Competency gaps in emergency obstetric and neonatal care: Assessing knowledge, skills, and confidence in the use of magnesium sulfate among providers in Malawi

Background Preeclampsia and eclampsia are major contributors to maternal mortality in Malawi. Magnesium sulfate (MgSO 4 ) is recommended by the World Health Organisation for the treatment of eclampsia. Despite its inclusion in national guidelines, there are inconsistencies in its clinical application, reflecting potential gaps in provider competency within Emergency Obstetric and Neonatal Care (EmONC) settings. Objectives This study evaluates the knowledge, skills, and confidence of EmONC providers regarding MgSO 4 administration and identifies context-specific barriers to optimal practice. Design A qualitative descriptive study using a Human-Centred Design (HCD) approach. Methods Data collection involved focus group discussions and participatory workshops with registered nurse-midwives, nurse-midwife technicians, clinical officers, and District Health Management team members from selected EmONC facilities in Malawi. Thematic analysis based on Braun and Clarke’s framework identified competency gaps and systemic barriers. Results Three interrelated gaps emerged: (1) fragmented knowledge of MgSO 4 protocols, especially on maintenance dosing and toxicity; (2) inconsistent performance in drug preparation and administration; and (3) low psychological readiness among junior staff due to fear of complications and limited mentorship. System-level barriers included inadequate simulation-based training and a lack of visual job aids. HCD sessions led to co-created solutions, such as laminated dosage charts and peer-led simulations. Conclusion Significant individual and systemic challenges exist in MgSO 4 administration within EmONC settings. Enhancing provider competency through simulation-based learning, targeted mentorship, and visual decision-support tools could improve emergency care responses.