Usability, acceptability, and feasibility of the World Health Organization Labour Care Guide: A mixed-methods, multicountry evaluation

Introduction: The World Health Organization’s (WHO) Labour Care Guide (LCG) is a “next-generation” partograph based on WHO’s latest intrapartum care recommendations. It aims to optimize clinical care provided to women and their experience of care. We evaluated the LCG’s usability, feasibility, and acceptability among maternity care practitioners in clinical settings. Methods: Mixed-methods evaluation with doctors, midwives, and nurses in 12 health facilities across Argentina, India, Kenya, Malawi, Nigeria, and Tanzania. Purposively sampled and trained practitioners applied the LCG in low-risk women during labor and rated experiences, satisfaction, and usability. Practitioners were invited to focus group discussions (FGDs) to share experiences and perceptions of the LCG, which were subjected to framework analysis. Results: One hundred and thirty-six practitioners applied the LCG in managing labor and birth of 1,226 low-risk women. The majority of women had a spontaneous vaginal birth (91.6%); two cases of intrapartum stillbirths (1.63 per 1000 births) occurred. Practitioner satisfaction with the LCG was high, and median usability score was 67.5%. Practitioners described the LCG as supporting precise and meticulous monitoring during labor, encouraging critical thinking in labor management, and improving the provision of woman-centered care. Conclusions: The LCG is feasible and acceptable to use across different clinical settings and can promote woman-centered care, though some design improvements would benefit usability. Implementing the LCG needs to be accompanied by training and supportive supervision, and strategies to promote an enabling environment (including updated policies on supportive care interventions, and ensuring essential equipment is available). This was a three‐phased, mixed‐methods project where skilled health personnel (ie, doctors, midwives, or nurses) were trained in how to use the LCG (Phase 1), applied the LCG in managing the labor of low‐risk women (Phase 2), and participated in focus group discussions on their experiences (Phase 3). We adopted the International Organization for Standardization definition of usability as “the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use.” 5 The LCG design used in this evaluation is provided (File S1). The project was conducted in accordance with Good Clinical Practice (GCP) standards, and results reported were in line with STROBE and COREQ guidance. 6 , 7 All participating practitioners and women signed an informed consent form before participation. A convenience sample of 12 hospitals across six countries (Argentina, India, Kenya, Malawi, Nigeria, and Tanzania) was identified. Participating hospitals were those with more than 1000 births per year, with a minimum of 25 skilled health personnel working in labor ward, and who were able to provide at least basic emergency obstetric and neonatal care (Table S1). Apart from the LCG, clinical care provided to women was according to the existing practices in these hospitals. At each hospital, at least 10 skilled health personnel who were employed on labor ward and experienced in use of a partograph were approached to participate. Practitioners were purposively sampled to ensure participation of relevant cadres providing labor care in the hospital, and representation from senior and junior staff and from different shifts. Consenting practitioners attended an in‐person workshop where they received practical training on how to use the LCG correctly, by means of a standardized implementation manual and training package in English (five countries) and Spanish (Argentina only). Women attending participating hospitals for childbirth were prescreened in order of arrival to identify women being admitted for childbirth with term, singleton pregnancies with a live fetus and normal vital signs. These women were formally screened using a standardized form. If eligible, they were invited to undergo an informed consent process by means of a private interview in a language of the woman’s choice. Eligible women were aged 18‐34 years; at ≤5 cm cervical dilatation with a cephalic presentation and a vaginal birth was anticipated; had no uterine scar; and were otherwise considered as low‐risk according to the local guidelines. Consenting women were enrolled and their data collected until 1 hour after complete expulsion of the placenta. Practitioners continued to enroll women until the per‐country sample size of 200 women was reached. In Phase 3, all participating practitioners were invited to attend a focus group discussion (FGD) and completed a questionnaire on their experiences with the LCG. One FGD per hospital was conducted using a structured discussion guide (File S2) and led by a local facilitator experienced in qualitative research methods. The FGDs explored health care practitioners’ views on usability, feasibility, and acceptability, and barriers and facilitators to using LCG in their setting. Participants were also invited to suggest improvements to the LCG design and training materials. In five of the six countries (India, Kenya, Malawi, Nigeria, and Tanzania), FGDs were conducted in English or a mix of English and local language. In Argentina, FGDs were conducted in Spanish. Participating practitioners and enrolled women were assigned unique numbers, and only deidentified data were collected. Each practitioner completed a questionnaire after the initial training workshop. Practitioner’s experiences with LCG were collected by means of a postpartum questionnaire after each birth using a 5‐point Likert scale. After enrollment had concluded, each practitioner completed a satisfaction and usability questionnaire. Satisfaction was measured for each section of the LCG and overall using a 5‐point Likert scale. Usability was assessed using an adaptation of the System Usability Scale (SUS), a valid, reliable, and widely used 10‐item instrument for assessing usability. 8 Project staff also extracted data from medical records on enrolled women’s characteristics, the use of obstetric interventions during labor and childbirth, and birth outcomes. All data were collected using paper forms and entered into REDCap, 9 a GCP‐compliant, password‐protected online data management system with validation checks. Data queries and discrepancies were resolved at site level. All project‐related information was stored securely at project sites, with participant information in locked file cabinets in areas with limited access. All data were generated from the online data management system, with the analysis based on the multicountry database. The analysis was descriptive (without statistical inference testing), with outcomes reported by site and overall. Categorical data were reported using proportions and percentages, and continuous variables, using median and interquartile range (IQR). Data on practitioner’s perspectives were assessed overall and by site, cadre (doctor, midwife, nurse), maternal parity (nulliparous or multiparous), and number of births attended using LCG (<5 or ≥5 births). SUS scores were converted to a score out of 100, with >70 considered “good” (File S3). 10 Analyses were performed using SPSS 26 (IBM Corp). All FGD transcripts, field notes, and participant‐generated data were imported into NVivo 12 (QSR International). Transcripts in Spanish were translated into English, with coding of all transcripts conducted centrally. Qualitative data were analyzed using framework analysis. 11 An a priori coding framework was developed based on two existing evidence syntheses exploring barriers and enablers for partograph use. 12 , 13 Two researchers applied these codes in duplicate to two transcripts from one country (Tanzania), and compared data under each code to refine the coding framework and code definitions. The final coding framework was applied independently by the researchers to the remaining 10 transcripts. Researchers met frequently during coding to share reflections on the data and discuss application of the coding framework. Once coding was complete, data under each code were reviewed, and axial coding was applied to develop subcodes and analytical themes. Qualitative research leads from each site verified country‐specific data contributing to each finding and contributed to overall interpretation.