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Good-quality evidence on hand hygiene compliance among birth attendants in low-resource labor wards is limited. The World Health Organization Hand Hygiene Observation Form is widely used for directly observing behaviors, but it does not support capturing complex patterns of behavior. We developed the HANDS at Birth tool for direct observational studies of complex patterns of hand rubbing/washing, glove use, recontamination, and their determinants among birth attendants. Understanding these behaviors is particularly critical in wards with variable patient volumes or unpredictable patient complications, such as emergency departments, operating wards, or triage and isolation wards during epidemics. Here we provide detailed information on the design and implementation of the HANDS at Birth tool, with a particular focus on low-resource settings. We developed the HANDS at Birth tool from available guidelines, unstructured observation, and iterative refinement based on consultation with collaborators and pilot results. We designed the tool with WOMBAT software, which supports collecting multidimensional time-and-motion data. Our analysis of the tool's performance centered on interobserver agreement and convergent validity and the implications of the data structure for data analysis. The HANDS at Birth tool encompasses various hand actions and context-relevant information. Hand actions include procedures relevant during labor and delivery; hand hygiene or glove actions; and other types of touch. During field implementation, we used the tool for continuous observation of the birth attendant. Interobserver agreement was good (kappa range: 0.7-0.9), and the tool showed convergent validity. Using the HANDS at Birth tool is a feasible way to obtain useful information about compliance with hand hygiene procedures. The tool could be used after simple training and allows for collection of reliable information about the complex pattern of hygiene behaviors. Future studies should explore using this tool to observe behavior in labor wards in other settings and in other types of wards.

A Practical Guide to Using Time-and-Motion Methods to Monitor Compliance With Hand Hygiene Guidelines: Experience From Tanzanian Labor Wards