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.