Over one-third of maternal deaths, nearly half of stillbirths, and a quarter of neonatal deaths are caused by complications during active labour (World Health Organization [WHO] 2020). While some maternal and neonatal deaths could be averted through prompt and effective interventions (WHO 2020), about 94% of these fatalities occur during the use of the partograph in low- and middle-income nations. The partograph is a monitoring tool used to monitor the well-being of the mother and foetus during labour by displaying the progression of cervical dilation over time (Mugyenyi et al. 2024). The partograph has been utilised as a standard tool for monitoring women in the latent phase (Mugyenyi et al. 2024). However, it does not incorporate any provisions for midwives to administer mild pain relief medications, such as paracetamol. Recent evidence (Hofmeyr et al. 2021; Patabendige, Wickramasooriya & Dasanayake 2021) suggests that the partograph may not yield significant benefits. Moreover, current research and global priorities indicate that the partograph has not fulfilled its original goal of enhancing the childbirth experience (Hofmeyr et al. 2021; Patabendige et al. 2021; WHO 2018). This study aims to understand midwives’ experiences and perceptions of implementing WHO Labour Care Guide (LCG).

In 2018, the WHO, in accordance with new recommendations on intrapartum care to enhance the childbirth experience, conducted a review and revision of the partograph design (Patabendige et al. 2021; Vogel et al. 2021; WHO 2018). This led to the creation of the LCG, the next generation partograph, in response to emerging evidence (Pingray et al. 2021). On the other hand, the LCG is a comprehensive resource designed to facilitate the provision of high-quality, evidence-based, and compassionate care throughout the process of labour and childbirth, irrespective of the healthcare setting or level of service available (WHO 2020). When utilised appropriately, the LCG not only facilitates the accurate identification of prolonged labour promptly, thereby avoiding unnecessary procedures and interventions, but it also enables the timely implementation of interventions to mitigate the risks associated with obstructed labour, including postpartum haemorrhage, sepsis, uterine rupture, and maternal and neonatal mortality (Mugyenyi et al. 2024). Importantly, the LCG covers both the first and second stages of labour in a multifaceted way, with special attention paid to monitoring and avoiding prolonged labour, unnecessary oxytocin augmentation, and cesarean deliveries (Patabendige et al. 2021).

The implementation of the LCG allows healthcare practitioners to effectively observe the health status of expectant mothers and their infants throughout the childbirth process through routine evaluations designed to detect any abnormalities without unnecessary interventions (Ghulaxe et al. 2022; Henderson 2020; WHO 2020). In addition, the LCG includes the woman’s companion of choice during labour and childbirth, ensuring respectful care, good communication, confidentiality and the ability for women to make decisions about their pain management, labour positions, and pushing (WHO 2018). The implementation of the LCG has been found by many studies (Patabendige et al. 2021; Mugyenyi et al. 2024; Vogel et al. 2021) to provide evidence-based care, yet the evidence regarding its effectiveness remains inconclusive. While a study by Laisser et al. (2021) presented positive perspectives on the implementation of the LCG, Vogel et al. (2021) highlighted challenges in incorporating the companionship element of LCG in settings such as India, Kenya, Malawi, Nigeria, and Tanzania, primarily because of the substantial workload in those countries’ labour wards.

Patabendige et al. (2021) suggested that the introduction of the LCG should be a gradual process with continuous audits and quality assessment, while Bovbjerg, Pillai and Cheyney (2021) found the LCG to be an essential tool, but argued that more work needs to be done to address the root causes of maternal and infant morbidity and mortality. More extensive research thus needs to be done on context-specific experiences and unique challenges in order to provide tailored recommendations and insights that can enhance the overall effectiveness of the LCG.

The training of registered and enrolled midwives in Namibia includes undergraduate certificates, diplomas and degree programmes, as well as postgraduate education offering specialised courses such as an advanced diploma in midwifery and neonatal nursing care (The Government Republic of Namibia 2004). Although there is no substantial data available on the ratio of birthing women to midwives in Namibia, it is the responsibility of all midwives to oversee and facilitate deliveries (Mlambo & Amukugo 2023). The Ministry of Health recommends that all women give birth under the guidance of a midwife who possesses the necessary skills and knowledge to support them throughout the birthing process (Ashipala & Mutsindikwa 2022). However, the country is grappling with a shortage of essential equipment related to the birthing process and is struggling to address a 40% deficit in nursing staff, including midwives who serve as the primary point of contact for expectant mothers (Mbathera 2022; U.S. Agency for International Development 2019). Consequently, Namibia’s maternal mortality ratio is estimated to be between 215 and 265/100 000 live births (Ashipala & Mutsindikwa 2022; World Health Organization Labour Care Guide Research Prioritization Group 2023).The government of Namibia aims to reduce this ratio to 70/100,000 live births by 2030, in alignment with sustainable development goal 3 (SDG 3)-good health and well-being. However, an enquiry into maternal deaths in Namibia from 2018 to 2019 reported that, because of several challenges such as staff and equipment shortages, record keeping was not being done consistently (Heemelaar et al. 2023).

Midwives assume a diverse range of roles and carry out numerous responsibilities to guarantee high-quality care during the birth process (Mattison et al. 2020). To prioritise the safety and welfare of mothers and newborns throughout the childbirth process, Namibia recently introduced national guidelines for antenatal care services and maternity records (Ministry of Health and Social Services [MoHSS] 2021), and has replaced the partograph with the LCG since 2019. Midwives’ perceptions or beliefs of quality care serve as an indirect yet valuable indicator of the successful implementation of the WHO’s recommendations for intrapartum care in Namibia. Despite several studies on various labour practices aimed at improving outcomes in maternity care (Mugyenyi et al. 2024; Pingray et al. 2021; Vogel et al. 2021; WHO 2018), the only study (Laisser et al. 2021) that focused on midwives’ views of LCG revealed a reluctance to implement LCG. Although LCG presents numerous evidence-based benefits, including enhancements in the childbirth experience and improved outcomes when active labour begins at 5 cm of cervical dilation (Hofmeyr et al. 2021; Patabendige et al. 2021; WHO 2018), it does not accommodate women in the latent phase (5 cm), who necessitate some level of monitoring. Research in this area would yield valuable insights into midwives’ experiences and perceptions of implementing the LCG for monitoring expectant mothers in Namibia. This study explored and described midwives’ experiences and perceptions of using WHO LCG at a training hospital in Namibia.

In this study, we explored and described midwives’ experiences and perceptions of the use of the WHO’s LCG at a training hospital in Namibia. The findings revealed several barriers to utilising the LCG. Midwives highlighted that the use of traditional oxytocin (Sivatu) by some pregnant mothers inadvertently leads to accelerated labour, presenting challenges for midwives to effectively monitor the progression of labour using the LCG because of rapid delivery. Furthermore, apart from its role in precipitating spontaneous birth, Sivatu also poses potential risks that can be life-threatening for both the mother and the baby. These findings are in agreement with those of Makombe et al. (2023) and Haikera (2021), who discovered that the practice of using herbal medicine during pregnancy and in labour can result in adverse obstetric outcomes such as uterine rupture. Most midwives indicated that expectant mothers in Kavango East region consume traditional oxytocin, primarily because of their belief that it provides protection for their infants. This finding agrees with previous studies that reported that most women around in the world believe that utilisation of specific herbal medicine is beneficial in hastening labour duration and protecting a baby from harm (Kamel, Boullani & Cherrah 2022; Tsitsi, Tabona & Esther 2021). There is, however, limited evidence of the safety of traditional concoctions such as Sivatu on unborn babies. Future longitudinal and ethnographic studies are thus warranted to investigate the safety of these medications.

The study also found inconsistencies regarding the exclusion of the latent phase of labour from the LCG. Some midwives expressed concerns that the lack of clear alert and action lines makes it difficult to identify problems related to a prolonged latent phase, especially on busy days. The findings of this study support the conclusions of Laisser et al. (2021) and Vogel et al. (2021), who shared that the absence of a graphical display on a chart makes it challenging for practitioners to interpret and identify abnormal labour progress. According to Hofmeyr et al. (2021), the decision to exclude the latent phase of labour in the LCG was based on several factors, including that defining the latent phase was problematic because of its unclear onset and varying duration among women. Nonetheless, some midwives expressed their satisfaction with the absence of the latent phase in the LCG, citing this prevents misdiagnosis of a prolonged latent phase and unnecessary medical interventions, especially in primigravida women. These findings are as per Angeby (2018), who emphasised that removing the alert line is important to prevent unnecessary interventions, such as caesarean section deliveries, instrumental births and oxytocin augmentation. These interventions come with risks like uterine rupture and foetal distress, which can potentially harm both the mother and the baby. To address this, documentation of labour progress is initiated only at 5 cm dilatation once the active phase is diagnosed. Arguably, the discontinuation of the partograph might have provoked anxiety and even antipathy among some practitioners, hence the need to make resources available to support the implementation of the LCG. The lack of consensus regarding timing in monitoring the latent phase of labour could be because of considerable individual variability among patients (Cohen & Friedman 2023).

The midwives also raised concerns regarding the shortage and unavailability of certain essential equipment, such as foetal heart rate monitors. These concerns were exacerbated by a growing number of patients, leading to a suggestion for resource mobilisation. This finding is in alignment with Vogel et al. (2021), who highlighted the significance of ensuring the availability of crucial equipment during the implementation of the LCG. According to Housseine et al. (2020), maternity units in low- and lower middle-income countries are experiencing a growing issue of overcrowding and are facing a significant resource crisis. Under such circumstances, it is extremely challenging to adhere to the LCG’s surveillance regime while simultaneously caring for more than two women in a country like Namibia, which grapples with a scarcity of medical equipment (Kasuto 2022; Rasmeni 2022). These findings regarding insufficient monitoring of mothers during labour lead to delayed identification of problems and increased complications for both mothers and babies (Moyimane, Matlala & Kekana 2017). Equally, insufficient midwives being employed in the maternity ward was highlighted as a major challenge to effectively monitor women in labour. These findings emphasise the necessity for midwives to receive comprehensive training and have readily-available resources to proficiently and effectively utilise the LCG across diverse clinical settings (Mugyenyi et al. 2024; WHO 2023). Similarly, Lumadi, T.G. & Matlala, M.S. (2019) discovered that a shortage of midwives has a direct impact on the provision of quality care.

While companionship is often seen as a positive, midwives in this study surprisingly identified it as a barrier to implementing the LCG. They cited limited hospital rooms and certain African cultural beliefs as the primary reasons. They argued that allowing companions would compromise patients’ privacy and confidentiality and that it is a Western concept, as African men are not permitted to witness women giving birth. Even though companionship during labour is known to provide comfort and advocacy (Afulani et al. 2018; Singh et al. 2021), a key finding of this study is that hospital overcrowding and privacy concerns remain major barriers to allowing it (Munson et al. 2025; Sarwal et al. 2023; Singh et al. 2021; Yaya Bocoum et al. 2023). This finding is consistent with the research conducted by Doba et al. (2023), whose study of birth attendants’ attitudes and the practice of companionship in Ethiopia reveals that societal norms and cultural beliefs are barriers to practising companionship. These findings suggest that encouraging men to be birth companions in Namibia would present a significant challenge because of the deeply ingrained cultural practices and long-standing beliefs that have shaped local societal norms around childbirth (Wesson et al. 2018). There is thus a pressing need to conduct comprehensive awareness campaigns that educate both men and women about the benefits of male involvement during childbirth, as well as to challenge and change the stereotypes that hinder progress towards shared parental responsibilities in this vital aspect of family life.

Participants advocated for specific changes to the LCG to improve record-keeping and quality of care. They recommended adding a column for vaginal delivery type (spontaneous, induced or instrumental) and increasing column sizes. This aligns with findings by Vogel et al. (2021) that vital information like blood type and HIV status is often missing. No literature was found to support an oxytocin space, possibly because of cultural factors in the Kavango region. These findings are critical for healthcare workers, as including this information is essential for proper maternal care.

Despite major challenges relating to the use of the LCG, the midwives highlighted some positive experiences, such as the contribution of supportive care elements, such as oral fluids, posture and pain relief. The interviewees described how these components contribute to maternal hydration, pain relief during labour and facilitation of foetal descent, ultimately resulting in a favourable birth outcome for both the mother and baby. These findings align with the research conducted by Vogel et al. (2021), which demonstrated that practitioners emphasised the use of the LCG as a guide for providing supportive care, regardless of their familiarity with the WHO guidance on supportive care. However, midwives in this study were hesitant to administer analgesics regularly because of concerns regarding potential side effects on both the mother and baby; paracetamol was identified as the most frequently used pharmacological pain relief method in this study. In line with Laisser et al. (2021), some midwives in this study questioned the necessity of pain relief as outlined in the LCG, stating the side effects on the baby.

Clearly, midwives agree that LCG is an effective tool for monitoring labour and identifying potential issues. However, they suggest that the tool could be improved by adding more columns and a section to specify the type of vaginal delivery, such as spontaneous, induced or assisted. This study has underscored the LCG’s profound importance in facilitating the monitoring of labour, detecting abnormalities at an early stage, and enabling timely interventions to prevent complications, as previously highlighted in scholarly works (Pingray et al. 2021; Vogel et al. 2021).

This study concluded that midwives have had both positive and negative experiences while utilising the WHO’s LCG. Some midwives have reported that using the guide allows them to monitor labour in real-time, ensuring the well-being of both the mother and her baby. The LCG also provides vital information about the mother’s condition and facilitates timely interventions, which may reduce labour complications and improve maternal and child outcomes. These findings could inform national health policies and contribute to achieving SDG 3 (good health and well-being) by 2030. Midwives also appreciate the additional care components that the LCG provides, such as pain relief, posture, and oral fluids. These elements enhance the childbirth experience and empower midwives to provide comprehensive care.

The use of traditional oxytocin (Sivatu) to speed up labour complicates midwives’ ability to monitor labour progression, according to the LCG. This traditional oxytocin can induce spontaneous delivery, causing a significant life-threatening risk for both the mother and infant because of intense and rapid contractions. To address this issue, it is vital to explore alternative methods and strategies that allow for safe labour monitoring and management, while minimising the risks associated with traditional oxytocin. Additionally, the omission of the latent phase of labour can pose a diagnostic challenge and hamper the timely identification of prolonged labour and other abnormalities. Moreover, a lack of essential equipment, such as foetal heart monitors, further impedes midwives’ ability to recognise potential risks, increasing healthcare costs and increasing the danger for both mother and child. Future research should prioritise conducting a comprehensive study on the acceptability, usability, and feasibility of the LCG using mixed methods research.