The implementation realities of a digital antenatal care improvement intervention: Insights from ethnographic work in primary health facilities in Nepal.

Nepal has significantly improved maternal health service coverage, including antenatal care (ANC), with a growing focus on quality care. The mobile health Integrated Rural Antenatal care (mIRA) project evaluated an electronic decision support system (EDSS) to improve ANC quality in primary healthcare facilities. This sub-study was undertaken within the context of a mixed-method evaluation. It aimed to explore how auxiliary nurse midwives (ANMs) implemented the EDSS and to provide insight into the real-world challenges and processes of the mIRA implementation project. We conducted a focused ethnography in four primary health facilities, where ANMs implemented the EDSS. Data were collected between December 2021 and January 2023 and involved repeat ethnographic observations, informal conversations, formal interviews (n = 16), and validation workshops for participants to respond to and reflect on findings. The data were analyzed thematically, drawing on street-level bureaucracy theory. ANMs verbalized they valued the EDSS, but this was not reflected in their use of it. ANMs adopted the EDSS primarily for recordkeeping and did not comply with care recommendations that conflicted with their usual way of working. ANMs viewed themselves as providing care for normal pregnancies and believed that quality was not an issue, as they felt they were already delivering good care at their level. This perception, coupled with a risk-averse attitude, led them to refer cases to doctors or higher centers rather than implement the EDSS recommendations. The EDSS recommendations to improve the quality of ANC did not align well with ANMs' usual practices, which were influenced by contextual factors and the complexities of organizing ANC in primary health facilities. By triangulating longitudinal data collected through multiple methods, the study provided a comprehensive insight into ANC provision in Nepal, revealing the challenges associated with improving quality, unpacking the realities of intervention implementation, and highlighting the disconnects between rhetoric and practice.