Date Published: May 8, 2019
Publisher: Public Library of Science
Author(s): Kenneth Finlayson, Soo Downe, Joshua P. Vogel, Olufemi T. Oladapo, Massimo Ciccozzi.
Postpartum haemorrhage (PPH) is a leading cause of maternal mortality and morbidity. Reducing deaths from PPH is a global challenge. The voices of women and healthcare providers have been missing from the debate around best practices for PPH prevention. The aim of this review was to identify, appraise and synthesize available evidence about the views and experiences of women and healthcare providers on interventions to prevent PPH.
We searched eight electronic databases and reference lists of eligible studies published between 1996 and 2018, reporting qualitative data on views and experiences of PPH in general, and of any specific preventative intervention(s). Authors’ findings were extracted and synthesised using meta-ethnographic techniques. Confidence in the quality, coherence, relevance and adequacy of data underpinning the resulting themes was assessed using GRADE-CERQual. A line of argument synthesis was developed.
Thirty-five studies from 29 countries met our inclusion criteria. Our results indicate that women and healthcare providers recognise the dangers of severe blood loss in the perinatal and postpartum period, but don’t always share the same beliefs about the causes and consequences of PPH. Skilled birth attendants and traditional birth attendants (TBA’s) want to prevent PPH but may lack the required resources and training. Women generally appreciate PPH prevention strategies, especially where their individual needs, beliefs and values are taken into account. Women and healthcare providers also recognize the value of using uterotonics (medications that contract the uterus) to prevent PPH but highlight safety concerns and potential misuse of the drugs as acceptability and implementation issues.
Based on stakeholder views and experiences, PPH prevention strategies are more likely to be successful where all stakeholders agree on the causes and consequences of severe postpartum blood loss, especially in the context of sufficient resources and effective implementation by competent, suitably trained providers.
An estimated 303,000 maternal deaths occurred in 2015 . Recent figures would suggest that more than a quarter of these deaths were due to haemorrhage, with post-partum haemorrhage accounting for almost 20% of all direct deaths . The vast majority of these fatalities took place in low and middle-income settings (LMICs) where more than 200 woman die every hour from a PPH . Despite concerted efforts to reduce these levels of mortality, the issue remains a global challenge.
We conducted a systematic qualitative review in accordance with the PRISMA guidelines (See S1 Table—PRISMA Checklist). Meta-ethnographic techniques  were used for analysis and synthesis. Study assessment included the use of a validated quality appraisal tool  and the findings were evaluated for confidence using the GRADE-CERQual tool .
Our electronic searches yielded 4265 citations. We screened 3196 unique records after duplicate removal. We assessed 121 full-text articles for eligibility and included 35 studies in this qualitative evidence synthesis. 21 studies reported on the views of healthcare providers, 14 reported on the views of women and 3 reported on both. [See Fig 1].
Our findings suggest that women and healthcare providers are aware of the potentially catastrophic consequences of uncontrollable postpartum bleeding, and that many communities and health care systems recognise warning signs for it. These range from physiological and psychological cues, to an assessment of the quantity of blood lost, by various means, most of which are very basic, even in high-income settings. However, all groups recognise that some blood loss is normal, and even that it might be essential, for example, to prevent the retention of ‘dirty blood’. It is possible that this term is used colloquially because of the association between retained products of labour and intrauterine infection, and this would indicate empirical knowledge of the consequence of apparently low blood loss in some women who later become very ill.
Our review highlights inconsistencies in the understanding of post-partum blood loss amongst women and healthcare providers. Policies designed to prevent PPH need to establish a coherent understanding of this issue amongst relevant stakeholders and find agreement on the causes and consequences of severe postpartum blood loss. Preventative strategies also need to pay attention to some of the outcomes that are of value to women and healthcare providers. Interventions and programmes focused on PPH prevention are more likely to be successful if they are acceptable to stakeholders, feasible to implement and sufficiently resourced to ensure any potential benefits are optimised across all income settings.