Stakeholder perspectives on Emergency Obstetric and Neonatal Care Signal Functions and Indicators in Malawi: A Qualitative Human-Centered Design Study

Abstract

Background: Emergency Obstetric and Neonatal Care (EmONC) signal functions and indicators are central to efforts to reduce preventable maternal and neonatal mortality. Their implementation in low- resource settings is often constrained by health care system, contextual, and data-related challenges. This study explored stakeholder perspectives on the relevance, feasibility, and utility of EmONC signal functions and indicators in Malawi.

Methods: We conducted a qualitative descriptive study informed by a human-centred design (HCD) approach. Data were gathered through 10 semi- structured key informant interviews and one participatory co-design workshop with national policymakers, district health managers, safe motherhood coordinators, midwives, neonatal specialists, and implementing partners. Data were analysed thematically through an iterative, team- based process that integrated interview and workshop findings.

Findings: Stakeholders affirmed the clinical and policy value of EmONC signal functions but noted implementation challenges at lower-level facilities, including limited provider confidence, low caseloads for key procedures, weak referral systems, and transport constraints. While indicators such as met need for EmONC and proportion of births in EmONC facilities were considered useful, participants raised concerns about data quality, infrequent reporting, vague definitions particularly for neonatal outcomes and indirect maternal deaths and contextual misalignment of caesarean section and case fatality rate indicators. Participants emphasised the need for indicators that better capture functional readiness, processes of care, and contextual interpretation of utilisation data.

Conclusion: EmONC signal functions and indicators remain essential for strengthening maternal and newborn care in Malawi but require contextual adaptation. Refining indicator definitions, improving data systems, and integrating measures of quality, effective coverage, and referral functionality are critical for improving accountability and outcomes in Malawi and similar low-resource settings.