Factors influencing postpartum haemorrhage detection and management and the implementation of a new postpartum haemorrhage care bundle (E-MOTIVE) in Kenya, Nigeria, and South Africa

Abstract

Background Postpartum haemorrhage (PPH) is the leading cause of global maternal deaths, accounting for 30–50% of maternal deaths in sub-Saharan Africa. Most PPH-related deaths are preventable with timely detection and initiation of care, which may be facilitated by using a clinical care bundle. We explore influences on current PPH detection and management and on the future implementation of a new PPH bundle (E-MOTIVE) in low-resource, high-burden settings. Methods Semi-structured qualitative interviews based on the Theoretical Domains Framework were conducted with 45 healthcare providers across nine hospitals in Nigeria, Kenya and South Africa, to identify barriers and enablers to current PPH detection and management and future implementation of a new PPH care bundle. Data were analysed using thematic and framework analysis. The Behaviour Change Wheel was used to identify potential interventions to address identified barriers and enablers. Results Influences on current PPH detection and management fell under 12 domains: Environmental Context and Resources (drug and staff shortages), Skills (limited in-service training), Knowledge (variable understanding of the recommended practice), Behaviour Regulation (limited quality improvement culture), Beliefs about Consequences (drawbacks from inaccurate detection), Emotion (stress from the unpredictability of PPH), Social Influence (teamwork), Memory, Attention and Decision-making (limited guideline use), Social/Professional Role and Identity (role clarity), Beliefs about Capabilities (confidence in managing PPH), Reinforcement (disciplinary procedures) and Goals (PPH as a priority). Influences on bundle uptake included: Beliefs about Consequences (perceived benefits of new blood loss measurement tool), Environmental Context and Resources (high cost of drugs and new tools), Memory, Attention and Decision-making (concerns about whether bundle fits current practice), Knowledge (not understanding ‘bundled’ approach), Social Influence (acceptance by women and staff) and Intention (limited acceptance of ‘bundled' approach over existing practice). These influences were consistent across countries. Proposed interventions included: Education, Training, Modelling (core and new skills), Enablement (monitoring uptake), Persuasion (leadership role) and Environmental Restructuring (PPH emergency trolley/kit). Conclusions A wide range of individual, socio-cultural and environmental barriers and enablers to improving PPH detection and management exist in these settings. We identified a range of interventions that could improve PPH care and the implementation of new care bundles in this context. Trial registration ClinicalTrials.gov: NCT04341662

An exploratory study to unveil the behavioral aspects and practical approaches of healthcare providers to detect and manage the post-partum hemorrhage: Insights from the COM-B model

“…This research found that obstetricians were unaware of E-MOTIVE bundle of care for PPH management, however, current PPH management already includes all individual components of E-MOTIVE in Pakistan. Our ndings are contrary to other studies conducted in Kenya, Nigeria and South Africa (34,35), where HCPs were familiar with this bundle of care. The reasons may include the limited training opportunities,…”

“…Lack of training of the HCPs, risk factor screening, timely diagnosis, volume administration, blood transfusion and hospital infrastructure were some barriers in PPH detection and management reported in this study. Although the WHO recommends the appointment of well trained staff to prevent and manage the PPH (31), the shortage of well-trained healthcare staff is global challenge but it is intensi ed in LMICs including Pakistan (13,20,21,31). Only one respondent of this study attended an awareness session conducted by an institution.…”

“…A combination of inductive thematic and deductive framework analysis was used to analyze the data (20,26). In the rst step, researchers listened the audio recordings of interviews and carefully read the transcripts to get familiarize with the data.…”

“…The interview schema was designed after a comprehensive literature review and was developed to best answer the research problems and identify gaps in the existing literature (19)(20)(21). Interview schema was pilot tested by conducting two interviews from target participants to con rm the validity of study protocol (20). The piloted interviews were not included in the nal analysis.…”

Barriers and Facilitators Influencing Midwives’ Implementation of South Africa’s Maternal Care Guidelines in Postnatal Health: A Scoping Review

“…Alkema et al,2017;Daemers et al, 2017, Forbes et al, 2023 Lodeka, 2017; Makin-Zimaliran et al, 2022); poor service delivery important factors in uencing midwives' implementation of the guidelines included a non-conducive environment, a lack of support, autonomy, and empowerment(Simona et al, 2023; Petterson, (2018), and poor role de nition, delegation, and supervision(Maaløe et al,2021). Poor health conditions, burnout, nancial struggles, and disregard from public and health teams were also identi ed(Simona et al, 2023; Petterson, 2018), as well as a lack of training, education, orientation, and poor adaptation to midwifery education(Forbes et al, 2023; Solnes mitten et al, 2017; Petterson, 2018).…”