Development and Piloting of Implementation Strategies to Support Delivery of a Clinical Intervention for Postpartum Hemorrhage in Four sub-Saharan Africa Countries

Capability(physical and psychological)

EducationTrainingEnablement

Training of new skills to use the calibrated drape: new blood loss collection and measurement tool to prompt and facilitate earlier detection.Training of core or new skills to deliver MOTIVE bundle including simulation practice drills.

Environmental restructuringModelingEnablement

Introduce PPH trolley or carry case to organize PPH drugs and equipment in 1 place accompanied by a checklist detailing the medicines and equipment to be stocked (country and site specific).Team-based training with simulation practice and drills to encourage and enable better coordination, teamwork, and communication when managing a PPH.

EducationPersuasionModelingEnablement

Introduce audit and feedback to monitor MOTIVE bundle uptake.Introduce a person in leadership role to “champion” the E-MOTIVE intervention implementation.

PPH detection:Calibrated drape

A calibrated drape will be tied around the woman’s waist after the baby is born to collect blood loss for the first hour after birth; if bleeding continued beyond the first hour, blood loss will be collected for a second hour.The calibrated drape includes 2 trigger lines at 300 ml and 500 ml of blood loss.Monitor vital signs (blood pressure and pulse rate), do clinical observations (uterine tone and vaginal blood flow) and take readings of calibration lines every 15 minutes and document it in patient notes.

• Agreement on how to respond when blood loss reaches 300 ml (i.e., be alert to possible PPH) and at 500 ml (i.e., trigger MOTIVE bundle).

• Calibration lines were perceived as useful. However, some health workers may diagnose a PPH at 300 ml when there are poor vital signs, so did not want to wait until 500 ml to act.

• Agreement on blood loss being recorded in patient notes every 15 minutes.

• Vital signs taken every 15 minutes and recorded in patient notes.

Limited scope to change 300 ml and 500 ml trigger lines because it is fixed by trial protocol.As agreed, what clinical actions should occur at specific volumes of blood loss:For Nigeria, Tanzania, and Kenya, the criteria for triggering the bundle were:

1. Clinical diagnosis of PPH, as per usual practice.

2. ≥500 ml blood loss in the drape.

3. ≥300–500 ml blood loss + an abnormal vital sign or observation.

• South Africa adopted criteria (1) and (2) above, but not (3).As agreed, develop a blood loss monitoring tool to support reading of calibration line and recording.

PPH treatment:MOTIVE bundle

• Local protocols do not always allow midwives to administer tranexamic acid. Tranexamic acid is either only given by doctors or by midwives under a doctor’s prescription.

• At some sites, only doctors would do an internal vaginal examination.

Limited scope to change the bundle components because it is fixed by WHO recommendations⁴As needed, adapt existing local protocols so midwives can administer tranexamic acid.Address skillsets in training as required (see E-MOTIVE training below).

• Limited consensus on the frequency of initial training of staff by on-site trainer.

• Concerns about holding follow-up practice simulation drill on a weekly basis, especially at sites where there are few or staff shortages.

• Merge E-MOTIVE training with Essential Steps in the Managing Obstetric Emergencies^b training to avoid any conflicts about best PPH practice (in South Africa).

• Adjust frequency of practice simulation drills (n=8) depending on the size of the workforce (in Nigeria, Tanzania).

• More training on tranexamic acid and internal examination specifically for midwives.

• Agreement about having a PPH trolley in the labor wards. Having a PPH trolley may be too large for some sites, therefore a smaller carry case was preferred.

• Some sites already have drugs and equipment checklist which could be used instead of an additional checklist which could increase paperwork workload of staff.

Sites to select the type of PPH kit, e.g., carry case in smaller wards (in Kenya, Nigeria and Tanzania), PPH box/ compartment as part of existing obstetric emergency trolley (in South Africa).

• Store oxytocin and other PPH drugs requiring cold chain in fridge on labor and delivery ward. Other drugs can be stored in the PPH trolley/carry case.

• Adapt existing stock checklist and assign to check and restock.

• Agreement that 2 champions of different clinical roles should be implemented.

• More clarity on the remit of a champion and how it fits in with other competing duties and if champions should be remunerated.

• Produce a champion handbook (all countries).

• Provide a platform for champions to virtually meet to give support and to share successes and challenges.

• None of the champions will be remunerated (all countries).

• On-site staff to document drugs used for PPH and stock-outs of PPH drugs.

• Trial program to share number of vaginal births, number of PPH, % of PPH cases given oxytocin and tranexamic acid using dashboard for use with all on-site staff.

• Agreement about having audit and feedback.

• Believed that the draft audit and feedback dashboard was difficult to interpret.

• All staff on maternity unit to receive feedback.