Ending preventable maternal deaths in Malawi: the stakeholders consensus approach to identify maternal health needs priorities

Abstract

Background

The Malawian context presents multifactorial challenges that hinder the provision of high-quality maternal health services, leading to high maternal morbidity and mortality rates. Priority setting is a crucial concept that can benefit the healthcare system in Malawi by efficiently distributing limited resources and maximising gains in maternal healthcare. We undertook a national maternal health prioritisation exercise involving key stakeholders to enhance delivery of maternal care in Malawi.

Methods

During group discussions, the Nominal Group Technique was adapted to facilitate consensus on priorities after data and real-life experiences from service users were presented. The process involved four stages: (1) Silent generation of priorities, where participants independently listed their priorities using pieces of paper, (2) Consolidation of priorities, where all individual priorities were combined into a single list on the flip chart and similar priorities merged, (3) Clarification and discussion at a group level using a prioritisation matrix, allowing participants to clarify and discuss the listed priorities, and (4) Ranking of generated priorities, where participants voted or used an online scoring system to determine the most important priorities. All papers and flip charts used were collected, and discussions were recorded to capture how decisions were made, and their rationales. Facilitators and authors met to manually analyse the summaries.

Results

Seventy-four stakeholders participated in the prioritisation workshop, forming eight groups. Through individual prioritisation exercises, 233 priorities were identified. Subsequently, the consolidation of priorities resulted in 104 priorities, which were further reduced to 40 priorities during clarification and discussion stage using the prioritisation matrix. After selecting the top two priorities from each group, 12 priorities remained, which underwent the final stage of ranking and voting, and 57 stakeholders voted. The top three priorities identified were: (1) respectful maternity care, (2) information and data management, and (3) strengthening skills of birth attendants.

Conclusion

Achieving national maternal health targets demands prioritising respectful maternity care, accessible information, robust data management/information, and skilled birth attendants, all of which empower staff and clients to drive positive changes. Stakeholders can leverage these priorities to guide future programme implementation, research investments, and country-specific adaptations through meaningful engagement with national stakeholders.

Introduction

Globally, the maternal mortality ratio (MMR) dropped from 339 maternal deaths per 100,000 live births in 2000 to 223 in 2020, a 34% reduction [1]. However, the burden remains high in low-and middle-income countries (LMICs), with 95% of the burden of maternal mortality and the majority of deaths occurring in sub-Saharan Africa (SSA) [1]. Ending preventable maternal deaths continues to be one of the most critical goals internationally. A Sustainable Development Goal for 2030 is to reduce the global MMR to 70 maternal deaths per 100,000 births, and no country should exceed two times that ratio (140 per 100,000). With the current trends, it is unlikely that LMICs, will meet the target unless more innovations are put in place to improve the quality of maternal care. The Malawi MMR stands at 381 maternal deaths per 100,000 live births in 2020 [2]. This is a 49% decrease from 749 in 2000 and a 13% decrease from the previous rate of 439 in 2017, according to the National Demographic Health Survey [3]. Even with this decline, progress to reduce rates has slowed and the MMR ratio has plateaued. Furthermore, Malawi’s MMR is still among the highest in the world, despite a significant increase in antenatal care attendance and skilled birth attendance at 97% [4]. High rates of institutional deliveries provide an opportunity for the provision of facility-level initiatives to enhance the quality of maternal care. Most maternal deaths in Malawi are preventable and are mainly due to infection, haemorrhage, and eclampsia, as highlighted in the recent report on maternal deaths in Malawi [5] and other sources [6, 7]. The recent report also highlighted healthcare worker factors as leading preventable causes of maternal deaths– such as inadequate monitoring of women in labour, prolonged abnormal observations without staff action and a lack of obstetric emergency skills amongst staff [5]. While there is notable improvement in access and coverage, health care must be of good quality; improving the quality of care is a global agenda [8].

Malawi has implemented several initiatives to reduce high maternal mortality and common morbidities, such as improved access to skilled birth attendants during childbirth and timely access to Emergency Obstetric and Newborn Care (EmONC) services. Both important measures lower both maternal and infant mortality in LMICs. EmONC is defined as a set of life-saving interventions aimed at the management of major obstetric and newborn causes of morbidity and mortality [9]. Basic Emergency Obstetric and Newborn Care (BEmONC) is designated for primary healthcare, whereas Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) targets the secondary or tertiary level of a nation’s health system. The set of interventions provided depends on the level of the health facility [9]. Additionally, the Ministry of Health (MoH) launched a Quality of Care (QoC) initiative for Maternal, Newborn, and Child Health (MNCH) in partnership with the World Health Organization (WHO) and other partners; the initiative aimed to enable health workers to identify and treat the underlying causes of maternal and newborn morbidity and mortality [10]. With the establishment of the Quality Management Directorate, quality improvement initiatives are continually promoted in maternal health services at all facility levels [10, 11].

Implementation of the MNCH initiative is limited due to health system challenges that need to be addressed pragmatically. These include a shortage of skilled and motivated health workers, inadequate infrastructure and equipment, inadequate financing, a lack of drugs and supplies, a poor referral system, ineffective leadership and governance and inadequate health information data to guide decision-making [12–14]. The weak healthcare systems in Malawi necessitates the need for collaborative and innovative efforts to strengthen the delivery of high-quality maternal health services and reduce mortality rates.

Priority setting is one of the concepts that can aid Malawi’s healthcare system in distributing limited resources and to maximise benefits for maternal healthcare [15]. Malawi’s resources are constrained, and basic health services are sometimes unaffordable with the need for substantial reliance on international donor support [16]. Priority setting in healthcare is the process of deciding how best to allocate resources to improve population health and ensure that the limited resources are equitably and efficiently allocated for effective gains in the prevention of maternal morbidity and mortality [15, 17]. There has been an increased interest in participatory approaches whereby individuals from different perspectives, such as patients, healthcare workers, partners, and members of the public, are brought together to support decision-making about which healthcare services to prioritise [18, 19]. The involvement of multiple stakeholders ensures comprehensiveness of the information generated to inform the prioritisation process, thus enriching the priorities developed, unlike when researchers and managers only participate. The involvement of multiple stakeholders yields increased equity, optimal uptake of and engagement with the services and increased transparency and objectivity in the prioritisation process [15, 18]. Additionally, prioritisation improves coordination of donor support, subsequently preventing duplication of efforts by the various donors, which is widespread in LMICs [16, 20]. This paper discusses a process applied to identify and prioritise maternal health needs in Malawi. The identified areas of focus could help improve women’s experiences when accessing services and reduce maternal morbidity and mortality.

Methods

Approach/design

To identify priorities for national maternal health needs in Malawi, an expert consensus process was undertaken following the principles of the Nominal Group Technique [21]. The meeting was facilitated by HP (Deputy Director of Reproductive Health in the Ministry of Health) and ALNM (Health system and policy specialist with a robust qualitative and implementation science publication history). The meeting was a full-day and face-to-face, held in Salima district, the central region of Malawi, on 25th May 2023. The meeting location was selected to reduce interruptions and ensure attendees stayed focused on the agenda for the day. The Nominal group technique is one of the most popular approaches for reaching consensus and incorporates participatory action research principles during group discussions. With this approach, the participant is an “active ingredient” in the research or process itself rather than being a passive participant [21]. The process also permits the participant to use their knowledge, experiences and expertise and incorporate these into the research process [21].

This process sought to identify priorities for maternal health with a sample of multidisciplinary stakeholders; the technique is an effective methodological approach to elicit priorities from a range of stakeholders in maternal health [22]. The NGT also overcomes group or committee decision-making that can be dominated by individuals who have a vested interest in a specific outcome [23]. The NGT is widely used to identify problems, generate appropriate research questions, develop solutions, and establish priorities for action [22]. Used as a tool for rapid assessment, the technique was well understood and appreciated by respondents as each member’s voice was equally represented.

Selection of participants

We selected a purposive sample of “experts” and key stakeholders involved in maternal health services to participate in the expert consensus process. For our purposes, “maternal health stakeholders” included representatives from the MoH and its partners, international donor organisations, national and international non-governmental organisations, research and training institutions, regulatory bodies, professional associations, maternal health service providers, service users, and community representatives.

To minimise selection bias and achieve a wider pool of stakeholders, we first organised a planning meeting with the Malawi MoH Reproductive Health Directorate (RHD) to discuss potential participants (Additional file 1). During these meetings existing programmes, projects, and partners in maternal health were listed with the assistance of RHD in the MoH. Other stakeholders were identified through the database of the recent quality care conference, organised by the Quality Management Directorate (QMD) in 2022. The research team screened the conference abstract list and identified stakeholders who presented the quality of maternal health projects that were relevant to the prioritisation process. In addition, the snowball approach was used to identify other stakeholders involved in maternal health programmes. Some of the participants were known to the researchers from previous research that was relevant to maternal health care. This process resulted in including relevant stakeholders in the field of maternal health in Malawi. We made sure to include organisations involved in policy or implementing programmes together with MoH at central, district and primary levels.

The longest time was spent on the initial consultation with RHD in the Ministry of Health, identifying stakeholders, gathering key information to use during the workshop, and drafting the agenda for the main workshop meeting (Additional file 2). This process created a shared understanding of need and provided sufficient evidence upon which to base decisions. We also spent time identifying the materials to use during the workshop and training the facilitators. We included a variety of stakeholders, rather than consulting only with one or two key decision-makers, and we conducted a robust and transparent analysis of stakeholder views. Among the stakeholders included were local organisations, community members, and patient representatives to ensure the voice of the community was represented. We engaged the pre-existing Patient, Public Involvement and Engagement (PPIE) group at the Malawi Liverpool Wellcome Programme (MLW), within the maternal and fetal health research group, to assist in planning and designing the prioritisation process and to participate in the event. The PPIE group consists of individuals with a variety of experiences and interests in maternal health, including those who have experienced maternal near-miss complications such as sepsis, haemorrhage, or eclampsia, community advocates and healthcare professionals with personal experience of maternal health services.

The stakeholders were invited through an email sent to the organisation, which helped in selecting the relevant individuals involved in maternal health programmes. The purpose of the meeting and the expectations of participants were also relayed in the email invitation. If we had no response within 10 working days, a follow-up email was sent.

Training of facilitators

Two sessions of facilitator training were conducted prior to the wide stakeholder meeting. Nine facilitators (MJG, LM, CK, AK, LM, CB, BM, MLO, and JR) were trained by ALNM in the process of running an NGT prioritisation matrix, Slido voting and facilitation of group discussions. Slido is a simple platform for polling using question and answer sessions at meetings and events. Meeting and event planners can use it to crowdsource the most essential questions, to spark interesting discussions, to draw attendees in with interactive polls and to gather insightful event statistics (https://www.slido.com). The training aimed to improve the facilitators skills to help stakeholders express their opinions and work together towards achieving a common goal of identifying national maternal health priorities.

Running of the workshop

We ran a one-day multi-stakeholder workshop on 25th May 2023 in Salima district, Malawi, with 74 stakeholders. The stakeholders engaged in an open and purposeful discussion to arrive at a well-founded shortlist of maternal health priorities. We started with presentations and posters (Additional File 3 and 4) which contained information related to current statistics on maternal morbidity and mortality, quality of care provided, specific maternal health challenges and a real-life experience from a service user (PPIE). These presentations contextualised the healthcare problems in Malawi. We then used an NGT to reach consensus and followed four steps: (1) silent individual prioritisation, (2) consolidating priorities from individual prioritisation, (3) clarification and discussion of priorities at a group level using a prioritisation matrix, and (4) ranking of generated priorities (voting). Figure 1 outlines the prioritisation and group discussion process. The facilitators recorded the group discussion sessions, which were then transcribed. The participants consented to have their discussions recorded. The recorded discussions addressed how decisions were made, areas of agreement and disagreement, and insights into participants’ perceptions of priorities and their rationale for selecting them.

Fig. 1

The prioritisation and group discussions process

Introduction to NGT and group division

At the start of the workshop, participants received a short presentation (Additional file 3) including a keynote address on the challenges for Malawi to achieve the Sustainable Development Goal targets. Other presentations (Additional file 3) were from RHD, partner and local organisations on challenges in implementing maternal health programmes in Malawi and their planned activities. Another presentation was on the recent maternal death report focusing on leading causes (infection, postpartum haemorrhage and eclampsia) and associated factors of maternal deaths in Malawi from August 2020 to December 2022. The full report can be accessed at the following link: https://www.mdmalawi.net.

The participants walked through poster presentations (Additional file 4) that highlighted projects and programmes relating to the quality of maternal health care in Malawi. The presentations and posters explained the context on which to base ideas during the prioritisation process, in addition to the stakeholder’s experience in the field of maternal health. Participants were introduced to an NGT process and tools to be used during the process and given an opportunity for any questions, comments, and clarifications. Participants were divided into groups of five to ten participants, depending on their area of expertise and programme of work, to prevent power imbalances during group discussion. Additional file 5 summarises the composition and expertise of the groups. A total of eight groups were formed, and each group had at least one facilitator. The groups were made up of individuals from reproductive health services, quality assurance, academic and professional associations/organisations/regulators, PPIE and community care providers, local organisations and UN/ International organisations.

NGT process

Stage 1-silent generation of individual priorities

Within their groups, participants were provided with a piece of paper (Additional File 6) that asked them to independently write down at least three priorities regarding maternal health in Malawi and their rationale. The paper also asked them to write down their role. A total of 10 min of silent time was given for this activity. This was the first prioritisation session. Figure 2 illustrates the NGT process.

Fig. 2

Nominal group technique process

Stage 2- consolidating priorities from individual prioritisation

During this stage, an initial discussion took place within their assigned groups. Participants were asked to exchange their pieces of paper with their neighbour to present the idea to the facilitator. Participants took turns describing their priorities. To help organise the ideas generated, a facilitator documented all priorities on the flip chart, which was visible to all participants. The facilitator and participants merged all similar priorities and finally had a list of priorities from everyone. This process lasted for 30 min. Figure 3 presents examples of filled flip charts from two of the groups.

Fig. 3

Examples of flip chart documentation during consolidation stage

Stage 3- clarification and discussion of priorities at a group level using a prioritisation matrix

Drawing on the prior discussions within the assigned groups, the participants were asked by the facilitator to review the list of individual priorities and to discuss and identify the top five priorities for their group, with the rationale for selection. The groups utilised the prioritisation matrix provided (Additional file 7). The prioritisation matrix consisted of five components, each scored against every priority based on individual prioritisation within each group. The matrix components included whether the suggested priority required more or less time (time required) and feasibility, affordability, acceptability and equity. Each component was scored one to three, with one being the lowest score and three the highest for a maximum total score of fifteen points. The eight groups picked their top five scoring priorities. This was the second prioritisation session.

After each group had identified five priorities, a prioritisation matrix (Additional file 7) was applied again to isolate two priorities per group with the highest score for final prioritisation following consensus. One of the facilitators then entered the two priorities from each group on the Slido platform (https://www.slido.com) in preparation for the final prioritisation session.

Stage 4- ranking of generated priorities (individual voting)

In the final prioritisation session, all workshop participants met in plenary to review the aggregate of the third-round prioritisation together. Participants were orientated to voting system using Slido, which listed the aggregated priorities from all groups (only the top two from each group (n = 12) some of which were merged). Participants used their mobile smartphone to vote for their individual top two priorities from the list. Participants without smartphones were assisted by the researchers to access the Slido platform and vote.

Analysis

The summary of top priorities was captured through the Slido platform, which had data on how many participants voted and the key priorities. All facilitators recorded discussions and collected papers and flip charts which documented individual and group priorities. The recordings covered how decisions were made, areas of agreement and disagreement, rationales, key issues, and insights discussed by the stakeholders during the NGT process. Each facilitator transcribed the discussion and put together notes on priorities and rationales from their group. Facilitators and authors met to manually synthesise the summaries, which have been included in the report. The facilitators grouped similar priorities during the synthesis.

The process (including project planning through to completion of final report) took six months (March-August 2023).

Ethical considerations

At the beginning of the meeting, all were briefed verbally on the process that will be taken to realise the goals of the workshop. They were made aware that they were not obligated to participate in the expert consensus process and could withdraw at any time, without any negative consequence. No personally identifiable information was used in this priority-setting workshop. Thus, approval from the Ethical Review Board was not necessary.

Results

Distribution of participants

Invitations were sent to 87 stakeholders, of which 85% (n = 74) attended the workshop. Out of 74 stakeholders who participated in the workshop, 88% (n = 65) participated in individual and group prioritisation exercises. The median number of stakeholders per group was 8 (Additional file 5). While 77% (n = 57) participated in individual voting to rank the top priorities. Table 1 indicates the stakeholder groups of which the 74 workshop participants came. There was strong representation by researchers, key departments in the Ministry of Health, health and clinical service providers and users, and UN/ international organisations, in particular.

Table 1 Types and numbers of stakeholders at the prioritisation workshop

Individual level priorities

In the first stage, 65 stakeholders provided their priorities in their eight respective groups (Additional file 5). A total of 233 priorities were identified during individual prioritisation. Additional file 6 summarises priorities per individual and the rationale for the selection. The participants’ rationale for selecting each priority is italicised. The median number of priorities per group was 27.5.

Consolidating individual-level priorities

In the second stage, after merging similar individual priorities as a group, the priorities were reduced to 104 (Additional file 7). The median number of priorities per group after merging was 14. We report the results from each group as follows:

• Group 1 (stakeholders working in reproductive health service in the MoH) had 14 priorities (n = 25) after merging. The top priorities were the reduction of maternal deaths related to main causes such as post-partum haemorrhage (PPH) and sepsis, deaths following Caesarean section (C/S) and the provision of adequate human and material resources to provide quality maternal care; each had four votes. This was followed by improving the skills of health care workers (HCWs) which had 3 votes, while the availability of blood for transfusion, family planning services, and reduction of child mortality each had 2 votes (Additional file 7).

• In group 2 (quality assurance staff), out of 16 priorities (n = 30) following merging, the highest priority vote went to mentorship and supervision services (4 votes), followed by performance management, improving quality of care and standards, quality improvement initiatives and reviews, and data management and use, which had 3 votes each. Community engagement, HCW skills, and human and material resources had two votes each (Additional file 7).

• In group 3 (training institution stakeholders), out of 14 merged priorities (n = 20), the highest priority vote went to community engagement activities (4 votes) to recognise danger signs, early antenatal care (ANC), and reduce delay in seeking care. This was followed by improving the skills of HCWs through pre- and in-service training, mentorship and supervision, and human resources, which had 2 votes each (Additional file 7).

• Group 4 (Professional and regulatory bodies), out of 13 merged priorities (n = 30), the highest frequency priority was inadequate human and material resources, which scored 7 votes, seconded by financing and staff attitude with 4 votes each. Community engagement had 3 votes, while leadership and governance, skills, and infrastructure had 2 votes each (Additional file 7).

• In group 5 (community and PPIE), out of 13 merged priorities (n = 23), the poor-quality care women receive during birth was the top priority with 5 votes, seconded by inadequate material resources with 3 votes and delayed reporting to facilities and staff attitude that scored 2 votes each (Additional file 7).

• In group 6 (care providers), out of 17 merged priorities (n = 51), the priority of highest frequency was inadequate human and material resources, which had 18 votes, followed by staff attitude (5 votes), community engagement, supervision, mentorship, and poor referral systems, which each had 4 votes. Then, staff skills (3 votes), poor quality of care, and inadequate information for mothers scored 2 votes each (Additional file 7).

• In group 7 (local organisations), out of 13 merged priorities (n = 24), the highest priority went to human and material resources with 4 votes, followed by supervision and mentorship, community engagement, and empowerment, which had 3 votes each, and then data management, respective maternity care, leadership, governance, and staff skills which had 2 votes each (Additional file 7).

• In group 8 (UN/international organisations), out of 17 merged priorities (n = 30), the top priority was data use, management, and quality of care with 4 votes each. This was followed by community interventions and engagement (3 votes), maternal complication management, staff skills and capacity, and human and material resources, each with 2 votes (Additional file 7).

Group-level priorities using a prioritisation matrix

Group one- reproductive health services

At the group level while using a prioritisation matrix, the reproductive health services group (group 1) prioritised motivating health care workers so that they provide respectful maternity care to mothers and strengthening skills of skilled birth attendants for provision of quality care (Table 2). Participants in the group expressed varying views on motivation and strengthening skills, highlighting that these are not the same thing. One said, “I do think motivating is a different thing” (Workshop Participant 6, G1)’ while another was clear about their similarities, as in the quote, “I do think it is the same thing [strengthening skills and motivating]” (Workshop Participant 2, G1)

Table 2 Top five priorities at group level

Participants expanded the concept of motivation to encompass the availability of resources that healthcare workers need to conduct their work. Participants argued that the availability of resources would motivate healthcare workers to deliver quality services.

“I think we can check the evidence, but what I think is the number one motivator for HCWs is resources. I think one of the things that motivate me is I must find everything I need to do something. By talking point number two (adequate resources), you can indirectly motivate staff.” (Workshop Participant 3, G1)

Participants also believed that there is a gap between knowledge and practice, hence the need to strengthen the skills to close the know-do gap.

“We have given the highest score to strengthen skilled birth attendants, but I will say motivating them to give respective maternity care is the same thing so that it should only be one.” (Workshop Participant 1 G1)

“Just to know how you do someone’s blood pressure, doesn’t mean you will be able to do it.” (Workshop Participant 6, G1)

The group members further discussed and agreed that both priorities of motivation/resources and skills would require a time frame of three to five months to implement changes successfully and were feasible and affordable with some efforts (need adequate resources, good remuneration, and intensifying monitoring and feedback). The group also agreed that the priorities are readily acceptable and equitable, as staff need skills and motivation to provide quality and respectful care. While the group members were able to prioritise two areas, members observed that most priorities were interrelated and may impact on each other.

Group two: quality assurance

The quality assurance group prioritised community-centered care and data management, use, and research (Table 2). The members of the group argued that the community has a role in improving health outcomes because their ability to demand and contribute to health care is fundamental to improving the quality of care. Furthermore, participants asserted that facilities do not use data in making decisions, despite collecting data. Based on the matrix score, the group members agreed that the required time to effect change may be less than 3 months for both priorities. Community-centered care is feasible and affordable to implement with some effort put into improving the reception of mothers by HCWs at the hospital and motivating those who do not, or delay reporting to the facility. It is also readily acceptable and partially equitable due to limited access to healthcare services in hard-to-reach areas. The group agreed that data management is feasible with some efforts to motivate HCWs to use the available data and is partially equitable due to limited data access to all staff. However, HCWs need to be convinced of its importance for them to accept and use it.

“We are not doing well on community-based maternal and newborn care (MNH); we prioritise using Health Surveillance Assistants (HSAs) who have a lot of roles to play in the community, despite the presence of Community Midwives Assistants (CMAs) with midwifery skills. Although they are low in numbers, we can utilise them to provide community-centered care as skilled community midwives.” (Workshop participant, Group 2)

Group three: training institutions

The training institutions group prioritised community engagement to reduce delays in women reporting to the facility and to facilitate leadership empowerment. Participants argued that a leader is the driver of all improvements in MNH services. Strong leadership is a prerequisite for optimal implementation of policies, mobilisation and accountability of resources. Using the matrix score, the group members agreed that it might take three to five months for meaningful community engagement to effect change and that it is readily feasible, affordable, acceptable, and equitable. While leadership empowerment may require less than three months to effect change, it is feasible with some efforts (leaders should be strong, accountable, and ready to embrace change), readily affordable, acceptable with some efforts (leadership will), and equitable.

“In our facility, we have a leadership crisis. The staff create shortages by giving each other unnecessary days of leave; the internal arrangement is made in the presence of their leaders and managers. For instance, if there are more than eight nurses on duty, they let the other four go for a holiday and vice versa. This happens while the leaders are watching. Because they are never disciplined, they are allowed to do so.” (Workshop participant Group 3)

Group four: professional and regulatory bodies

For professional and regulatory bodies, their top two priorities were related to the health workforce in terms of numbers, availability, skills, and motivation to provide quality MNH services also, including operational research to use data for decision-making. Using a matrix score, the group agreed that health workforce activities may require a longer time to effect change, but activities are readily feasible, affordable, acceptable, and equitable. While operational research to use data may need a moderate time of three to five months to effect change, it is feasible and affordable with some effort (staff need the skills and will to use data) but readily acceptable and equitable (Table 2).

“We need to improve the health workforce by improving their work environment so that staff could be motivated to provide quality of care. The staff should be adequate, although sometimes they give each other shifts and create shortages [when there are more staff on a shift], but we need strong leadership to minimise this habit of creating shortages. But we need to support our staff with good remuneration by increasing their salaries, ensuring that they have resources, and ensuring that they have adequate skills. Eventually, we will have skilled, motivated staff who will be able to provide respectful maternity care with a good attitude.” (Workshop Participant Group 4)

Group 5: PPIE and community members

In the PPIE and community, their two top priorities were bridging the information gap that exists between facilities and the community and also addressing the attitudes of staff that affect women when seeking care. They argued that most women wait until labour is advanced to shorten the hospital time during which they interact with midwives. Using a matrix score, the group agreed that bridging the information gap needs a moderate time of three to five months to effect this change, and it is readily feasible, affordable, acceptable, and equitable. Impacting the attitude of staff also needs a moderate time of three to five months to effect change and is readily feasible and affordable with some efforts (midwives or nurses need skills, motivation, and resources to provide respectful care) and readily acceptable (Table 2).

“We need to bridge the communication gap that exists between communities and facilities. The community needs to know how many maternal deaths are happening and the causes. The information should reach every concerned individual in the community, and it should be in a clear language that even those who are illiterate may be able to understand. If maternal death has not occurred in their specific community, the community may think deaths are not happening in other areas. When communicating numbers, use simple examples that the community could understand. “Workshop participant group 5)

Group 6: care providers

For care providers, their two priorities were the need for more staff motivation and skills to provide quality care. The absence of resources, inadequate staff, and lack of recognition lead to frustration among health workers, burnout, and consequently the development of a bad attitude, which affects the care provided to patients. Using the matrix, they agreed that motivating staff may require less time than three months to change; it is feasible, affordable, acceptable with some effort (improving working conditions) and equitable. Although the healthcare workers highlighted strengthening the skills of healthcare workers as a priority, they stated that it may require a longer time of more than five months. Still, they found that it was feasible and affordable with some effort (may require skills training) and was readily acceptable and equitable (Table 2).

“I think we [healthcare workers] lack the motivation to provide quality of care; the working conditions are not good with an inadequate number of staff, resources to use, inadequate supervision, mentorship, and even lack of recognition where we have done well regardless of the challenges we face.” (Workshop participant Group 6)

Group 7: local organisations

For local organisations, their top two priorities were respectful maternity care (RMC) which they stated was broad and would address issues with attitude, commitment of staff, communication, coordination of care, and proper management and monitoring of mothers during birth. The second priority was the generation of good quality data that is optimally managed and used for decision-making. Using a matrix, the group agreed that both RMC and data management require a short time, less than three months, to effect change; these are feasible and affordable with some efforts (skills needed to achieve it) and are readily acceptable and equitable.

“Respectful maternity care is key in proving quality care as clients are empowered as they know their rights and staff are also accountable for actions provided. Under this [Respectful Maternity Care], provider’s (health workers) attitude and commitment, communication, and coordination will improve, and facility leadership will be accountable and improve infrastructure like toilets. This will do good mostly on how providers speak to patients, addressing attitude issues, giving them information, explaining, and interacting with them at every stage during delivery of care. “ (Workshop participant group 7)

Group 8: UN/ international partners

The two priorities from the UN/ International partners were related to data management for improved evidence-based decision-making and capacity building of healthcare workers to enhance skills to respond to emergencies during pregnancy, labour and the postnatal period. Using the matrix, the group agreed that data management requires less time of three months to affect this change since data is already available. They asserted that it is feasible and affordable with some effort (staff skills and knowledge on the importance of data use) but is readily acceptable and equitable. Staff capacity building requires a moderate period of 3 to 5 months to effect change, and is feasible and affordable with some effort (meaningful training) but readily acceptable and equitable.

“Data generation, management, and use is key to enhancing evidence-based decision-making. The availability of dedicated internet in the facility will ensure reporting, online learning, distance-based mentoring, and monitoring in facilities”. (Workshop participant group 8)

“We need to strengthen capacity building for health workers through mentorship and online CPD as opposed to taking them away from their duty station, which creates staff shortages.” (Workshop participant group 8)

Consensus level at the larger group through individual voting

At the point of consensus, the top two priorities from each group (highlighted in Table 2) were put together with similar priorities being merged. A total of 12 priorities were included (Fig. 4). Participants were asked to choose 2 priorities each on the list of 12 priorities to improve maternal and newborn health in Malawi. Fifty-seven (57) workshop participants participated in consensus voting using an online voting system (Slido). The top 3 priorities identified were respectful maternity care, information and data management, which had a tie with strengthening the skills of birth attendants (Fig. 4).

Fig. 4

Top three priorities to improve maternal and newborn health in Malawi

Priority 1- respectful maternity care

It was argued that respectful maternity care (RMC) encompasses everything a woman needs to have a positive pregnancy and childbirth experience and to ensure patient safety during the peripartum period. RMC is a fundamental aspect of providing quality healthcare and can help address the problem of disrespectful care that many women experience when accessing healthcare services. In addition, RMC will address challenges related to infrastructure that compromise women’s privacy.

“Respectful maternity care encompasses the attitudes of the nurses and, of course, the working environment that they are in, so once we deal with that, then I think we will have quality maternal care.” Workshop Participant

“It [RMC] usually is a neglected component in the delivery of quality of care; it may also serve as a key driver to ensure clients are comfortable to deliver in government facilities. Most complications can be prevented if providers provide good care and people have positive experiences.” Workshop Participant

Priority 2- information and data management

It was argued that with good data, healthcare workers will be able to monitor the progress and effectiveness of health systems investments. Information and data management are crucial components of health systems because they facilitate the monitoring of resources and indicators, resulting in prompt and tailored actions to improve the quality of care and outcomes.

“Making sure that information and data management go beyond the aspects of completeness, timeliness, and other data quality issues and include the existence of a proper feedback loop between the top and the bottom [managers to front workers], including communities will reinforce behaviour in terms of improving whatever is happening on the ground.” Workshop participant.

“I just want to complement what the other one said on information and data management. It is crucial to have proper data for decision-making, as well as for acquiring all resources. So, if we could be very eager to put much effort into those things (data), we would see that most of our indicators would change because that’s the way you can acquire more resources and decide on how to improve indicators.” Workshop participant.

… but also, the data from health facilities should not just go to other stakeholders but also to us (community members). The data should also go back to the community and let them know what is going on at the facility so that people in the community should be alerted to that and be able to assist.” Workshop participant.

Priority 3-Strengthening skills of birth attendants

Our participants emphasised the importance of enhancing the skills of birth attendants, as they play a crucial role in delivering good quality care and ensuring patient safety. As frontline workers, they require the essential skills to promptly respond to and manage emergencies. A key strategy for averting maternal mortality is early management of most obstetric complications.

“Birth attendants are key in improving maternal and neonatal care because they offer services to pregnant mothers; if they lack appropriate skills, they will not be able to deliver the necessary care in the facilities.” Workshop participant

“I feel like this [strengthening skills of birth attendants] is very important because the birth attendants are not skilled in other aspects of how they are supposed to treat the patients.” Workshop participant

Discussion

Our reflection on priority setting for maternal health needs in Malawi pertains firstly to the findings of three priorities to improve maternal and newborn care in Malawi and secondly to the lessons learned from iterative consultation with different stakeholders in maternal health. We also outline the mechanism by which the three priorities will help address the three common causes of maternal deaths in Malawi, along with their associated factors, as detailed in the 2023 national maternal death report [5]. We note that the top priorities for maternal health are similar across the stakeholder groups who participated in the prioritisation workshop. Again, the three top priorities we identified were respectful maternity care, information and data management, and strengthening the skills of birth attendants.

Prioritised areas

When considering the results presented in Table 2 of the top two priorities across all groups, alongside the top three priorities in Fig. 2, it is clear that priorities reflect the value participants placed on improving the quality of maternal health care delivered by healthcare staff and on offering pregnant women a positive pregnancy and childbirth experience. Given the global emphasis placed on the SDG target 3.1 of each country having fewer than 140 maternal deaths per 100,000 live births by 2030 and slow progress in reaching this target, the importance our stakeholders placed on improving quality of care delivered in Malawi is expected. Furthermore, as of 2021, uptake of facility-based birth with skilled attendance was 97% in Malawi [4], but this has not translated into declining maternal mortality, which is currently at 381 maternal deaths per 100,000 live births in 2020 and continues to rise [2]. We were not surprised to find consensus that healthcare for women and babies in Malawi must improve.

Our stakeholders prioritized not just improved care but respectful maternity care (RMC) for pregnant women, and this focus may be a consequence of numerous reports on disrespect, abuse, malpractice, mistreatment, and neglect of the pregnant woman during the entire pregnancy cycle, which is documented as widespread in low- and middle-income countries (LMIC) and infringes upon women’s human rights [24–29]. The RMC result here therefore aligns with the global calls to achieve RMC championed in most LMIC settings and also advocated by the International Council of Midwives [30, 31].

Significantly, recent studies reviewed have shown that receiving disrespectful care is often linked to complications or poor clinical outcomes like prolonged labour, injuries, and death [32]. Moreover, some studies have also linked the lack of respectful maternity care (RMC) to a decrease in facility-based deliveries, which subsequently leads to higher maternal mortality rates [32]. WHO defines RMC during labour and childbirth as “care organised for and provided to all women in a manner that maintains their dignity, privacy, and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth” [33]. With the promotion of institutional births, it is necessary to focus on the quality of care rendered in the facilities. Disrespectful care is a barrier to institutional delivery, which consequently hinders skilled birth utilisation [34]. Evidence has shown that women are not treated well both verbally and physically during pregnancy and childbirth which dissuades women from delivering at the hospital or delays women from reporting to a facility, which negatively affects maternal outcomes [35, 36].

The World Health Organization (WHO) recommends respectful maternity care for a positive childbirth experience and asserts that RMC is following human rights-based approaches to maternity care that could improve women’s experiences of labour and childbirth and address health inequalities [33]. Lack of RMC is an important contributor to poor quality of care [33]. The experience of care has a significant impact on both individual and health facility–level outcomes and is associated with other factors such as the provision of quality care, competent and motivated human resources, and the availability of essential physical resources [35, 36]. For RMC to be effectively implemented, there is a need to overcome barriers such as lack of resources, lack of staff, uncooperative pregnant women with unmet needs, communication issues, privacy issues, lack of clear written staff policies, and workload [37–39]. Employing capacity-building programmes, performance management, and supervision, health workers may prevent disrespectful behaviour toward women [37, 38].

Furthermore, a strategy to promote rights-based and respectful maternal care must be instituted to improve the quality and outcomes of maternal and child health and staff motivation. Approaches might include strengthening disciplinary measures against HCWs failing to comply with RMC principles to ensure accountability; provision of adequate resources to enable HCWs to provide optimal care to their patients and thereby improve their job satisfaction; intensifying performance management systems and supervision; and considering increases in pay and staffing numbers [40]. On promoting RMC awareness, all cadres of HCWS need to be trained in delivering women-centered, gender-sensitive, rights-based maternal care. Patient feedback mechanisms must be instituted to assist with monitoring of RMC practice. Raising awareness about women’s rights in childbirth must include the right to bodily autonomy and informed consent as essential elements of quality maternal care [40]. RMC is addressed through a lens of health systems strengthening that addresses bottlenecks, including the rights of providers of childbirth care. It is worthy to implement both bottom-up and top-down health system strengthening to promote RMC [40].

The second priority put forward by our stakeholders was improved information and data management; this focus aligns well with best practice globally [41] and follows global goals for improving evidence-based decision making among maternity health workers, despite known challenges and inefficiencies with routine data [42]. Prioritising improved data management also align well with WHO’s goal to improve national routine health information systems (RHIS) in maternal, newborn, child, and adolescent health (MNCAH) [43]. The WHO guidance aims at increasing national uptake of RHIS data for evidence-based decision-making around resource allocation and programming [40, 41]. The guidance further provides possible analyses, visualizations of the indicators, and references on how to assess the quality of the data [40, 41]. Additionally, the second of eight WHO standards for enhancing the quality of maternity and newborn care in health facilities—which many nations, including Malawi, have adopted—highlights the significance of enhancing medical records and healthcare information systems with the goal of improving monitoring, evaluation of performance, and ultimately improving maternal and perinatal outcomes [42, 43] Notably, health information systems is one of the six essential and interrelated building blocks of a health system as advocated by WHO [44]. Improving the quality of maternal and newborn care requires a functioning health information system that enables decision-makers at all levels of the health system to identify needs, solve problems, and reward progress; make evidence-based decisions for health policies and programs; and allocate limited resources as efficiently as possible [43].

Despite the press on the importance of good data systems, in many low- and middle-income countries (LMICs), RHISs are still dispersed and disorganised, and there are significant concerns regarding the quality, accuracy, timeliness, and completeness of data [45, 46]. Studies from LMICs have shown that there are organisational, behavioural, and technical barriers to effectively introducing, implementing, and utilising RHISs systems in this context, which need to be considered for effective data use [45, 47–49].

Organisational challenges for best practice in the use of health data include inadequate governance and management, limited feedback, a lack of training, supervision and resources and the institutional/organisational failure to promote a culture of data use [45, 47–49]. Behavioural challenges to best practice include poor demand for RHIS data, as well as poor staff motivation, incomplete data documentation, incorrect input, delayed data submission, and low competency among health workers, while the technical challenges include a lack of staff knowledge, skills, tools, and specialised technical infrastructure in health facilities [45, 47–49].

In Malawi, similar challenges have been reported in a situation analysis of health information systems, where poor data quality, intermittent supply of data collection and reporting tools, overreliance on manual data collection tools, lack of staff, and inadequate use of data for decision-making were among the identified challenges [50]. In response, in 2020 Malawi established a national maternal surveillance (MAT Survey) platform to capture quality of care and maternal outcome indicators [51]. This data platform is customised to the needs of the practitioners to support clinical care, communication, service improvement and relationship building in a challenging working environment. The creation of Mat-survey platform is one of the improvements Malawi has achieved regarding data management in MNCH; now, data use needs to be intensified. Other strategies to improve data management and use in LMICS include indicator development, dashboard development, mobile health management, data quality audits, data use workshops, staff training, management support, and having dedicated personnel for monitoring and evaluation support [52]. Further, the importance of electronic records over paper-based has been stressed in a study conducted in Australia where the implementation of an Electronic Health Record (EHR) significantly enhanced the gathering of best practice data, and the information within an EHR was more accessible to the relevant clinical staff who had the proper login credentials and could be retrieved more easily compared to data from a paper hand-held record [53].

Data is only useful for those who understand it; providing communities with feedback on maternal indicators in the language that they can understand is key, including translating findings into local language (as in the Democratic Republican of Congo) [54]. Health facilities may also benefit communities’ health literacy over the longer term by sharing accurate data on maternal indicators to raise awareness and indicate local change and progress over time [55–57]. Other studies have also reported that communities may also have limited understanding of how to interpret and manage health data, underscoring the importance of simplifying the data for a diverse audience [58]. Finally, incomplete and inconsistent data at health facilities impedes the ability for programmes to plan and evaluate their own impact [55].

Our third priority involved strengthening the ability for skilled birth attendants to deliver high-quality maternal and newborn health services. This priority aligns well with best practices globally and within the region. Strengthening of skills of health care workers as suggested in this study is similar with the call made in Tanzania to strengthen midwives competencies through trainings that are focused on capacitating midwives with skills to manage emergencies [59]. This has been done as a measure to curb maternal and neonatal mortality and morbidity. Going forward, Malawi can also leverage the existing continuous professional development platforms in existence both at the Nurses and Midwives Council and Ministry of Health levels to ensure that midwives are well skilled in management of maternity cases. The call to strengthen skills of staff cements what UNFPA has been promoting over the years in several countries in Africa [60].

A recent study done in Malawi echoed the similar findings and reported that inadequate skills are one of the challenges in providing better preeclampsia care [61]. Likewise, a recent Malawi maternal death report has indicated that a lack of obstetric emergency skills is among the key healthcare worker-related factors contributing to maternal deaths. [5]. Additionally, healthcare providers’ limited skills in the management of the third stage of labour were reported in a study conducted in Tanzania, which is likely to contribute to postpartum haemorrhage [62]. While another study from Tanzania found registered nurses trained at degree level were more knowledgeable in postpartum haemorrhage prevention and management than enrolled nurses trained at diploma level [63]. Given that most primary health care centres where most pregnant women first seek care are staffed by enrolled nurses, it is essential to beef up their on-the-job training skills. This evidence reinforces assertions that competence-based training in obstetric complications and midwifery skills increased knowledge, skills, and confidence in the provision of midwifery care and management of obstetric emergencies [59, 64, 65]. The competency-based training also improved communication skills, trust, and support between midwives and the community and transformed the attitudes of midwives toward continued professional development [59, 64, 65]. Training of SBAs needs to extend beyond the numbers to include improvements in their knowledge and skills and how those relate to the care they provide to women and their babies [66]. Additionally, an integrated approach focusing on enhancing the clinical and management competencies of the training has the potential to yield better results than isolated approaches.

While training may offer promising benefits, it is crucial to acknowledge that clinical outcomes could be limited by inadequate health facility readiness, including issues with communication, supportive clinical leadership, and referral processes that require attention [67]. In a systematic review for LMICs, it was reported that skilled birth attendants face challenges that can reduce their morale and ability to provide quality care, increase their workload and infection risk, and decrease their productivity [68]. Some of these challenges include insufficient training during pre-and In-service, low pay, inadequate or lack of equipment, drugs, and supplies; blood and the infrastructure to manage blood transfusions; electricity and water supplies; and adequate space and amenities on maternity wards [68]. Other skilled birth attendants also felt that managers lacked capacity and skills, and they felt unsupported when their workplace concerns were not addressed and where facilities lacked staff, skilled birth attendants’ workloads could increase, it could become difficult to provide supervision, and mothers could receive poorer care. These factors need to be considered so that skilled birth attendants are enabled to utilise skills necessary to provide respective maternity care to pregnant women [68].

Stakeholders also emphasised the need to strengthen strategies for training HCWs. The stakeholders stressed the scaling up of mentorship sessions and the constituting of skills labs in the facilities to support onsite training compared to external training. Training in a skills laboratory or simulation centre allows both pre-service and in-service healthcare providers to practice their skills in a controlled setting [69]. The use of simulation training in obstetrics has demonstrated improvements in healthcare providers’ knowledge, skills, and confidence in managing obstetric cases [69]. The practical details of establishing obstetric skills laboratories have been thoroughly explained [69]. The relevance of speed drills has been highlighted in a project implemented in Ethiopia [70]. While evidence reviews have called for more robust research on training programme effectiveness [71], this result calls for more reflection on how the HCWs are equipped with skills and knowledge that will improve the outcomes. In a Malawian study on barriers and enablers of implementing bubble continuous positive airway pressure, nurses reported that on-the job training was inadequate, and others felt incompetent despite on-the job training [72]. The use of skills laboratories could be an effective method for LMICs to adopt easily. However, their functionality depends on the commitment and enthusiasm of the staff, while sustainability depends on program managers’ dedication to implementing and maintaining simulation training [70].

The NGT process

We chose a NGT because it prioritises issues under debate and reach consensus in a methodical way [21]. As a consensus approach, it gave the participants the chance to work through the procedures and first think about the areas that needed individual priority before reaching a group decision [21]. The issue of dominant members affecting the course of the decisions was lessened by the NGT’s structured nature.

Implications

This study has produced the top three priorities to improve maternal and newborn health in Malawi. These priorities offer guidance to policymakers, partners, implementers, and donors to direct their investment to specific areas to build the capacity of staff and promote equitable maternal and neonatal health outcomes. Similarly, it provides guidance to researchers in the field to undertake research that is aligned with defined priorities.

Malawi will need to consider the priority areas in the plans that it makes regarding maternal and neonatal health. This can be done by sharing and impressing on its developmental partners to embrace the priorities, inclusion of the priorities in the plans to accelerate the reduction of maternal death and every newborn action plans. Furthermore, the Government as a custodian of health activities could keep track of organisations that are working in each of the priority areas and be able to stir upcoming funders in the areas that need the most support.

It is necessary to define and contextualise RMC for Malawi and provide specific action items at each step of a woman’s interaction with the healthcare system. Through advocacy, campaigns, and IEC materials, it is necessary to increase knowledge of the 12 elements of RMC for women in the community as well as for health care workers. Women must feel empowered to demand the care they deserve to promote the provision of respectful maternity care. To improve the quality and outcomes of maternal and child health as well as staff motivation to give rights-based and respectful maternal care, strategies that focus on healthcare worker training, community awareness, patient/client feedback systems, and empowerment must be implemented.

Healthcare workers must possess the skills necessary to analyze and use the locally gathered data at their facility. For the individual communities to understand how well they are performing in terms of maternal health indicators, there should be a feedback loop for information. Locally addressable research issues related to operations and implementation should be informed by actionable data gathered at the facility level. Additionally, by utilising data to provide staff with feedback, they will be more motivated and inclined to provide RMC as they identify areas for improvement or where they have effectively contributed to improving the outcomes.

Although there has been much implementation and promotion of in-service training, additional strategies such as the use of skills labs and mentorship programmes need to be further explored and utilised to improve skilled birth attendant skills at the facility level. Other factors contributing to Malawian hospitals’ poor management of obstetric emergencies include “inadequate monitoring,” “prolonged abnormal observations without action,” and “lack of obstetric emergency skills as reported in the recent maternal death report under review” [5]. Well-organised skills training that not only equips HCWs with the necessary skills but also inspires them to put those abilities into practice will also address these problems. Having required skills makes healthcare workers satisfied with their job, more motivated, and potentially even more productive and might promote RMC.

For future research, it is important to identify strategies for implementing the three priority areas, providing a conceptual framework that can successfully achieve these despite limited resources. Additionally, organising a review meeting to assess the progress of implementation in Malawi will help guide the development of this conceptual framework.

Strengths and limitations

To our knowledge, this is the first specific priority-setting exercise for maternal and newborn health and provides clearer guidance to maternal neonatal health stakeholders on priorities for both research and implementation. The participation of maternal and newborn health stakeholders from the different organisations and the mix of stakeholders that contributed to defining the priorities are an important strength of this exercise. Participation captures the views of those who generate evidence, service users, and those who need and use evidence to inform practice and policy in the programmes to improve maternal and neonatal health. We acknowledge that the presentation to stakeholders may have affected participants’ priorities as it was focused on maternal health. Priorities might have been different had this been considered. Ensuring a more balanced approach should be considered for similar activities in future. The use of NGT methods as a validated method ensured a balance between views and opinions from all stakeholders who attended the workshop and facilitated agreement. The use of online voting to reach consensus was intended to produce final priorities with minimal bias. However, we observed that some community representatives had no access to smartphones or limited knowledge on how to navigate through the smartphone to access the poll. However, the facilitators assisted them to access and vote online.

The NGT process also observed power dynamics in the groups by grouping stakeholders with similar interests together and allowing individual prioritisation before group consensus. This ensured that individuals’ views and opinions were accounted for in the discussion. We acknowledge that individual final voting decisions might be affected by the group discussions that happened after individual prioritisation. However, the use of a prioritisation matrix reduces bias and increases the validity of the findings.

One of the limitations identified was the limited time we engaged with stakeholders (one-day workshop). This meant that stakeholders were unable to suggest priorities prior to the workshop and therefore the suggested priorities may have been limited, potentially biased, or missed. However, we tried to ensure that we identified as many priorities as possible during individual prioritisation and gave time to the group to decide on what is critical using a prioritisation matrix. We also conducted checks to ensure that the risk of biases or missing priorities was minimised (recording to group discussions). It is acknowledged, however, that groups reflecting service users with disabilities were not prominent in our stakeholders’ groups. This was an oversight that needs to be considered in similar activities in the future.

Linkages of the prioritised areas against the major causes of maternal death in Malawi

Respectful Maternity Care is essential for providing comprehensive, equitable maternity services, improving the quality of the physical environment and resources, ensuring the availability of competent and motivated healthcare workers to deliver efficient and effective care, and promoting continuity of care. This approach is likely to encourage mothers to seek care early, reducing the risk of complications such as maternal sepsis, postpartum haemorrhage, and eclampsia.

An effective data management system facilitates tracking progress on major causes of maternal deaths and supports decision-making processes. The data can inform resource planning to address stockouts that can hinder care delivery. Additionally, the data reveals trends in causes of maternal deaths, death rates, referrals due to major causes within facilities and communities, and associated factors. This information can guide decision-making and monitor outcomes and progress.

Having competent personnel is crucial for providing comprehensive care to prevent, treat, and manage maternal sepsis, pre/eclampsia, and postpartum hemorrhage in a timely manner. Skilled personnel who are motivated to use available data can make informed decisions for timely referral, treatment, and counseling for women. Additional file 8 illustrates the link between prioritised areas and three major causes of maternal deaths in Malawi.

Conclusion

If progress to achieve sustainable development goal 3.1, ‘’to reduce the global MMR to 70 maternal deaths per 100,000 births and no country should exceed two times that ratio (140 per 100,000)’’ is to be accelerated, investment in evidence-based interventions that support building the capabilities of skilled birth attendants to provide quality of care and capacities of the community to demand the quality of care must increase. However, if programme goals or research agenda do not respond to global or national priorities, it may impede the uptake of MNH interventions within national strategies. This study has resulted in three key priorities that need to be considered in improving maternal and newborn outcomes in Malawi. Stakeholders in maternal and newborn health are strongly encouraged to consider these priorities to guide future investment in MNH.