![](bg2.png)
attending health care providers when conditions
arise that require additional observation or
intervention. In addition, timers on the digital pen
can be triggered when measurements are plotted in
order to provide audio reminders to take routine
patient measurements at specified time intervals.
The PartoPen thus provides a low-cost, and intuitive
solution that addresses several of the identified
barriers to successful partograph use, including form
complexity and data interpretation challenges.
This paper describes two preliminary studies that
examined the PartoPen in use in Nairobi, Kenya
from June 2012 – August 2012; the first was
conducted with ninety-five third and fourth-year
nursing students at the University of Nairobi School
of Nursing Sciences, and the second, with nurse
midwives in the labor wards of Kenyatta National
Hospital (KNH) and Pumwani Maternity Hospital
(PMH) over a period of one month. The principal
findings of these two studies, reported in more detail
below, are (1) the PartoPen improved the ability of
nursing students to accurately complete partograph
worksheets using synthetic maternal data, (2) use of
the PartoPen during actual labor increases both the
rate of partograph completion, and partograph
accuracy, and (3) that the PartoPen was readily
accepted and adopted by both students and
practitioners.
2 RELATED WORK
There is a large body of research that examines the
potential relationships between paper-based systems
and digital tools, particularly mobile phones. Mobile
phone tools have been designed to simplify data
collection (Hartung et al. 2010), improve community
health worker performance and effectiveness
(Grameen Foundation, 2010; Parikh, 2005;
Sherwani, 2007; Svoronos, 2010; Derenzi, 2008),
and digitize data from paper forms (Dell et al, 2012;
Ratan et al., 2010).
Digital pens offer the unique affordances of
retaining the physical motion of natural writing, and
simultaneous creation of a paper and digital record.
Digital pens have been customized for context-
specific research tools (Yeh et al., 2006; Cowan et
al., 2011; Song et al., 2011; Landau et al., 2008) due
to their programmability, portability, audio and note
synchronization, and their ability to digitize sketches
as well as handwritten notes for easy transmission
via email. A specific example of how digital pens
have been used in a healthcare setting is the
TraumaPen (Sarcevic, 2010). The TraumaPen
integrates paper emergency patient intake forms
with a digital display component in the exam room
to reduce redundancy of verbal data transmission
between health care practitioners.
Prior research on improving the paper
partograph form includes the ePartogram device
developed by Jhpiego (Jhpiego, 2011), and the
partograph e-Learning tool created by the WHO
(Mathai, 2010). Jhpiego is currently testing three
ePartogram implementations, which include an
Android tablet application, a digital clipboard
system, and a custom hardware solution, but at this
time, no data has been collected or analysed for any
of these models. The WHO e-Learning tool is
distributed to facilities like KNH via CD-ROM.
However, the CD-ROMs are not given to every
student or directly incorporated into the nursing
curriculum. Single copies of the tool are often
passed from student to student throughout the
academic year, placing the primary responsibility for
learning the material upon the students themselves.
Less than half of the students who participated in the
PartoPen study had used the eLearning tool.
To the best of our knowledge, the PartoPen
system is the only standalone digital partograph
solution that can be used interchangeably as a
training tool and in active labor theaters without
altering the currently paper-based system or
requiring significant additional training for the
technology itself.
3 THE PartoPen SYSTEM
The current implementation of the PartoPen system
uses the Livescribe 2GB Echo digital pens, which
can capture and synchronize audio and handwritten
text, and digitize handwritten notes into searchable
and printable PDF documents. These pens use an
infrared camera in the tip of the pen that is triggered
when a user presses the pen tip to a piece of paper.
The camera captures a pre-printed unique dot pattern
(see Figure 1) at a rate of 70 images per second.
Each printed dot contains location information,
which the pen interprets and uses to perform
location-specific functions, such as play an audio
instruction prompt when an instruction button is
tapped or trigger a decision-support prompt when a
birth attendant plots a measurement indicating
abnormal labor. The digital pens also include a
speaker, a microphone, a 3.5mm audio headphone
jack, up to 8GB of memory storage (approximately
800 hours of audio recording storage), an OLED
display, a rechargeable lithium-ion battery, and a
micro-USB connector for charging and data transfer
(Figure 2). Ink cartridges can be easily ordered and
replaced.
ThePartoPeninTrainingandClinicalUse-TwoPreliminaryStudiesinKenya
113