Table 3 Example of how the qualitative evidence informed the final recommendations in the OptimizeMNH guidance (1): provision of continuous support during labour by lay health workers, in the presence of a skilled birth attendant

The guidance panel was asked to consider whether lay health workers could provide continuous support, such as emotional and practical support, during labour, while in the presence of a skilled birth attendant providing the necessary clinical care.

Information regarding benefits and harms came from a systematic review of trials [51]. This evidence suggested that this support, when provided by lay health workers or other birth supporters, may have important health benefits (low to moderate certainty evidence). Based on discussion in the technical team, we also concluded that the intervention would require little additional training, supervision and supplies.

Information regarding acceptability and feasibility came from two syntheses of qualitative evidence [19, 20]. The evidence suggested that mothers appreciated this support from lay health workers and that health professionals working alongside lay health workers often appreciated their contribution to their busy workload and their skills in communicating with mothers (moderate confidence in the evidence). However, the relationships between lay health workers or other birth supporters and professional midwives was sometimes ambivalent and, at times, conflictual, possibly because the midwife role was shifted in a more medical direction (moderate confidence in the evidence). Having to be present during labour and birth could also lead to irregular and unpredictable working conditions for the lay health worker, which might have implications for their expectations regarding incentives (low confidence in the evidence) and could lead to concerns about personal safety when working in the community or travelling at night (low confidence in the evidence).

This information was presented to the guidance panel in a summarised form using the DECIDE evidence to decision framework. More detailed versions were presented in appendices using summary of findings tables and full versions of each review were also made available to the panel.

Based on this evidence, the panel decided to recommend the intervention. Potential challenges regarding the acceptability of the intervention to lay health workers and other healthcare providers were highlighted under “Implementation considerations”.