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Abstract: Objective: to verify the data quality of childbirth registers and explore factors that influence quality at two rural district hospitals in Western Kenya. Design: a retrospective comparative case study for data quality of the 2006 childbirth registers by quantitative and qualitative methods. Setting: Siaya and Bondo District Hospitals. Methods: after confirming the physical condition and availability of childbirth registers, the total number of births; number of complete/incomplete data; and number of complete data that were illegible, incorrectly coded, inappropriate and unrecognised were verified quantitatively to evaluate accuracy and completeness. Data categories and instructions were examined qualitatively to assess the relevance, completeness and accuracy of the data. Semi-structured interviews were conducted with key informants to capture their views and factors that influence data quality. Findings: the childbirth registers used by the two hospitals were not developed by the Ministry of Health, and their supply to Bondo was interrupted. Of the 30 data categories in the registers, five for Siaya and 23 for Bondo were more than 20% incomplete. Data for number of antenatal consultations and use of human immunodeficiency virus drugs were at least 50% incomplete for both hospitals. The percentage of illegible, incorrectly coded and inappropriate data was relatively low, and only the place of residence had unrecognised data. Data categories in the registers did not correspond well with those of monthly reports, and inappropriate instructions suggested hidden inaccuracy among apparently valid data. Organisational impediments of the health information system in general, perinatal and intrapartum contexts were identified. Key conclusions: data quality of the childbirth registers was unsatisfactory. Influential factors were primarily organisational and technical, which may have had an adverse effect on midwives'' record keeping behaviour. Implications for practice: data quality of the registers can be improved by re-examining technical challenges and organisational impediments at different levels. Midwives'' awareness of data quality needs to be increased by sharing the purpose of the childbirth registers. Strong political commitment is also indispensable for putting these findings into action. [Copyright &y& Elsevier]

Evidence suggests that health care providers' non-adherence to clinical guidelines is widespread and contributes to poor patient outcomes across low- and middle-income countries. Through observations of maternity care in Kenya, we found limited adherence to guideline-recommended active monitoring of patients for signs of postpartum hemorrhage, the leading cause of maternal mortality, despite providers' having the necessary training and equipment. Using survey vignettes conducted with 144 maternity providers, we documented evidence consistent with subjective risk and perceived uncertainty driving providers' decisions to actively monitor patients. Motivated by these findings, we introduced a simple model of providers' decision-making about whether to monitor a patient, which may depend on their perceptions of risk, diagnostic uncertainty, and the value of new information. The model highlights key trade-offs between gathering diagnostic information through active monitoring versus waiting for signs and symptoms of hemorrhage to manifest. Our work provides a template for understanding provider decision-making and could inform interventions to encourage more proactive obstetric care. • Postpartum hemorrhage (PPH) is the leading cause of maternal mortality. • Providers in three Kenyan hospitals performed little monitoring for signs of PPH. • Survey vignettes uncover links between subjective risk, uncertainty and monitoring. • A simple model draws from these links to explain under-monitoring. • The model also illuminates key tradeoffs between monitoring and wait-and-see. [ABSTRACT FROM AUTHOR]