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Background: Effective antenatal care is fundamental to the promotion of positive maternal and new-born outcomes. International guidance recommends an initial visit in the first trimester of pregnancy, with a minimum of four antenatal visits in total: the optimum schedule being eight antenatal contacts. In low- and middle-income countries, many women do not access antenatal care until later in pregnancy and few have the recommended number of contacts., Aim: To gain understanding of women's antenatal experiences in Tanzania and Zambia, and the factors that influence antenatal engagement., Methods: The study was underpinned by Strauss's grounded theory methodology. Interviews were conducted with 48 women, 16 partners, 21 health care providers and 11 stakeholders, and analysed using constant comparison., Findings: The core category was 'The tipping point of antenatal engagement', supported by four categories: awareness of health benefits, experiential motivators, influential support, and environmental challenges. Although participants recognised the importance of antenatal care to health outcomes, individual motivations and external influences determined attendance or non-attendance. The 'tipping point' for antenatal engagement occurred when women believed that any negative impact could be offset by tangible gain. For some women non-attendance was a conscious decision, for others it was an unchallenged cultural norm., Conclusion: A complex interplay of factors determines antenatal engagement. Short-term modifiable factors to encourage attendance include the development of strategies for increasing respectful care; use of positive women's narratives, and active community engagement. Further research is required to develop innovative, cost-effective care models that improve health literacy and meet women's needs., (Crown Copyright © 2021. Published by Elsevier B.V. All rights reserved.)

Background: The partograph is a tool used to record labour observations and support decision-making. Although used globally, it has not reached its full potential. We aimed to determine whether an educational board game can improve labour-monitoring skills and influence practice., Study Design: A quasi-experimental study, underpinned by Kirkpatrick's evaluation model, was used. Midwives and student midwives from Malawi, Kenya and Tanzania were given an identical hypothetical case-scenario of a woman in labour pre-and post-implementation of a game, to assess recording and interpretation abilities. This was supplemented by qualitative inquiry 3 months post-game-playing using semi-structured interviews (n = 24) and expert case-record reviews (n = 24). Quantitative data were analysed using the paired t-test and qualitative data were subjected to framework analysis., Results: 95 midwives and 97 students participated. In each country the mean test scores improved; Kenya from 86.5 (6.7) to 95.5 (3.7) (paired t = 11.82, p < 0.001), Malawi from 83.6 (6.7) to 94.6 (4.1) (paired t = 13.35, p < 0.001), and Tanzania from 83.8 (6.2) to 94.9 (4.1) (paired t = 15.27, p < 0.001). Qualitative findings revealed six themes: 'an enjoyable way of practicing,' 'learning and re-learning,' 'improved clinical decision-making', 'promoting team-work', 'a catalyst for additional learning' and 'barriers to transference of learning'. Expert case-record review demonstrated good adherence to recommendations., Conclusion: Board games have the ability to improve labour-monitoring knowledge. Retention of information was apparent and application of learning into practice was encouraging. Health-system barriers need to be resolved for midwives to apply theory to practice. Whether such application results in improved clinical outcomes is uncertain and requires further evaluation., (Copyright © 2019 Elsevier B.V. All rights reserved.)