Effect of the WHO Labour Care Guide Implementation on Maternal and Newborn Outcomes in Selected Referral Hospitals of Zambia: A Difference-in-Differences Analysis

Background Despite being originally developed to support labour monitoring in low-resource and rural settings, the partograph has remained the standard tool for labour management and continues to be used by obstetricians and midwives across diverse settings worldwide. However, inappropriate use and non-use of the partograph persist and have been associated with increased odds of adverse perinatal outcomes, including perinatal death. To address these limitations, the World Health Organization introduced the Labour Care Guide in 2020 as a comprehensive tool to standardise and improve the quality of care during childbirth. Henceforth, some countries such as Rwanda and Uganda have since implemented its use. This study aimed to assess the effect of WHO Labour Care Guide implementation, compared with the traditional partograph, on selected maternal and perinatal outcomes across participating facilities. Methods This was a quasi-experimental implementation study conducted in selected referral hospitals in Zambia, comparing maternal and perinatal outcomes before and after implementation of the WHO Labour Care Guide. Facilities were grouped into implementation and comparison sites. Routine HMIS/DHIS2 data were used to assess selected outcomes across the pre- and post-implementation periods. Descriptive statistics were used to summarise outcome trends, while a difference-in-differences analytical approach was applied using Stata version 18 to compare changes over time between implementation and comparison sites. Results The analysis included 12 hospitals, 192 facility-month observations, 89,122 total births, and 87,004 live births. Overall, the stillbirth rate was 23.8 per 1,000 total births, birth asphyxia rate was 40.1 per 1,000 live births, caesarean section rate was 34.6 per 100 live births, low-birthweight rate was 168.6 per 1,000 live births, and maternal mortality ratio was 313.8 per 100,000 live births. The implementation sites reporting higher birth asphyxia rates (42.7 versus 38.0 per 1,000 live births). Difference-in-differences analysis showed no statistically significant effect of LCG implementation on stillbirths, IRR 1.07 (95% CI: 0.69-1.67, p=0.752); fresh stillbirths, IRR 1.23 (95% CI: 0.74-2.05, p=0.431); birth asphyxia, IRR 0.65 (95% CI: 0.34-1.27, p=0.207); or caesarean section, IRR 1.02 (95% CI: 0.80-1.30, p=0.892). Conclusion Implementation of the WHO Labour Care Guide was not associated with statistically significant changes in stillbirths, fresh stillbirths, birth asphyxia, or caesarean section rates during the study period. Despite the higher birth asphyxia rates in the implementation sites the difference remained statistically not significant. Scale-up of the LCG should be accompanied by sustained training, mentorship, audit and feedback, and strengthening of emergency obstetric and newborn care systems.