Mixed-Methods Evaluation of a Digital Tool to Support Skilled Birth Attendants during Labor and Delivery: Effect of Mlabour Use on Adherence to Clinical Protocols and Provider Experience of Care in Tanzania

Background and Purpose:Poor quality facility-based care contributes to elevated rates of maternal and neonatal mortality in Tanzania. Effective strategies for ending preventable deaths must focus on the quality of care provided on the day of birth, the most dangerous day for mothers and newborns. In the face of poor uptake and incorrect use of the paper partograph, long the standard for monitoring progress of labor, digital applications have emerged as promising strategies to improve adherence to clinical protocols and to provide decision support to skilled birth attendants. mLabour is a tablet-based, labor management tool that mimics the role of the paper partograph while offering enhancements meant to reduce provider workload and provide real-time decision support during labor.

Methods: A mixed-methods evaluation was conducted over a nine-month period to assess the impact of mLabour’s use at three Tanzanian maternity health facilities. Change in clinical adherence to labor management protocols, the primary outcome of interest, was assessed using paper-based patient records at baseline and electronic patient records (captured through the mLabour application) at midline and endline. Provider perspectives on the usability and perceived impact of the tool on quality of care were explored both quantitatively and qualitatively: A usability survey to gauge the perceived usefulness and ease of use of the tool was administered to providers at three and nine-months post-implementation; in-depth interviews were conducted with 15 providers to obtain a more nuanced understanding of providers’ experience operating the application and their perceptions of mLabour’s impact on the quality of service delivery.

Results: We observed astatistically significant 22% increase in clinical adherence to labor management protocols between baseline and endline, from a mean adherence score of 4.6 to 5.6 (out of 10). Changes in the timeliness of individual assessments were mixed, with the half-hourly assessments (i.e. fetal heart rate and of timing of contractions assessments) proving difficult for providers to meet. Allproviders who participated in the endline usability survey (n=44) agreed that mLabour made it easier to follow labor management protocols and that the tool increased the likelihood of following these protocols; however, a small proportion of respondents cited difficulty navigating the different features of the tool (8%) and not having received enough training to use mLabour independently (12%). In-depth interviews revealed that participants were overwhelmingly receptive to their respective facility’s adoption of mLabour to support labor management, citing increased efficiency and improved rapport with patients. Main barriers to use cited by participants included managing multiple patients and lack of refresher trainings. 

Conclusions and Implications: The introduction of mLabour resulted in a statistically significant increase in overall provider adherence to timely clinical assessments during labor.  Additionally, providers consider mLabour both feasible and acceptable to use in lieu of the paper partograph. These findings contribute to a limited evidence base on the impact of a digital decision-support tool on clinical and provider-experience of intrapartum care. Future research should consider the role of mLabour in under-resourced public facilities as well as the impact of mLabour on provider reporting burden and workload.