Table 3 Summary of key barriers and enablers of PPH detection and management in Kenya, Nigeria and South Africa

Environmental Context and Resources

Health hospitals organised into separate wards or rooms for maternity care

45

E

E

E

“It is made up of 2 wards, the labour room where we admit all the labour patients in, we have 5 beds in each ward” (Nurse, Nigeria)

Guidelines, clinical protocols, posters related to PPH are (not) displayed in the maternity ward

41

M

E

M

“We have SOPs in the labour ward, and they are all useful. The protocols are displayed on the walls. Everyone can check quickly”(Nurse, Kenya)

“No … I don’t really know why they [posters, charts] are not displayed” (Nurse, South Africa)

Variable readiness of theatres and availability of surgeons

29

M

M

M

“We don’t have problem with them [theatres] actually, they run calls here at any point on time you have anesthetist on call, the peri-op on call, and other staffs in the theatre so we only have to inform them” (Doctor, Nigeria)

“Have one theatre so there can be delays getting the patient into theatre if there is another emergency” (Doctor, South Africa)

Skills

Inconsistent in-service training in PPH

44

M

M

M

“We do patient training, for example sometimes, at a time, there was a time when there was a demonstration on the use of anti-shock garment and all that, and most of the training are not online” (Doctor, Nigeria)

“There is not any other training outside medical school and residency training program specifically on postpartum haemorrhage” (Admin, Nigeria)

Regular continuing medical education (CME), including case reviews, will reduce PPH cases

16

E

E

E

“We also undertake CMEs, monthly or twice a month” (Midwife, Kenya)

Continuous and additional training helps to keep up-to-date with new approaches and current recommendations

14

X

E

E

“It is very much helpful because you cannot only rely on the knowledge from training school while there are new trends” (Midwife, Kenya)

Knowledge

Variable understanding of how to detect different aetiologies of PPH

44

E

M

B

“Postpartum haemorrhage is by definition, a vaginal bleeding after birth. And in terms of quantification when a woman has lost more, more or equal 500 ml of blood at the definition” (Doctor, South Africa)

“I think it is not having enough knowledge [among new staff] on the PPH…Because maybe sometimes we are unable to quantify the amount of blood lost, then we say this is PPH, or this is just normal blood loss.” [Doctor, Kenya]

Variable understanding of what constitutes appropriate clinical practice for PPH management

37

E

M

B

“We always have them be made aware of these guidelines. But for the rest of us, we [Doctors] sort of go ahead without knowing or reading the guidelines” (Head of Dept, South Africa)

“We always use them as a reference. We want all of us to have the same level of understanding and care” (Midwife, South Africa)

Higher-level hospitals receive limited information about the previous care received by woman referred from lower hospitals

23

B

B

X

“In some cases, the patient arrives here with no IV line, no samples, and quite often the reason for referral could be something they could have easily managed, such as retained placenta, but they do not know what to do” (Nurse, Kenya)

Behavioural Regulation

Receiving feedback on current practice helps identify areas for improvement

38

E

E

E

“I think anything that could make it better, it’s still welcomed” (Doctor, Nigeria)

Lack of quality improvement strategies for PPH (e.g., meetings where feedback is given)

17

B

B

B

“We would like to hold such meetings more frequently. Sometimes due to inadequate staffing we skip monthly meetings” (Midwife, Kenya)

Current strategies in place, e.g., having a PPH kit, continuing education and hospital specific protocols are perceived to work

16

X

E

E

“I am not aware of any specific strategies of improvement, apart from perhaps resuming CMEs, whereby clinicians would continue to get training on PPH management” (Doctor, Kenya)

Beliefs about Consequences

Maternal mortality due to PPH is low if birth occurs within hospital

38

B

M

M

“It is really it’s a big issue especially with those that are referred from another hospital or referred from home...… [if] it occurs in our centre, because of early intervention and prompt treatment, we usually have good outcome” (Doctor, Nigeria)

“It’s very common we see it very often, but I think we respond to it quite quickly .... within an hour or two after birth…. so, every PPH will get picked up at a certain” (Midwife, South Africa)

Lack of accurate and objective measurement of blood loss delays detection of PPH

34

B

B

B

“We still rely on the gross method that we use, of assessing the amount of blood based on the amount of blood by our under-pads or the sanitary pads that we use or occasionally if it is too much, we use the kidney dish to collect the blood, but you know we have a high tendency for underestimating because it will not take into account” (Admin, Nigeria)

Referrals by other hospitals can be too late for the receiving hospital to effectively manage the PPH

21

B

B

B

“Late presentation is also one of the issues and challenges that we have especially from those who are coming from outside because most times they would have gone to other peripheral hospitals” (Doctor, Nigeria)

Emotion

Negative emotions resulting from the unpredictability and fatality associated with PPH

40

M

M

M

“You are a little bit on edge you know that this is a complication it’s a leading cause of maternal mortality” (Midwife, South Africa)

“it’s an incident that can be managed. So, it’s just that nothing to fear or to worry about” (Doctor, Nigeria)

Limited impact from emotions as doctors’ work ‘on autopilot’

7

E

E

X

“At that time, you are being put on one autopilot that all you're trying to do is trying to save that person’s life, so even thinking of yourself as being stressed out does not even come into play, it’s after you’ve finished” (Doctor, Nigeria)

Emotional support is received from colleagues and religious beliefs

7

E

E

X

“There is need for debriefs, especially after a complication ends in maternal death” (Midwife, Nigeria)

Social Influences

Team-working is necessary to manage a PPH

42

E

E

E

“We worked with the midwife who conducted the delivery and also some other nurses and me as a Medical Officer” (Doctor, Kenya)

Team working reassures individuals that support is readily available

8

E

E

E

“We work well as a team and when you call for the help everyone comes here. Everyone comes here, everyone doctors, nurses, even the cleaners at times” (Midwife, South Africa)

Mothers lack knowledge of PPH signs and symptoms can delay timely detection and management of PPH

3

X

X

B

“I’m bleeding too much, so you educate your patient please call for help as much as bleeding after delivery is normal but excessive bleeding is not normal” (Midwife, South Africa)

Memory, Attention and Decision-making

International guidelines adapted into hospital-specific clinical guidelines are more likely to be implemented by staff

36

M

M

M

“We use WHO guidelines. But we have tailored these to the basics. We sometimes substitute the drugs of choice as per the guidelines, with what we have available in the hospital” (Doctor, Kenya)

“We [Doctors] sort of go ahead without knowing or reading the guidelines” (Head of Dept, South Africa)

Good clinical understanding of when and how to escalate to refractory PPH management intervention

24

M

E

M

“Patient can be taken to a theatre…. under resuscitation on IV fluids and blood if available, check for cervical laceration, and then since the uterus is flabby has not contracted, we can institute other modalities like minimally invasive modalities or more extensive modalities” (Doctor, Nigeria)

“Oxytocic was given, then checking if the uterus has contracted yet and then he noticed that the uterus was not contracting and he did the bimanual contraction of the uterus until the doctor came” (Midwife, South Africa)

Delayed treatment due to reliance on vital signs to detect a PPH

10

M

E

M

“Especially from the signs and symptoms the mother starts experiencing headaches, light headedness and also dizziness and from the vitals when you check the blood pressure” (Doctor, Kenya)

“The extent of blood loss is the first thing that we pay attention to, and then the patient’s vital status” (Doctor, Nigeria)

Social/Professional Role and Identity

Good levels of role clarity

34

E

E

E

“My role is that after I detect that the woman has PPH, I will call the attention of my colleague and later on the doctor on call” (Midwife, Nigeria)

There is a clear division of tasks based on profession

33

E

E

B

“The person doing the delivery, the midwife will examine and then they would call, usually call the doctor who take over examination or just double check” (Midwife, South Africa)

The team managing a PPH should be multi-disciplinary

10

X

E

X

“Midwives even the sub-staff can help but if there are many doctors on ground they can come and help in managing the patient. For instance, one setting the line, one taking the sample for blood for grouping and cross-matching or some applying anti-shock garment, so it is multi-disciplinary activity” (Doctor, Nigeria)

Beliefs about Capabilities

Varied levels of confidence in ability to detect and manage PPH

24

M

M

M

“I can confidently say I can be able to do it” (Midwife, South Africa)

“Not all workers, like nurses and intern doctors [are confident]” (Doctor, Kenya)

Concerns about abilities to detect and manage PPH with un-booked women

6

B

X

X

“The patients come from outside (un-booked] because that's where the problem is” (Admin, South Africa)

Coping with the quick and sudden onset of PPH can be challenging

2

B

X

X

“Her condition suddenly changed, and she showed symptoms of PPH” (Midwife, Kenya)

Reinforcement

Varied approaches to disciplinary procedures across hospitals and countries

29

E

B

B

“When something goes wrong, the entire team should take responsibility, review what happened and use it positively as a learning experience” (Doctor, Kenya)

“If there was a higher incident of obstetric haemorrhage ……they would either give training or they would discipline the people involved” (Midwife, South Africa)

Disciplinary procedures across hospitals and countries are unlikely to change PPH care

18

B

B

X

“The most important thing is about having the passion…. [to] save the patient rather than thinking that whether you are going to be disciplined for doing it or not” (Admin, Nigeria)

Goals

Mortality associated with PPH makes it a clinical priority

42

E

E

E

“It’s a very huge priority because for me it’s a very serious challenge and very serious priority that I need to consider it with too much seriousness. Because it’s something that I may just…can result to maternal mortality within the blink of an eye” (Midwife, Nigeria)

Eclampsia perceived as a higher priority than PPH because eclampsia causes more mortality

3

B

B

B

“Severe pre-eclampsia and eclampsia are first on priority list as they cause more mortality” (Doctor, Nigeria)