Table 5 Identified barriers and enablers mapped to proposed implementation interventions using the BCW

Capabilities (Physical and Psychological)

Skills

Inconsistent ongoing training on PPH; lacking in some core skills (Barrier)

Training,

Education,

Modelling,

Enablement

Demonstration of the behaviour;

Instruction on how to perform a behaviour;

Behavioural rehearsal/practice;

Habit formation;

Action planning; Feedback on behaviour;

Feedback on outcome of behaviour;

Salience of consequences

- Training to provide core or new skills required to deliver the bundle; for example, using new calibrated drape, administering tranexamic acid by midwives

Additional education and training to improve knowledge of PPH detection and management and an understanding of a bundled approach of care (i.e., use all components of the bundle), provide setting specific guidelines

- Introduce audit and feedback as a way to monitor bundle uptake and to prompt implementation by providing feedback to staff; set targets

Knowledge

Varying understanding of PPH aetiologies including signs and symptoms (Mixed)

Behaviour Regulation

Acknowledged missed opportunities to improve current PPH practice (Enabler)

Memory, Attention & Decision-making

Visual estimation of blood loss and deciding to use the bundle and to use the bundle as intended (Barrier)

Opportunity (Physical and Social)

Environmental Context and Resources

Varying accessibility of stock of consumables, equipment and drugs (Mixed)

More staff is needed to deliver the bundle (Barrier)

Enablement,

Environmental Restructuring,

Training,

Modelling

Prompts/Cues;

Adding objects to the environment;

Credible source;

Social support (Practical);

Social support (Emotional)

- Introduce a trolley/kit to organise stock of consumables, equipment and drugs for PPH into one place to reduce time taken to fetch everything; reduce the sense of panic felt by staff by sudden and unpredictable onset of PPH

Social Influence

Teamwork is required to deliver the bundle (Barrier)

Motivation (Automatic and Reflective)

Beliefs about Capabilities

Relying on subjective estimation of blood loss leading to delayed or inaccurate detection of PPH (Barrier)

Enablement,

Environmental Restructuring,

Persuasion,

Modelling,

Education,

Training

Demonstration of behaviour;

Behavioural rehearsal/ practice;

Pros and cons;

Information on health consequences;

Information on emotional consequences;

Verbal persuasion to boost self-efficacy;

Social support (Practical);

Social support (Emotional);

Social support (Unspecified)

- Calibrated drape as a new tool to both prompt and facilitate detection; provide more accurate blood loss - Introduce a bundle champion in a leadership role who can encourage, support and model bundle use; promote collective use of the bundle as a means to motivate staff to adopt new clinical practices or adapt existing practice and to overcome any resistance to change

Beliefs about Consequences

Beliefs that quicker and accurate PPH detection can reduce maternal mortality (Enabler)varying confidence in delivering some elements of the bundle (Enabler)

Goals

Reducing PPH is important; it is main cause of maternal fatalities (Enabler)

Social/Professional Role and Identity

Mixed views on both doctors and midwives or nurses performing some or all parts of the bundle (Mixed)

Intention

Potential lack of buy-in to the bundle over existing practice (Barrier)

Emotion

Coping with negative feelings of panic and stress from unpredictably of PPH (Barrier)