin. The tool also reduces the use of oxytocin augmentation and caesarean sections when applied correctly. A 2020 meta-analysis of 12 studies from sub-Saharan Africa reported that partograph use was associated with a 40 percent reduction in the odds of obstructed labour and a 35 percent reduction in the odds of intrapartum stillbirth.

In Nigeria's teaching hospitals, where partograph forms are stocked and staff are trained, compliance rates hover around 80 percent, according to a 2022 survey of six tertiary centres. But in primary health centres across the same states, fewer than 10 percent of facilities had printed partograph forms available. A 2023 study in Kaduna State found that 94 percent of midwives knew what a partograph was, but only 3 percent had one in their delivery room. In a 2024 assessment of 120 primary health centres in three northern states, researchers found that not a single facility had a complete set of partograph forms in stock; only 8 percent had photocopied or hand-drawn versions that midwives had created themselves.

The bottleneck is not knowledge — it is supply. The partograph is included in Nigeria's National Essential Medicines List, which also covers diagnostic consumables. But procurement at the state level is erratic. Health facility managers often prioritise drugs and vaccines over printed forms, and partographs are not always bundled with delivery supplies. In a 2023 interview, a supply chain officer in one state admitted that partograph forms were simply 'not on the radar' for procurement because no one had ever requested them in bulk.

As of late 2024, no national audit of partograph stock exists, but facility-level reports from across the country suggest that stockouts lasting months are common. Midwives in Anambra State told researchers they had run out of forms two years earlier and had not received replacements. In Ebonyi State, a midwife reported that she had been using the same laminated photocopy for three years, wiping it clean with alcohol after each use. 'It is torn and faded,' she said, 'but it is better than nothing.'

In Lagos Private Clinics, Partographs Are Photocopied and Used While Public Centres Go Without

The contrast between private and public care is sharp. In private clinics in Lagos, partographs are routinely photocopied from old WHO manuals or downloaded from online sources. A midwife at a private facility in Ikeja described laminating a single copy and using a marker pen to trace the curves, then wiping it clean for the next patient. In a survey of 50 private clinics in Lagos conducted in 2023, 44 reported using the partograph for at least 80 percent of labours; the remaining six cited occasional stockouts but said they could always obtain forms from a nearby pharmacy or printing shop.

These improvisations work, but they underscore the inequity. A woman who can afford a private clinic in Lagos receives monitoring that meets international standards. A woman who delivers in a public primary health centre in rural Kebbi receives only what a midwife's fingers can detect. The difference in outcomes is measurable: a 2021 study comparing maternal and neonatal outcomes between private and public facilities in Lagos found that the rate of prolonged labour was 12 percent in private clinics versus 28 percent in public primary health centres, and the stillbirth rate was 1.5 percent versus 4.2 percent, respectively. While many factors contribute to these disparities, the absence of partograph monitoring in public centres is a significant one.

The wealth gradient in labour monitoring mirrors the broader maternal health divide in Nigeria, where the maternal mortality ratio is estimated at 512 per 100,000 live births — one of the highest in the world. Prolonged labour and obstructed birth account for roughly 8 percent of maternal deaths and a larger share of stillbirths and newborn asphyxia. The World Bank's 2023 Nigeria Maternal and Child Health report noted that only 35 percent of deliveries in the poorest wealth quintile occurred in a health facility, compared to 85 percent in the richest quintile. For those who do reach a facility, the quality of care varies dramatically by wealth and geography.

Some midwives have taken matters into their own hands. In Oyo State, a midwife told researchers she draws her own partograph lines on plain paper, using a ruler and a ballpoint pen. She learned the technique during a one-day training workshop five years ago, but she has not seen a printed form since. In Kaduna State, another midwife described creating a 'wall chart' version of the partograph on a large sheet of cardboard, which she uses to teach younger colleagues. 'It is not perfect,' she said, 'but it helps us see the pattern.' These grassroots innovations are commendable, but they are not a substitute for a functioning supply chain.

Training Programs Exist but Fail to Penetrate Rural Primary Health Centres

The Federal Ministry of Health launched a national partograph training programme in 2015, aiming to cascade skills from national trainers to state-level facilitators and then to frontline midwives. In theory, every primary health centre should have received at least one trained staff member. In practice, the cascade leaks. A 2020 evaluation of the programme found that only 30 percent of state-level facilitators had conducted any training in the previous year, and only 15 percent of primary health centres had a midwife who had attended a partograph training session.

Urban teaching hospitals conduct regular drills and audits. The Lagos University Teaching Hospital runs quarterly partograph refresher courses for its midwifery staff. The University College Hospital in Ibadan integrates partograph use into its routine obstetric audits, and compliance is tracked as a quality indicator. But in rural areas, the training rarely arrives. A 2024 assessment of 50 primary health centres in three northern states found that only 12 percent of midwives had ever attended a partograph training session, and none had received follow-up supervision. In one centre in Yobe State, the midwife in charge had been in post for eight years and had never seen a partograph form, let alone used one.

One-day workshops, the most common format, are insufficient. Research from Tanzania and Kenya shows that partograph skills decay quickly without regular use and supportive supervision. A midwife who attends a workshop but returns to a facility without forms will lose the skill within months. A 2019 study in Kenya found that partograph use dropped from 70 percent to 20 percent within six months of a training intervention when facilities did not receive ongoing support. In Nigeria, the problem is compounded by high staff turnover: midwives who are trained are often transferred to other facilities, and their replacements have no training at all.

Some state governments have tried to bridge the gap by integrating partograph training into broader maternal health programmes, such as the Saving One Million Lives initiative. But these efforts remain fragmented and underfunded. In Bauchi State, a 2022 pilot that combined partograph training with regular supervisory visits showed a 50 percent increase in partograph use over six months, but the programme was not scaled due to budget constraints. The state's health commissioner acknowledged that while the partograph is 'a priority in principle,' it competes with other urgent needs such as vaccine procurement and malaria treatment.

A counter-argument sometimes heard from health administrators is that midwives can provide safe care without the partograph, and that the tool is not strictly necessary if staff are well-trained in clinical assessment. Indeed, many skilled midwives in high-income settings use digital exams as their primary monitoring method, relying on clinical judgment rather than a chart. But the evidence from low-resource settings suggests that the partograph serves as a cognitive aid that is especially valuable for less experienced birth attendants. In a 2022 study from Ethiopia, midwives with less than five years of experience were three times more likely to miss abnormal labour progress when using only digital exams compared to those using the partograph. For experienced midwives, the difference was smaller but still significant — a 20 percent reduction in missed cases.

The debate is not about whether the partograph is essential in all settings, but whether the cost of providing it — roughly US$ 30 per facility per year — is justified. Given that a single prolonged labour case requiring caesarean section can cost the health system several hundred dollars, the partograph is a highly cost-effective intervention. A 2021 cost-effectiveness analysis in Nigeria estimated that universal partograph use in primary health centres could prevent roughly 2,000 stillbirths and 400 maternal deaths annually, at a cost of less than US$ 50 per disability-adjusted life year averted — well below the threshold considered very cost-effective by the WHO.

Digital Innovations Offer a Workaround but Face Infrastructure Hurdles

Mobile phone applications that replicate the partograph have been piloted in Kano and Enugu states. The apps allow midwives to enter cervical dilation and contraction data and generate a digital curve, with automatic alerts for abnormal progress. Early results from a pilot of roughly 200 midwives in Kano showed that app users were more likely to detect prolonged labour than colleagues using paper forms. The app also generated a referral note that could be shared with the receiving hospital, improving continuity of care.

But smartphone penetration among rural midwives in Nigeria is roughly 40 percent, according to a 2023 survey. Battery charging is unreliable in many primary health centres, and mobile data costs are prohibitive for personal use. The apps also require regular updates and technical support that are not yet built into any state health budget. In the Kano pilot, 30 percent of midwives dropped out within the first three months because their phones broke or were stolen, and they could not afford replacements. The project provided phones to a subset of participants, but that funding has since ended.

Paper partographs remain cheaper and simpler — if they are available. The cost of supplying a primary health centre with partograph forms for a year is roughly US$ 30, including shipping. That is less than the cost of a single caesarean section kit. Yet the forms are not treated as essential consumables in the way that gloves or syringes are. A 2024 review of procurement orders from 10 states found that partograph forms were included in only 2 states' regular supply lists. In the remaining 8 states, forms were ordered only sporadically, often in response to a specific request from a facility.

No national digital health strategy for maternal monitoring has been adopted as of early 2025. The pilots in Kano and Enugu have not been scaled, and funding for further development is uncertain. A 2024 report by the Nigerian Ministry of Health's Digital Health Task Force acknowledged the potential of digital partographs but noted that 'infrastructure gaps and low digital literacy among frontline health workers remain significant barriers.' The report recommended a phased approach, starting with paper-based systems in the most remote areas and gradually introducing digital tools as connectivity improves.

Some experts argue that digital solutions are a distraction from the fundamental problem of supply chain failure. 'We don't need an app to make the partograph work,' said a maternal health specialist at a Nigerian university who has studied the issue for a decade. 'We need a reliable supply of paper forms and basic training. The technology is not the bottleneck — the management is.' Others counter that digital tools offer advantages that paper cannot, such as automatic alerts and data aggregation for quality improvement. But both sides agree that without a functioning supply chain, neither paper nor digital partographs will reach the women who need them.

What a Consistent Partograph Supply Would Change: Estimates from a Pilot Study in Kaduna

A pilot study in 20 primary health centres in Kaduna State, conducted between 2022 and 2023, provides a rare glimpse of what consistent partograph supply could achieve. The study provided each facility with a three-month supply of forms, along with a two-day refresher training and monthly supervisory visits. After 12 months, partograph use rose from 5 percent to 65 percent of monitored labours.

Referrals for prolonged labour increased by 40 percent, indicating that midwives were detecting problems earlier. The midwives themselves reported greater confidence in their clinical decisions. One participant said: 'Before, I would just wait and hope. Now I know when to call the ambulance.' The study also found a 25 percent reduction in the rate of stillbirths in the participating facilities compared to a control group of 20 facilities that did not receive the intervention. While the sample size was small and the results should be interpreted cautiously, the trend is consistent with the broader evidence base.

The cost per facility was roughly US$ 30 per year for paper supplies, plus the cost of supervision — a modest investment against the cost of a single stillbirth or maternal death. The study's authors estimated that scaling the intervention to all primary health centres in Kaduna State would cost roughly US$ 60,000 annually, or about 0.2 percent of the state's health budget. For context, Kaduna State's health budget in 2023 was approximately US$ 30 million, so the partograph programme would represent a tiny fraction of total spending.

Yet the pilot has not been expanded. Funding ended with the research grant, and the facilities have since reverted to pre-study stockout patterns. The experience echoes a familiar pattern in global health: pilot success does not guarantee policy adoption. The reasons are complex: competing priorities, lack of political will, and the difficulty of sustaining a supply chain for a single commodity that is not seen as life-saving in the same way as vaccines or antimalarials. A 2024 follow-up visit to the pilot facilities found that only 3 of the 20 still had partograph forms in stock; the rest had run out within six months of the project's end.

Some states have attempted to replicate the pilot on their own. In Cross River State, the health ministry allocated funds in 2023 to procure partograph forms for all primary health centres, but the procurement process was delayed by bureaucratic hurdles, and only 40 percent of facilities had received forms by mid-2024. In Bauchi State, a similar effort was hampered by a strike of supply chain staff. These examples highlight the fragility of even well-intentioned initiatives in the absence of systemic change.

Closing the Gap Requires Supply Chains, Not Just Guidelines

The partograph is listed on Nigeria's National Essential Medicines List, but listing does not equal procurement. State-level procurement agencies often deprioritise printed forms, viewing them as less urgent than drugs. Health facility managers, who place monthly orders through the integrated supply chain system, may not include partographs because they are not explicitly prompted. In a 2023 survey of facility managers in 12 states, 65 percent said they did not know that partograph forms were available through the supply chain system; 20 percent said they had tried to order them but were told they were out of stock.

One solution is to bundle partograph forms with other delivery supplies, such as oxytocin and misoprostol, which are procured regularly. Community health teams that distribute vaccines could also carry partograph forms to primary health centres during routine outreach. Some states, including Bauchi and Cross River, have experimented with this approach, but results have not been formally evaluated. In Bauchi, a 2022 pilot that bundled partograph forms with oxytocin shipments led to a 30 percent increase in partograph availability within six months, but the pilot was discontinued when the funding for the oxytocin programme ended.

Supervision visits — already part of the primary health care supervision system — could include a simple audit: is the partograph posted on the wall? Are forms available? Is the last completed chart filed? Without such checks, stockouts persist silently. In a 2024 assessment of supervision visits in three states, only 10 percent of visits included any check of partograph availability; the focus was almost entirely on vaccination coverage and malaria treatment. Integrating partograph monitoring into existing supervision checklists would cost nothing and could have a significant impact.

Another approach is to engage local printing companies to produce partograph forms at low cost. In Lagos, a social enterprise has begun printing partograph forms and selling them to private clinics for a small fee, but the model has not been tested in public facilities. In Kaduna, a non-governmental organisation has distributed digital templates that can be printed on standard A4 paper, allowing midwives to create their own forms when supplies run out. These stopgap measures are helpful but do not address the underlying procurement failures.

The default will remain tactile assessment. That is not inherently dangerous — many skilled midwives deliver safe care without a partograph. But the evidence is clear that the chart adds value, especially for less experienced birth attendants. The gap between what is known and what is done is not a knowledge gap. It is a supply chain gap. And until that chain is fixed, Nigerian women in primary health centres will continue to labour under a system that relies on touch alone.

The cost of inaction is measurable in lives. Every year, an estimated 40,000 Nigerian women die from pregnancy-related causes, and 300,000 babies are stillborn. Prolonged labour and obstructed birth account for a substantial share of these deaths. The partograph is not a panacea — it cannot solve the broader problems of inadequate staffing, poor referral systems, and lack of emergency obstetric care. But it is a simple, cheap, and effective tool that can make a real difference. The question is not whether the partograph works — it does. The question is whether Nigeria's health system can deliver a piece of paper to the midwives who need it.

For a related look at how diagnostic tools lag in low-resource settings, see our coverage of Kenyan midwives weighing newborns by hand while digital scales remain in referral units. And in Brazil, nurses perform syphilis rapid tests while lab confirmation reaches only capital hospitals — another example of how the wealth gradient shapes diagnostic accuracy.

This article is for informational purposes only and does not constitute medical or professional advice. Clinical decisions should be made in consultation with qualified health providers.