BOLD: Better Outcomes in Labour Difficulty

Bill & Melinda Gates Foundation
Year: 2014-2016
Where: Uganda, Nigeria
Project Status:

A participatory design approach to strengthen the link between communities
and facilities.

M4ID is nearing the completion of a multi-year maternal health research and design project in collaboration with WHO’s Reproductive Health Research department. In this project, we’ve designed and tested tools to improve the demand for better quality of care address quality of care improvements in facilities and to enhance the understanding of pregnancy and childbirth in communities.

Labour difficulties result in deaths and long-term disabilities for thousands of mothers and newborn babies every year, particularly in underserved communities.

As a part of the Better Outcomes in Labour Difficulty (BOLD) project we aimed to design a set of tools to improve the quality of care provided to women and their families by strengthening linkage between communities and facilities, called Passport to Safer Birth (PSB). The project takes place in Nigeria and Uganda and aims ultimately to reduce maternal morbidity and mortality in low resource settings.


The BOLD initiative was launched by M4ID and the World Health Organization Department of Reproductive Health and Research (RHR) in collaboration with the Department of Maternal, Newborn, Child and Adolescent Health. Local partners include University of Ibadan in Nigeria and Makerere University in Uganda.

M4ID led the service design work for the Passport to Safer Birth and applied design research, co-design and prototyping in our participatory design. The three tool prototypes developed aim to support health workers in providing appropriate care during childbirth and to increase demand for respectful, quality care among communities in low resource settings.

A human-centred design process

The project has applied a human-centred design process, in which the the paper based prototypes have been explored, evaluated and validated in a participatory process involving women, men and community leaders as well as health practitioners and maternal health experts.

Prior to the co-design work, design research was conducted to gain a broad understanding of pregnancy and delivery related experiences in both rural and urban areas of Nigeria and Uganda.

The insights gained through design driven in-depth interviews, focus group discussions and observations were analysed and synthesized into a prioritized collection of main themes.

The outcomes of the design research give a comprehensive understanding of the woman’s journey through pregnancy and delivery highlighting gaps and opportunities for design.

Pregnancy and delivery have no narrative

No compelling and holistic service story and weak macroview
around pregnancy and childbirth

Endless acceptance

Low demand for quality of care within communities and acceptance
for poor or lacking services

Information format error

Health talks, information brochures and other health message formats
do not meet needs of mothers

Waiting and hoping

Waiting and hoping are the main activities in the facility, and often there
is no clear process nor are the outcomes communicated to women

Men are just the providers

Men are often perceived merely as “the providers”. They lack ownership
in the service experience which leaves them as outsiders in the event

Short cuts are part of the uniform

Lack of right tools, processes and collaboration models
and the challenging working environments have lead to making shortcuts
in care provision a norm, rather than the exception

The elephant in the ward

Abuse is a topic that is only spoken in the community
and never in the facility

In god we trust

Religion plays a big role in the decision making
around pregnancy and delivery

Tools capture only samples

Tools to monitor, track and document labour allow only
capturing of sample data

Pregnancy needs no attention

Being in physical pain during labour is accepted and often ignored.
Often in communities, pregnancy receives no extra attention

Money buys better care

Money is perceived as the key to good quality of care

There is always tomorrow

Delaying decisions related to health is common in low resource settings

Lonesome in the crowd

Women are lonely with lack of peer support and forums to discuss issues

Design principles are the backbone
of any good design

Based on the design research insights and to address the themes identified above, we developed a set of design principles that should be reflected in the prototypes.

Shared and deeper understanding of pregnancy
  • Emphasize positive outcomes and messages
  • Prepared is the new strong
  • Make pregnancy real
Preparedness for decision making and action
  • Show every decision has an impact for the baby
  • Create new rituals for new behaviours
  • Empower self reflection and risk detection
Feeling of control and being cared for
  • Enable dialogue between women & healthcare providers
  • Embrace women’s individual needs during delivery
  • Utilise the capabilities of the companion in the facility

These design principles have been identified through the co-design activities with women, their supporters and health care providers and have been carried through as a compass for the design team to align with the needs and desires of the actual user groups of the services.

Outcomes: Passport to Safer Birth

The design deliverables of this project include a set of three different tools to improve the quality of care provided to women and their families.

a) the Pregnancy Assistant, which aims to improve the pregnant couple’s understanding of pregnancy and delivery creating better communication and increased birth preparedness for the expectant woman and her companion

b) the Labour Mediator, a paper based tool to provide health and medical information and offer emotional support during the delivery process. This tool aims to enhance the quality of communication between the care provider and the woman.

c) the Expectation Manager, a tool to visualise the roles and responsibilities of the birth companion and the extended family in a childbirth situation, simultaneously creating increased demand for quality care as well as increasing family members’ sense of control during the delivery process.

Next Steps

The M4ID team is currently finalising the design of the tools. The final set of tools will then be piloted and tested across multiple low-resource countries over the next two years.

Read more about BOLD on