Acceptability of Modified Early Obstetric Warning Systems Among Midwives in Malawi; An Exploratory Qualitative Study.

Background: The Modified Early Obstetric Warning systems (MEOWS) has received global endorsement as a key strategy for reducing maternal mortality over the past decade. However, evidence on MEOWS acceptability among midwives in sub-Saharan Africa, including Malawi, remains limited. Understanding how potential users perceive a newly introduced intervention is required to assess acceptability prior to implementation. Purpose: To explore the acceptability of MEOWS among midwives using Sekhon's Theoretical Framework of Acceptability. Methods: We conducted an exploratory qualitative study between June and August 2025. Using purposive sampling, midwives across practicing, supervisory and policy making levels from Bwaila Hospital and Kamuzu Central Hospital were recruited for in-depth interviews. Data were analyzed using a deductive thematic approach with a priori coding guided by Sekhon et al's Theoretical Framework of Acceptability (TFA). Results: Thirty participants were interviewed. MEOWS was found acceptable across the seven domains of Sekhon et al's TFA. Participants reported that MEOWS could guide clinical judgement and ease the workload. However, inadequate stationery and equipment were identified as key sources of burden that may threaten sustained use. Conclusion: This study demonstrated that MEOWS was broadly acceptable among the various levels of midwives. The study identified inadequate stationery and equipment as potential barriers. Addressing these challenges may sustain MEOWS adaptation and implementation,enable early identification of maternal critical illness and reduction of maternal deaths.