Paper-Based, Electronic and Hybrid Documentation in Midwifery Practice: A Systematic Review of Provider Experiences and Implementation Outcomes

Abstract

Background: Documentation is central to midwifery practice, underpinning continuity of care, clinical accountability, and patient
safety across the antenatal, intrapartum, and postnatal continuum. Health systems worldwide are transitioning from paperbased to electronic or hybrid documentation models, but the evidence base remains fragmented, with most studies examining individual systems in isolation rather than comparing approaches. This review aimed to systematically synthesize evidence on midwifery documentation approaches - paper-based, electronic, and hybrid - with respect to provider experience and implementation outcomes.

Methods: A systematic review was conducted following PRISMA 2020 guidelines. PubMed, CINAHL, Scopus, Web of Science, and Google Scholar were searched for peer-reviewed publications from January 2020 to September 2025, supplemented by manual citation screening. Eligible studies reported on paper-based, electronic, or hybrid documentation in midwifery or maternal health settings and addressed provider experience, perception, or implementation outcomes. Two reviewers independently screened records and assessed eligibility. Methodological quality was appraised using the CASP, JBI, and MMAT checklists according to study design. Findings were synthesized narratively due to heterogeneity of study designs and outcome measures.

Results: Of 1,266 records identified, 28 studies met inclusion criteria, spanning qualitative (n=11), quantitative (n=9), mixedmethods (n=5), and review (n=3) designs across 11 geographic contexts. Three documentation approaches were identified. Paper-based systems remained the operational default in low-resource settings, valued for infrastructure independence and narrative flexibility but limited by illegibility, incompleteness, and vulnerability to loss. Electronic systems offered auditability, legibility, and decision support but were associated with usability challenges, workflow disruption, and - in one landmark study - near-universal midwife dissatisfaction with care-quality impact (88% disagreement). Hybrid systems, the most prevalent operational reality globally, provided resilience against infrastructure failure but imposed substantial duplication and synchronization burdens. Training adequacy, technical support, and workflow alignment were consistent cross-cutting determinants of implementation success across all three approaches.

Conclusions: No single documentation approach universally meets the needs of midwifery practice. Paper-based systems remain indispensable in resource-limited contexts; electronic systems are transformative when designed around midwifery workflows rather than adapted from general medical models; hybrid models function as necessary but poorly managed transitional states. Documentation reform should be approached as a socio-technical challenge requiring midwife-centred design, contextual suitability assessment, and sustained infrastructure investment, rather than a purely technical implementation exercise.