Gender and Women's Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Australia.
Centre for Behaviour Change, University College London, London, UK.
Cochrane Database Syst Rev. 2023 Nov 27;11(11):CD013795. doi: 10.1002/14651858.CD013795.pub2.
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.
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.
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.
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.
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.
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.
产后出血（PPH）定义为分娩后出血量达 500 毫升或以上，是全球产妇死亡的主要原因。通过及时和适当的检测及管理，有可能预防 PPH 的并发症。然而，在中低收入国家，实施 PPH 预防、检测和管理的最佳方法可能具有挑战性。
我们的总体目标是探索经历过 PPH 或预防、检测和管理 PPH 的妇女、社区成员、非专业卫生工作者和熟练医护人员的看法和经验，这些人在社区或卫生机构环境中。
我们于 2022 年 11 月 13 日在 MEDLINE、CINAHL、Scopus 和灰色文献中进行了搜索，没有语言限制。然后我们对纳入的研究进行了参考文献检查和正向引文搜索。
我们纳入了定性研究和混合方法研究，这些研究具有可识别的定性部分。我们纳入了探讨妇女、社区成员、传统助产士、医护人员和管理人员预防、检测和管理 PPH 看法和经验的研究。
我们使用三阶段最大变异抽样，以确保研究与审查目标的相关性、数据的丰富性以及关键背景元素的覆盖范围多样化：设置（地区、国家收入水平）、视角（参与者类型）和主题（预防、检测、管理）。我们使用专为本次审查设计的数据提取表提取数据。我们使用主题综合分析来分析和综合证据，并使用 GRADE-CERQual（从定性研究中评价证据的信心）方法来评估我们对每个发现的信心。为了确定可能影响干预措施实施的因素，我们将每个审查发现映射到理论领域框架（TDF）和行为变化的能力、动机和机会模型（COM-B）。我们使用行为改变轮来探讨对实践的影响。
我们纳入了 67 项研究，并对其中 43 项研究进行了分析。大多数研究来自中低收入国家（33 项），并且大多数研究都包括妇女和卫生工作者的观点。我们将几个发现的置信度从高置信度下调至中、低或极低置信度，主要是因为对研究方法的局限性或对某些类型的参与者或在某些环境中缺乏重要观点的担忧（相关性）。在许多社区中，分娩后和分娩期间出血被认为是“正常”的，是排出“杂质”和恢复、净化妇女怀孕和分娩后身体所必需的（中等置信度）。在一些社区中，人们对 PPH 的原因有误解，或者认为 PPH 是由超自然力量或邪恶势力引起的，这些力量惩罚那些忽视或违反社会规则或过去犯过错误的妇女（高置信度）。对于在家中或社区分娩的妇女，女性家庭成员或传统助产士是第一个识别出分娩后过量出血的人（高置信度）。如果怀疑有 PPH，家庭成员通常会做出是否以及何时寻求护理的决定，这些家庭成员通常会受到可信赖的传统助产士或社区助产士的影响（高置信度）。如果在家中或社区分娩的妇女发生 PPH，随后的转介和护理途径的决策可能是多方面和复杂的（高置信度）。第一个发现 PPH 的人并不总是有技能或受过培训的医护人员（高置信度）。在卫生机构中，助产士可能认为使用肾脏盘或下垫来估计出血量很容易，但很难准确解释出血量（非常低置信度）。量化（而不是估计）失血量可能是卫生工作者改变实践的一个复杂和有争议的问题（低置信度）。在卫生机构分娩并经历 PPH 的妇女描述说这是痛苦、尴尬和创伤性的。伴侣或其他家庭成员也感到压力很大。虽然一些妇女对参与 PPH 管理决策的程度不满意，但其他妇女认为卫生工作者最适合做出决策（中等置信度）。资源（药物、医疗用品、血液）的供应不一致导致 PPH 的及时管理延迟（高置信度）。由于缺货、供应系统差以及难以为社区卫生工作者采购米索前列醇，社区中米索前列醇的供应有限（中等置信度）。卫生工作者描述说，在产科病房工作压力大且紧张，由于人员短缺、长班和紧急情况的不可预测性，工作人员可能无法适当监测所有妇女，特别是当多名妇女同时分娩或在卫生机构的病房地板上时；这可能导致 PPH 的检测延迟（中等置信度）。人手不足、熟练卫生工作者的高离职率以及较低级别的卫生工作者任命是提供高质量 PPH 护理的关键挑战（高置信度）。通过基于团队的模拟培训，不同职级的卫生工作者（医生、助产士、非专业卫生工作者）可以发展出一种共同的心理模型，帮助他们在管理 PPH 妇女时快速、高效和友好地合作（中等置信度）。
我们的研究结果强调了如何通过一个由相互作用的角色和行为组成的复杂系统来改善 PPH 的预防、检测和管理（社区、妇女、不同类型和经验的卫生工作者）。多个个人、社会文化和环境因素影响着妇女、家庭、社区、卫生工作者和管理者的决策和行为。在设计和实施 PPH 干预措施以改变或影响这些行为时，必须考虑更广泛的卫生和社会系统。我们已经制定了一组提示，可能有助于方案管理人员、政策制定者、研究人员和其他关键利益攸关方识别和解决影响干预措施实施和扩大的因素，以改善 PPH 的预防、检测和管理。
