Communication dynamics in the care of preterm infants: a multi-level qualitative study from a high-burden district in Indonesia

Background Preterm birth remains a major contributor to infant mortality and long-term morbidity globally, with disproportionate burdens in low- and middle-income countries, including Indonesia. Global maternal and newborn health agendas increasingly promote continuity of care, family-centred approaches, and behaviour-informed communication across levels of service delivery. However, how globally endorsed principles are translated into routine communication during hospital-to-home transitions is shaped by local health systems, provider capacity, and household contexts, and remains insufficiently understood in high-burden settings. This study aimed to map communication dynamics in preterm infant care in a high-burden district in Indonesia using a multi-level qualitative approach. Methods This exploratory multi-level qualitative study applied behavioural and communication frameworks to examine communication processes across clinical, household, and systemic levels in Bandung District, a high-burden area in West Java, involving referral hospitals and community health facilities. Purposive sampling included 59 participants, comprising mothers of preterm infants, hospital and primary health care providers, district and provincial health authorities, professional groups, and the national health insurance administrators. Data were gathered via in-depth interviews, focus group discussions, participant observations, and document analysis. Reflexive Thematic Analysis was conducted with NVivo 15, incorporating iterative coding, memoing, cluster analysis, and theme refinement. Rigour was maintained through triangulation, audit trails, and peer debriefing. Result Four interconnected themes encapsulated the communication landscape: Communication Practices (channels, techniques, timing, message content, interprofessional handover); Household and Community Support (health literacy, practical skills, beliefs, motivation/self-efficacy, emotional coping, family and peer support); Worker Capacity and Resources (training deficiencies, workload/time constraints, educational materials, supervision, standard operating procedures); and System, Policy, and Access (policy, monitoring, financing, interagency coordination, referral pathways, infrastructure, geographic/economic accessibility). These themes collectively demonstrate how fragmented practices, inconsistent provider capability, and varying family preparedness produce inequitable continuity of care, hindering effective transitions from hospital to home. Conclusion Communication in preterm infant care is influenced by interrelated interpersonal, household, workforce, and systemic factors. Strengthening continuity of care requires integrated, multi-tiered strategies that align communication practices across levels of service delivery to reduce inequities in post-discharge care and prevent avoidable neonatal risks in high-burden settings.