Global research priorities related to the World Health Organization Labour Care Guide: results of a global consultation

Promoting respectful maternity care with the WHO labor care guide and the checklist mnemonic "COPE": A quality improvement project

OBJECTIVES

To improve the quality of intrapartum care at Princess Marina Hospital, Gaborone, Botswana, through a champion-led educational intervention, introduction of the World Health Organization's Labor Care Guide (LCG), which highlights four key measures to promote respectful maternal care (RMC).

METHODS

In August 2022, we engaged medical and nursing staff in interactive training on the WHO LCG and implemented a mnemonic-based checklist-"COPE" (Companions, Oral fluids, Pain relief, Eliminate the supine position). Motivational posters were displayed in the labor ward. Surveys to assess client labor experiences were conducted in November 2022 (n = 204) and October 2024 (n = 211). An anonymous staff survey assessed personal practice changes before and after the training.

RESULTS

Over 2 years, significant improvements in reported maternal experience were observed. Reports of a "very bad" experience decreased from 116/204 (56.9%) to 13/211 (6.2%) and dissatisfaction with care reduced from 22/204 (10.8%) to 3/211 (1.4%). Adequate fluid provision increased from 108/204 (52.9%) to 159/211 (75.4%) and pain relief from 41/204 (20.1%) to 108/211 (51.2%). The reported presence of a labor companion increased from 14/204 (6.9%) to 133/211 (63.0%). Patient reports of exclusive supine positioning during the second stage of labor decreased from 106/204 (52.0%) to 11/211(5.2%). Staff questionnaires showed a consistent improvement in reported adoption of "COPE" practices compared with recollected practices before the intervention.

CONCLUSIONS

Deeply entrenched labor care practices are difficult to change; however, sustained, champion-led quality improvement interventions using the LCG and with sustained supportive supervision can yield meaningful improvement in women's birth experiences.

Health policy and systems research priority-setting exercise in Ethiopia: a collaborative approach

INTRODUCTION

Health policy and systems research (HPSR) is a multi-disciplinary approach of generating health system and policy-level evidence. Setting HPSR agendas is considered as an efficient strategy to map and identify policy and cost-effective research topics, but its practice in developing countries is limited. This paper aimed to conduct a collaborative health policy and system research priority-setting exercise in Ethiopia.

METHOD

The WHO's plan, implement, publish, and evaluate (PIPE) framework and the Delphi technique were used to conduct the priority-setting exercise. The PIPE model was used to lead the priority-setting process from planning to evaluation, while the Delphi technique was used to run the rating and ranking exercise with the aim of reaching a consensus. Two rounds of expert panel workshops supplemented with an online survey were used for the HPSR agenda setting, rating and ranking purposes. Groups were formed using the WHO health system building blocks as a base framework to identify and prioritize the HPSR topics.

RESULT

Under 8 themes, 32 sub-themes and 182 HPSR topics were identified. The identified research themes include leadership management and governance, health policy, health information system, healthcare financing, human resource for health, medical products and supply, service delivery and cross-cutting issues.

CONCLUSIONS

Priority HPSR topics focussing on national health priority issues were identified. The identified topics were shared with policymakers and academic and research institutions. Evidence generation on the identified priority topics will guide future research endeavours and improve evidence-informed decision-making practice, health system performance and national health goals and targets.

Improving management of first and second stages of labour in low- and middle-income countries

Labour care must balance aspirations of parents with vigilance for unanticipated calamities. The 'on-site midwife-led primary care birth unit' facilitates this. The World Health Organization have replaced the traditional partograph with the 'Labour Care Guide'. An implementation project in Botswana included the mnemonic COPE: Companion, Oral fluids, Pain relief and Eliminate the supine position. The Parto-Ma project in Tanzania used guidelines, training and support to improve childbirth outcomes. We list labour practices supported by recent evidence, and highlight new developments. Foetal macrosomia increases risk but mistaken diagnosis increases caesarean births. Obstructed labour is a complex clinical diagnosis, and is difficult to predict. For shoulder dystocia prioritise delivery of the posterior shoulder, facilitated if needed by posterior axilla sling traction. 'Extended balloon labour induction' with two or three Foley catheters side by side, may reduce risks associated with uterine stimulants. Bedside ultrasound may facilitate the diagnosis of cephalic malpositions and malpresentations.

Effects of the WHO Labour Care Guide on cesarean section in India: a pragmatic, stepped-wedge, cluster-randomized pilot trial

Cesarean section rates worldwide are rising, driven by medically unnecessary cesarean use. The new World Health Organization Labour Care Guide (LCG) aims to improve the quality of care for women during labor and childbirth. Using the LCG might reduce overuse of cesarean; however, its effects have not been evaluated in randomized trials. We conducted a stepped-wedge, cluster-randomized pilot trial in four hospitals in India to evaluate the implementation of an LCG strategy intervention, compared with routine care. We performed this trial to pilot the intervention and obtain preliminary effectiveness data, informing future research. Eligible clusters were four hospitals with >4,000 births annually and cesarean rates ≥30%. Eligible women were those giving birth at ≥20 weeks' gestation. One hospital transitioned to intervention every 2 months, according to a random sequence. The primary outcome was the cesarean rate among women in Robson Group 1 (that is, those who were nulliparous and gave birth to a singleton, term pregnancy in cephalic presentation and in spontaneous labor). A total of 26,331 participants gave birth. A 5.5% crude absolute reduction in the primary outcome was observed (45.2% versus 39.7%; relative risk 0.85, 95% confidence interval 0.54-1.33). Maternal process-of-care outcomes were not significantly different, though labor augmentation with oxytocin was 18.0% lower with the LCG strategy. No differences were observed for other health outcomes or women's birth experiences. These findings can guide future definitive effectiveness trials, particularly in settings where urgent reversal of rising cesarean section rates is needed. Clinical Trials Registry India number: CTRI/2021/01/030695 .