Participant selection
Participants in both the antenatal and postpartum period were
interviewed to elicit women and healthcare providers’ experiences and
practices with FMs throughout pregnancy and labor care (including the
time of admission). Between October 2017 and February 2018, all
nurse-midwives and doctors (registrars and intern doctors) of the
department were invited to participate in a questionnaire and FGD which
took place outside working hours. In addition, pregnant women, ≥18 years
and ≥18 weeks gestational age presenting to the ANC clinics (either
routine or obstetric clinic) were selected via convenient sampling for
one-time semi-structured interviews. Postpartum women were recruited
before hospital discharge using purposeful sampling to include women
with and without adverse perinatal outcomes (stillbirth, neonatal death
and/or Apgar score <7 at 5 minutes). Privacy was ensured by
interviewing women in private rooms or spaces.
Data collection
The researchers developed a questionnaire and interview- and
FGD-guidelines to explore the main themes (Table S2): awareness and
knowledge, behavior and practices, barriers and opportunities for
improvements in the usage of maternal perception of FMs for fetal
surveillance. Behavior and practices around FMs were assessed at three
distinct time points: during antenatal care, on admission to the labor
ward and intrapartum. Data collection tools were translated to Kiswahili
and pilot tested. A Kiswahili speaker, either a female intern doctor or
a female researcher with a diploma in psychology, conducted the
antepartum and postpartum interviews, assisted by a foreign medical
student (KW). A male intern doctor and native speaker (RSK) with prior
experiences in moderating FGDs mediated the FGDs, assisted by KW and NH.
All researchers except NH did not work at the maternity unit at the time
of the study. Antepartum and postpartum interviews lasted 15-30 minutes
and 5-20 minutes respectively, while the FDGs with staff members lasted
40-90 minutes. Recruitment of participants continued until saturation of
information was reached. Interviews were translated immediately to
English and detailed field notes were written down during interviews,
both in Kiswahili and English. FGDs were audio recorded with the
permission of participants and afterwards transcribed and translated by
RSK. Transcripts were not returned to participants. Questionnaires (a
combination of multiple-choice and five-point Likert scale questions)
were anonymously self-administered and completed by the health providers
prior to the FGDs (Table S3).
Sociodemographic characteristics (age, marital status, education,
occupation and obstetric history) and perinatal outcomes of
participating women were collected from participants, ANC cards,
hospital files and, if necessary, from data of the main study.