'At the right time, in the right way, with the right resources': perceptions of the quality of care provided during childbirth in Malawi

Background: Improving the quality of care women receive during childbirth is as important as ensuring increased availability of care and numbers of healthcare providers. To be able to improve quality of care, it is important to understand what quality means for mothers as well as providers of care. Methods: 33 postnatal mothers and 10 healthcare providers from all 4 major hospitals in one district in Malawi were interviewed via 27 in-depth interviews and 2 focus group discussions. Data was transcribed and analysed using the thematic framework approach. Results: Perceptions of quality of care differed substantially between care providers and postnatal mothers. For caregivers, characteristics of good quality care included availability of resources while for postnatal mothers positive relationships with their caregiver were important. Lack of autonomy and decision making power is a barrier to quality of care and it exists both at the level of the patient (mother) and at the level of her caregiver with healthcare providers unable to influence decisions made by more senior staff or management. Lack of autonomy was linked with the emerging themes of staff de-motivation, frustration, lack of empowerment to make change and resulting in a poor quality of care provided. Conclusions: Creating a reciprocal understanding of what good quality care comprises and the barriers as well as promoters of this should be the starting point for improving the quality of maternity care. A renewed focus is needed on improving communication, strengthening patient rights and autonomy whilst simultaneously motivating and enabling healthcare workers to provide comprehensive and inclusive quality of care.