Table 3. Summary of qualitative findings.

#	Summary of qualitative review findings	Contributing qualitative studies	Overall CERQual assessment	Explanation of overall assessment
1	Inaccurate assessment of gestational age
1.1	Limitations about determining gestational age Women and health providers reported that last menstrual period or last month of menstrual period were the most common methods in assessing gestational age in LMICs, despite health providers acknowledging their limited accuracy. Some health providers in these settings were aware of ultrasound assessments of gestational age, whereas community health workers were not aware on the role of ultrasound dating in pregnancy.	[68,80,81]	Moderate confidence	No or very minor concerns on coherence, yet we downgraded due to minor concerns regarding adequacy, and moderate concerns on methodological limitations and relevance.
2	Inconsistent practice guidelines
2.1	Inconsistent practice guidelines There were substantial variations in the content of practice and implementation guidelines on ACS across contexts, typically about appropriate gestational age criteria, determination of what constitutes imminence in preterm labour birth, how to exclude maternal infection that precludes ACS use, adequacy of childbirth and preterm newborn care environment, and use in specific populations of women.	[63,79]	Moderate confidence	No or very minor concerns regarding coherence and relevance but downgraded due to minor concerns regarding adequacy and moderate concerns regarding methodological limitations.
3	Variable knowledge about the interventions
3.1	Health providers’ knowledge of the interventions Health providers’ knowledge about guidelines for and use of ACS, magnesium sulphate, and tocolytics was variable. Where there was high levels of knowledge and experience in administering the interventions, this improved implementation feasibility. Lack of knowledge or outdated knowledge were barriers to appropriate use. The key existing knowledge gaps were related to differences between research evidence and previous clinical training or experience, which sometimes involved different courses, dosing, and duration.	[23,24,40,63,80–82]	Moderate confidence	No or very minor concerns regarding coherence and adequacy but downgraded due to moderate concerns regarding methodological limitations and relevance.
3.2	Knowledge about optimal gestational age for intervention administration Knowledge about optimal gestational age for administration of ACS and magnesium sulphate varied across health providers, with mixed opinions about the earliest gestational age they would administer and agreement that these were challenging to have with women and families. Opinion about optimal gestational age for administration of interventions were also balanced with other factors including estimated time to birth, threatened versus imminent preterm birth, and local standards of practice.	[24,63,79,82]	Moderate confidence	No or very minor concerns regarding coherence, but we downgraded due to minor concerns regarding adequacy, and moderate concerns regarding relevance as well as serious concerns regarding methodological limitations.
4	Perceived risks and benefits
4.1	Uncertainties in prescribing and administering ACS for specific populations of women Health providers had uncertainties and lacked confidence regarding certain aspects of prescribing and administering ACS, such as whether to use repeat doses, or whether to use ACS in specific clinical situations (such as in women with diabetes, hypertension, fetal complications, maternal infection, or PPROM).	[40,63,80]	Moderate confidence	No or very minor concerns regarding coherence yet downgraded due to minor concerns regarding adequacy as well as moderate concerns regarding methodological limitations and relevance.
4.2	Scepticism of the evidence base for interventions Health providers had mixed beliefs about the evidence supporting ACS and magnesium sulphate for fetal neuroprotection. While some providers agreed with and believed in the evidence supporting their use, others were sceptical about long-term outcomes, availability of high-quality trials, mixed evidence of effects and sufficiency of evidence, all of which may act as barriers to use.	[23,24,40,63,82]	Moderate confidence	No or very minor concerns regarding coherence but downgraded due to minor concerns regarding adequacy, moderate concerns regarding methodological limitations and relevance.
4.3	Beliefs about risks of interventions While many health providers believed that risks of ACS and magnesium sulphate were negligible, some had concerns about possible safety issues (particularly interactions with tocolytics, exacerbation of pulmonary oedema), low tolerance by women, long-term risks of complications for women, whether use at earlier gestational age is appropriate (<28 weeks), and risk of maternal infection.	[23,24,79,80]	Moderate confidence	No or very minor concerns regarding coherence, but downgraded due to minor concerns regarding adequacy, and moderate concerns regarding methodological limitations as well as relevance.
4.4	Beliefs about risks of interventions—interaction with tocolytics Some health providers believed that interaction of magnesium sulphate and ACS individually with tocolytic agents (particularly nifedipine) is associated with exacerbated adverse effects and toxicity for women. This belief may hinder administration of magnesium sulphate and ACS, in women who are also eligible for ACS and tocolytics.	[23,24]	Low confidence	No or very minor concerns regarding coherence but downgraded due to moderate concerns regarding methodological limitations and relevance as well as serious concerns regarding adequacy.
4.5	Beliefs about benefits of interventions Most health providers recognised the benefits of magnesium sulphate and ACS, believing that these interventions save lives, and benefits mostly outweigh risks. Women similarly believed that administration of ACS is beneficial, stressing the importance of using only when necessary and receiving information about potential side effects. In contrast, many health providers believed that tocolytics do not work and do not stop labour.	[23,24,40,62,63,80]	High confidence	No or very minor concerns regarding coherence and adequacy yet downgraded due to minor concerns regarding methodological limitations and moderate concerns regarding relevance.
5	Barriers in administration of interventions
5.1	Uncertainties on when to administer interventions The unpredictability of preterm birth, including difficulty diagnosing threatened versus imminent preterm birth, can lead to provider hesitation in administering ACS and magnesium sulphate—providers fear being held responsible or blamed for potentially unnecessary treatment. To cope with these uncertainties, providers may delay treatment, preferring a “wait and see” approach.	[23,24,63,80,82]	Moderate confidence	No or very minor concerns regarding coherence yet downgraded due to minor concerns regarding adequacy as well as moderate concerns regarding methodological limitations and relevance.
5.2	Time constraints and complexity in prescribing and administering Health providers described time constraints in prescribing and administering ACS and magnesium sulphate as a critical overarching barrier to appropriate use, due to the acute nature and time pressures of imminent preterm birth, high intensity of workload, and competing tasks. Many health providers believed that prescribing and administering magnesium sulphate is complex, as preparation takes too much time, or is difficult to “draw it all up,” which could deter health providers in administering the medication when they feel under pressure.	[23,63,82]	Moderate confidence	No or very minor concerns regarding coherence, yet downgraded due to moderate concerns regarding methodological limitations, relevance, and adequacy.
5.3	Stocking medications in maternity ward Maintaining consistent stock of ACS and magnesium sulphate that is readily available in the maternity ward and emergency department, and the availability of health providers who are readily able to assess women in preterm labour, was critical to ensure that women received prompt treatment.	[23,40,68,79,80]	High confidence	No or very minor concerns regarding coherence, yet downgraded due to minor concerns regarding relevance, adequacy, and moderate concerns regarding methodological limitations.
5.4	Regulatory policies and beliefs about prescribing and administering authority National-level guidance is often limited about who can prescribe and administer ACS and magnesium sulphate; where there is guidance, typically only obstetricians are authorised to prescribe and administer, while other health providers can administer under clinical oversight, but not prescribe. Many health providers (obstetricians, neonatologists, midwives) likewise believe that prescription and administration of ACS and magnesium sulphate should be prescribed and administered by obstetricians-only, even though multidisciplinary decision-making was highly valued.	[23,40,63,79]	High confidence	No or very minor concerns regarding coherence and relevance yet downgraded due to minor concerns on methodological limitations and adequacy.
6	Appropriate settings for administration
6.1	Appropriate settings for ACS administration In some national guidelines and in clinical practice, administration of ACS is allowed at only at tertiary facilities where CEmONC and essential preterm newborn care interventions are available. While some country guidelines allow prereferral first dose administration of ACS at lower-level facilities (where BEmONC is available), implementation is limited due to challenges around identifying preterm labour, lack of knowledge about importance of prereferral dosing, and transportation issues.	[23,40,79–82]	High confidence	No or very minor concerns regarding coherence and adequacy yet downgraded due to minor concerns regarding relevance and moderate concerns regarding methodological limitations.
7	Strategies to improve appropriate use
7.1	Implementing reminder systems and educational materials Reminder systems and printed education materials (pamphlets, posters, signage) to prompt staff to prescribe and administer magnesium sulphate and ACS can facilitate appropriate use.	[23,40,63]	High confidence	No or very minor concerns regarding coherence and relevance yet downgraded due to minor concerns regarding methodological limitations and adequacy.
7.2	Developing reporting indicators and audit and feedback cycles Developing and implementing key performance indicators on magnesium sulphate and ACS use for health facilities and implementing audit and feedback cycles may be enablers to encourage appropriate use.	[23,40,68,79]	Moderate confidence	No or very minor concerns regarding coherence but downgraded due to minor concerns regarding relevance and adequacy, as well as moderate concerns regarding methodological limitations.
7.3	Implementing education and training for health providers Training for health providers to improve their knowledge about current research evidence, knowledge about impact of treatment on the woman and baby, and skills to administer ACS and magnesium sulphate were viewed as highly necessary and valuable.	[23,40,68,79]	High confidence	No or very minor concerns regarding coherence and adequacy yet downgraded due to minor concerns regarding relevance and moderate concerns regarding methodological limitations.
7.4	Appointing “change champions” Nominating facility-level influential obstetricians and midwives as “change champions” may help to promote and enable magnesium sulphate and ACS training and use.	[23,40,72,82]	Moderate confidence	No or very minor concerns regarding coherence, yet downgraded due to minor concerns regarding relevance, adequacy, and moderate concerns regarding methodological limitations.
7.5	Multidisciplinary teamwork to improve quality of care Multidisciplinary teamwork was highly valued by health providers to optimise ACS use, but fears, concerns, and frustrations were expressed over poor communication between the obstetric, midwifery, neonatal, and paediatric teams. Improved and standardised communication on ACS during handover and referral were highly valued but often lacking, particularly regarding whether interventions were administered yet and timing of administration.	[40,63]	High confidence	No or very minor concerns regarding coherence, yet downgraded due to minor concerns regarding methodological limitations, relevance, and adequacy.
8	Women’s perspectives and experiences
8.1	Women and partners’ knowledge of interventions Women’s and partners’ knowledge of ACS varied across settings. In high-income countries, some women and partners understood that ACS improved fetal lung maturity but were less aware of number of doses or the name of the medication administered. In contrast, in LMIC settings, very few women or their partners were aware of ACS.	[62,80,81]	Moderate confidence	No or very minor concerns regarding coherence yet downgraded due to minor concerns regarding relevance and moderate concerns regarding methodological limitations as well as adequacy.
8.2	Women learning about preterm birth management Many women and partners first learned about preterm birth and its management (including use of tocolytics, ACS, and magnesium sulphate) during emergency situations, hindering their understanding about potential interventions and sometimes contributing to hesitancy when risks and benefits were not well understood. Some women felt that decisions concerning ACS administration should be made solely by health providers, while others felt that they needed adequate time and information to consider risks and benefits. Women felt that their knowledge and ability to make informed decisions was improved by clear communication, adequate time for discussion with their provider, as well as educational sessions and materials.	[23,40,51,62,66,67,80]	High confidence	No or very minor concerns regarding coherence and adequacy yet downgraded due to minor concerns regarding methodological limitations and moderate concerns regarding relevance.
8.3	Women’s experiences of and concerns about side effects Despite personal experiences of and concerns about potential side effects of tocolytics and ACS among women in high-income countries, women mostly felt that they would take tocolytics and ACS in a future pregnancy if indicated. Some women preferred intravenous to oral tocolytics, as side effects were more consistent, with fewer “peaks and troughs” and uterine contractions.	[51,62,67]	Moderate confidence	No or very minor concerns regarding coherence but downgraded due to minor concerns regarding methodological limitations and adequacy, as well as moderate concerns regarding relevance.
8.4	Women’s concerns about on impact of interventions on baby Women and partners expressed concerns about the baby’s health—both from the possibility of preterm birth and from the potential impact of tocolytics on the baby. Balancing the fear of these 2 unknowns could be highly stressful, particularly as some women described feeling decreased fetal movement after tocolytic administration.	[51,66,67]	Moderate confidence	No or very minor concerns regarding coherence yet downgraded due to minor concerns regarding methodological limitations and adequacy, as well as moderate concerns regarding relevance.
8.5	Regaining control and empowerment Women experiencing preterm labour placed high value on interventions that helped them to maintain autonomy and regain control over their bodies and premature labour, such as interventions that enabled them to stay out of hospital or regain mobility. These types of interventions helped to promote their freedom while giving them a sense of security regarding their baby’s health.	[51]	Low confidence	No or very minor concerns regarding methodological limitations and coherence yet downgraded due to moderate concerns regarding relevance and serious concerns regarding adequacy.
8.6	Trust and relationships between women and health providers Women highly valued time and space to have a 2-way conversation and build trust with their health providers to understand their condition and treatment options. While some women reported experiencing positive relationships with health providers, critical threats to building trust included insufficient health provider time due to workload, lack of continuity of carers, and perceived invalidation of women’s concerns about whether they were in labour or not.	[51,62,67]	Moderate confidence	No or very minor concerns regarding coherence yet downgraded due to minor concerns on methodological limitations and adequacy, as well as moderate concerns regarding relevance.
8.7	Seeking support from families and peers During preterm birth management, women leaned on their families and partners for emotional and physical support, such as motivation for staying on bedrest, general advice about pregnancy and baby health, sharing experiences, and developing coping strategies. Several women and their partners described it as challenging to ask for support from families and friends during preterm birth management, as it is less common to ask for support during pregnancy compared to after the baby is born.	[51,62,67]	Moderate confidence	No or very minor concerns regarding coherence yet downgraded due to minor concerns regarding methodological limitations and adequacy, as well as moderate concerns regarding relevance.
8.8	Coping strategies—reframing experiences For women and their partners, reframing experiences of preterm birth management was critical to avoid disappointment and strengthen resolve. Reframing experiences led women and their partners to attempt to focus on positive aspects of their lives, enjoying moments with the baby, building relationships with babies, and learning to let go.	[51,67]	Moderate confidence	No or very minor concerns regarding methodological limitations and coherence yet downgraded due to minor concerns regarding adequacy and moderate concerns regarding relevance.

ACS, antenatal corticosteroid; BEmONC, basic emergency obstetric and newborn care; CEmONC, comprehensive emergency obstetric and newborn care; LMIC, low- or middle-income country; PPROM, preterm prelabour rupture of membranes.