Safe Motherhood Africa - NIHR Global Health Research Group on Improving quality of maternal healthcare in Africa Most maternal deaths occur in Sub-Saharan Africa. Nearly all are preventable with good quality maternal healthcare. Both Malawi and Zambia are committed to improving maternal and neonatal health outcomes but are making limited progress. The aim of the NIHR DIPLOMATIC research group is to improve maternity outcomes in Malawi and Zambia by improving the quality of care. The senior leadership of the DIPLOMTIC research team are all based in Malawi and Zambia. The formal locus of control for research activity is the Malawi-Liverpool-Wellcome Trust in Blantyre, Malawi. 
The four-year (August 2022 – July 2026) programme of work described here builds upon previous DIPLOMATIC research in Zambia and Malawi to leverage its research strengths – strong social, political, and institutional networks in both countries – and to initiate new work to ensure meaningful impact on maternal and neonatal health outcomes. The NIHR group’s aim will be delivered through 4 themes, which operate alongside the cross-cutting domains of capacity building in institutions in both countries, communicating widely across professional and public settings for impact, and community engagement and involvement to ensure the sustainability of key changes implemented in systems of maternal care. 
Theme 1. Data-driven improvement 
High quality maternal and neonatal health data is essential for quality improvement. By implementing online dashboards in clinical settings, we will provide real-time digital reporting of maternal death, near-miss cases, and quality of care data. Data will identify critical improvement needs and measure progress following interventions. A well-established community Demographic Health Surveillance System sites will give information beyond the clinic, to understand longer term outcomes and critical gaps in facility-based data such as loss to follow-up. 
Theme 2. Placing users at the centre of change 
We will use qualitative methods to represent the experience of vulnerable service users, in particular pregnant adolescents, and pregnant women with mental health problems. Their personal narratives will identify how services can better target their needs and inform priority setting for both health systems change and future health research. User experience is an important outcome alone, but it often also drives other health behaviours. Few data represent users’ experience of maternity care in Malawi and Zambia. We will optimise a tool to gather maternity users’ feedback and evaluate its use in clinical practice. 
Theme 3. Prioritisation and co-design 
Many changes to improve maternal health target the health facility, and yet the root causes of poor maternal health span the whole health system.  We will conduct an annual maternal health needs prioritisation meeting to galvanise broad stakeholder engagement to identify and champion complex issues to establish a sector-wide focus for change. To ensure sustainable implementation of the priority interventions, we will train health managers and providers in rational intervention design using the Behaviour Change Wheel methodology We will also ensure wide participation of diverse stakeholders in the co-design process for implementation. 
Theme 4. Implementing and evaluating change 
We will support sites across Malawi and Zambia to implement carefully designed behaviour change interventions and then robustly evaluate the implementation process. One intervention has already been prioritised and is ready to implement at the start of the new DIPLOMATIC programme. Alongside implementation, we will evaluate this package of “Enhanced Antenatal Care,” which aims to improve local compliance with WHO guidance and ensure consistent delivery of evidence-based practice. A second priority is to improve antenatal identification of sexually transmitted infections in pregnant women. We will explore how the existing approach of syndromic management can be improved. Following staff training and co-design of a behavioural change intervention, local development teams will test the intervention. We will then select the most effective pilot interventions for a multi-site implementation study across Malawi and Zambia. 
Capacity building 
Plans for developing local researchers include 3 PhD studentships and support for integrated MSc student projects. Ongoing research skills, policy engagement and management training will be provided for all levels of the research team. 
Communicating for impact 
In addition to high quality scientific outputs, we are superbly positioned with national and international partners to communicate the group’s work to social, political, and institutional networks to maximise impact of changes in the practice of antenatal care. We will further support the impact of our research findings by forming “policy and impact committees” and by distributing policy briefs.