Anqi HeFollow

Date of Award

January 2023

Document Type

Open Access Thesis

Degree Name

Master of Public Health (MPH)


School of Public Health

First Advisor

Rafael R. Perez-Escamilla


High maternal and neonatal mortality rates persist in Mozambique, with the issues of stillbirth remaining understudied. Most maternal and neonatal deaths in the country are due to preventable and treatable direct childbirth-related complications that often occur in low-resource settings. The World Health Organization (WHO) introduced the Safe Childbirth Checklist (SCC) in 2015 to reduce adverse birth outcomes. The SCC, a structured list of evidence-based practices, targets the main causes of maternal and neonatal deaths and stillbirths in healthcare facilities. Despite successful implementation in over 15 countries, the SCC has not been adopted in Mozambique. This study aimed to identify potential facilitators and barriers to SCC implementation from birth attendants’ and clinical administrators' perspectives, proposing future strategies.A qualitative study using focus group discussions (FGD) with birth attendants (n=23) and individual interviews with clinical administrators (n=6) was conducted. The Consolidated Framework for Implementation Research (CFIR) guided interview and FGD question creation and qualitative data analysis. A mixed inductive-deductive thematic analysis of Portuguese-to-English translated transcripts was performed. CFIR constructs were mapped to the High-Quality Health System Framework to synthesize findings and make recommendations. Three CFIR constructs were identified as facilitators (complexity, adaptability, and culture), while three other constructs and one emerging code were recognized as barriers (relative advantage, cost, available resources, and social recognition for birth attendants). Three CFIR constructs functioned as both facilitators and barriers (external policies and incentives, compatibility, knowledge, and beliefs about the intervention). In Mozambique, most barriers to the SCC implementation are due to the inadequacy of the health system, highlighting the need for health system strengthening and capacity building. Participants' dedication to improving childbirth practices and openness to SCC changes were identified as facilitators. To improve the feasibility of SCC implementation and increase compatibility with the current childbirth work routine for birth attendants, the SCC should also be adapted to context-specific needs.


This is an Open Access Thesis.

Open Access

This Article is Open Access