Associations between organizational readiness and implementation fidelity in national implementation of WHO’s labour care guide in Sweden: a prospective observational study

Abstract Background During 2024 and 2025, an adapted version of the World Health Organization’s Labour Care Guide was implemented in approximately half of Sweden’s labor wards within the PICRINO trial. Organizational readiness is widely regarded as a key determinant of successful implementation, however, empirical evidence linking organizational readiness to implementation outcomes remain limited. This study aimed to examine the association between organizational readiness for implementing the Labour Care Guide in Sweden and implementation fidelity, to explore variations in readiness and fidelity across organizational and individual factors and to assess changes in fidelity over time. Methods The study included the implementation of the Labour Care Guide at ten labor wards in Sweden. Organizational readiness was measured among health care staff ( n = 282) using the E-Ready 2.0 questionnaire before implementation was launched. Fidelity was assessed by analyzing degree of documentation within the Labour Care Guide tool at 3, 6, and 9 months ( n = 750). A coding protocol including all seven sections of the tool, in which two sections were considered core components, was used to systematically analyze fidelity. Fidelity was then compared between wards with the aggregated highest, intermediate, and lowest levels of readiness at ward level. Results The three wards reporting the aggregated highest levels of organizational readiness also demonstrated the highest implementation fidelity, while the three wards with the lowest reported aggregated readiness showed the lowest fidelity. In addition, staff at smaller labor wards reported greater readiness than staff at larger wards, and readiness was higher in non-university hospitals compared with university hospitals. Physicians reported higher readiness than midwives. Overall fidelity to the Labour Care Guide declined over time, however, this trend was not observed among core components. Conclusions This study provides empirical support for an association between organizational readiness and implementation fidelity when introducing the Labour Care Guide in Sweden. Fidelity to core components remained stable, suggesting that essential elements were more resilient to implementation challenges. Findings highlight the importance of assessing and strengthening organizational readiness prior to implementation and of providing sustained support over time to maintain fidelity, particularly for non-core components. Trial registration www.clinicaltrials.gov NCT05560802, 2022-09-17.