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. 2023 Nov 27;11(11):CD013795.
doi: 10.1002/14651858.CD013795.pub2.

Perceptions and experiences of the prevention, detection, and management of postpartum haemorrhage: a qualitative evidence synthesis

Shahinoor Akter  1 , Gillian Forbes  2 , Martha Vazquez Corona  1 , Suellen Miller  3 , Fernando Althabe  4   5 , Arri Coomarasamy  6 , Ioannis D Gallos  5 , Olufemi T Oladapo  5 , Joshua P Vogel  7 , Fabiana Lorencatto  2 , Meghan A Bohren  1
Affiliations

Perceptions and experiences of the prevention, detection, and management of postpartum haemorrhage: a qualitative evidence synthesis

Shahinoor Akter et al. Cochrane Database Syst Rev. .

Abstract

Background: Postpartum haemorrhage (PPH), defined as blood loss of 500 mL or more after childbirth, is the leading cause of maternal mortality worldwide. It is possible to prevent complications of PPH with timely and appropriate detection and management. However, implementing the best methods of PPH prevention, detection and management can be challenging, particularly in low- and middle-income countries.

Objectives: Our overall objective was to explore the perceptions and experiences of women, community members, lay health workers, and skilled healthcare providers who have experience with PPH or with preventing, detecting, and managing PPH, in community or health facility settings.

Search methods: We searched MEDLINE, CINAHL, Scopus, and grey literature on 13 November 2022 with no language restrictions. We then performed reference checking and forward citation searching of the included studies.

Selection criteria: We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that explored perceptions and experiences of PPH prevention, detection, and management among women, community members, traditional birth attendants, healthcare providers, and managers.

Data collection and analysis: We used three-stage maximum variation sampling to ensure diversity in terms of relevance of the study to the review objectives, richness of data, and coverage of critical contextual elements: setting (region, country income level), perspective (type of participant), and topic (prevention, detection, management). We extracted data using a data extraction form designed for this review. We used thematic synthesis to analyse and synthesise the evidence, and we used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. To identify factors that may influence intervention implementation, we mapped each review finding to the Theoretical Domains Framework (TDF) and the Capability, Motivation, and Opportunity model of Behaviour change (COM-B). We used the Behaviour Change Wheel to explore implications for practice.

Main results: We included 67 studies and sampled 43 studies for our analysis. Most were from low- or middle-income countries (33 studies), and most included the perspectives of women and health workers. We downgraded our confidence in several findings from high confidence to moderate, low, or very-low confidence, mainly due to concerns about how the studies were conducted (methodological limitations) or concerns about missing important perspectives from some types of participants or in some settings (relevance). In many communities, bleeding during and after childbirth is considered "normal" and necessary to expel "impurities" and restore and cleanse the woman's body after pregnancy and birth (moderate confidence). In some communities, people have misconceptions about causes of PPH or believe that PPH is caused by supernatural powers or evil spirits that punish women for ignoring or disobeying social rules or for past mistakes (high confidence). For women who give birth at home or in the community, female family members or traditional birth attendants are the first to recognise excess bleeding after birth (high confidence). Family members typically take the decision of whether and when to seek care if PPH is suspected, and these family members are often influenced by trusted traditional birth attendants or community midwives (high confidence). If PPH is identified for women birthing at home or in the community, decision-making about the subsequent referral and care pathway can be multifaceted and complex (high confidence). First responders to PPH are not always skilled or trained healthcare providers (high confidence). In health facilities, midwives may consider it easy to implement visual estimation of blood loss with a kidney dish or under-pad, but difficult to accurately interpret the amount of blood loss (very low confidence). Quantifying (rather than estimating) blood loss may be a complex and contentious change of practice for health workers (low confidence). Women who gave birth in health facilities and experienced PPH described it as painful, embarrassing, and traumatic. Partners or other family members also found the experience stressful. While some women were dissatisfied with their level of involvement in decision-making for PPH management, others felt health workers were best placed to make decisions (moderate confidence). Inconsistent availability of resources (drugs, medical supplies, blood) causes delays in the timely management of PPH (high confidence). There is limited availability of misoprostol in the community owing to stockouts, poor supply systems, and the difficulty of navigating misoprostol procurement for community health workers (moderate confidence). Health workers described working on the maternity ward as stressful and intense due to short staffing, long shifts, and the unpredictability of emergencies. Exhausted and overwhelmed staff may be unable to appropriately monitor all women, particularly when multiple women are giving birth simultaneously or on the floor of the health facility; this could lead to delays in detecting PPH (moderate confidence). Inadequate staffing, high turnover of skilled health workers, and appointment of lower-level cadres of health workers are key challenges to the provision of quality PPH care (high confidence). Through team-based simulation training, health workers of different cadres (doctors, midwives, lay health workers) can develop a shared mental model to help them work quickly, efficiently, and amicably as a team when managing women with PPH (moderate confidence).

Authors' conclusions: Our findings highlight how improving PPH prevention, detection, and management is underpinned by a complex system of interacting roles and behaviours (community, women, health workers of different types and with different experiences). Multiple individual, sociocultural, and environmental factors influence the decisions and behaviours of women, families, communities, health workers, and managers. It is crucial to consider the broader health and social systems when designing and implementing PPH interventions to change or influence these behaviours. We have developed a set of prompts that may help programme managers, policymakers, researchers, and other key stakeholders to identify and address factors that affect implementation and scale-up of interventions to improve PPH prevention, detection, and management.

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Conflict of interest statement

  1. SA has no conflicts of interest.

  2. GF has no conflicts of interest.

  3. MVC has no conflicts of interest.

  4. SM was a co‐author on two studies included in this qualitative evidence synthesis (Jordan 2016; Berdichevsky 2010), but was not involved in the critical appraisal of these studies or GRADE‐CERQual assessments of review findings where these studies contributed evidence.

  5. FA has no conflicts of interest.

  6. AC is the Chief Investigator for "Early detection of Postpartum Haemorrhage and treatment using the WHO MOTIVE 'first response' bundle: a cluster randomised trial with health economic analysis and mixed methods evaluation" (E‐MOTIVE trial). This work is supported by a research grant from the Bill and Melinda Gates Foundation [Grant Number: INV‐001393].

  7. IG was involved in conducting a study eligible for inclusion in this review.

  8. OTO has no conflicts of interest.

  9. JPV has an editorial role with Cochrane but was not involved in the editorial process for this review. JPV has worked as a health professional.

  10. FL has no conflicts of interest.

  11. MAB has an editorial role with Cochrane but was not involved in the editorial process of this review. MAB was involved in conducting a study eligible for inclusion in this review.

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References

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    1. Ellard DR, Chimwaza W, Davies D, O'Hare JP, Kamwendo F, Quenby S, et al. Can training in advanced clinical skills in obstetrics, neonatal care and leadership, of non-physician clinicians in Malawi impact on clinical services improvements (the ETATMBA project): a process evaluation. BMJ Open 2014;4(8):e005751. - PMC - PubMed
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References to studies awaiting assessment

Alwy Al‐beity 2022 {published data only}
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MacGuire 2018 {published data only}
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Njolomole 2022 {published data only}
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Parameshwar 2022 {published data only}
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Posever 2022 {published data only}
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Ramavhoya 2021 {published data only}
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Singh 2021 {published data only}
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Walker 2021 {published data only}
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Yargawa 2021 {published data only}
    1. Yargawa J, Fottrell E, Hill Z. Women's perceptions and self-reports of excessive bleeding during and after delivery: findings from a mixed-methods study in Northern Nigeria. BMJ Open 2021;11(10):e047711. - PMC - PubMed

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References to other published versions of this review

Akter 2020
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Publication types