Creating order in the uncertainty of childbirth: A qualitative study of obstetric admission and triage practices in rural Malawi

Maternal and neonatal mortality continues to be a concern in sub-Saharan Africa. Although standardized obstetric triage improves clinical outcomes, little is known about how locally developed admission practices function in low-resource settings where national obstetric triage guidelines are absent. This study explored how hospital-based obstetric admission procedures in rural Malawi were experienced by maternity care providers, laboring women, and companions. We used qualitative methods including in-depth interviews with mothers and maternity care providers, focus group discussions with companions and maternity care providers, and observations of two labor wards. Study participants were chosen purposively to represent diverse birth outcomes and professionals. Data analysis followed reflexive thematic analysis, concentrating on obstetric admissions. Mary Douglas' concepts of purity, danger, and risk informed interpretation during theme development. Obstetric admissions were organized through standardized admission forms that structured assessment and enabled providers to classify women according to visible danger signs and labor progression. Although the forms were not formal triage tools, they functioned as the primary mechanism for prioritizing care, organizing patient movement through maternity spaces, and managing high patient volumes. Shared recognition of danger signs among providers, women, and companions reinforced the legitimacy of risk-based decision making. At the same time, communication was selectively restricted, limiting patient and companion participation while reinforcing professional authority and hierarchical relationships. Standardized admission procedures created order by classifying obstetric risk and prioritizing clinical efficiency, but they also reinforced hierarchical relationships that limited communication and patient participation. Efforts to strengthen obstetric admissions should preserve the benefits of standardized risk assessment while incorporating more person-centered communication and companion engagement.