RESEARCH ARTICLE Factors associated with poor adherence to intrapartum fetal heart monitoring in relationship to intrapartum related death: A prospective cohort study Annette Ekblom ID 1 , Mats Målqvist ID 1 , Rejina Gurung 1 , Angela Rossley 1 , Omkar Basnet ID 2 , Pratiksha Bhattarai 2 , Ashish K. C. ID 1,3 * 1 Uppsala Global Health Research on Implementation and Sustainability (UGHRIS), Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden, 2 Golden Community, Lalitpur, Nepal, 3 Society of Public Health Physicians Nepal, Kathmandu, Nepal * ashish.k.c@kbh.uu.se Abstract Background Poor quality of intrapartum care remains a global health challenge for reducing stillbirth and early neonatal mortality. Despite fetal heart rate monitoring (FHRM) being key to identify fetus at risk during labor, sub-optimal care prevails in low-income settings. The study aims to assess the predictors of suboptimal fetal heart rate monitoring and assess the association of sub-optimal FHRM and intrapartum related deaths. Method A prospective cohort study was conducted in 12 hospitals between April 2017 to October 2018. Pregnant women with fetal heart sound present during admission were included. Inferential statistics were used to assess proportion of sub-optimal FHRM. Multi-level logis- tic regression was used to detect association between sub-optimal FHRM and intrapartum related death. Result The study cohort included 83,709 deliveries, in which in more than half of women received suboptimal FHRM (56%). The sub-optimal FHRM was higher among women with obstetric complication than those with no complication (68.8% vs 55.5%, p-value<0.001). The sub- optimal FHRM was higher if partograph was not used than for whom partograph was completely filled (70.8% vs 15.9%, p-value<0.001). The sub-optimal FHRM was higher if the women had no companion during labor than those who had companion during labor (57.5% vs 49.6%, p-value<0.001). After adjusting for background characteristics and intra-partum factors, the odds of intrapartum related death was higher if FHRM was done sub-optimally in reference to women who had FHRM monitored as per protocol (aOR, 1.47; 95% CI; 1.13, 1.92). PLOS GLOBAL PUBLIC HEALTH PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.0000289 May 23, 2022 1 / 16 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 OPEN ACCESS Citation: Ekblom A, Målqvist M, Gurung R, Rossley A, Basnet O, Bhattarai P, et al. (2022) Factors associated with poor adherence to intrapartum fetal heart monitoring in relationship to intrapartum related death: A prospective cohort study. PLOS Glob Public Health 2(5): e0000289. https://doi.org/ 10.1371/journal.pgph.0000289 Editor: Hamish R. Graham, MCRI, University of Melbourne, Royal Children’s Hospital Melbourne, AUSTRALIA Received: September 2, 2021 Accepted: February 24, 2022 Published: May 23, 2022 Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: https://doi.org/10.1371/journal.pgph.0000289 Copyright: © 2022 Ekblom et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.