BackgroundMost 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/DesignWe 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.DiscussionThis 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’.

Objective: To demonstrate how a human-centered service design approach can generate practical tools for good-quality childbirth care in low-resource settings.Methods: As part of the WHO "Better Outcomes in Labour Difficulty" (BOLD) project, a service design approach was used in eight Ugandan and Nigerian health facilities and communities to develop the "Passport to Safer Birth." There are three phases: Research for Design, Concept Design, and Detail Design. These generated design principles, design archetype personas, and Passport prototypes. Data collection methods included desk research, interviews, group discussions, and journey mapping to identify touchpoints where the woman interacts with the health system. Results:A total of 90 interviews, 12 observation hours, and 15 group discussions were undertaken. The resulting design principles were: a shared and deeper understanding of pregnancy and childbirth among family and community; family readiness for decision-making and action; and the woman's sense of being in control and being cared for. Four archetype personas of women emerged: Vulnerable; Passive; Empowered;Accepter. Subsequent development of the Passport to Safer Birth tools addressed three domains: Care Mediator; Expectation Manager; and Pregnancy Assistant. Conclusion:The service design approach can create innovative, human-centered service solutions to improve maternity care experiences and outcomes in low-resource settings. K E Y W O R D SCo-design; Human-centered design; Maternal health; Nigeria; Passport to safer birth; Service design; Uganda | INTRODUCTIONIn 2014, the WHO initiated the "Better Outcomes in Labour Difficulty" (BOLD) project to address the quality of facility-based childbirth care in low-resource settings. The goal of this project is to accelerate the reduction of childbirth-related maternal, fetal, and newborn mortality and morbidity by addressing critical impediments in the process of labor and childbirth care, taking advantage of the interactions between the health system and the community. 1 The project sought to achieve this goal through a two-pronged approach: the development of a Simplified, Effective, of service prototypes and/or tools that improve or enable new interactions between communities and health facilities. These tools were designed using an approach that applies humancentered design methods to co-design solutions together with end users. This paper reports on the development process. The PSB tools developed as a result are described in Salgado et al. 4 | Service design process as a tool to engage users and stakeholders in service innovationThe approach used to design the PSB service tools and concept is called service design, which is an emerging discipline focused on ideating, defining, and implementing services using a customer centric approach. 5 The service design process aims to innovate and improve new or existing services to make them more useful, desirable, and usable to the customer while ensuring efficiency and effectiveness to the service provi...

Objective: The "Better Outcomes in Labor Difficulty" (BOLD) project used a service design process to design a set of tools to improve quality of care during childbirth by strengthening linkages between communities and health facilities in Nigeria andUganda. This paper describes the Passport to Safer Birth concept and the tools developed as a result.Methods: Service design methods were used to identify facilitators and barriers to quality care, and to develop human-centered solutions. The service design process had three phases: Research for Design, Concept Design, and Detail Design, undertaken in eight hospitals and catchment communities. Results:The service concept "Better Beginnings" comprises three tools. The "Pregnancy Purse" provides educational information to women throughout pregnancy. The "Birth Board" is a visual communication tool that presents the labor and childbirth process.The "Family Pass" is a set of wearable passes for the woman and her supporter to facilitate communication of care preferences. Conclusion:The Better Beginnings service concept and tools form the basis for the promotion of access to information and knowledge acquisition, and could improve communication between the healthcare provider, the woman, and her family during childbirth. K E Y W O R D SCo-design; Maternal health; Newborn health; Nigeria; Quality of care; Service concept; Service design; Uganda | INTRODUCTIONGood quality maternity care is a multidimensional concept that includes timely, effective, and appropriate use of clinical and nonclinical interventions that are sensitive to women's values and preferences. 1 To achieve improved quality of care, efforts are needed to address both facility-and community-based factors, including perceptions of quality, decision-making processes, and demand for womancentered services. There is growing recognition of the importance of including the perspectives of service users and providers to improve quality and organization of care. 2-4 However, the expectations, needs, and values of women and communities have often been neglected in the design of maternity services, particularly in low-and middleincome countries.To address this gap, the WHO initiated the "Better Outcomes in Labour Difficulty" (BOLD) project to improve quality of care during facility-based childbirth. The BOLD project was conducted in Nigeria and Uganda, two settings with a high burden of maternal and neonatal morbidity and mortality. As part of this project, the concept of the "Passport to Safer Birth" (PSB) was developed, its aim to increase

Reflections from 3 global health programs using humancentered design (HCD) offer 3 categories of lessons for those considering similar approaches: n Planning while considering the needs of both traditional global health and HCD approaches n Engaging key stakeholders to build understanding, alignment, and buy-in from the outset n Applying approaches differently from the way both designers and global health actors are accustomed to working to promote long-term program sustainability and learning Key Implications nIf implemented appropriately, integrating HCD into global health programming can produce a virtuous cycle between co-creation, stakeholder buy-in, and quality of outputs. The more that programs engage stakeholders in an inclusive, participatory process, the greater their continued willingness and motivation. This in turn allows for more iteration and higher quality, better-tailored outputs that are more likely to be sustainably used and scaled. n To engender this virtuous cycle, programs that incorporate an HCD approach will need to be scoped differently than traditional global health programs (e.g., more flexible timelines; dedicated budget for implementation and capacity building, etc.). n Because stakeholders may perceive a higher risk of failure with a new approach, proponents of HCD are faced with a substantial burden of evidence to persuade actors to consider its benefits. However, traditional global health actors should consider alternative approaches to measuring HCD's contributions, including perceived end user value.

Background: This paper presents learnings from the Re-Imagining Technical Assistance for Maternal, Neonatal, and Child Health and Health Systems Strengthening (RTA) project implemented in the Democratic Republic of the Congo and Nigeria from April 2018 to September 2020 by JSI Research & Training Institute, Inc. and Sonder Collective and managed by the Child Health Task Force. The first of RTA’s two phases involved multiple design research activities, such as human-centered design and co-creation, while the second phase focused on secondary analysis of interviews and reports from the design research. This paper explores the limitations of current technical assistance (TA) approaches and maps opportunities to improve how TA is planned and delivered in the health sector. Methods: We analyzed project reports and 68 interviews with TA funders, providers, and consumers to explore in greater detail their perspectives on TA, its characteristics and drawbacks as well as opportunities for improvement. We used qualitative content analysis techniques for this study.   Results: The issues surrounding TA included the focus on donor-driven agendas over country priorities, poor accountability between and within TA actors, inadequate skill transfer from TA providers to government TA consumers, an emphasis on quick fixes and short-term thinking, and inadequate governance mechanisms to oversee and manage TA. Consequently, health systems do not achieve the highest levels of resilience and autonomy. Conclusions: Participants in project workshops and interviews called for a transformation in TA centered on a redistribution of power enabling governments to establish their health agendas in keeping with the issues that are of greatest importance to them, followed by collaboration with donors to develop TA interventions. Recommended improvements to the TA landscape in this paper include nine critical shifts, four domains of change, and 20 new guiding principles.