Factors impacting—stillbirth and neonatal death audit in Malawi: a qualitative study

Abstract

Background Over one million babies are stillborn or die within the first 28 days of life each year due to preventable causes and poor-quality care in resource-constrained countries. Death audit may be a valuable tool for improving quality of care and decreasing mortality. However, challenges in implementing audit and their subsequent action plans have been reported, with few successfully implemented and sustained. This study aimed to identify factors that affect stillbirth and neonatal death audit at the facility level in the southern region of Malawi. Methods Thirty-eight semi-structured interviews and seven focus group discussions with death audit committee members were conducted. Thematic analysis was guided by a conceptual framework applied deductively, combined with inductive line-by-line coding to identify additional emerging themes. Results The factors that affected audit at individual, facility and national level were related to training, staff motivation, power dynamics and autonomy, audit organisation and data support. We found that factors were linked because they informed each other. Inadequate staff training was caused by a lack of financial allocation at the facility level and donor-driven approaches to training at the national level, with training taking place only with support from funders. Staff motivation was affected by the institutional norms of reliance on monetary incentives during meetings, gazetted at the national level so that audits happened only if such incentives were available. This overshadowed other benefits and non-monetary incentives which were not promoted at the facility level. Inadequate resources to support audit were informed by limited facility-level autonomy and decision-making powers which remained controlled at the national level despite decentralisation. Action plan implementation challenges after audit meetings resulted from inadequate support at the facility level and inadequate audit policy and guidelines at the national level. Poor documentation affected audit processes informed by inadequate supervision and promotion of data usage at both facility and national levels. Conclusions Given that the factors that facilitate or inhibit audits are interconnected, implementers, policymakers and managers need to be aware that addressing barriers is likely to require a whole health systems approach targeting all system levels. This will require behavioural and complex intervention approaches.

Resource availability and barriers to delivering quality care for newborns in hospitals in the southern region of Malawi: A multisite observational study

“…We also observed variations among hospitals in terms of the management of necessary medications and supplies. This could be because the hospitals typically execute an incomplete drug assessment plan before placing orders from the central medical store, In a qualitative study which examined the facilitators and barriers to implementing stillbirth and neonatal death audit [56], causes of insufficient supplies included limited facility autonomy and decision-making powers despite decentralisation, one sole supplier for drugs and essential drugs with limited powers to outsource if they were not available, and inadequate leadership support. Financial support also remained inadequate in the facilities, which depended on external donors to fund activities, resources and equipment.…”

Establishment of a neonatal nursery in a rural district hospital in Malawi: A retrospective review of neonatal outcomes in Neno District Hospital (2014 - 2021)

“…The decline in Malawi's neonatal mortality rate can be attributed to the collaborative efforts of multiple sectors through strengthening infrastructure, space, staff, equipment, medications, and hospital care delivery and scaling up effective interventions targeting the major causes of neonatal mortality [12][13]. Despite the literature indicating that delivery in a health facility can reduce the risk of neonatal mortality by 29% in low-and middle-income countries [14][15][16], other studies have demonstrated that reductions in neonatal mortality require capacitated health facilities with su cient infrastructure, health workforce, equipment and diagnosis and treatment systems to demonstrate decreased mortality [17][18]. For example, despite 90% of deliveries occurring in a health facility in Malawi [19], many vital inputs to reduce neonatal mortality are missing, likely linked to the slowed neonatal mortality rate [20].…”