title: Formative research and development of innovative tools for "Better Outcomes in Labour Difficulty" (BOLD): study protocol.
abstract: BACKGROUND
  Most complications during labour and childbirth could be averted with timely interventions by skilled healthcare providers. Yet, the quality and outcomes of childbirth care remains suboptimal in many health facilities in low-resource settings. To accelerate the reduction of childbirth-related maternal, fetal and newborn mortality and morbidity, the World Health Organization has initiated the "Better Outcomes in Labour Difficulty" (BOLD) project to address weaknesses in labour care processes and better connect health systems and communities. The project seeks to develop a "Simplified, Effective, Labour Monitoring-to-Action" tool (SELMA) to assist healthcare providers to monitor labour and take decisive actions more efficiently; and by developing an innovative set of service prototypes and/or tools termed "Passport to Safer Birth", designed with communities and healthcare providers, to promote access to quality care for women during childbirth. This protocol describes the formative research activities to support the development of these tools.
  
  
  METHODS
  We will employ qualitative research and service design methodologies in eight health facilities and their catchment communities in Nigeria and Uganda. In the health facilities, focus group discussions (FGD) and in-depth interviews (IDI) will be conducted among different cadres of healthcare providers and facility administrators. In the communities, FGDs and IDIs will be conducted among women who have delivered in a health facility. We will use service design methods to explore women's journey to access and receive childbirth care in order to innovate and design services around the needs and expectations of women, within the context of the health system.
  
  
  CONCLUSIONS
  This formative research will serve several roles. First, it will provide an in-depth understanding of healthcare providers and health system issues to be accounted for in the final design and implementation of SELMA. Second, it will help to identify key moments ("touch points") where women's experiences of childbirth care are shaped, and where the overall experience of quality care could be improved. The synthesis of findings from the qualitative and service design activities will help identify potential areas for behaviour change related to the provision and experience of childbirth care, and serve as the basis for the development of Passport to Safer Birth. Please see related articles 'http://dx.doi.org/ 10.1186/s12978-015-0027-6 ' and 'http://dx.doi.org/ 10.1186/s12978-015-0029-4 '.
authors.affiliation: Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Avenue Appia 20, 1201, Geneva, Switzerland. bohrenm@who.int.|Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA. bohrenm@who.int.
authors.forename: Meghan A
authors.initials: MA
authors.lastname: Bohren
authors.affiliation: Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Avenue Appia 20, 1201, Geneva, Switzerland. oladapoo@who.int.
authors.forename: Olufemi T
authors.initials: OT
authors.lastname: Oladapo
authors.affiliation: Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Avenue Appia 20, 1201, Geneva, Switzerland. tuncalpo@who.int.
authors.forename: Özge
authors.initials: Ö
authors.lastname: Tunçalp
authors.affiliation: M4ID - Leveraging new communication technology for development and health, Snellmaninkatu 15, 00170, Helsinki, Finland. melanie.wendland@m4id.fi.
authors.forename: Melanie
authors.initials: M
authors.lastname: Wendland
authors.affiliation: Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Avenue Appia 20, 1201, Geneva, Switzerland. vogeljo@who.int.
authors.forename: Joshua P
authors.initials: JP
authors.lastname: Vogel
authors.affiliation: M4ID - Leveraging new communication technology for development and health, Snellmaninkatu 15, 00170, Helsinki, Finland. mari.tikkanen@m4id.fi.
authors.forename: Mari
authors.initials: M
authors.lastname: Tikkanen
authors.affiliation: Department of Obstetrics and Gynaecology, College of Medicine, University of Ibadan, Ibadan, Nigeria. fawoleo@yahoo.co.uk.
authors.forename: Bukola
authors.initials: B
authors.lastname: Fawole
authors.affiliation: Department of Obstetrics and Gynaecology, Makerere University, Kampala, Uganda. kidzamugerwa@yahoo.com.
authors.forename: Kidza
authors.initials: K
authors.lastname: Mugerwa
authors.affiliation: Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, Brazil Av. Bandeirantes, 3900, Ribeirão Preto, SP, Brazil. jpsouza@fmrp.usp.br.
authors.forename: João Paulo
authors.initials: JP
authors.lastname: Souza
authors.affiliation: Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Avenue Appia 20, 1201, Geneva, Switzerland. bahlr@who.int.
authors.forename: Rajiv
authors.initials: R
authors.lastname: Bahl
authors.affiliation: Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Avenue Appia 20, 1201, Geneva, Switzerland. gulmezoglum@who.int.
authors.forename: A Metin
authors.initials: AM
authors.lastname: Gülmezoglu
mesh_terms: D005260:Female; D005323:Fetal Monitoring; D017144:Focus Groups; D006268:Health Facilities; D006282:Health Personnel / Q000193:education; D006302:Health Services Research; D006801:Humans; D007231:Infant, Newborn; D007743:Labor, Obstetric; D008427:Maternal Health Services; D009549:Nigeria; D007744:Obstetric Labor Complications / Q000517:prevention & control*; D009774:Obstetrics / Q000193:education; D036801:Parturition; D011247:Pregnancy; D011256:Pregnancy Outcome; D014454:Uganda; D014944:World Health Organization