Factors promoting eRegister and data use for evidence-based midwifery practice in Lesotho: a qualitative study

Abstract

Objectives

Electronic health register's (eRegisters) use have recently gained popularity in Africa. eRegisters are used to capture real-time patient information on several encounters with a healthcare provider. Given poor maternal and child health outcomes in Lesotho, eRegisters provide a promising innovative means of enhancing health outcomes, especially those related to midwifery. eRegisters capture maternal and newborn care services provided at healthcare facilities. Such data are important for informing evidence-based midwifery practice. Lesotho, a landlocked, sub-Saharan African country, piloted use of an eRegister in 2018. However, factors promoting eRegister and data use have not been fully documented. Therefore, this study explored factors promoting eRegister and data use for midwifery practice in Lesotho.

Design

The study used a descriptive qualitative approach with interviews and focus group discussions used to collect data. Descriptive content analysis as outlined by Erlingsson and Brysiewicz (2017) was followed during data analysis.

Setting

The study was conducted at three of the eRegister piloting facilities in Lesotho to examine eRegister implementation across different levels of care. Data collection occurred between December 2023 and March 2024.

Participants

Purposive sampling was used to recruit healthcare workers across the three facilities. Participants were selected to capture the range of relevant roles and experience with eRegister across each facility, and 7, 6 and 5 participants were recruited.

Results

Five categories emerged as factors promoting eRegister and data use: system readiness, organisational environment, data value and utility in practice, human resource competency and digital literacy and governance and stakeholder engagement.

Conclusion

This study identified critical factors that promote the use of the eRegister and data in Lesotho. The findings suggest that while external funding and partner responsiveness have been pivotal in sustaining eRegister operations, long-term sustainability will require stronger national ownership, including domestic investment in infrastructure, technical support and digital health governance. Future studies should explore the effect of eRegister use on clinical outcomes and examine strategies for scaling up digital health interventions in resource-limited settings.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The study analysed participants’ experiences of using electronic health registers (eRegisters) to reflect a true picture of what promoted eRegister and data use.

• The study triangulated data from one-on-one interviews and focus group discussions.

• Responses were collected from different healthcare workers including nurse-midwives.

• The study was limited by solely relying on participants’ experiences.

• Data were also collected from only three healthcare facilities in the country.

Introduction

Electronic health registers (eRegisters) are a crucial component of healthcare in the 21st century.¹ In contrast to industrialised nations, African healthcare facilities are gradually replacing paper-based records with eRegisters.² eRegisters have emerged as a promising tool to strengthen data capture, accuracy and use at the point of care.^{1 3} eRegisters reduce duplication, improve timeliness of reporting and foster a culture of data use. Importantly, studies have suggested that when implemented effectively, eRegisters support evidence-based clinical decision-making, enhance accountability and ultimately contribute to better patient outcomes.4,7

For the same benefits realised by Western and Asian countries, many African countries, including Malawi, Kenya, Ethiopia and Zimbabwe, are now using eRegisters to capture patient data for maternal and neonatal health.8,10 Despite the efforts made by African national health ministries in adopting eRegisters, full integration of eRegisters and the level of data use in midwifery practice are still in the early stages across the region. For instance, only Ethiopia has reported 65% level of eRegister data use among healthcare workers.11,13

Re-designing midwifery care is necessary to increase the quality of healthcare, as the needs for mother and child healthcare become more complex.⁴ Jayeoba et al and Fraser et al indicate a need to enhance midwifery practice through innovative means because of unsatisfactory mother and child health outcomes.^{5 6}

Evidence from other low-income and middle-income countries highlights consistent associations between eRegister implementation and improved health service delivery.¹⁰ Studies have demonstrated gains in documentation quality, timeliness of surveillance and adherence to antenatal care processes when electronic registries are integrated into routine practice. Moreover, eRegisters have been shown to reduce the time care providers spend on reporting, allowing greater focus on clinical care.¹¹ Although improvements in maternal and neonatal outcomes are less consistently observed through the use of eRegisters, the gains represent essential precursors to long-term health impact. Importantly, the effectiveness of eRegisters depends heavily on implementation factors, including adequate training, supportive governance and integration into existing health system workflows.12,14

Lesotho faces persistent high maternal mortality rates (478 deaths per 100 000 live births).¹⁵ According to the Lesotho demographic health survey, some of the deaths could be avoided if midwives had acted accordingly and timeously.¹⁵ Midwifery practice in Lesotho faces challenges that are closely tied to limitations in data and information systems. The continued reliance on fragmented paper-based records undermines continuity of care, whereas delayed and incomplete reporting hampers timely decision-making at both facility and policy levels. Midwives often spend excessive time on manual data entry and aggregation, leaving less time for direct patient care, and errors in transcription further compromise data quality. In addition, limited access to point-of-care decision support tools means that adherence to evidence-based guidelines is inconsistent, increasing the risk of missed opportunities for the early detection of complications. Data collected often flow upwards for reporting purposes but are rarely fed back into clinical practice in ways that empower midwives to make evidence-informed decisions.^{8 9}

To address these gaps, the ministry of health and implementing partners have introduced an eRegister, designed to digitise maternal health records and strengthen midwifery practice. The system enables longitudinal tracking of women across antenatal, intrapartum and postnatal care, providing midwives with real-time access to patient histories and clinical decision support prompts. By automating reporting, the eRegister reduces administrative burdens and transcription errors while improving the timeliness, completeness and usability of health information. Dashboards and feedback loops embedded in the system are intended to facilitate more responsive management and supervision, aligning midwifery practice with national and global standards for evidence-based care.

Given Lesotho’s high maternal and perinatal mortality burden and the ongoing national investment in digital health platforms, evaluating the use of the eRegister for evidence-based midwifery practice is both timely and policy-relevant. Therefore, this study sought to explore factors promoting eRegister and data use to strengthen data use and hence improve evidence-based midwifery services.

Literature review

In contrast to industrialised nations, African healthcare facilities are gradually replacing paper-based records with eRegisters.⁷ Despite several factors that hinder successful adoption of eRegisters in developing nations, slow progress has been remarkable. The notable milestones are attributed to several promoting factors.¹⁵

In literature, several factors are associated with the successful use of eRegisters. Rahal et al reported that the ease of use of eRegisters promoted their utility. In addition, healthcare professionals often used eRegisters when they considered it compatible with the clinical care settings.^{16 17} Furthermore, Rahal et al. found that eRegister use increased significantly among users with more related experience.¹⁶ However, Fennelly et al did not find an association between the extent of eRegister’s experience and proficiency of its use.¹⁸

Dutta and Hwang exposed that team-based methods through assigning responsibility to team members facilitated eRegister use.¹⁹ Rahal et al, Hung et al and Martin have discovered that peer mentorship and coaching helped physicians in using eRegisters.^{16 20 21} Physicians who took part in a coaching and peer mentoring support programme reported satisfaction and sophisticated eRegister use.²²

According to Chona et al, having sufficient technical support from stakeholders expanded eRegister use.²³ Wynter et al indicate that mature usage of eRegisters by end users is associated with possession of eRegister-related information.²⁴ In addition, a trustworthy knowledge base, such as reliable data sets and recommendations from trusted peers, facilitated eRegister use.²⁵

Furthermore, the benefit of using eRegisters in encouraging their usage was highlighted 54 times in a systematic study by Sung et al,²⁶ making it the most reported facilitator. Enhanced accessibility, round-the-clock real-time data access and the ability to obtain current information whenever it is convenient were the other reported benefits. Additionally, studies comparing time use show that electronic entry reduces time spent on health information management, potentially freeing midwives for clinical care.²⁷

Objective

To investigate factors facilitating eRegister use and data for evidence-based midwifery practice in Lesotho.

Methods

Study design

This study is part of the first phase of a two-phased researcher’s PhD work aimed at developing a framework for improving eRegister data utility for evidence-based midwifery practice in Lesotho. The study employed a descriptive qualitative design, which is well suited to exploratory inquiries that seek to provide a comprehensive and straightforward description of participants’ perspectives and experiences without imposing a priori theoretical frameworks.^{28 29} This approach allowed us to remain close to the data and inductively capture the range of factors that promote the use of eRegisters and data in practice. A descriptive qualitative design was particularly appropriate given our focus on identifying enablers in real-world implementation rather than on exploring the deeper essence of lived experience.²⁹

One-on-one interviews and focus groups were conducted by the researcher who had knowledge in conducting qualitative research, as she had conducted a mixed-methods study at her master’ degree work. The interviews were conducted to explore a broad perspective of collective views from participants while delving into individual accounts of eRegisters and data use. This was done to enhance the validity and depth of the findings.

The study used a 32-item checklist designed to help researchers report qualitative interview and focus group studies more transparently and comprehensively.

Study setting

Lesotho’s healthcare system provides services at different facility levels of care ranging from health centre, filter clinic, district hospital, regional hospital to referral hospitals. In 2018, the government of Lesotho, through its implementing partners, piloted the eRegister in four health centres and two hospitals as a stepping stone towards a nationwide rollout across 178 government facilities. The eRegister is configured to automatically compile and send facility-level data into the district health information management system.¹⁵

The government of Lesotho envisages that paper-based recording will be phased out when the eRegister is completely operational and implemented across the nation. Currently, the eRegister captures information on five programmes: (1) elimination of mother-to-child transmission of HIV and syphilis, (2) tuberculosis, (3) pregnancy and antenatal care, (4) HIV and human papillomavirus and (5) cervical cancer.²² The study was conducted at three of the eRegister piloting facilities in Lesotho, namely, Lesotho Defence Force clinic (health centre), Domiciliary Filter clinic (filter clinic) and Scott Hospital (district hospital). The researcher selected the three study sites arbitrarily to examine eRegister implementation across different levels of care.

Population and sampling

Participants who worked with the eRegister for >6 months were purposively chosen based on their experience³⁰ from three facilities. Staffing at each facility, which included 13 nurse-midwives, 4 pharmacists, 3 HIV counsellors, 2 data clerks and 2 nursing assistants; 18 participants across the three sites (8 registered nurses-midwives, 5 data clerks, 2 pharmacists, 2 HIV counsellors and 1 nursing assistant), volunteered to participate. Participants were selected to capture the range of relevant roles and experience across each facility, and 7, 6 and 5 participants were recruited from the three facilities. This composition enabled representation of the cadres most directly involved in eRegister use.

The researcher introduced the study to the target population during the prayer meeting at each facility. Potential participants who expressed interest were then contacted directly and provided with information sheets outlining the purpose of the study, eligibility criteria and the voluntary nature of participation before giving informed consent.³¹ Healthcare workers with >6 months of experience with the eRegister and who were willing to participate were included in the study, as they met the inclusion criteria.

Data collection

A semi-structured interview guide (online supplemental file 1) that addressed experiences of eRegister use, perceived facilitators and barriers informed by Sekhon et al³² was used to guide the audio-taped interviews, which lasted between 20 and 40 min, and the focus group discussions lasted for 1 hour. The interview guide was piloted with the two participants whose data were not analysed, and changes were deemed necessary. The interviews were conducted in English since every participant understood it. The research aim and objectives were explained, and their participation was requested. The researcher expressed that the study was solely conducted to improve maternal and neonatal health. The participants and the researcher had no formal relationship before the study. To record non-verbal communication, field notes were made during the data gathering process.

Data collection occurred between December 2023 and March 2024 through interviews and focus group discussions in a quiet room. Because in-depth interviews and focus group discussions were conducted, saturation was assessed across and within both data sources.³³ For interviews, a coding log was maintained, saturation was defined as the point when two consecutive interviews produced no new codes and three consecutive interviews produced no new categories. For focus group discussions, saturation was monitored when successive groups reiterated categories already identified without generating novel insights. After three focus groups and 18 individual interviews across the three facilities, no new codes or categories emerged in either data source. Triangulation of categories between the interviews and focus groups further confirmed that data saturation had been reached. This was consistent with Hennink and Kaiser’s results that data interviews reach data saturation with 9–17 participants.³³

Data analysis

Data were analysed using descriptive content analysis as outlined by Erlingsson and Brysiewicz by the researcher and her supervisor who had supervised PhD students conducting qualitative and quantitative studies.³⁴ This method is suitable for describing participants’ perspectives while remaining close to the raw data. All transcripts from interviews and focus group discussions were read multiple times to gain an overall understanding of the content. Notably for this study, words, sentences and paragraphs relevant to factors promoting eRegister and data use were identified and highlighted. Those relevant to the factors hindering eRegister and data use were spared for the other manuscript.

Meaning units were condensed and labelled with codes that captured their essence. Codes with similar content were grouped into subcategories, and the subcategories were further organised into broader categories representing key factors that facilitated eRegister and data use. This process was iterative, involving constant comparison across transcripts to refine categories and ensure they reflected the data accurately. Categories were described and illustrated with representative quotations from participants to maintain transparency and fidelity to the original data.³⁴

Ethical principles and study approval

The study received ethical clearance from the Biomedical Research and Ethics Committee at the University of KwaZulu-Natal (Reference no. HSS/1772/018D), and the Research and Ethics Committee of the Ministry of Health Lesotho (Reference no. 86–2023). Written informed consent was obtained from all the participants, and anonymity was maintained throughout the study.

Rigor in research

Credibility, dependability, confirmability and transferability are the means by which trustworthiness is attained. As put out by Haq et al, trustworthiness is ensured to guarantee authenticity and quality in a qualitative study.³¹

To maintain the study’s credibility, the researcher took into account the experiences of the participants and appropriately analysed the data collected to preserve its original meaning. Conversely, transcripts were sent back to the participants to confirm the study results. Beyond this, the credibility of findings was strengthened through triangulation across multiple participants, iterative comparison of emerging categories and peer debriefing with research supervisor.³⁵ An audit trail was maintained to document analytical decisions.

To enhance transferability, a detailed description of the study design and data analysis was peer reviewed. The study context was presented to enhance the robustness of the descriptions. This was done to ensure that the study findings are replicable to other healthcare facilities in Lesotho and other areas with similar settings.

Dependability involves the study’s evaluation, interpretation and recommendation to ensure that the collected data from the study participants support them. To ensure dependability, a co-author conducted an audit trail that involved establishing that the findings are based on participants’ responses and not the researcher’s preconception. Confirmability was achieved by establishing that the data and interpretations are derived from the participants using direct quotes to ensure the objectivity of the study findings.³⁵

Patient and public involvement

None.

Results

Characteristics of study participants

In this study, 2 male and 16 female healthcare workers, with ages ranging from 25 to 50 years, were recruited. Participants’ experience with the eRegister ranged from 1 to 4 years. The participants were heterogeneous in terms of their professions. They comprised data clerks, pharmacists, registered nurses, midwives, certified nursing assistants and HIV/AIDS counsellors (table 1).

Table 1. Participant characteristics.

Variable	Frequency (18)	Percentage (%)
Age (years)
25–34	7	39
35–44	8	44
45–54	3	17
Sex
Female	16	89
Male	2	11
Highest qualification
Diploma	8	44
Bachelor degree	5	28
Bachelor degree plus other	5	28
Current position
Data clerk	5	28
HIV counsellor	2	11
Nurse midwife	8	44
Nursing assistant	1	6
Pharmacist	2	11
Years of experience with eRegister
0–1	3	17
2–3	8	44
4–5	4	22
≥5	3	17

Factors promoting eRegister use in Lesotho

The categories and sub-categories (figure 1) that emerged across the three facilities included system readiness, organisational environment, data value and utility in practice, human resource competency and digital literacy, and governance and stakeholder engagement

Figure 1. Factors promoting eRegister and data use in Lesotho. System readiness (hardware and software availability; reliable internet and electricity and adequacy of external funding). Organisational environment (availability of technical support, managerial reinforcement and accountability, change management and adaptability to innovation). Data value and utility in practice (perceived usefulness of data and evidence-informed decision-making). Human resource competency and digital literacy (pre-existing computer skills and continuous professional development). Governance and stakeholder engagement (shared responsibility in advancing eRegister adoption and responsiveness of implementing partners).

System readiness

Hardware and software availability: internet and electricity availability

Some participants emphasised that the availability of digital equipment has been instrumental in facilitating the use of the eRegister. However, they also highlighted the importance of expanding procurement of computers to ensure sustainability and continuity of service delivery. For instance, one participant explained that existing computers, often provided through donor support, form the foundation for effective eRegister use:

The availability of computers, internet and electricity were the backbone of our eRegister operations. Currently, we rely on computers that have been donated by NGOs, and these have significantly supported our work. (Participant 14)

Another participant underscored the necessity of additional devices, not only to improve access but also to provide backup in the event of technical failures:

Each department using the eRegister has laptops, which makes our work easier. However, we still need more laptops to serve as contingency measures because if the current ones fail, we do not have alternatives, and that can disrupt the whole system. (Participant 6)

Adequacy of external funding

Participants generally perceived the financial support provided by implementing partners as adequate to sustain basic operations of the eRegister. This support was considered essential in ensuring that each implementing unit had at least one functional laptop and reliable internet connectivity, thereby enabling consistent data entry and reporting. One participant noted:

ICAP is funding this project. They bought computers and internet. (Participant 1)

This suggests that external funding not only addresses immediate infrastructure needs but also plays a central role in maintaining the functionality of the eRegister system across different units.

Organisational environment

Availability of technical support

Participants consistently described timely technical support as essential in promoting eRegister use. They explained that the availability of an information technology (IT) personnel to troubleshoot challenges and provide in-person guidance during the introduction of new modules minimised disruptions and built user confidence. This responsiveness created an environment where staff felt supported and capable of engaging with the system:

IT staff are always there to guide us. Even when they come to introduce a module or anything, they come in person. (Participant 13)

Managerial reinforcement and accountability

In addition to technical support, management played an important role in motivating staff to consistently use the eRegister. Participants described managerial follow-up and reminders about performance targets as a form of positive enforcement that reinforced accountability and encouraged continuous engagement with the system:

The management was also after us, reminding us of the set targets; they would say that by this time you should have performed to this level. Have you met it? (Participant 4)

Change management

Participants described how the introduction of the eRegister required adjustments in their work routines and mindsets. They highlighted both the challenges of transition and the strategies they adopted to adapt. One participant reflected:

At first it was difficult to move from paper to the system, but with time we adjusted and now it feels normal. (Participant 1)

Another participant emphasised the importance of adaptability, stating:

Change is never easy, but we learnt to accept it because the system is improving how we work. (Participant 7)

Similarly, a participant noted the role of support during transition:

The training helped us manage the change better; without it, many of us would have struggled to use the eRegister. (Participant 13)

Adaptability to innovation

Participants highlighted varied experiences in adapting to the eRegister. Although some described smooth adjustment and eventual acceptance, others reported challenges in coping with the new system.

Several participants expressed confidence in their ability to adapt to the eRegister technology:

At first, the system looked complicated, but with continued use, I became comfortable, and now, it saves me time. (Participant 9)

We were not used to digital systems, but the more we practiced, the easier it became to work with the eRegister. (Participant 13)

When new tools are introduced, there is always fear, but we adapted quickly because we could see the benefits. (Participant 10)

Conversely, some participants reported difficulties in adapting to the innovation:

I still find it difficult to navigate the system, and sometimes, I prefer the old paper-based methods. (Participant 4)

Adapting to the eRegister is not the same for everyone; some of us take longer to adjust and need more support. (Participant 9)

These responses demonstrate that adaptability was not uniform across participants. Although many were able to adjust positively and even recognise benefits over time, others continued to struggle, highlighting the importance of ongoing support and capacity building during the adoption of innovations.

Data value and utility in practice

Evidence-informed decision making

Participants indicated that the availability of data from the eRegister supported their decision-making processes. They explained that access to reports enabled them to prioritise areas of concern and base their actions on facts rather than assumptions. As one participant noted:

We rely on data and reports from the eRegister; it helps me decide which areas need more attention, so our decisions are not just guesses but based on fact. (Participant 4)

Another participant echoed this view, noting:

The evidence gives us confidence because when we act, we know it is based on real information, not just what we think. (Participant 7)

Similarly, another remarked:

Before making changes, I check the reports. They show me the trends, and that directs where to focus our efforts. (Participant 15)

Perceived usefulness of data

Participants reported that the eRegister enables retrieval of patient information, organisation of files, ease of stock inventory and ordering. They reported that appreciating the benefits of using the eRegister helped them adjust to its use. Participants' comments were as follows:

I have seen that it is important. I have seen that when a patient from a male clinic comes here and he is on ART, once I put him on the system, all his information appears on the eRegister. (Participant 17)

We can now use the eRegister to order drugs easily; when the stock arrives, we receive it in what I can call eRegister warehouse. I no longer conduct inventory manually; we identify medications with bar codes, so it is easy to identify. (Participant 11)

Human resource competency and digital literacy

Continuous professional development on information and communications technology

Participants emphasised that both the initial and ongoing call-and-answer training sessions were instrumental catalysts in building their capacity to operate the eRegister effectively. They described the training as foundational to their confidence and proficiency, particularly in the early stages of system adoption. As two participants explained:

The trainings that were done during introduction helped us. (Participants 1 and 16)

Beyond initial exposure, continuous refresher training was regarded as equally important in addressing knowledge gaps and reinforcing practical skills. Participants acknowledged that while demonstrations during training made tasks appear straightforward, actual application in daily practice could still present challenges, thereby underlining the importance of repeated and hands-on training opportunities:

The other time the IT department trained everyone on the module of consultation of patients, there were nurses, even those who are using the eRegister, who were saying, ‘ohh, this I didn’t know’. When the trainings are done, it seems easy, but when you are alone in front of the machine, you get stuck. (Participant 16)

Pre-existing computer skills

Participants explained that pre-existing technology-related knowledge, skills and experience significantly enhanced their ability to use the eRegister with ease. They noted that computer literacy served as a foundation for quickly adapting to the system and overcoming potential barriers. As one participant remarked:

If one has a background of computers and is computer literate, it is just so easy. (Participant 13)

This suggests that individual digital competence not only influences the pace of adaptation but also shapes confidence and efficiency in engaging with the eRegister. It further underscores the importance of integrating digital literacy considerations into training and capacity-building strategies to ensure equitable adoption across all cadres of staff.

Governance and stakeholder engagement

Shared responsibility in advancing eRegister adoption

Healthcare workers recognised the eRegister as an indispensable component of service delivery and expressed a collective commitment to mastering its use. They described the system not as a temporary project but as a permanent shift in how care is documented and monitored, which fostered a sense of shared responsibility to support one another in becoming proficient users. This was illustrated by participants who associated full adoption with ‘graduating’ from dual documentation, where both paper records and the eRegister had to be maintained simultaneously:

I think everyone wants to graduate because truly it is tiresome to do both paperwork and the eRegister at the same time, so it is everyone’s desire to graduate. (Participant 16)

The notion of graduation also symbolised progress towards complete integration of the eRegister, with participants expressing optimism that sustained collective effort would lead to full transition:

Now that we are all in this, maybe next year we will graduate if we maintain the same pace. (Participant 4)

Furthermore, participants noted a growing seriousness in their approach to the eRegister, including efforts to retrospectively capture data that had previously been omitted:

It is now that we are getting serious with the eRegister. We have gone back to fill those files that we didn’t enter. (Participant 1)

Responsiveness of implementing partners

Participants acknowledged that the responsiveness of implementing partners played a pivotal role in encouraging consistent use of the eRegister. They highlighted that prompt feedback and timely problem-solving fostered confidence and minimised interruptions in data entry. For example, one participant explained that partners not only addressed connectivity issues quickly but also provided tangible solutions by procuring additional resources:

They do respond fast, people from ICAP, they even bought the WIFI routers for each laptop, because we had told them that WIFI was a problem. (Participant 7)

The speed of communication was further emphasised, with participants describing the partners’ efficiency in resolving technical queries almost immediately:

If you phone them now, within 2 min they will have responded. (Participant 4)

Notably, participants also appreciated the partners’ availability beyond regular working hours, which ensured that urgent issues encountered during late data entry were still addressed:

Funders are available even after working hours… let’s say I was not able to enter patients in the eRegister and I am doing it late, when I encounter a problem at that time, they respond without a problem. (Participant 13)

Discussion

This study explored the factors that promote the use of the eRegister in Lesotho and identified five major categories: system readiness, organisational environment, data value and utility in practice, human resource competency and digital literacy and governance and stakeholder engagement. These findings reveal that successful adoption of the eRegister depends on both structural readiness and human and organisational dynamics.

Participants’ accounts of the eRegister and data use highlight the centrality of adequate infrastructure, particularly hardware, internet connectivity and electricity, in sustaining eRegister use. The reliance on donor funding echoes that of Agarwal et al and Labrique et al, who state that external funding often fills gaps in procurement and maintenance budgets of technical infrastructure in low-income and middle-income country contexts.^{36 37} However, the expressed need for additional devices and contingency planning underscores a potential vulnerability. Without sustainable domestic financing, system readiness remains donor-dependent. This finding reinforces prior literature, which stresses that scalability and sustainability of digital health interventions require long-term national investment and integration into health budgets.¹⁹

The importance of technical support and managerial reinforcement identified in this study reflects the broader evidence that supportive organisational environment is crucial for digital health adoption.^{38 39} Participants’ emphasis on IT staff responsiveness and managerial follow-up aligns with research from Tanzania and Ethiopia, where timely troubleshooting and accountability structures were found to enhance user confidence and system use.⁴⁰ The findings further demonstrate how changes in management processes influence user adaptation. Although some midwives described initial resistance to abandoning paper-based records, continuous support and visible benefits facilitated gradual acceptance, an experience consistent with models of technology adoption which emphasise perceived usefulness and ease of use.⁴⁰

One of the key drivers of eRegister adoption and data use was the perceived value of eRegister data in guiding evidence-informed decision making and improving service efficiency. Participants’ accounts of using reports to prioritise interventions resonate with studies showing that when health workers experience data as actionable, rather than extractive, their motivation to engage with digital systems increases.⁴¹ Beyond decision-making, participants noted efficiency gains in patient tracking and stock management. These findings illustrate how demonstrating practical utility can transform data systems from reporting obligations into tools for clinical practice.

The findings reveal that human capacity remains both a facilitator and a constraint. Continuous professional development in information technology was described as essential for building confidence and competence, and pre-existing digital literacy accelerated adaptation. Similar conditions have been observed in Kenya and Malawi, where health workers with prior computer skills adjusted more quickly to eHealth systems.⁴² Importantly, the unevenness of digital literacy within facilities suggests that training must be iterative, hands-on and tailored to different levels of competence. Without this, the risk of unequal adaptation may reinforce disparities in data use across cadres.

Governance and stakeholder responsiveness emerged as critical enablers. Participants’ recognition of shared responsibility, symbolised by the desire to ‘graduate’ from dual documentation, illustrates a collective ownership of the system.^{43 44} This is consistent with who identifies stakeholder buy-in as essential for sustainability.⁴⁵ The responsiveness of implementing partners, particularly in providing timely solutions and after-hours support, further strengthened trust in the system. However, the heavy reliance on external partners raises questions about long-term sustainability and the need for stronger government stewardship to institutionalise these functions.

Overall, this study reinforces the understanding that the use of eRegister and data is shaped not only by technological readiness but also by organisational culture, user competencies and governance frameworks. Although the eRegister in Lesotho has been embraced as a valuable tool for midwifery practice, its sustainability depends on transitioning from donor-driven support to nationally owned systems. Continuous training, investment in infrastructure and mechanisms for accountability and feedback will be essential to ensure that the system’s benefits such as improved data use, efficiency and evidence-informed practice are maintained and expanded.

The study was important to the eRegister end users, particularly nurses and midwives. The strategic and facility managers should provide an opportunity for end-users to play an active role in the design process from the outset. This may promote the eRegister utility in this nation.

The facility managers should provide adequate training that meets the needs of the end users to facilitate eRegister use. Additionally, peer programme and team-based approaches that connect end users with clinicians, who are super-users, will promote mature use of the eRegister. Furthermore, policies that assist facilities in transitioning from paper-based registers would be advantageous.

The study was limited by solely relying on the experiences of participants from only three healthcare facilities in the country, who may not be representative of the entire population. In facilities with fewer resources than the study sites, the experiences and outcomes could differ. Therefore, while the findings provide valuable insights into factors promoting eRegister use, their transferability should be considered in light of contextual differences across healthcare settings within Lesotho and in similar low-resource environments. Additionally, future research should broaden the scope of perspectives by including further evidence from facilities countrywide.

Conclusion

This study identified critical factors that promote the use of the eRegister and data in Lesotho. The findings suggest that while external funding and partner responsiveness have been pivotal in sustaining eRegister operations, long-term sustainability will require stronger national ownership, including domestic investment in infrastructure, technical support and digital health governance.

The results further underscore that successful adoption of the eRegister is not merely a technological achievement but also a social and organisational process. Midwives’ adaptability, continuous training and recognition of the eRegister’s value for evidence-informed decision making were essential drivers of acceptance. These findings point to the need for sustained capacity building and inclusive change management strategies to ensure equitable adaptation across all cadres of staff.

For policy and practice, the study highlights the need to integrate the eRegister into routine health system functions, with mechanisms for continuous training, reliable infrastructure and accountability structures. For research, future studies should explore the effect of eRegister use on clinical outcomes and patient experiences and examine strategies for scaling up digital health interventions in resource-limited settings.

In summary, the eRegister demonstrates significant potential to enhance evidence-based midwifery practice in Lesotho, provided that its current momentum is consolidated through robust national stewardship, sustainable financing and ongoing investment in the digital competence of healthcare providers.

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study. Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.