More than a lack of resources: a mixed-methods assessment of the barriers and facilitators to infection prevention practices in three low-resource maternity units in Malawi.

Authors

Jennifer M Riches, Chimwemwe Kachiwaya, Marthe Onrust, Linda Nyondo-Mipando, Catriona Waitt, Abi Merriel, David Lissauer

Published in

BMJ global health. Volume 11. Issue 9. Sep 15, 2026. Epub Sep 15, 2026.

Abstract

Maternal sepsis is a leading cause of maternal mortality and morbidity. Caesarean section is a risk factor for infection, particularly in low-resource settings. This study aimed to identify barriers and facilitators to recommended infection prevention (IP) practices prior to implementation of a complex intervention to improve IP during caesarean section in a low-resource setting.
This was a mixed methods study conducted in three semi-rural maternity hospitals in Malawi between June and December 2022. Participants were healthcare workers (HCWs) and women undergoing caesarean section. Data collection included case note review, weekly surveys and ethnographic participant observation to assess resource availability for IP and adherence to recommended IP practice. Preliminary data were integrated and used to inform in-depth interviews with HCWs to further explain findings. Inductively coded themes from interviews were mapped to the Communication-Opportunity-Motivation-Behaviour (COM-B)/Theoretical Domains Framework (TDF) model.
We found a lack of resources and suboptimal infrastructure for IP across the facilities, with many basic items available only intermittently. Observation revealed significant gaps in recommended IP practices, including hand hygiene, aseptic technique during vaginal examination, surgical scrubbing and sterile practice in the operating theatre. Scarcity of resources and infrastructure functioned as both direct and indirect barriers to IP due to their impact on staff motivation (reflective and automatic). Having 'passion' for patients, regular senior supervision and 'reminders' acted as facilitators to recommended IP practice.
Our study demonstrates that adherence to recommended IP practice is determined by more than the availability of resources; the indirect impact of scarcity on staff motivation also played an important role. The study identified further barriers and facilitators to general IP practices, the understanding of which was subsequently used in the selection and development of a complex behaviour change intervention to improve IP practices in the same facilities.

PMID:
42744564
Bibliographic data and abstract were imported from PubMed on 16 Sep 2026.

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