Provider coping strategies and behaviours in overcoming challenges during maternity healthcare delivery in positive and negative outlier facilities in Kenya: An explanatory sequential mixed-methods feasibility study

Background Maternal mortality in Kenya, as in many sub-Saharan African countries, remains unacceptably high despite ongoing efforts to reduce it. Exploration of alternative and complementary approaches to improving maternal health is required. One such underexplored and underutilised approach is Positive Deviance. We aimed to explore the feasibility of using a Positive Deviance approach to improve maternal health outcomes following post-partum haemorrhage and accelerate the reduction of preventable maternal deaths in sub-Saharan Africa, using Kenya as a case study. Methods A two-stage, exploratory, explanatory sequential mixed-methods design, beginning with quantitative analysis to identify positive and negative outlier facilities based on post-partum haemorrhage (PPH) rates. The study was conducted in four secondary-level hospitals in Kenya: two positive and two negative outliers. In the qualitative phase, 43 maternity care providers were interviewed using semi-structured key informant interviews to explore challenges, coping strategies, and the feasibility of a Positive Deviance approach to tackling the challenges they face. Thematic analysis was conducted using Braun and Clarke’s method, followed by deductive framework analysis and mapping with the ‘4S’ framework (Staff, Stuff, Space, and Systems). Results Quantitative analysis of PPH data from 14 facilities revealed rates ranging from 8.9% to 23.5%, with two positive outliers (8.9% and 10.1%) and two negative outliers (24.3% and 23.5%) identified. Most challenges were shared across both positive and negative outlier facilities. Shared challenges across all aspects of the ‘4S’ framework were identified. Negative outlier facilities faced unique challenges, particularly those related to human factors such as high-power distance, hierarchies hindering clinical escalation, conflicting staff opinions, and failure to adhere to clinical guidelines. Shared and unique coping behaviours and practices were identified at both positive and negative outlier facilities. While only 30% of participants felt the Positive Deviance approach was feasible, potential facilitators and barriers were highlighted. Conclusion Most challenges faced by providers of maternity care in Kenya are shared; however, unique coping behaviours and practices can be harnessed to develop tailored, local solutions to improve outcomes and reduce preventable maternal deaths in Kenya and similar low-resource and underserved settings.