title: Too few staff, too many patients: a qualitative study of the impact on obstetric care providers and on quality of care in Malawi.
abstract: BACKGROUND
  Shortages of staff have a significant and negative impact on maternal outcomes in low-income countries, but the impact on obstetric care providers in these contexts is less well documented. Despite the government of Malawi's efforts to increase the number of human resources for health, maternal mortality rates remain persistently high. Health workers' perceptions of insufficient staff or time to carry out their work can predict key variables concerning motivation and attrition, while the resulting sub-standard care and poor attitudes towards women dissuade women from facility-based delivery. Understanding the situation from the health worker perspective can inform policy options that may contribute to a better working environment for staff and improved quality of care for Malawi's women.
  
  
  METHODS
  A qualitative research design, using critical incident interviews, was used to generate a deep and textured understanding of participants' experiences. Eligible participants had performed at least one of the emergency obstetric care signal functions (a) in the previous three months and had experienced a demotivating critical incident within the same timeframe. Data were analysed using NVivo software.
  
  
  RESULTS
  Eighty-four interviews were conducted. Concerns about staff shortages and workload were key factors for over 40% of staff who stated their intention to leave their current post and for nearly two-thirds of the remaining health workers who were interviewed. The main themes emerging were: too few staff, too many patients; lack of clinical officers/doctors; inadequate obstetric skills; undermining performance and professionalism; and physical and psychological consequences for staff. Underlying factors were inflexible scheduling and staff allocations that made it impossible to deliver quality care.
  
  
  CONCLUSIONS
  This study revealed the difficult circumstances under which maternity staff are operating and the professional and emotional toll this exacts. Systems failures and inadequate human resource management are key contributors to the gaps in provision of obstetric care and need to be addressed. Thoughtful strategies that match supply to demand, coupled with targeted efforts to support health workers, are necessary to mitigate the effects of working in this context and to improve the quality of obstetric care for women in Malawi.
authors.affiliation: School of Health Sciences, City University London, 1 Myddelton Street, London, EC1R 1UW, UK. susan.bradley@city.ac.uk.
authors.forename: Susan
authors.initials: S
authors.lastname: Bradley
authors.affiliation: University of Malawi, College of Medicine, Centre for Reproductive Health, Blantyre, Malawi. fwkamwendo@hotmail.com.
authors.forename: Francis
authors.initials: F
authors.lastname: Kamwendo
authors.affiliation: University of Malawi, College of Medicine, Centre for Reproductive Health, Blantyre, Malawi. effie_chipeta@yahoo.com.
authors.forename: Effie
authors.initials: E
authors.lastname: Chipeta
authors.affiliation: University of Malawi, College of Medicine, Centre for Reproductive Health, Blantyre, Malawi. wchimwaza@medcol.mw.
authors.forename: Wanangwa
authors.initials: W
authors.lastname: Chimwaza
authors.affiliation: Heilbrunn Department of Population and Family Health, Averting Maternal Death and Disability Program (AMDD), Mailman School of Public Health, Columbia University, New York, USA. hd2122@cumc.columbia.edu.
authors.forename: Helen
authors.initials: H
authors.lastname: de Pinho
authors.affiliation: School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland. eilish.mcauliffe@ucd.ie.
authors.forename: Eilish
authors.initials: E
authors.lastname: McAuliffe
mesh_terms: D001291:Attitude of Health Personnel; D005260:Female; D006301:Health Services Needs and Demand; D006280:Health Workforce; D006801:Humans; D008295:Malawi; D008297:Male; D008427:Maternal Health Services / Q000592:standards; D008880:Midwifery / Q000592:standards; D009042:Motivation; D009773:Obstetric Nursing / Q000592:standards; D009774:Obstetrics / Q000592:standards; D011247:Pregnancy; D036301:Qualitative Research; D011787:Quality of Health Care; D016526:Workload