Table 1 Themes from interviews with participants and illustrative quotations

Maternal health assessments are not consistently completed

 1-week visit

• At the first week, we are assessing if the baby is breastfeeding well; we ask them if they have experienced any problems. So, if they say there is no problem then we do an assessment of the baby. Midwife 2, Clinic B

• They weighed the baby, then she was 2.5 kgs but his birth weight was 2.9 kgs. And then they said that I should go and get vaccine for the baby; they gave the baby an injection on the arm and then also some on the tongue…they did not ask me how I am doing…They checked the baby on the cord, and they also gave me iron tablets. Mother, Clinic C

 6-week visit

• At 6 weeks they [women] don’t meet us; they go for vaccines. Midwife, Clinic A

• [At 6 weeks] I reported here…they checked the baby on the cord and then they told me to go for immunization. Mother, Clinic C

• [At 6 weeks] they report at the under-five clinic but if they have problems, they come back to the maternity. But those who are ok don’t come back unless if the woman wants family planning methods. Midwife 2, Clinic A

Challenges exist to postpartum and well-child care attendance and delivery of care

 Responsibility of health care workers and their attitude

• I think the gaps are many, but I think for most of the gaps, we are the ones that create them; may be because sometimes we have work overload, and we tend to skip most of the things that are supposed to be done with the woman. But we have everything that we need to tell the women…So it all starts with us; we need to teach them. At one week they come but at 6 weeks to be honest they don’t come to be reviewed by the nurse, they just come for a vaccine, if they come here, it’s because they have a problem. Midwife 2, Clinic A

• At the moment, they [health care workers] don’t give any health education. Mother, Clinic C

• …If the health workers’ attitude is good, women come to the under-five clinic, but if the attitude of the health worker is not right, women stop coming to the clinic. They seek care from another place. HSA 2, Clinic B

• We know the baby is supposed to get vitamins every 6 months. But you find that 6 months have elapsed, and the baby is not given the vitamins. So sometimes we just look, we can’t ask because we are afraid. Mother, Clinic B

 Lack of resources (e.g., staff shortage, lack of equipment)

• But sometimes we are busy, when the woman just says that she is fine, you just continue without paying attention to the woman, not knowing that she has other issues. But because she didn’t say, you don’t know and because you didn’t inquire, then the woman is not properly assisted. Midwife 2, Clinic B

• At the under-five clinic, the care is not that much; I am saying that because like today, they have weighed the baby; and the people that weighed the baby are strangers. Mother 3, Clinic B

• We need to also be checking vital signs but at this facility we don’t have equipment. Midwife 1, Clinic A

 Perceived lack of knowledge

• We can also say it is a lack of understanding on the importance of postnatal care. So, to them, it’s enough if the baby got the initial vaccine. The rest is not important to them; I also think it’s because of lack of knowledge. So, we just need to sit down with them and explain in detail, so they understand. Midwife 1, Clinic C

• Another thing that I noted was that the first vaccine that she was supposed to receive that day she did not receive. I don’t know maybe they took it that we work here, and we know these things. But to me I didn’t know. So, the baby was not given BCG…. They should have made sure that before I was discharged, the baby has received all the vaccines that she was supposed to receive. My baby didn’t receive any. What I would have loved was that the nurses should have make sure that we have received everything that we were supposed to receive. Mother 1 Clinic B

 Environmental

• …there are some who are very far, but we fail to reach out to them because of floods. You find that a place which is close by, become inaccessible during rainy season… HSA 1, Clinic C

• The issue of distance in this area, being a hilly area, and also rivers during rainy season, make women not come to the clinic if it’s raining…The distances are very long and it’s difficult for a woman to travel with a small baby. Midwife 2 Clinic B

Maternal and child health concerns included physical and psychological issues

 Physical

• Then another problem is nutrition; when they tell you that they baby is not having enough breastmilk, you can see that the nutrition of the mother is very poor. And you can see that the way the woman is looking she is poor. Midwife 1, Clinic C

• The other problem was that I was having problems to walk. It was because of the tear; I was even having problems to carry the baby so what happened was that I could lay down. Mother, Clinic A

• Malnutrition is about 10–12% of all the children that we see at the under-five clinic. HSA 2, Clinic C

• But sometimes the problem is with the child, difficult to eat and you find that the weigh is not increasing yet the food is there. Mother, Clinic B

• But most of the women when they come, we find that their BPs are very high, so we give them medication. Midwife 1, Clinic A

• They were giving me the blood pressure medication…They told me that the I should be taking the medication and then after 7 days I should stop. Mother, Clinic B

• Most of the times the women don’t say, but sometimes they would tell you that the baby had diarrhea. For the first 6 months we have common problems like diarrhea and also malaria…But we emphasize a lot on the growth monitoring and if we see that the weight has dropped a lot, we refer women to the nutrition unit. HSA 1, Clinic C

 Mental health

• On the psychological, we check so many things; like here, most of the women have children with men that left them, and they don’t have any support for the child; some women are staying with someone who abuses them, and this affects how they are breastfeeding the baby. Midwife 2, Clinic A

• They also told me that when a woman has just delivered, sometimes you may have psychological problems so when I feel like that, I should rush to the hospital because it shows that something is happening in the body. Mother 3, Clinic B

Health promotion topics discussed in both postpartum and well-child visits are not standardized

• See Fig. 2 for list of health topics currently being discussed at health visits

There is buy-in for the group healthcare model from both women and health care workers

• I believe that the group postnatal care could assist a lot because there are so many things that the women don’t know; and when they are in groups and they receive counseling, I feel this can help to improve their well-being, both the mother and the baby. Because I strongly feel that these women can take very good care of their babies, they only need enough time to get enough counseling. But I feel that if you can adopt that model, it will be very helpful. HSA 1, Clinic C

• I think that [extending group care into the postpartum period] would be a very good thing because if like the way we were doing when we were pregnant, we were sharing ideas so that we should not be in the dark, so I think that if we do the same thing now that we have delivered, it can still help us; we can still share ideas. For example, if someone has a problem and she shares it on the group, we can help each other. For example, the way I was struggling with my baby when she was having fevers, there could be some women who had also experienced that, and they know exactly what to do They could have assisted me. Maybe it’s at night, I can’t come to the hospital right away, those advice help. So, to me, I think the group care approach is the best; it is very helpful. Mother 1, Clinic B

• That can work very well, and it can be very good. Because as for us we just see the babies once, but that can assist us to be following up on the babies to some point and be monitoring them, so it can be very good because it will bring change. It can also improve the way we do our work because then the babies can also be seen at 6 weeks. So, it is very good so many things can change. Midwife 1, Clinic A

• I would have loved if these groups continued. Sometimes things happen in the village; emergencies and the doctor is not readily available you can assist someone and save a life because at least you know some things. Mother 2, Clinic B