Conclusion:To increase, improve, and sustain facility-based childbirth in Nigeria, health systems should appreciate the uniqueness and importance of each woman's needs during childbirth. Practical and sustainable actions should be taken to meet these needs, within the confines of the acceptable sociocultural norms. K E Y W O R D S

Objective: To demonstrate how a human-centered service design approach can generate practical tools for good-quality childbirth care in low-resource settings.Methods: As part of the WHO "Better Outcomes in Labour Difficulty" (BOLD) project, a service design approach was used in eight Ugandan and Nigerian health facilities and communities to develop the "Passport to Safer Birth." There are three phases: Research for Design, Concept Design, and Detail Design. These generated design principles, design archetype personas, and Passport prototypes. Data collection methods included desk research, interviews, group discussions, and journey mapping to identify touchpoints where the woman interacts with the health system. Results:A total of 90 interviews, 12 observation hours, and 15 group discussions were undertaken. The resulting design principles were: a shared and deeper understanding of pregnancy and childbirth among family and community; family readiness for decision-making and action; and the woman's sense of being in control and being cared for. Four archetype personas of women emerged: Vulnerable; Passive; Empowered;Accepter. Subsequent development of the Passport to Safer Birth tools addressed three domains: Care Mediator; Expectation Manager; and Pregnancy Assistant. Conclusion:The service design approach can create innovative, human-centered service solutions to improve maternity care experiences and outcomes in low-resource settings. K E Y W O R D SCo-design; Human-centered design; Maternal health; Nigeria; Passport to safer birth; Service design; Uganda | INTRODUCTIONIn 2014, the WHO initiated the "Better Outcomes in Labour Difficulty" (BOLD) project to address the quality of facility-based childbirth care in low-resource settings. The goal of this project is to accelerate the reduction of childbirth-related maternal, fetal, and newborn mortality and morbidity by addressing critical impediments in the process of labor and childbirth care, taking advantage of the interactions between the health system and the community. 1 The project sought to achieve this goal through a two-pronged approach: the development of a Simplified, Effective, of service prototypes and/or tools that improve or enable new interactions between communities and health facilities. These tools were designed using an approach that applies humancentered design methods to co-design solutions together with end users. This paper reports on the development process. The PSB tools developed as a result are described in Salgado et al. 4 | Service design process as a tool to engage users and stakeholders in service innovationThe approach used to design the PSB service tools and concept is called service design, which is an emerging discipline focused on ideating, defining, and implementing services using a customer centric approach. 5 The service design process aims to innovate and improve new or existing services to make them more useful, desirable, and usable to the customer while ensuring efficiency and effectiveness to the service provi...

Objective: "Negotiated standards" describe a level of quality of care that is acceptable and achievable within a specific health system, based on consensus between key stakeholders. This paper presents the development of negotiated standards for effective labor and childbirth care in selected hospitals and communities in Nigeria and Uganda.Methods: A four-step development process involving different methodologies. The process included: (1) review and synthesis of internationally recognized intrapartum clinical principles and practices; (2) primary qualitative research to assess values and preferences of women and healthcare providers, and practices that align with these preferences; (3) draft contextualization of effective and ineffective behaviors to reflect values and preferences; and (4) WHO-mediated negotiations between relevant stakeholders, including community members, providers, and administrators.

Objective: The "Better Outcomes in Labor Difficulty" (BOLD) project used a service design process to design a set of tools to improve quality of care during childbirth by strengthening linkages between communities and health facilities in Nigeria andUganda. This paper describes the Passport to Safer Birth concept and the tools developed as a result.Methods: Service design methods were used to identify facilitators and barriers to quality care, and to develop human-centered solutions. The service design process had three phases: Research for Design, Concept Design, and Detail Design, undertaken in eight hospitals and catchment communities. Results:The service concept "Better Beginnings" comprises three tools. The "Pregnancy Purse" provides educational information to women throughout pregnancy. The "Birth Board" is a visual communication tool that presents the labor and childbirth process.The "Family Pass" is a set of wearable passes for the woman and her supporter to facilitate communication of care preferences. Conclusion:The Better Beginnings service concept and tools form the basis for the promotion of access to information and knowledge acquisition, and could improve communication between the healthcare provider, the woman, and her family during childbirth. K E Y W O R D SCo-design; Maternal health; Newborn health; Nigeria; Quality of care; Service concept; Service design; Uganda | INTRODUCTIONGood quality maternity care is a multidimensional concept that includes timely, effective, and appropriate use of clinical and nonclinical interventions that are sensitive to women's values and preferences. 1 To achieve improved quality of care, efforts are needed to address both facility-and community-based factors, including perceptions of quality, decision-making processes, and demand for womancentered services. There is growing recognition of the importance of including the perspectives of service users and providers to improve quality and organization of care. 2-4 However, the expectations, needs, and values of women and communities have often been neglected in the design of maternity services, particularly in low-and middleincome countries.To address this gap, the WHO initiated the "Better Outcomes in Labour Difficulty" (BOLD) project to improve quality of care during facility-based childbirth. The BOLD project was conducted in Nigeria and Uganda, two settings with a high burden of maternal and neonatal morbidity and mortality. As part of this project, the concept of the "Passport to Safer Birth" (PSB) was developed, its aim to increase