Table 4 List of TDF domain belief statements about factors potentially influencing uptake of the E-MOTIVE bundle In Kenya, Nigeria and South Africa

Environmental Context & Resources

Concerns about cost and availability of the calibrated drape

Calibrated Drape

13

B

B

B

“This item looks expensive. I am imagining if it we discard the blood and sterilize the tool could be used by another, and therefore reduce the cost” (Midwife, Kenya)

Use of drape requires appropriate beds

Calibrated Drape

5

B

B

B

“The funnel won’t be able to hang down so then, I think it’s gonna make it difficult for them to detect the blood loss cause if it’s not hanging it’s gonna be flat on the bed” (Midwife, South Africa)

Mixed views about the supply chain and ready availability of oxytocin

Oxytocic drugs

15

M

M

M

“They [oxytocic drugs] are usually kept at the store at the pharmacies so they are not…even the cold chain has been broken” (Doctor, Nigeria)

“I think it’s stored in the fridge, ... so anytime, it’s always there” (Doctor, Nigeria)

Poor quality brands of oxytocin procured

Oxytocic drugs

6

B

B

x

“Particular brand of oxytocin that we got in recent times which we have actually reported that we thought it wasn’t quite effective” (Admin, Nigeria)

Limited tranexamic acid supplies due to high costs

Tranexamic acid

7

B

B

x

“They [hospital] don’t supply it... [available] in the pharmacy, and it is costly....  some patients cannot afford to buy it” (Midwife, Nigeria)

IV fluids readily available in the ward

IV Fluids

12

E

E

E

“It is easy because we have it in the emergency drugs” (Nurse, Nigeria)

More than one person is required to do an examination (Lack of staff)

Examination

6

M

M

M

“It is not something you need to do alone, you need about two assistants to help you” (Doctor, Nigeria)

“As a midwife, I examine the woman” (Midwife, Kenya)

Inadequate lighting due to electricity outages limits ability to conduct examinations

Examination

5

B

B

B

“There are periods that this light has had a problem and then the generator also had an issue” (Admin, Nigeria)

More staff needed to deliver the E-MOTIVE bundle

All components

2

B

B

X

“You’ll find yourself sometimes alone you understand manpower the other one has gone to receive a baby, you will be left with the patient, so you just have to do it alone” (Midwife, Nigeria)

Skills and Knowledge

Lack of education and skills on how and when to use a calibrated drape

Calibrated Drape

28

B

B

B

“People need to be educated on how to work with this, they need to know how to use it first, and then they need to practice” (Doctor, Nigeria)

Training to use tranexamic acid is required, particularly for midwives and nurses who do not currently administer it

Tranexamic acid

8

B

B

B

“It is not specifically ordered by the doctor, when we are managing the patient, we do not think of this Cyclokapron. We only think of it when the doctor prescribes it” (Midwife, South Africa)

Further training on how to use the E-MOTIVE bundle is required

All components

22

M

M

M

“The team should be trained [on the bundle components] because all these treatments need extra hands. Therefore, everyone should be well acquainted to assist when required” (Doctor, Kenya)

Beliefs about Consequences

Accurately measuring blood loss improves detection of PPH

Calibrated Drape

45

E

E

E

“One of the biggest challenges estimating getting a close to a good estimate of the blood loss so if you are able to get something that gives that then I think it would be a very good thing” (Midwife, Kenya)

Uterine massage is effective in managing PPH when used in conjunction with Oxytocics/ uterotonics

Massage

16

E

E

E

“I start massaging I will now inject oxytocin but immediately you start massaging you will see the uterus starting to contract…. definitely it comes with reduction in blood loss” (Doctor, Nigeria)

Oxytocin is routinely administered as it is effective at preventing and managing PPH

Oxytocic drugs

15

E

E

E

“Usually by the time you give oxytocin, the PPH often stops, other than in a few cases” (Midwife, Kenya)

Beliefs that using the bundle is limited (by not having tranexamic acid readily available)

Tranexamic acid

10

B

B

B

“Sometimes it is not available in the nearby pharmacy we have” (Midwife, Nigeria)

Tranexamic acid is effective at stopping bleeding after oxytocic drugs have not worked, although tranexamic acid is not more effective than oxytocin

Tranexamic acid

9

M

M

M

“You only use oxytocin, and they respond so there is no need for you to give Cyclokapron [tranexamic acid] and other drugs in the bundle” (Midwife, South Africa)

“Tranexamic acid is there to help clot the blood, so I don't know if that makes a difference that I think oxytocin is number one” (Head of Dept, South Africa)

IV fluids help stabilise the patient by maintaining haemodynamic status

IV fluids

6 

E

E

E

“…. we have delays in getting blood so initially we have to make do with IV fluids until the blood is available to maintain haemodynamic status” (Doctor, Nigeria)

Using the bundle will increase the effectiveness and improve current management of PPH

All components

34

E

E

E

“…it [the bundle] is going to improve the services rendered and then it will really reduce the morbidity and mortality associated with this condition” (Doctor, Nigeria)

Using the bundle will reduce PPH mortality and morbidity

All components

10

E

E

E

“It [the bundle] will impact positively because it will reduce morbidity and mortality associated with postpartum haemorrhage” (Manager, Nigeria)

Concerns about misoprostol not being part of the bundle when it is perceived to be effective at treating a PPH

All components

1

x

x

B

“We use misoprostol as well before tranexamic acid” (Head of Dept, South Africa)

Social Influences

Concerns about giving uterine massage causing discomfort and pain to women

Massage

4

B

B

X

“Some patients will refuse” (Midwife, Nigeria)

Some women refuse to have an examination of the genital tract

Examination

13

B

B

B

“Sometimes the mother becomes uncooperative. It is uncomfortable for mothers so some refuse to be examined” (Midwife, Kenya)

Memory, Attention and Decision-making

Concerns about calibrated drape fitting in with current methods for estimating blood loss

Calibrated Drape

4

B

B

B

“I think it’s gonna make it difficult for them to detect the blood loss cause if it’s not hanging it’s gonna be flat on the bed” (Midwife, South Africa)

Uterine massage currently used as first line treatment for PPH

Massage

38

E

E

E

“…… know to rub the uterus, that one they definitely have to rub the uterus and then the drugs” (Doctor, South Africa)

Oxytocin currently administered simultaneously with uterine massage

Oxytocic drugs

38

E

E

E

“Uterine massage and oxytocics are quite important because of their significance in preventing postpartum haemorrhage” (Admin, Nigeria)

Tranexamic acid is not routinely used (unless as a last resort when oxytocin has not worked)

Tranexamic acid

38

B

B

B

“Normally we give tranexamic when oxytocin fails, when we do all the measures and it fails then we get a tranexamic acid” (Midwife, Nigeria)

IV fluids are routinely used managing PPH

IV Fluids

21

E

E

E

“That is the second thing they will do. So, we use it always” (Nurse, Kenya)

Genital tract examination currently done to detect cause of bleeding

Examination

45

E

E

E

“We do it [examine] immediately after delivery to know whether there is any tear, and if the patient is also bleeding, we also still assess” (Nurse, Nigeria)

Current PPH management already includes all individual components of E-MOTIVE, but not delivered as a care bundle

All components

9

B

B

B

“I think it is better to use one after the other, than using all at once. The reason for the bleeding, could be trauma, tears, so when you repair a trauma the bleeding stops” (Midwife, Kenya)

Social/Professional Role and Identity

Mixed beliefs that both doctors and midwives or nurses can do examinations

Examination

19

M

M

M

“It should be…the registrar does it [examine], and the senior registrar and then maybe the midwife” (Doctor, Nigeria)

“As a midwife, I examine the woman” (Midwife, Kenya)

Teamwork is required to use the E-MOTIVE bundle where each person will have assigned role(s)

All components

1

X

E

X

“The bundle actually emphasizes and enhances teamwork” (Doctor, Kenya)

Beliefs about Capabilities

Confident in ability to give a uterine massage

Massage

9

E

E

E

“All the staff should be confident in performing a uterine massage” (Admin, Nigeria)

Confident in administering oxytocin

Oxytocic drugs

10

E

E

E

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

Healthcare providers are confident at using IV fluids

IV fluids

5

E

E

E

“100% [confident], It works. It is very effective” (Midwife, Nigeria)

Clinical staff feel (un-)skilled and (not) confident in examining the genital tract

Examination

9

M

M

M

“If there is something I find that I am not sure about I can always ask my seniors, midwife or the medical officer on duty” (Midwife, Kenya)

“All the doctors can effectively do examination, even a significant number of our midwives can be able to do [it]” (Admin, Nigeria)

Lack of confidence will affect overall use of the E-MOTIVE bundle

All components

6

B

B

X

“Not everyone is confident, newer staff might not manage all of them all at once” (Nurse, Kenya)

Intentions

Potential lack of buy-in of using the bundle over existing practice

All components

3

B

B

B

“We massage the uterus, administer oxytocic, tranexamic acid, and IV and also examine the vaginal track to remove any retained tissues. We do not refer to it as bundle, but we do all these in the EMOTIVE bundle” (Midwife, South Africa)