Globally, approximately 140 million births occur every year (1). The majority of these are vaginal births among pregnant women with no identified risk factors for complications, either for themselves or their babies, at the onset of labour (2, 3). However, in situations where complications arise during labour, the risk of serious morbidity and death increases for both the woman and baby. Over a third of maternal deaths and a substantial proportion of pregnancy-related life-threatening conditions are attributed to complications that arise during labour, childbirth or the immediate postpartum period, often as result of haemorrhage, obstructed labour or sepsis (4, 5). Similarly, approximately half of all stillbirths and a quarter of neonatal deaths result from complications during labour and childbirth (6). The burden of maternal and perinatal deaths is disproportionately higher in low- and middleincome countries (LMICs) compared to high-income countries (HICs). Therefore, improving the quality of care around the time of birth, especially in LMICs, has been identified as the most impactful strategy for reducing stillbirths, maternal and newborn deaths, compared with antenatal or postpartum care strategies (7).

Over the last two decades, women have been encouraged to give birth in health care facilities to ensure access to skilled health care professionals and timely referral should the need for additional care arise. However, accessing labour and childbirth care in health care facilities may not guarantee good quality care. Disrespectful and undignified care is prevalent in many facility settings globally, particularly for underprivileged populations, and this not only violates their human rights but is also a significant barrier to accessing intrapartum care services (8). In addition, the prevailing model of intrapartum care in many parts of the world, which enables the health care provider to control the birthing process, may expose apparently healthy pregnant women to unnecessary medical interventions that interfere with the physiological process of childbirth.

Studies have shown that a substantial proportion of healthy pregnant women undergo at least one clinical intervention during labour and birth, such as labour induction, oxytocin augmentation, caesarean section, operative vaginal birth or episiotomy (9, 10). In addition, women in labour continue to be subjected to ineffective and potentially harmful routine interventions, such as perineal shaving, enemas, amniotomy, intravenous fluids, antispasmodics and antibiotics for uncomplicated vaginal births (11). This interventionist approach is not adequately sensitive to the woman's (and her family's) personal needs, values and preferences, and can weaken her own capability during childbirth and negatively impact her childbirth experience (11). Furthermore, the questionable use of technologies in high-resource settings, even when the clinical benefits are unclear, has further widened the equity gap for pregnant women and newborns in disadvantaged populations.

As highlighted in the World Health Organization (WHO) framework for improving quality of care for pregnant women during childbirth, experience of care is as important as clinical care provision in achieving the desired person-centred outcomes (12). However, non-clinical intrapartum practices, such as provision of emotional support through labour companionship, effective communication and respectful care, which may be fairly inexpensive to implement, are not regarded as priorities in many settings. Similarly, birthing options that respect women's values and promote choice during the first and second stages of labour are not consistently provided. These non-clinical aspects of labour and childbirth care are essential components of the experience of care that should complement any necessary clinical interventions to optimize the quality of care provided to the woman and her family.

In the context of a shortage of skilled health care professionals in low-resource settings, the medicalization of normal childbirth can overburden front-line health workers, with resultant poor quality of intrapartum care and poor birth outcomes. It is therefore important that intrapartum clinical interventions are implemented only when there is clear evidence that they can improve outcomes and minimize potential harms (13).

To safely monitor labour and childbirth in any setting, a clear understanding of what constitutes normal labour onset and progress is essential. However, consensus around the definitions of the onset and duration of the different phases and stages of “normal” labour is lacking (14). The routine use of the partograph has been widely promoted by WHO; however, the validity of the most important components of its cervicograph, the alert and action lines, has been called into question in the last decade, as the findings of several studies suggest that labour can indeed be slower than the limits proposed in the 1950s (15–18), on which these lines are based. The question of whether the current cervicograph design can safely and unequivocally identify healthy labouring women at risk of adverse outcomes has become critical to clinical guidance on intrapartum care, and a careful consideration of the evidence supporting its use was required.

This up-to-date, comprehensive and consolidated guideline on intrapartum care for healthy pregnant women and their babies brings together new and existing WHO recommendations that, when delivered as a package of care, will ensure good quality and evidence-based care in all country settings. In addition to establishing essential clinical and non-clinical practices that support a positive childbirth experience, the guideline highlights unnecessary, non-evidence-based and potentially harmful intrapartum care practices that weaken women's innate childbirth capabilities, waste resources and reduce equity.