Acceptability of the Moyo device for intrapartum fetal heart rate monitoring at a referral hospital in Uganda: a qualitative study

Abstract

Background

The Moyo device is an easy-to-use device that allows continuous electronic fetal heart rate monitoring (FHRM). We explored the acceptability of using the Moyo device for continuous intrapartum FHRM in Eastern Uganda.

Methods

Between November 2023 and August 2024, we introduced the Moyo device for continuous intrapartum FHRM among mothers with high-risk pregnancies at Mbale Regional Referral Hospital in Eastern Uganda. We then conducted 34 in-depth interviews with 14 health workers who had used the Moyo device for continuous FHRM and with 20 mothers on whom the Moyo device was used. Participants were purposively selected and interviewed using a semi-structured interview guide. The interviews were audio recorded and transcribed verbatim. We analyzed data using thematic content analysis in Atlas ti.9 software and presented our findings using Sekhon’s acceptability model.

Results

Participants perceived the Moyo device as a useful and an easy-to-use tool for intrapartum FHRM. Mothers felt involved in monitoring their babies’ condition, with the freedom to ambulate during labour. Moyo facilitated early detection of fetal distress, and triage of patients awaiting caesarean section in a very busy setting. The facilitators to its use were: adequate staff training, health education and counselling of mothers about the device, and tool attributes such as accuracy, reliability and being user friendly. The barriers included poor health worker attitudes, risk of cross-infection, short battery life and the device alarms that were perceived as disturbances.

Conclusion

The Moyo device was acceptable to both health workers and mothers, with perceived improvements in both obstetric outcomes and birth experience. When introducing the device, careful attention needs to be paid to the training of both staff and the laboring women. Potential success of large scale roll out is supported by participants’ positive attitudes toward the Moyo and high perceived effectiveness.

Background

The World Health Organisation (WHO) recommends that intrapartum fetal heart rate monitoring should be done every 15 to 30 minutes in the first stage of labour and every 5 minutes during second stage of labour [1]. In high-risk pregnancies, continuous fetal heart rate monitoring (FHRM) is recommended during labor. Fetal monitoring is suboptimal in most low-resource settings, mainly because the only option is for it to be done intermittently using a Pinard fetoscope or fetal Doppler, with findings plotted on a partograph [2–5]. This practice is not only labor intensive, but also requires adequate staffing and equipment which is commonly not available [5].

Prompt detection of fetal distress during the intrapartum period coupled with appropriate and early interventions can prevent perinatal morbidity and mortality [6]. Up to 40% of the two million annual global stillbirths occur during labor, and many could be prevented with effective intrapartum FHRM [7]. Most of these deaths occur in low- and middle-income countries where quality intrapartum care is still suboptimal, and perinatal morbidity and mortality remain unacceptably high. Sub-Saharan Africa has the highest rate of stillbirths, accounting for nearly half (45%) of the global stillbirths [8]. In Uganda, 60% of the 6100 early neonatal deaths and 84% of the 1500 fresh stillbirths reviewed and recorded in the 2022/2023 maternal and perinatal death surveillance report were attributed to birth asphyxia [9].

Several studies have highlighted the key challenges that hinder provision of effective intrapartum FHRM [10–12]. These include the mismatch between patient volumes and number of staff, inadequate supplies including partographs and equipment, lack of skills, poor knowledge and attitude. One possible solution is to adopt new technologies to make the practice of FHRM quicker and easier [10–12]. The Moyo device is an easy-to-use fetal heart rate monitor that facilitates both continuous and intermittent fetal heart rate (FHR) monitoring [3, 6]. It has a 9-crystal sensor that accurately detects the fetal heart rate (FHR) within seconds and dual electrodes that differentiate the maternal from the fetal heart rate [13]. It also has an audio-visual alarm that is activated if an abnormal FHR is detected [13]. Based on the available literature, we believed that it could be part of the solution to improve intrapartum FHRM and documentation in busy low resource settings. Therefore, in 2023/4, we introduced the Moyo device for continuous intrapartum FHRM among high-risk pregnancies on the labor ward at Mbale Regional Referral Hospital in Uganda. Exploring the acceptability of this device among health workers and mothers is crucial to its successful adoption. In parallel with this intervention, we explored the acceptability of using the Moyo device for intrapartum FHRM, the facilitators and barriers to its use and borrowed upon Sekhon’s acceptability framework to present our results. According to Sekhon, Acceptability is a multi-faceted construct that reflects the extent to which people delivering or receiving a healthcare intervention consider it to be appropriate, based on anticipated or experienced cognitive and emotional responses to the intervention [14]. The theoretical framework of acceptability (TFA) consists of seven component constructs: affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs, and self-efficacy [14].

Methods

Study design

We interviewed mothers and health workers involved in a feasibility study on the use of the Moyo device for fetal heart rate monitoring at Mbale Regional Referral Hospital (MRRH) to explore their experiences with this device.

Study setting

The study was conducted at Mbale Regional Referral Hospital in Eastern Uganda with a catchment population of over 4–5 million people. The hospital has about 10,000 births and 200 stillbirths annually, with a caesarean section rate of 35% [4]. The hospital has one labour ward, six delivery beds, and a dedicated obstetric theatre with a single operating table. The obstetrics and gynecology department is staffed with nine specialists, six senior house officers, ten junior house officers and thirty-five midwives. On average, the labour ward admits twenty-seven mothers in a day and about fifteen mothers require fetal heart rate monitoring at any time. Between two and four midwives are available at any time to monitor and attend to the mothers. Prior to the introduction of the Moyo device, intrapartum fetal heart monitoring at the labour ward in this hospital was done intermittently using either a Pinard fetoscope or a hand-held ultrasound fetal Doppler.

Study population

These included health workers who used the Moyo device to monitor the fetal heart rate (FHR) and mothers whose FHR was monitored using the Moyo device.

Moyo device

The Moyo device (Moyo, Laerdal Global Health, Stavanger, Norway) is a novel strap-on FHR monitor equipped with a rechargeable battery, contains a nine-crystal Doppler ultrasound sensor, which facilitates the rapid identification of FHR. The Moyo can display a 30-minute graph of FHR history, has an audio-visual alarm which alerts the midwife every time there is an abnormal FHR or undetected FHR lasting for more than three minutes. It has two dry electrodes where the mother can place her fingers for heart rate monitoring; both the maternal and fetal pulse rates can be displayed simultaneously allowing differentiation between the two [3, 6] (Fig. 1). During the study, we had a total of seven Moyo devices and these were used to monitor fetal heart rate among women carrying high-risk pregnancies.

Fig. 1.

Moyo (Moyo, Laerdal Global Health, Stavanger, Norway)

Participant selection

Health workers who used the Moyo device for continuous intrapartum FHRM were earmarked by the research assistant and later invited to participate in an in-depth interview. Mothers on whom the Moyo device was used for FHRM were also invited by the research assistant to participate in an in-depth interview shortly before their discharge from the hospital. This process of participant selection was continued until we reached data saturation. A total of 34 in-depth interviews were conducted with health workers [14] and mothers [15]. Participants were purposively selected, aiming for participants with rich experiences in fetal heart rate monitoring, and with variation in age, parity, and educational background. The characteristics of the participants are presented in Table 1. None of the approached participants declined to participate in the qualitative interviews.

Table 1.

Characteristics of participants

Characteristic	Frequency (%) Median (IQR)/ Mean ± SD
Health workers ( n  = 14)
Age (years, median)	27.5 (26–34)
Gender
Male	7 (50.0)
Female	7 (50.0)
Designation
Midwife	8 (57.1)
Medical Doctor	6 (42.9)
Working experience (years, median)	2.5 (1–9)
Religion
Christian	10 (71.4)
Muslim	2 (14.3)
Atheist	2 (14.3)
Mothers ( n  = 20)
Age (years, median)	28 (22–30)
Marital status
Married	19 (95.0)
Single	1 (5.0)
Religion
Christian	16 (80.0)
Muslim	4 (20.0)
Education level
Primary	2 (10.0)
Secondary	14 (70.0)
Tertiary	4 (20.0)

Data collection

We started conducting interviews with the health workers two months into the post implementation phase. The interviews were conducted by two male and two female study midwives trained in qualitative research data collection. We used semi-structured interview guides for the different categories of study participants including health workers and mothers. The guides were used flexibly and modified according to the preliminary findings and as the need arose during the study. All the interviews with health workers were conducted in English because it is the official language of medical education and professional communication in Uganda, and all the health workers were fluent in the language. We interviewed mothers who were at least 24 h after birth, at a time when they felt they were comfortable participating in the interview. Interviews with the mothers were conducted either in English or in their preferable local dialect (Luganda, Lumasaba, Lugwere, Ateso). First, the research assistant explained the purpose of the study to the participant and sought their consent. Upon consenting, demographic information of the participant were collected before starting the interview. All interviews were conducted face to face in a private room within the maternity unit and audio recorded with prior permission from the participants. The interviews lasted between 30 and 60 min and notes were taken during the interview. The collected data was kept confidential and stored on a password-protected computer. All audio recordings were carefully transcribed verbatim in English by the study midwives who had an excellent command of both English and at least one of the local languages (Lumasaba, Luganda, Lugwere and Ateso). Author, RN proofread the transcripts comparing them to the audio recording.

Data analysis

Data were analyzed using thematic analysis according to Braun and Clarke [16]. First, we read the transcripts and became familiar with the data. Secondly, we identified meaningful statements from phrases and sentences to generate the initial codes. Once the data had been sufficiently coded, the third step was to identify potential themes and sub-themes by combining all the relevant codes and data extracts into categories. We then reviewed, modified themes and summarized our findings. Data analysis was done by MM and RN. We used Atlas ti.9 to organise the analysis process.

Rigor and trustworthiness of the data were ensured through triangulation of study participants. Themes and codes were derived inductively, ensuring that the interpretation of transcripts was grounded in the data. The use of trained research assistants, midwives experienced in intrapartum care, and native speakers of the local language ensured the credibility of the findings. We used Sekhon’s acceptability model to present the study findings.

Results

Participant characteristics

A total of 34 participants were recruited; 14 health workers and 20 mothers. The median age of the health workers was 27.5 (26–34) and 8 (57.1%) were midwives. Mothers’ age ranged from 20 to 38 years. Most of them were married and had secondary education. Details are in Table 1.

Acceptability of using the Moyo device for intrapartum fetal heart rate monitoring

The results revealed themes that we present using Sekhon’s framework [14] to understand the acceptability of using the Moyo device for intrapartum fetal heart rate monitoring (Table 2).

Table 2.

A summary of results on acceptability of the Moyo device in Uganda study, reported using constructs from Sekhon’s theoretical framework of acceptability (TFA) [14]

TFA construct	Finding (subtheme)	Meaning unit
Affective attitude Implies how an individual feels about the intervention	Moyo simplifies work	“when the Moyo device came, it made our work simpler, because we are able to monitor these mothers, ideally, every 30 minutes, when she’s within or when she’s even ambulating.” HW 003
	It promotes patient involvement	“With Moyos, the mother is able to know unlike where it is me a health worker only who knows about the fetal wellbeing.” HW 014 “And I also saw that it helps because for you, you may not be knowing that your baby is getting tired but when only the health worker knows but with the moyo device, even me the mother I can know” Mother 003
	It facilitates triage	“it also helps us in triaging these mothers. There might be other mothers who are for C-section, but there is no fetal distress. It might be other indications. So, it helps us in triaging which one goes first, which one goes after the other one. Yeah. And then also it helps us to agree on certain areas.” HW 003
	It promotes patient satisfaction	“Mostly patients get that sensation that you’re really caring for their upcoming babies. Okay. They are newborns. In case you put the device, it shows that sense of bond between the clinician and the mother” HW 013
	Allayed mother anxiety	“I was really disturbed and too much stressed but the moment I heard my baby’s heartbeat is when I calmed down”. Mother 009
	Myths and misconceptions: the Moyo belt delays head descent	“…but the time of pushing, I was feeling like removing the belt, because in my mind, I was thinking that this belt have tied this baby from not coming out because the Moyo was placed down, near my baby’s head, where I am going to push from” Mother 005
Burden and self-efficacy Burden: The perceived amount of effort required to participate in the intervention Self-efficacy: Participant’s confidence that they can perform behavior required by intervention	Moyo is easy to use	“I don’t know which ultrasound of strength it uses, but for it, it can easily pick out compared to even the what, the fetal scopes for the ears, the manual.” HW 012 “So even for a person who does not know how to interpret that result. It is self-explanatory. All you need is to pick where the fetal heart is” HW 009
Intervention coherence and perceived effectiveness Intervention coherence: Extent to which the participant understands the intervention and how it works. Perceived effectiveness: Extent to which intervention is perceived to achieve its purpose.	Moyo can easily be used by non-skilled birth attendants	“We found in our setting that even our patients have learned to interpret it. It is just a matter of giving instructions. Multiple times they have come to us and they are like ‘the other musawo [healthworker] told me that, when it comes to yellow or red, I have to find out what is the problem’.” HW 009
	Moyo promotes early detection of fetal distress	“It helps us even to identify cases of fetal distress early, if really the mothers are few. Even when there are many, we can identify so long as we are using the Moyo, because the Moyo” HW 003
	Moyo guides early intervention	“At least you know now the mother, that one is getting distressed. I should hurry, even in my trial as an intern doctor, it actually even guides me a lot. This one is distressing, I need to save this mother” HW 011
	Moyo use improves birth outcomes	“The Moyo device is good. Yeah, it has helped us save many babies…. because we take up quick actions. Yeah, we don’t wait until things go bad. We make immediate decisions, we save the baby, and mothers go back home happy” HW 013
Opportunity costs and Ethicality Opportunity costs: Extent to which benefits, profits, or values must be given up to engage in the intervention Ethicality: Extent to which the intervention has good fit with an individual’s value system	Noise from the Moyo device	“No, just because of pain, I never wanted that one making noise. Yes, that’s why. It can disturb your mind when it makes noise when you are in pain” Mother 004
	Moyo has a short battery life	“Then the other thing is the battery. Yes, it is rechargeable, but you find sometimes with the mothers, when they move around, you find the batteries are already done” HW 011
	Many false alarms to the mother	“…it makes me worried. Because before they give you, they first tell you the uses of those colors. So, when that color goes to red, you can begin saying, is my baby dead or what?” Mother 012
	Moyo belt can be a source of infection	“Another barrier I missed out was that infection control, because it is used from one mother to another. Liquor pours on the belt; it is made of cloth…” HW 014
	Perceived benefit from the Moyo	“…. the musawo (health worker) told me they are protecting the baby in my womb so that the baby comes out alive and I also knew that very many people have lost their babies in the process of delivery because they don’t know when the baby is tired or alive. So, when she told me it’s to protect my baby, I just accepted her to put it.” Mother 009

Affective attitude

Six subthemes were identified as affective attitudes towards using the Moyo device for intrapartum fetal heart rate monitoring. These were that the Moyo simplified work, promoted patient involvement, facilitated patient triage, promoted patient satisfaction, allayed mother anxiety, and had some myths and misconceptions (i.e. that the Moyo belt delays head descent).

Moyo simplified work

Health workers reported that use of the Moyo device simplified their work of FHRM especially in high patient volumes. This which enables them to monitor the mothers every 30 min as recommended by WHO.

“when the moyo device came, it made our work simpler, because we are able to monitor these mothers, ideally, every 30 minutes, when she’s within or when she’s even ambulating.” HW 003.

Promoted patient involvement in care

Participants highlighted that use of Moyo device for FHRM promotes the involvement of patient and caretakers in their care because they are able to see and interpret the fetal heart rate readings based on the colour codes and alarms from the device.

“Even the caretakers of the patient can easily watch, see and say no, no, something is wrong. They even run to me and say, Musawo (health worker), Musawo (health worker), this is reading, this colour. So I trust the Moyo device because it is a continuous thing. Compared to the what? The Doppler.” HW 011.

Facilitated patient triage

Some health workers reported that Moyo use for FHRM guides them in triaging of patients.

“it also helps us in triaging these mothers. There might be other mothers who are for C-section, but there is no fetal distress. It might be other indications. So, it helps us in triaging which one goes first, which one goes after the other one. Yeah. And then also it helps us to agree on certain areas.” HW 003.

Promoted patient satisfaction

Some health workers also reported that the Moyo device fosters their interaction with patients, thereby enhancing patient satisfaction.

“Mostly patients get that sensation that you’re really caring for their upcoming babies.…. In case you put the device, it shows that sense of bond between the clinician and the mother” HW 013.

Allayed mother anxiety

Mothers reported that the Moyo device was a source of strength to them, they were reassured by hearing their baby’s heartbeat.

“I was in a lot of pain before putting Moyo but when you put moyo, I felt my energy was coming back” Mother 013.

“I was really disturbed and too much stressed but the moment I heard my baby’s heartbeat is when I calmed down”. Mother 009.

Myths and misconceptions: Moyo belt delays head descent

One mother perceived that the tied Moyo belt delays head descent during labour and removed it prematurely.

“at the time of pushing, I was feeling like removing the belt, because in my mind, I was thinking that this belt have tied this baby from not coming out because the Moyo was placed down, near my baby’s head, where I am going to push from. So, I removed the belt and Moyo by myself. Because I felt that it has tied my baby from not coming out.” Mother 005.

Burden and self-efficacy

Moyo is easy to use

Participants reported that the Moyo device promptly picks the fetal heart rate with ease, gives instant feedback on whether its normal or abnormal. They thought this made it easy for even a non-skilled birth attendant to use with minimal instruction.

“So even for a person who does not know how to interpret that result. It is self-explanatory. All you need is to pick where the fetal heart is” HW 009.

Intervention coherence and perceived effectiveness

Moyo can easily be used by non-skilled birth attendants

Some participants highlighted that with guidance, even non-skilled birth attendants are able to monitor the fetal heart rate using the Moyo device.

“We found in our setting that even our patients have learned to interpret it. It is just a matter of giving instructions. Multiple times they have come to us, and they are like the other musawo (health worker) told me that, When it comes to yellow or red, I have to find out what is the problem.” HW 009.

Moyo promotes early detection of fetal distress and intervention

Participants said that the Moyo device enabled them detect fetal distress early. The feedback/alerts from the Moyo device, particularly the alarms prompted the health workers to intervene early.

“At least you know now the mother, that one is getting distressed. I should hurry, even in my training as an intern doctor, it actually even guides me a lot. This one is distressing, I need to save this mother” HW 011.

Improved birth outcomes

Health workers also reported that Moyo use for FHRM resulted in improved newborn outcomes.

“The Moyo device is good. Yeah, it has helped us save many babies…. because we take up quick actions. Yeah, we don’t wait until things go bad. We make immediate decisions, we save the baby, and mothers go back home happy” HW 013.

Facilitators and barriers to using Moyo for continuous intrapartum FHRM

We summarized facilitators and barriers to using/implementation of the Moyo device for continuous intrapartum FHRM under four categories including hospital setting, health workers’ perceptions, tool characteristics and mothers’ experience, using a schema adapted from a study by Suttels et al. [17] (Fig. 2).

Fig. 2.

Barriers and facilitators to using/implementation of the Moyo device for continuous intrapartum FHRM

Hospital setting

The mothers felt the availability of the Moyo device would improve the practice of intrapartum FHRM by the available few health workers given the high number of patients.

“patients are many and yet the health workers are few yet they won’t check on everyone but when you have the Moyo device, they put on this one and the other one and she will just come to check on you later but the fetoscope takes time and the patients are many and then will end up not checking you because of the numbers.” Mother 009.

However, one health worker noted that the facility needs to be connected to the power grid or have an alternative power source for charging the device in case of power outages.

“And once charged, the money is used. And the power elapses. Remember, also, we have to pay for electricity. You know, this is Uganda where power can go for the whole day. There is no power. Sometimes the generator is there, but sometimes it is there. And actually, it’s there, but in the wards where there’s a lot of emergency, you can’t tell someone, please put the generator on to charge the Moyo device” HW 006.

In addition, some participants were concerned about the security of the device within the hospital.

“In hospital, there is also safety. Somebody might get the belt and think this is maybe something to take for my kids to play with it while you’re inside in the ward. Going outside, you find, oh, the thing has been taken. It’s very hard for me to do it, taking care of it.” HW 006.

Health worker perceptions

Training of health workers about the device promoted adoption of the Moyo device for intrapartum FHRM. They were more confident about using the device and also education of the mothers. This is besides the fact that health workers felt the device simplified their work.

“The good thing when we were taken through the training, some of the midwives were there. Yeah. So, we were the ambassadors to bring the information to our colleagues, who were not trained”. HW 003.

Poor attitude towards the adoption of new technology, lack of refresher training and a perceived risk of cross infection by the Moyo device were some of the barriers to its use for intrapartum FHRM.

“another barrier I missed out was that infection control, because it is used from one mother to another. Liquor pours on the belt, it is made of cloth,.” HW 014.

“The first barrier will be change. The attitude towards change…the attitude towards change.…. People don’t easily accept change” HW 008.

Tool characteristics

Participants reported that the Moyo device is easy to use, fast, reliable and portable. In addition, the device has an interactive visual display.

“.it doesn’t need for me to remove, to again put using my ear, using my what, once I locate where there’s a fetal heart, like, once I locate where the, what we call our long continuous curved line, where we shall get the fetal heart rate, then we put that device, the sensor, the sensor and the, like, the device will be reading,….” HW 006.

Participants said that Moyo is portable and has an elastic belt.

“The Moyo was portable and for it, it’s good because it’s not like a fetoscope where the midwife is going to first of all palpate to see where the fetal heart rate is, you know.….” Mother 011.

Further, participants also reported that Moyo device can keep fetal heart rate history for the past 30 min which one can look at.

“Why I would opt for the Moyo, for reading, even if you have not read the past 30 minutes, you can still read through and get the past readings” HW 003.

However, noise from the device, and short battery life were highlighted as barriers to its use.

“No, just because of pain, I never wanted that one making noise. Yes, that’s why. It can disturb your mind when it makes noise when you are in pain” Mother 004.

Then the other thing is the battery. Yes, it is rechargeable, but you find sometimes with the mothers, when they move around, you find the batteries are already done HW 011.

Mother experiences

Mothers reported that the Moyo device was a source of strength to them, they were reassured by hearing their baby’s heartbeat.

“And it made me strong as I would check and see that my baby is okay.” Mother 003.

In addition, mothers appreciated the fact that the Moyo device made them involved in their care.

“The Moyo helped me. It is the simplest way to understand how the baby is doing. For the other method (fetoscope), the musawo (health worker) does not tell you what they have heard. Some okay may tell you but many won’t tell you. But for Moyo, all the time I know.” Mother 014.

Freedom to ambulate

Mothers acknowledged the fact that they were able to move around while using the Moyo device, as it kept informing them of the baby’s condition.

“I would prefer the moyo device because for it you can move with it every time, and you see the baby’s heartbeat if it is okay than the metallic instrument (Fetoscope) where they check and go, and go to another mother so you can’t know how the baby is doing after. But the moyo you walk with it yourself and you see, in case of anything, you can inform the doctor.” Mother 004.

However, some mothers reported feelings of anxiety when interfaced with colour indicators from the device that show that the baby’s heart rate is not normal.

“it makes me worried. Because before they give you, they first tell you the uses of those colors. So when that color goes to red, you can begin saying, is my baby dead or what?….” Mother 012.

Suggested solutions and or recommendations

We also interviewed study participants to suggest some solutions that could inform the scale up of this intervention.

Regarding the challenges of battery outages, participants suggested the possibility of exploring either designing a solar powered device or a fast charging / long lasting battery

“So I would opt, since we told these mothers, go out, ambulate in the sun. If they can provide some provision for solar, so that they can be charged, like continuously being on, it would be better” HW 012.

.

“Maybe if we can have batteries that maybe we charge batteries separately. I can keep on changing the battery I think that will also be better than taking the whole thing. It is better that I have batteries somewhere, very many (of them), I charge them and replace.” HW 014.

Participants also highlighted that during scale up, it’s important to have enough devices for each laboring mother, and also planning for ongoing capacity building

“….availing more moyo devices to serve the purpose because you will find the mother will have the device for like 20 hours, 8 hours. That means that device is not available for the next mothers that might come within those 8 hours.” HW 009.

“So I would recommend that this should be adopted by the government and they implement in all health facilities such that we can use these things and benefit from them and we reduce the issues of the fresh still birth and early neonatal deaths because of avoidable issues which we could intervene in early” HW 011.

Some participants suggested that we could explore the possibility of using the Moyo device for antenatal FHRM at home among high-risk pregnancies.

“I would even advocate for mothers using it at home like when you are pregnant” HW 005.

Discussion

We found that use of the Moyo device for continuous intrapartum FHRM was acceptable to both the health workers and the mothers. Participants perceived it as a useful tool for intrapartum FHRM and an easy-to-use device. The Moyo device was perceived as a solution to the high patient volumes because it was easy to use, fast and more reliable, than the existing gold standard of FHRM (the pinard fetoscope or hand-held Doppler device). The facilitators to its use were staff training on the use of the Moyo device, health education and counselling of mothers about the device, tool attributes such as accuracy, reliability of the results, user friendliness and its interactive/engaging output. The barriers included poor health worker attitudes, risk of cross infections, short battery life and alarms output from the device were perceived as disturbances.

Consistent with previous studies in similar low-resource settings [18–20], participants commented that use of the Moyo device facilitated early detection of fetal distress and timely initiation of evidence-based interventions for intrauterine resuscitation such as changing mother’s position, giving intravenous fluids and stopping oxytocin. The Moyo device picks up the fetal heart rate very easily and provides continuous FHRM, which promotes early detection of abnormal FHR [6]. Moreover, it streamlined workflow by promoting triage and prioritization of patients awaiting emergency caesarean section. With the Moyo, health workers found it easier to quickly identify high-risk cases and make timely informed decisions. As such, health workers perceived it as a useful tool for intrapartum FHRM and they also saw a clear need for its use in a setting with high caseloads. Several studies have highlighted the fact that people are more likely to adopt a device if they perceive it as useful [15, 21–23]. Similar findings were reported in studies done in Tanzania, Nepal and India [18–20].

Mothers felt involved in their care and satisfied with the care provided to them. The interactive and visual output from the Moyo device is easy to understand with minimal instructions, enabling mothers to stay informed about their baby’s condition during labour [18, 19]. This transparency also made mothers feel that health workers were committed to their baby’s well-being during labour. Similar findings were reported in a study done in Nepal which revealed that Moyo use for FHRM improved communication between nurses and women [18]. Active involvement of mothers in their care is a promising approach to improving intrapartum care in low resource settings [18].

Health workers perceived the Moyo device to be user friendly because it rapidly picked up the FHR and provided almost instant feedback. Thus, it could easily be used even by non-skilled birth attendants including patients and their caretakers. This attribute has been consistently reported in a variety of settings [18–20]. It is possible that the health workers were attracted to this device because of its simplicity. It would be interesting to evaluate the utility of this device for high-risk pregnancies being intermittently monitored in antenatal clinic instead of counting fetal movements, the only currently available alternative.

As it has been reported elsewhere [18], adequate training of healthcare providers on how to use and care for the Moyo device before its implementation was key to its implementation. Training improved the capacity and confidence of the health workers which are key attributes needed to offer quality education and counselling about usefulness of the device to mothers [24]. This is one of the ways that has been known to improve attitude and change behaviors [24]. Poor health worker attitude towards the adoption of new technology has been consistently highlighted as a potential barrier to the successful adoption of new technologies [25, 26]. This underscores the need to address attitudes of intended users because lack of knowledge and skills could be a contributor to this seemly resistant negative attitude.

The favorable characteristics of the Moyo device such as ease of use, reliability, being portable, having an interactive and visual display were identified as facilitators to its use. This has been highlighted consistently in a number of studies where the Moyo device has been used [18–20, 27]. New technologies with favourable features are more likely to be adopted [21–23]. On the other hand, one of the barriers to the use of the Moyo device was related to the short battery life and the long charging hours. We recommend that the designers of the device explore the possibility of having either a solar powered device for remote areas that are not connected to the power grid or a fast-charging battery with a long life.

The perceived risk of cross infection was also identified as a barrier to this device’s use, particularly due to the belt that participants felt could carry germs from one mother to another. The belts were washed, but took a long time to dry especially in bad weather. There is need to explore the use of rubber belt that could be easy to clean and disinfect, without the need for air drying.

Methodological discussion

One of the strengths of our study is that we captured both the views of the health workers and the mothers. Additionally, the use of in-depth interviews enabled us to get rich and detailed data from the participants, as they shared their thoughts freely. Our findings are likely to be transferable to similar settings in other low- and middle-income countries. However, our study has limitations, the researchers who conducted the interviews were involved in the implementation of the Moyo device for FHRM at the Labour ward, which may have biased the views/responses from the participants. Furthermore, this is a relatively small scale roll out in a high need area, which does not necessarily reflect the potential for overuse leading to higher c-section rates or additional pressure on operating theatres.

Conclusion

The Moyo device was acceptable to both the health workers and the mothers as it was perceived to be useful for intrapartum FHRM and a user-friendly device. Adequate training prior to its implementation and having favourable characteristics were facilitators to its use. Poor attitude of the health workers, and battery related challenges were the perceived barriers. Potential success of large scale roll out is supported by participants positive attitudes toward the Moyo and high perceived effectiveness.

Author contributions

MWM, DM, JNW, ADW and RN conceived and designed the study. RN, AS, US and AE were involved in data acquisition. MWM, and RN analyzed the data and drafted the first draft of the manuscript. DM, ADW, JNW, AN, AS, US, AE, BN, FO, KM, and JSO, interpreted the data and reviewed the subsequent versions of the manuscript. All authors read and approved the final manuscript.

Funding

This work was supported by Thrasher Research Fund (ID#01851). The funding sources had no role in the study design, data collection, data analysis, data interpretation, the manuscript’s writing, or the decision to submit the manuscript for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding sources.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval to conduct the study was obtained from the Busitema University Research and Ethics Committee, approval number; REF BUFHS-164 and Uganda National Council of Science and Technology, reference number; HS3196ES. We also sought administrative clearance from the Mbale regional referral hospital. Written informed consent was obtained from the participants before conducting the interview. The consent form was translated into the local dialects (Lumasaba, Luganda, Lugwere and Ateso) to ensure that participants understood what they were signing. All study procedures were conducted according to the Declaration of Helsinki and in line with the principles of Good Clinical Practice.

Consent for publication

We obtained consent for publication from the participants.

Competing interests

The authors declare no competing interests.