The aim is to explore co-design facilitators’ perspectives and experiences of using co-design to improve intrapartum care in four sub-Saharan African settings. The inquiry focuses particularly on how they fostered engagement, built trust and mitigated unintended consequences during the co-design process.

Qualitative interview study with reflexive thematic analysis.

Sixteen public and private not-for-profit hospital-based maternity units in Benin, Malawi, Tanzania and Uganda (four per country).

A total population sample of 10 co-design facilitators involved in a hospital-based co-design project implemented in maternity units in Benin, Malawi, Tanzania and Uganda were interviewed. Semistructured interviews were conducted between December 2022 and January 2023.

Co-design facilitators viewed co-design as a collaborative process to develop contextually relevant solutions. Our findings elucidate their role in facilitating consensus-building and fostering stakeholder ownership amidst significant power divides. They described approaches co-design facilitators take to maintain ongoing stakeholder engagement and manage misaligned expectations in a trusting and collaborative environment, while being mindful of existing tensions and power imbalances. They also highlighted key challenges faced, including navigating norms, power imbalances and unintended consequences.

This study underscores the importance of power-sharing, fostering ownership and engaging end users equitably and continuously in co-design efforts, while also being aware of how to address its potential unintended consequences. Further research is needed to understand co-design facilitators’ impact on co-design and how to address unintended consequences for stakeholders during and after co-design activities in intrapartum interventions in low-resource settings.