Qualitative assessment of knowledge transfer regarding preterm birth in Malawi following the implementation of targeted health messages over 3 years

Figures & data

Table 1 Composition of focus groups at each of the eight sites

Sites	Year added to this educational program	Number of patients and partners interviewed	Number of providers	Total interviewed	Types of providers interviewed
		n=36	n=34	n=70
Area 18	2012	4	4	8	Midwives CHWs Nurses
Area 25	2012	4	4	8	Midwives CHWs Nurses Health surveillance assistants
Chitedze	2015	5	6	11	Midwives CHWs Medical assistants Health surveillance assistants
Kabudula	2012	6	9	15	Midwives Clinical officers Nurses Medical technicians Sonographers Dental technicians Medical assistants Field health workers
Kawale	2012	4	6	10	Midwives CHWs Dental officers Clinical officersa
Lumbadzi	2015	6	0b	6
Mitunduc	2015	1	1	2	CHWs
Nathenje	2015	6	4	10	Midwives CHWs Clinical officers Nurses

Notes: An independent researcher and the facilitators manually recorded the time, number of responses, and verbatim nature of the recorded notes. These tabulations were internally checked, and consensus was reached immediately following each session. Further clarification regarding language, statement, and contextual inference was achieved with the help of interpreters. Such clarification was sought either immediately after the interview or by the end of the same day as the interview occurred. Patients were either pregnant or recently postpartum, and partners were defined as the self-identified father of the index pregnancy. Patient participants had pregnancies complicated by HIV, history of pregnancy loss, preterm birth, miscarriage, hypertensive disorders, anemia, and malaria. Such information was not formally collected or reported due to confidentiality concerns, particularly in the setting of the low number of participants. However, this information may have been self-disclosed during the course of the group discussions.

a Clinical officers are similar to a community practice physician or advanced physician assistant, typically with 2 years of formalized training followed by 18–24 months of multidisciplinary internship. Clinical officers are well-versed in prevalent complications in obstetrics and gynecology and common interventions, including cesarean deliveries and assisted deliveries, dilation and curettage, and basic ultrasound.

b Providers were not available for focus groups due to a staff meeting.

c This site had low attendance, therefore semi-structured individual interviews occurred with the same lead in prompts utilized for the focus groups.

Abbreviation: CHW, community health worker.

Table 2 Lead-in prompts for focus group discussion

Topic	Question
General pregnancy questions
Gestation	• What is the normal length of pregnancy? • How is expected date of delivery determined?
Prenatal and obstetric care	• Why would women not come or come late for antenatal care appointments? • Do you know of women who plan to deliver at home or in their village? • Would it matter if the baby was being born too soon? • On their due date?
Preterm birth
Counseling	• What if a woman has pain a few months prior to her expected delivery date?
Epidemiology	• How common is preterm birth? • Scripted prompt: “If you had ten women gathered who have had children, how many would have had a preterm birth? One? Two? Three? Four? Five? Six?” • What are causes of women delivering early, like at 6 or 7 months? • At what gestational age can a baby survive?
Recurrent preterm birth	• Have you heard of recurrent preterm birth? • If a woman has a history of preterm birth (800 g or 1 kg or even 2 kg), would she be referred antenatally?
Management of preterm birth	• Why would a woman not come to a health center when in preterm labor or with antenatal problems? • What can be done at a health center if preterm delivery occurs or might occur? • Have you ever heard of medicines that can be given to the mother to make the baby more ready if she delivers early or that can prevent the recurrence of preterm labor? • Have you heard about using antenatal steroids for fetal lung maturity? Shots to the mom for helping a baby breathe better? What have you heard? Any potential harm? When can they be used? When can they not be used? • Would women come in early if medications were available?
Prevention of preterm birth	• Are there ways to prevent preterm birth?
Smoking and tobacco
General information	• Do people in Malawi smoke tobacco? Chew or gum tobacco? What are your thoughts on pregnant women smoking or chewing or gumming tobacco?
Risks of smoking or tobacco	• Are there potential risks or harm to chewing or smoking tobacco?
Oral health and xylitol-containing gum
Chewing gum	• Would you believe it if someone told you that chewing gum might help prevent preterm birth? • Is gum acceptable?
Oral health and preterm birth	• If we tell you that the same bacteria that can cause gum disease may cause preterm birth, would you believe it?
General tooth care	• What is usual tooth care?

Table 3 Iterative responses by discussion group, highlighting emerged major and minor themes

Topic discussed	Patients/patient couples Major themes • Minor themes	Healthcare providers Major themes • Minor themes
Pregnancy/ANC
Length of a normal pregnancy	9 finished months • 36 or 37 weeks	40 weeks • 9 completed months
How due date is known	Counts from LMP • [Ultrasound]	History taking with LMP • [Ultrasound]
Barriers to ANC	Ignorance Afraid to come • [Distance/transportation] • [Too many visits/tired]	[Culture/religion] [Distance/transportation] • Afraid of HIV testing • Do not want to come to ANC
Whether women deliver at home and when those women would go to the hospital	[Yes] • Many come to the health center when they have pain before the due date	[Yes, if preterm contractions]
Preterm birth
Actions to take if preterm contractions	She would come in • She will find her way to the health center hoping for care or for proper management • [Goat fines]	Now the women will come • Many think of getting more help
Frequency of preterm birth	Two or maybe three [out of ten]	Two or three of ten
Causes of preterm birth	[Infection] • Malaria • [Periodontal disease] • [Short interpregnancy interval] • Hard work	[Infection] • Malaria • Anemia • [Short interpregnancy interval]
Earliest age a baby can survive	6 or 7 months • 1 kg • 1.5–2 kg	28 weeks • We have heard of 600 or 800 g • 1–1.5 kg • For sure above 1.5–2 kg
Knowledge of recurrent PTB	[Yes] • Yes but not common	• [Yes] • Yes but it is not so common
Referral for history of PTB	Yes • We do not know	Yes
Barriers to accessing a community health center for preterm labor	Ignorance • Following advice is a problem • For the reasons we have already shared against going to antenatal care	Ignorance • For many of the same reasons as not ANC
Services available at health facilities	Kangaroo care • Be referred to KCH or district • Help for baby	[Send to KCH] • [Kangaroo care] • Help for baby
Knowledge of antenatal steroids	No • We heard of the medicine for the lungs from the health worker	Yes
Would women come for medications?	Yes if they knew	Yes and they do
Knowledge of ways to prevent preterm birth	Antenatal care • [Come to health center for PTL] • [Avoiding causes] • [Avoiding/treating malaria]	Good history taking • Contraception to keep the pregnancy spaced • [Avoiding causes]
Smoking and tobacco
Pregnant women and tobacco	Yes they do • More women will gum when they are pregnant • Some women stop when pregnant but sometimes cannot	Yes • The pregnant women gum the tobacco
Risks of tobacco	[Preterm birth] • [Maternal complications] • [Fetal/newborn complications]	[Preterm birth] • [Fetal/newborn complications]
Oral health and gum
Belief that gum could prevent PTB	Yes • [Request proof or explanation]	Yes, maybe
Is gum acceptable?	Yes	Yes
Belief that the same bacteria responsible for gum disease cause PTB	Yes • [Request proof or explanation]	Yes • [Request proof or explanation]
Usual tooth care	They use fingers and sand • Colgate some use • They use ashes	Some use ash [Brush and paste]

Note: All responses are direct quotations unless indicated with brackets.

Abbreviations: ANC, antenatal clinic; LMP, last menstrual period; PTB, preterm birth; PTL, preterm labor; KCH, Kamuzu Central Hospital.

Figure 1 This is an example of one of the songs used to transfer information about preventing a short interpregnancy interval.

Notes: The lyrics shown here have been translated from Chichewa into English and are shown verbatim as translated. In Chichewa, this song is set to a locally familiar tune. This and other songs (not included here) were presented and sung in the waiting room at the antenatal clinics.

Table

Community health worker	Individuals without formal health training, typically hired for a specific project or by community health centers or (more commonly) by a nongovernmental organization (NGO). Their role is to educate patients and community members through prepared speeches and songs. They also serve as a liaison with the community leaders to further promote health messages^Citation153
Primary health center/community health centers	Often rural. Comprised of outpatient units (including antenatal clinics), holding beds, maternity units, antenatal units, postnatal beds, and holding wards^Citation154
Central hospital/tertiary hospital	Outpatient units (including antenatal clinics), holding beds, maternity units, antenatal units, postnatal beds, holding wards, X-ray, imaging, ambulance, operating theater, laboratory, engineering department, specialized services^Citation154
Kangaroo care	Kangaroo care is a method of holding the baby on the chest that maximizes skin to skin contact^Citation74

Table S1 Lead-in prompts for providers only

Topic	Question
Additional education requests
“Open Day”	• What would you like to know more about during an “Open Day”
Preterm birth	• Are there areas of preterm birth or being born too soon/too small that you wish you knew more about?
Knowledge gaps	• Are there gaps in your knowledge you would like to be filled?
Obstetrical or clinical skills	• Are there obstetrical skills or practicum that you wish you were more comfortable with?

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