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Background: Maternal morbidity and mortality related to infection is an international public health concern, but detection and assessment is often difficult as part of routine maternity care in many low- and middle-income countries due to lack of easily accessible diagnostics. Front-line healthcare providers are key for the early identification and management of the unwell woman who may have infection. We sought to investigate the knowledge, attitudes, and perceptions of the use of screening tools to detect infectious maternal morbidity during and after pregnancy as part of routine antenatal and postnatal care. Enabling factors, barriers, and potential management options for the use of early warning scores were explored. Methods: Key informant interviews (n = 10) and two focus group discussions (n = 14) were conducted with healthcare providers and managers (total = 24) working in one large tertiary public hospital in Blantyre, Malawi. Transcribed interviews were coded by topic and then grouped into categories. Thematic framework analysis was undertaken to identify emerging themes. Results: Most healthcare providers are aware of the importance of the early detection of infection and would seek to better identify women with infection if resources were available to do so. In current practice, an early warning score was used in the high dependency unit only. Routine screening was not in place in the antenatal or postnatal departments. Barriers to implementing routine screening included lack of trained staff and time, lack of thermometers, and difficulties with the interpretation of the early warning scores. A locally adapted early warning screening tool was considered an enabler to implementing routine screening for infectious morbidity. Local ownership and clinical leadership were considered essential for successful and sustainable implementation for clinical change. Conclusions: Although healthcare providers considered infection during and after pregnancy and childbirth a danger sign and significant morbidity, standardised screening for infectious maternal morbidity was not part of routine antenatal or postnatal care. The establishment of such a service requires the availability of free and easy to access rapid diagnostic testing, training in interpretation of results, as well as affordable targeted treatment. The implementation of early warning scores and processes developed in high-income countries need careful consideration and validation when applied to women accessing care in low resource settings.
Key informant interviews and focus group discussions were conducted with healthcare providers working in the obstetric department the Queen Elizabeth Hospital, in Blantyre, Malawi, in June 2019 (prior to Covid-19 pandemic caused by SARS-Co-V). This hospital is the largest teaching hospital in the south of Malawi providing routine and specialised antenatal, intrapartum, and postnatal care, in addition to receiving high risk referrals from surrounding healthcare facilities. There are on average 1000 deliveries per month, with a Caesarean rate of 30%. All interviews were held a quiet office in the healthcare facility away from the clinic rooms to ensure privacy. Healthcare providers (doctors, nurses, midwives) were included if they provided routine maternity care (including antenatal and postnatal care) at the chosen study site. Healthcare managers (Ward matron, Head of Department, Head of facility) were included to enable the triangulation of the data and broadened the scope of the topic. Snowballing and opportunistic sampling techniques were employed to identify the participants. Participants were chosen purposively, based on their ability to speak English, and were recruited sequentially until data saturation was met. A topic guide was developed and piloted at the study site in Malawi. The topic guide was a flexible tool that enabled the interviewer to capture the healthcare providers’ responses as well as acting as a cue to probe further to understand the participants’ perceptions and beliefs (Supplementary File 1). In addition to sociodemographic questions, the topic guide included five main subject areas: (1) overall understanding of screening for infectious morbidity (2) knowledge and perception of early warning scores; (3) experience and views on use of early warning scores; (4) approaches to management of women with infectious morbidity; and (5) suggestions on how to identify or screen women with possible infectious maternal morbidity. Key informant interviews and focus group discussions were conducted face-to-face in English, lasted on average 30–45 min, were recorded on a digital recording device, and transcribed on completion. Anonymity and confidentiality with regards to data reporting were emphasised to reassure participants’ confidence in providing honest answers. All participants approached agreed to participate in the study and completed the interviews. The interviews and focus group discussions were transcribed verbatim by the first author (ES). The first author (ES) and a second reviewer (HWU) independently coded all transcripts. The identified codes were grouped into categories and reviewed by three researchers (ES, HU, MMC) to ensure consistency. This enabled the first extraction of data [36]. Key themes were then discussed and checked by all researchers together to reach consensus. We used the Standards for Reporting Qualitative Research guidelines in reporting the analysis [37]. Ethical approval was granted by the Liverpool School of Tropical Medicine, UK (LSTM14.025) and by the University of Malawi College of Medicine Research and Ethics Committee (COMREC 2724). This research was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants of the study.
