We found statistically significant improvement in the documentation of maternal vital signs for the first and last SCC Pause Points during the period following the implementation of the intervention compared to the period prior. Importantly, this study relied on a retrospective review of patient charts and not direct observation of care, and thus the recording of Pause Points may not reflect the actual care received by the patient. Indeed, pre-dissemination discussions with stakeholders at the health centres, QECH, and with study team midwife mentors suggested that this can explain the lack of documentation for Pause Point 2. Collaborative review of our findings also shed light on the lower documentation of temperature compared to pulse and BP as an electric BP machine records both of the latter at once, while temperature must be manually taken by a provider.
Understaffing at the health centres in Blantyre results in significant and often conflicting demands on midwives’ time, particularly at the time of birth. When tasked with providing immediate care to a laboring mother and neonate (or multiple mothers and neonates at various stages of care), charting naturally takes second priority. However other studies, including those as part of GAIN in Malawi, have shown that mentorship increases not only documentation of, but also directly observed, QoC.14 Accordingly, the increases seen in documentation at Pause Point one and three are likely to also represent an overall increase in the provision of that care. It is also worth noting that an increase in documentation on its own is important, as the results are key to informing the tracking of outcomes and thus allocation of vital resources.
Downstream issues stemming from understaffing are nuanced and the number of providers at any given facility only tells part of the story. While the global shortage of midwifery personnel has grown over the past decade, Malawi has nonetheless made tremendous improvements reaching more than 90% skilled attendance of births.8 Despite this, as with other countries, Malawi continues to face challenges of provider burnout and workforce retention and motivation.6,8,20,21 Difficulties were exacerbated by indirect effects of the COVID-19 pandemic worsening shortages and reducing access to professional development opportunities.22 While improving staffing infrastructure is needed at the systems-level in Malawi, QoC is also threatened by a lack of ongoing training to ensure existing staff have the confidence and skills to address complications.6 In this way, the longitudinal mentorship component of the intervention appeared to prove beneficial despite shortages by scaling up current evidence-based approaches among staff, aligning with prior findings.14 While not directly measured in our study, meaningfully supporting providers has also been shown to be critical to ensuring respectful care on the experience side of QoC.4,23
The discrepancies seen between health centres were not necessarily surprising. In low-resource settings such as Malawi, the social, cultural, and clinical norms of specific centres have been shown to have a greater impact on QoC than individual providers’ behavior change.24 These differences are also often influenced by geographical and population divisions (i.e., rural vs urban), with those proximal to desired amenities in urban areas able to recruit, retain, and support higher trained staff. In our study, the peri-urban site, known to be busier, had consistently lower documentation of vital signs. This relates directly to our earlier discussion of understaffing. We found that both the peri-urban and rural centre saw similar improvements in QoC indicators, despite significant centre-based differences. This suggests it is critical to provide the same level of training, support, and longitudinal mentorship across all centres.
Additionally, the role of supplies in the documentation of care is complex and demands more study. Although medical supplies are frequently tracked and quantified, our findings align with prior research stating that equipment is weakly related to QoC.25 The peri-urban centre was frequently found to have one or more medical device(s) out of stock, which was suggested as due to providers from elsewhere in the facility borrowing supplies and not returning them. This naturally limits the ability of midwives to utilize those tools in the provision of care, and thus report the necessary vital signs. In our study, each centre was supported in the acquisition of critical medical devices for maternity care; however, their use as it pertains to QoC was unable to be captured in a maternal chart itself. For instance, while a functional BP cuff may be available, it also may be shared across multiple departments and not available for a given maternity patient or found during a site visit. In this way, both technological innovations and manual equipment that does not rely on power sources must be scaled up, supplemented with personnel training, and introduced with plans for sustainable, equitable use.26
While our study sheds light on the benefits of longitudinal mentorship on a key aspect of maternal QoC, our approach was limited in a few ways. First, data collection was challenged given the retrospective nature of the study and local record-keeping practices. Women referred to tertiary care at QECH during labor, for instance, often had partial chart data at the primary centre which limited the number of charts with at least three SCC Pause Points recorded for analysis. Second, both quarterly and monthly stock checks varied in frequency—on average monthly checks were recorded two to five times per month per site. As a result, the number of checks in a particular month could have significantly impacted the availability of equipment recorded at that time. Additionally, data collection for our study was limited to maternal partographs. This may explain our inability to analyze Pause Point 4 which we later learned is often documented separately in patients’ personal health passports that are not retained at the facilities. Still, we find confidence in our alignment with prior findings while acknowledging opportunities for further exploration.
A deeper dive into the bottlenecks of supplies and equipment needed for vital sign measurement and how it affects QoC indicators is warranted. Particularly in resource limited settings, including Malawi, it may be worth exploring a way to document when supplies are not available directly in patient charts to prevent assumptions of poor care from providers. In this way, weak associations with supplies may be nuanced with patient-level data. Alternatively, investigating innovative solutions to improve the availability of supplies and measure the impact on QoC may shed light on the true barriers, which may include staff shortages or low motivation, among others.6 Additional research should also be conducted to explore appropriate management of complications as well as patient outcomes related to SCC Pause Point documentation in Malawi given the goal to improve QoC in their design.27
Alongside continued rigorous research efforts, district-level support should be increased to address ongoing issues and prevent further strain on human and physical resources. To partially compensate for staffing shortages and prevent burnout of nurse-midwives, it would be helpful to monitor staff placement across health centres. Similarly, a communication system directly to the DNO should be built to facilitate real-time access to site supply needs. Anecdotally, we have learned that stockouts at local pharmacies can cause delays in accessing key clinical supplies preventing quality care. Supply needs, however, are uneven across sites and a way to facilitate effective redistribution from one centre to another could alleviate short-term stockouts as occasionally a particular centre has an abundance of a needed supply. Routine tracking of supplies by a designated staff at each centre and DNO-led mobilization of supplies may also reduce the expiration of resources with a set shelf-life while allowing pharmacies time to replenish. Additionally, ensuring that relevant decision-makers have timely information to assess and improve health care quality is essential to improving care and trust from the community.25 Resourceful approaches to support existing infrastructure while investing in strengthening it continues to be needed to improve QoC.