Monitoring intrapartum fetal heart rates by mothers in labour in two public hospitals: an initiative to improve maternal and neonatal healthcare in Liberia

In Liberia, over the past 6 years, a partnership between the Ministry of Health and Social Welfare (MOHSW), The World Health Organization (WHO), The United Nations Population Fund (UNFPA), the Liberian Board for Nursing and Midwifery (LBNM) and the registered charity (not-for profit organization), Maternal and Childhealth Advocacy International (known as MCAI), has been established to train senior birth attendants (19 midwives and 2 physician assistants) in advanced obstetrics to become obstetric clinicians, able to undertake emergency clinical procedures to expedite the delivery of a distressed fetus, such as vacuum delivery and Caesarean section [18]. Currently, 10 obstetric clinicians have completed training, 10 more are currently in their final year of training and 9 more have just been appointed following an examination and interview.

More recently, the partnership initiated a new programme to improve neonatal resuscitation and hospital neonatal care by training selected nurses and midwives to become advanced neonatal nurse practitioners (neonatal clinicians) and is now based in both of the two hospitals involved. Currently three have completed their training, 6 are in their final year and 8 have just been appointed following an examination and interview.

The fetal monitoring initiative took place in CB Dunbar Hospital in Bong County and CH Rennie Hospital in Margibi County. The main training hospital for both obstetric clinicians and advanced neonatal nurse practitioners (neonatal clinicians) is CB Dunbar Maternity Hospital. During this initiative and working in these two hospitals, there was one fully qualified and licensed obstetric clinician, 4 trainee obstetric clinicians and 9 trainee neonatal clinicians at CB Dunbar Hospital. There were 5 trainee obstetric clinicians at CH Rennie Hospital but no neonatal clinicians at the time of this feasibility study.

This initiative represented an integrated project between obstetrics and neonatology. Both qualified and trainee obstetric clinicians and trainee neonatal clinicians and their trainers were involved.

The management committee oversaw the day to day running of the initiative and was responsible for the data analysis. If there were any problems identified, in particular involving the need for improving the recording methods, the management committee would make the necessary changes to the initiative as appropriate.

As members of the management committee, two trainee Obstetric Clinicians (KP and NJ), and the international advanced neonatal nurse practitioner (AK) managing the recently established neonatal intensive care unit, led the day to day running of the fetal monitoring component of this initiative.

The fetal monitoring project started as a service delivery intervention; when authors realized the possible significance of the outcomes, we decided to approach the work from a research angle for publication. As a programmatic intervention, it was fully within the domain of the Ministry of Health to implement. Re-framed as a research project, it was relevant to seek National Research Ethics Board approval.

Because of poverty and complex social circumstances, it is common for mothers in Liberia to be aged under 16 years. Also, young mothers frequently attend the hospitals in labour by themselves, with no legally assigned family members in attendance and sometimes only a traditional birth attendant for support. Many women and adolescent girls do not know their age, and the illiteracy rate in Liberia is high (63%) [19].

Over a 15-month period (from 31 July 2017 to 24 October 2018), 474 women admitted in the active first stage or second stages of labour, who were not experiencing any complications such as haemorrhage, severe pre-eclampsia or obstructed labour, were invited to participate. Before participation, each mother was asked to give her informed consent by a trainee or fully trained obstetric clinician. Initially (given a female literacy rate from UNICEF data 2011–2016 [19] of those aged 15 to 24 years of approximately 37%) this consent was requested verbally and recorded and later (after 27th April 2018) a dedicated consent form was signed (either by fingerprint or in writing).

From the start, all authors considered this work as the implementation of a new project that would improve health service delivery, in particular regarding fetal monitoring during labour. The severe lack of midwives and the infrequency of adequate completion of the partograph, indicated to the authors that this project was an essential part of health service delivery rather than a research study. The project had the prior approval of the Liberian Ministry of Health. As the focus was improved health service delivery and did not involve any invasive procedures, authors initially sought verbal consent from all potential participants. However, as the initial results of the project were so encouraging, authors recognised the value in sharing our experience of this project through a peer-reviewed publication and so changed the consent process to require written consent from all participants. Informed consent, written or verbal, was therefore obtained from all participants.

Throughout, this non-invasive project was supervised by the Liberian Ministry of Health (the original Minister of Health, BD, up to January 2018 and current Minister, WJ, from January 2018 are both authors of this paper).

The seeking of consent, whether verbal or written, was dependent on each woman understanding what was being requested of her. The consent form (part of the Additional File 1) was read out and discussed with each woman before she was enrolled in the study. Only women or adolescent girls (those potential participants aged under 18 years) who fully understood what they were being asked to undertake were recruited. The obstetric clinicians who gained consent were skilled health workers with years of experience in managing pregnant women in Liberian public hospitals. All had undergone a medical ethics and professional standards course as part of their training. Therefore, these health workers were well placed to ascertain if each woman who was invited to participate understood what was required. Each woman could change her mind at any time, and her wishes were always respected.

Having determined what was a normal rate, the mother was then asked to identify and immediately inform a midwife of any changes in the FHR that she detected. In the ward areas in the hospitals undertaking this initiative, there is no buzzer or bell alert and so if a participating woman thought that she had detected a change in FHR, she called out for a midwife or obstetric clinician to come and confirm possible changes. As the labour wards in both hospitals were small, this system worked well. Sometimes, the mothers reported actual heart rates (if literate) but mostly identified a fall or increase in heart rates without counting the numbers involved. The midwives and obstetric clinicians who responded to the mother, recorded and reported the actual heart rates. Additional File 1 contains the form that was used for the recording process which was completed as soon as possible after delivery.

Additional file 2 is a Table containing the comments made on the monitoring process by the mother, either written directly or transcribed for illiterate mothers by the obstetric clinician completing the form. To help with anonymity, age groups for each participant have been used instead of actual ages.

In all participating women, the partograph was supposed to be completed according to WHO recommendations by a midwife on the labour ward every 30 min during the first stage and every 5 min during the second stage of labour [20, 21]. However, in reality, the fetal section of the partograph was inconsistent and rarely completed due to time pressures on the small number of midwives available.

If a participating woman decided that she could not continue to monitor the FHR, for whatever reason, her wishes were respected and documented. If a woman’s condition during labour made it difficult for her to continue making recordings, a midwife or obstetric clinician would, if possible, and if time allowed, assist or take over the monitoring from her with the woman’s permission.

If a woman declined to undertake the monitoring herself but still wanted her fetus to be monitored, with the mother’s permission, the monitoring could be done by a midwife or by an obstetric clinician, provided they had time available given their heavy workloads.

The midwives working in the two hospitals were informed of the plans and scope of the initiative by the management committee team and educated in their role and responsibilities regarding the initiative, especially that they must, if possible, respond immediately when alerted by the participating women to a change in FHR and to examine the woman. If the FHR was potentially of concern, the midwife would then immediately notify the obstetric clinician and/or doctor on duty who would assist the midwife in the management of labour until the FHR had either recovered or the baby was safely delivered (as per the birth asphyxia prevention protocol: see below). This remedial protocol was already in place on the maternity units should potential fetal distress be detected. However, unfortunately, FHR monitoring as part of the partograph was rarely undertaken prior to this initiative for reasons outlined in the earlier “Background” to this project. At CB Dunbar Hospital, the neonatal clinician on duty would also be asked to be present at the delivery to resuscitate the neonate if necessary.

The clinical condition of the baby at birth, the need for neonatal resuscitation, admission to the neonatal unit and any signs of subsequent birth asphyxia (also known as Hypoxic Ischaemic Encephalopathy: HIE) were documented. A clinical summary of the pregnancy and delivery was also documented.

From 23rd October 2017, through written or verbal comments (the latter transcribed by the midwife or obstetric clinician), mothers were asked for their views on the monitoring process.

One hundred fifty-three out of 154 participants who had consented at CH Rennie hospital (where the project started on 21st March 2018) were approached for comment (on admission one potential participant’s fetus was found to be dead during her training in monitoring).

This request for comments was not in place for the 33 of the consented mothers, who had enrolled before 23rd September 2017 at CB Dunbar Hospital.

Two authors (DS and RM), categorized the comments retrospectively by first agreeing the common themes after reading all of the comments provided by the participating women. Any discrepancies between DS and RM were discussed and agreed by consensus.

The comments in Table 3 were selected as being representative of the basic themes, as subjectively agreed by the two authors RM and DS. The full set of comments from all participants are available in the Supplementary Information (Additional file 2).

MCAI was responsible for the data analysis and undertook a descriptive analysis.

The lead obstetric clinician in each hospital (KP and NJ) was responsible for charging the batteries and for ensuring gel, consent, and monitoring forms were constantly available. Forms were scanned and sent to the UK by MCAI programme and finance managers in Liberia (Fig. 1).

Over 15 months from 31 July 2017 until 24 October 2018, 474 women (157 from CH Rennie and 317 from CB Dunbar Hospitals) admitted in the first or second stages of labour and without obstetric complications were approached. Four hundred sixty-one gave their informed consent to participate in the FHR monitoring (97%) and 13 declined.

Maternal age was available for 416 of 461 participants. 51 (12%) were aged under 18 years (24 mothers aged 17; 18 mothers aged 16; 5 mothers aged 15; 3 mothers aged 14; and one mother aged 13 years).

Four hundred participants provided written or verbal (transcribed) comments on their experiences of the monitoring. Their comments included reference to the lack of any pain control, which was not available during labour in any of the public hospitals in Liberia at the time of this initiative.

Three hundred eighty-seven mothers found listening to their unborn baby a positive experience expressing one or more of the following words or phrases: alright, not bad, good, fine, helpful, loved or liked it, happy, comfortable, gives me joy, or other positive comments such as “Thank you”. A selection of these comments is shown in Tables 3, 4, 5 and 6, including some from mothers who identified changes in FHR. The complete set of comments from all participants are available in the supplementary information (Additional file 2).

Thirteen participants reported only negative comments: 5 reported weakness or tiredness (including feeling nauseated in one case), 6 reported pain (which in 3 interfered with the monitoring), 1 said it was not easy and 1 said it was bad.

Selected maternal comments from mothers at both Hospitals (additional maternal comments following changes in fetal heart rate are reported in Tables 4 and 6below).

Out of the 387 providing positive comments, 86 also reported how much they were affected by pain or severe pain. This pain interfered with their ability to undertake the monitoring in 52 of the 86 (60%).

Within the 387 with positive comments, 44 women also reported discomfort, 5 reported tiredness and weakness and 4 reported difficulties applying the sonicaid.

Three mothers said that they would hope that monitoring would be available during their future pregnancies. Six mothers said they would return to the hospitals to deliver in the future as a result of the project. An additional 6 mothers said they would hope that monitoring will continue to be available so that other mothers can benefit and 5 said they would encourage other mothers to participate. Nine participants said monitoring helped them to cope with labour pain.

As the forms were to be completed by busy obstetric clinicians, not dedicated researchers, forms were designed to record the most relevant information for the purposes of the study objectives rather than detailed information which, although useful, was not necessary for the purposes of this initiative and could have taken the health workers away from their clinical work.

The initial design of the tick sheet documenting each contraction monitored did not always allow enough space to record every contraction and obtaining extension sheets was sometimes a logistic problem. To minimise the workload of the scarce midwifery workforce, forms were also re-designed to record clinical data that were appropriate but not excessive given time restraints.

Due to a communication problem, 57 mothers at CB Dunbar Hospital (between 19 Feb 2018 and 8 May 2018) incorrectly monitored their FHR every 30 min (similar to the partograph). However, unlike the partograph, monitoring was always undertaken for approximately 60 s immediately following the nearest contraction to each 30-min window. We did not identify any clinical differences or differences in experiences between the 57 women who monitored the fetal heart every 30 min and the women who monitored after every contraction.

In 474 mothers approached for consent, there were 33 caesarean sections (7.0 %) including 14 with FHR changes. There were 20 vacuum deliveries (4.2 %) including 8 with FHR changes, (the latter included a mother with a stillborn baby identified during the training in the use of the sonicaid, confirmed by ultrasound scan).

Clinical information and outcomes where FHR changes were identified by monitoring Table 4.

Fetal death was identified on admission during training in the use of the sonicaid in one mother (see Table 4 below).

Table 4 describes the clinical information and outcomes relating to identified FHR changes. Changes in FHR were reported in 28 of 461 participants (6.1%,) which in two cases were not confirmed by the attending midwife, giving 26 confirmed cases (5.6%). Twenty-four of these FHR changes were first identified by their mothers. In 23 of the 26 confirmed cases, the FHR decreased and in 3 the FHR increased. Two changes related to unrecognized obstetric complications, with one mother found to have Bandl’s ring with obstructed labour and the other, cord prolapse.

All 26 neonates with changes identified in FHR survived, including 13 requiring resuscitation at birth. Twelve neonates were admitted to the neonatal unit. One neonate developed birth asphyxia/HIE but the immediate clinical outcomes of the 25 other neonates were good and all 26 were discharged home apparently well.

One of the 26 changes in FHR was identified by a midwife who had taken-over monitoring from a mother who became too tired to continue. In a second case, the mother had declined to undertake monitoring herself but had consented to the monitoring being undertaken by a student midwife.

In 16 of the 26 with confirmed FHR changes, plus 1 intrauterine fetal death detected on admission, there was accompanying meconium-stained liquor.

Thirteen of the 26 (50%) neonates with prior FHR changes had low Apgar scores and needed resuscitation. There were no deaths following resuscitation. One baby had convulsions managed with Phenobarbital, recovered, and was feeding normally at discharge home aged 7 days. None of the other 26 neonates developed birth asphyxia (also known as Hypoxic Ischaemic encephalopathy-HIE). However, long-term infant follow-up was not undertaken.

Seven of the 26 neonates with confirmed FHR changes, plus 1 who had suffered intrauterine fetal death, were born by vacuum, 14 by Caesarean Section (CS) and 5 by vaginal delivery. In one case, CS followed a failed vacuum delivery.

Clinical information and outcomes in 3 newborn infants needing resuscitation at birth where mothers had declined to participate in FHR monitoring. Table 5.

In one such case, the baby was born with Apgar scores of 2 at 1 min and 3 at 5 min and, despite resuscitation, died of HIE in the neonatal unit aged 2 days. In 2 other cases, there were low Apgar scores at 1 and 5 min (4 and 6; and 2 and 6) and the babies needed resuscitation. Both were admitted to the neonatal unit. One responded well to resuscitation with no evidence of HIE and was discharged home well. The other died aged 3 days from birth asphyxia/HIE.

Clinical information and outcomes in newborn infants needing resuscitation at birth where monitoring had not identified any FHR changes. Table 6.

In addition to the neonates requiring resuscitation where FHR changes had been detected, 8 other neonates without detected changes in the FHR required resuscitation (Table 6). Two were of low-birth weight (1.8 and 1.3 Kg). Despite resuscitation for 25 min one of the low birth weight babies died at birth. None of the 7 babies who survived showed evidence of birth asphyxia/HIE.

In one mother, a vacuum delivery was undertaken for inability to push during the second stage of labour., Apgar scores were 5 and 8 and the baby required  10 min of bag and mask ventilation. He was discharged home aged 7 days well. No evidence of birth asphyxia/HIE was evident on clinical assessment.

Three cases were born following vacuum delivery and 5 cases by vaginal delivery. In one mother progress of her fetus was arrested at the perineum and an episiotomy was undertaken to expedite vaginal delivery.

Three of these 8 neonates had been monitored in utero only every 30 min in a temporary deviation to the protocol because of a communication problem with one of the trainee obstetric clinicians but none developed birth asphyxia/HIE.

The costs of the project were low. The fetal doppler monitors (Sonicaids: 12 in total) cost USD 40 each. Rechargeable AA batteries were used. Additional costs included paper and printing for the consent, data collection and monitoring forms including the internet costs of scanning and sending them to MCAI for analysis, and KY jelly (or locally available clear hair gel) for interfacing the ultrasound probe with the abdomen: commercial ultrasound gel was too expensive.

Because of problems with the completion of medical records and the work pressure on the health workers involved, it was sometimes difficult to fill the gaps of any missing information, such as birth weights, retrospectively. Every effort was made by the management committee to minimise missing data, especially regarding maternal and neonatal outcomes.

This initiative aimed to assess whether mothers were able to undertake fetal heart rate monitoring of their unborn babies immediately following the end of every contraction during labour in two rural public hospitals in Liberia, a country with extremely poor resources (both human and material). As 93% of consenting mothers were able to undertake the monitoring themselves until their baby was born, the results suggest that this approach is feasible.

The comments and feedback from the participating women and adolescent girls (not just those selected in the Maternal Comment sections of the tables but also the complete set of comments provided in Additional File 2 as supplementary information), showed that the overwhelming response (387 out of 400) was positive, with several comments reflecting how the monitoring helped a women/ adolescent girl “feel strong”, cope with the pain of labour, or made her feel closer to her baby.

In our experience, it is most unusual for mothers in Liberia (as in many other low-resource settings where the hospital workforce is so limited and stretched) to be asked for their opinions on their experiences of labour and how it was managed. We asked for their opinions in an open way and did not raise the question as to whether they would prefer any alternative approaches to fetal monitoring, as stretched resources, lack of health workers, and subsequent high workloads, made such alternative approaches unfeasible. Also, as explained in our Background, without this approach, many women would not have had her fetus routinely monitored because of the scarcity and high workload of midwives.

To go through a pregnancy only to have a fetus or baby die because of a preventable condition that might have been detected by adequate fetal monitoring is a tragic and traumatic experience. This initiative may have helped to prevent some deaths, while helping women/adolescent girls feel involved in what was happening to them and their babies during labour.

Studies of mothers assisting midwives in monitoring the FHRs of their unborn babies have not been previously reported, as far as we can identify, so it is difficult to compare our results with other studies.

This initiative confirmed that midwives responded to alerts from mothers regarding changes in FHR in a timely fashion and that trained, senior, health professionals (obstetric clinicians and doctors) were able to intervene appropriately and promptly. In 26 out of 461 women undertaking monitoring (in one undertaken with consent by a student midwife and the other by the midwife who took over from the mother who became tired), confirmed changes in fetal heart rates were identified. Actions to improve the placental circulation (such as lateral tilt, oxygen and intravenous fluids), and, where possible, expedited delivery by vacuum or Caesarean section were undertaken following standard obstetric management as recommended by WHO [21].

All 26 neonates with changes in FHR survived, including 13 requiring resuscitation at birth. Ten neonates were admitted to the neonatal unit. One neonate developed birth asphyxia/HIE, but the immediate clinical outcomes of the 25 other neonates were good and all 26 were discharged home apparently well. However, long-term infant follow-up was not undertaken and should be in the future. The presence of neonatal clinicians and a functioning neonatal unit at CB Dunbar hospital were particularly valuable. Neonatal units that can provide advanced neonatal care by appropriately trained nursing staff (also a form of task-sharing) have now been established at 2 other rural county hospitals in Liberia.

In two mothers, the identification of FHR changes revealed previously unrecognized life-threatening obstetric complications. More experience may identify whether maternal FHR monitoring can consistently identify obstetric complications. Our results support Hofmeyr and colleagues [16] who stressed the importance of task-sharing in the integration of obstetric and neonatal care. Rapid access to effective obstetric management if FHR changes are identified must be ensured. Fetal monitoring in isolation has little value without an available health support system so that appropriate clinical intervention can be promptly undertaken. This situation may not be the case in some resource-limited settings, limiting the applicability of maternal fetal monitoring.

Comparing figures with those from Tanzania [14] and from Sub-Saharan African countries [1, 12, 13, 15], the absence of intrapartum stillbirths in the 461 fetuses monitored is encouraging, as is the low prevalence of birth asphyxia/HIE. However, given no comparator, we cannot conclude that stillbirths and birth asphyxia/HIE can be prevented or reduced by maternal FHR monitoring. However, in reality, the lack of comparator data is represented by almost no fetal monitoring in public health hospitals in Liberia. We considered having a control group for this study, but decided that given the situation described in the “Background”, such an approach would have been difficult. However, partway through this initiative, data on neonatal deaths and intrapartum stillbirths began to be collected by the Ministry of Health in Liberia. In the future, such data may provide control information for those maternity facilities where maternal FHR monitoring has not yet been undertaken.

Since we do not have robust baseline (comparator) data we cannot at this stage comment on whether Caesarean Section or operative vaginal delivery rates were increased or decreased by maternal FHR monitoring.

This initiative was conducted in a “real world” setting and suggests that maternal fetal monitoring can be incorporated into the daily work of a busy hospital maternity unit. The constant presence of obstetric clinicians was of considerable assistance, but such experienced health professionals may not always be available and alternative plans to address the health-workforce-shortage may be needed. Even with this additional cadre, communication and adherence to the study protocol were sometimes difficult, depending on the enthusiasm and involvement of all health professionals. Feedback of results to the midwifery workforce appeared helpful. Although we did not explicitly seek the views of attending midwives, which was a major limitation, the finding that midwives sometimes took over the monitoring if a woman was too tired or in too much pain to do it herself, shows their engagement in the process. More information from midwives could also be useful in helping to improve this technique, make it more sustainable, and give a further guide to the additional time needed to undertake maternal-fetal monitoring.

The potential for blaming mothers if there is an adverse outcome for their baby due to perceived failings in their self-monitoring is a very important consideration. However, there was no evidence that this situation happened, and, in our view, potential blame is unlikely as sadly, neonatal death and stillbirths are such common experiences in Liberia, that such events are almost expected.

We appreciate the frequency of monitoring can be onerous for some women, but there was no provision for birth partners or other relatives to be with women during labour, because of shortage of space and lack of privacy. We are planning to address this situation in the future.

The long-term solution to fetal monitoring and improving the care of women in labour and their babies is undoubtedly to increase the availability of trained midwives. However, as explained in the “Background” to this paper, and especially the Global WHO/World Bank data concerning midwives and nurses [2], given the current situation in Liberia and many other low income settings with minimal midwives and nurses, a vast amount of resources and an increase is suitably trained health workers would be necessary to meet this goal, which is not possible in the short-term. However, once and if this situation is achieved, given the positive responses of participating mothers, we would continue to consider that the involvement of mothers in fetal monitoring may work well in collaboration with the enhanced role of skilled birth attendants.

The need for resuscitation in 8 of 461 (1.7%) of babies born without FHR changes identified by maternal monitoring, requires future research to ascertain whether changes are being missed or whether in some cases there are no measurable FHR changes identifiable by this monitoring technique in fetuses who subsequently require resuscitation. In particular, it is important to know whether mothers and/or midwives can monitor reliably after every contraction with the same quality during the end of the first and second stages of labour when contractions can be much more painful.

When appropriately undertaken and documented, with timely responses by care givers, the partograph is of major value in monitoring the progress of labour and safety of mother and her fetus. In support of Hofmeyr et al. [16] who stressed the importance of task-sharing (in this case involving mothers), our findings show that it is feasible for pregnant women to undertake fetal heart monitoring during labour so that changes in FHR in relation to the end of every contraction are monitored. A decrease in FHR that persists after the end of a contraction, or continues after a contraction, is more likely to be pathological (Type 2 decelerations). WHO recommendations in place at the beginning this initiative [20, 21] specified FHR documentation on the partograph every 30 min in the first stage and every 5 min in the second stage of labour and not with every uterine contraction, as in our initiative. Moreover, in these earlier guidelines [21], WHO had recommended that the FHR be listened to immediately following the end of a contraction ONLY during 1) the initial assessment of the mother during labour; 2) when malpresentation or malposition are present; and 3) when inducing or augmenting labour. However, during the implementation of this initiative, in February 2018, WHO updated its guidelines on intermittent FHR auscultation in labour, now recommending auscultation every 15–30 min during the first stage, and every 5 min during the second stage of labour stating that auscultation should begin during a contraction and continue for at least 30 s after the contraction has ended [7]. These latest guidelines also recommend that if the FHR is not always within the normal range (110–160 bpm), auscultation should be prolonged to cover at least 3 contractions and also recommend recording the baseline FHR and the presence or absence of accelerations and decelerations [7]. These updates in guidelines are welcome but, in our opinion, are quite complex, difficult to implement in facilities where there are few midwives, and do not concentrate on the most important time for intermittent auscultation, that is, at the end of every contraction. Our approach which involved auscultation from the end of every contraction, was relatively easy to teach, convenient and feasible for individual mothers to undertake, and covered the most critical time for monitoring. For low resource settings, this approach may merit consideration by WHO and the wider international community.

Future expansion of the project to include the possible role of female relatives and traditional birth attendants in supporting the mothers during monitoring, especially at times when contractions are particularly frequent and painful around the end of the first stage and during the second stages of labour, could be helpful. Unfortunately, the lack of space, privacy and resources such as toilets in the labour and delivery wards at present does not readily support this approach. Helpers such as traditional birth attendants or nurse aides may also be of value in collecting baseline/comparative data, and feedback from midwives.

An introduction to self-fetal monitoring during labour at antenatal visits would be beneficial, noting that a significant proportion of pregnant women in rural Liberia do not always attend their assigned antenatal clinics.

The mothers’ comments on the lack of any pain control were of great concern and several mothers were clear about the need for pain control during labour. We have now followed up on the need for adequate pain control during labour within the Liberian Ministry of Health and Social Welfare and have started a clinical audit on the use of intravenous paracetamol at CB Dunbar Hospital.

Some mothers stated that they would encourage relatives and friends to attend the hospitals involved in this initiative so that they might benefit from the fetal monitoring process. Given the encouraging findings of this study, we suggest that other hospitals in low resource settings, where there are few midwives and consequently, inconsistent fetal monitoring on the partograph, consider introducing maternal FHR monitoring, possibly assisted by relatives where circumstances allow. Although a small minority of mothers expressed negative comments, there does not appear, to the best of our knowledge, to have been have any negative clinical consequences to maternal fetal monitoring. Given the circumstances in countries where there are so few nurses and midwives, this approach supports realizing the rights of adolescent girls and women by enabling them to become more involved in their health care and the welfare of themselves and their unborn babies.

This initiative is continuing in both CH Rennie and CB Dunbar hospitals with further expansion planned in the near future to three additional rural maternity hospitals in Liberia.