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Akter S, Forbes G, Vazquez Corona M, Miller S, Althabe F, Coomarasamy A, Gallos ID, Oladapo OT, Vogel JP, Lorencatto F, Bohren MA. Perceptions and experiences of the prevention, detection, and management of postpartum haemorrhage: a qualitative evidence synthesis. Cochrane Database Syst Rev 2023; 11:CD013795. [PMID: 38009552 PMCID: PMC10680124 DOI: 10.1002/14651858.cd013795.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND 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. OBJECTIVES 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. SEARCH METHODS 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. SELECTION CRITERIA 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. DATA COLLECTION AND ANALYSIS 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. MAIN RESULTS 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.
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Affiliation(s)
- Shahinoor Akter
- Gender and Women's Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Gillian Forbes
- Centre for Behaviour Change, University College London, London, UK
| | - Martha Vazquez Corona
- Gender and Women's Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Suellen Miller
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, and Safe Motherhood Program, Bixby Center for Global Reproductive Health and Policy, University of California, San Francisco, California, USA
| | - Fernando Althabe
- Department of Mother and Child Health Research, Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Buenos Aires, Argentina
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Ioannis D Gallos
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Olufemi T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Joshua P Vogel
- Maternal and Child Health, Burnet Institute, Melbourne, Australia
| | | | - Meghan A Bohren
- Gender and Women's Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Australia
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Latt SM, Alderdice F, Elkington M, Awng Shar M, Kurinczuk JJ, Rowe R. Primary postpartum haemorrhage and longer-term physical, psychological, and psychosocial health outcomes for women and their partners in high income countries: A mixed-methods systematic review. PLoS One 2023; 18:e0274041. [PMID: 37315027 PMCID: PMC10266652 DOI: 10.1371/journal.pone.0274041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 05/15/2023] [Indexed: 06/16/2023] Open
Abstract
OBJECTIVES Most research about outcomes following postpartum haemorrhage (PPH) has focused on immediate outcomes. There are fewer studies investigating longer-term maternal morbidity following PPH, resulting in a significant knowledge gap. This review aimed to synthesize the evidence about the longer-term physical and psychological consequences of primary PPH for women and their partners from high income settings. METHODS The review was registered with PROSPERO and five electronic databases were searched. Studies were independently screened against the eligibility criteria by two reviewers and data were extracted from both quantitative and qualitative studies that reported non-immediate health outcomes of primary PPH. RESULTS Data were included from 24 studies, of which 16 were quantitative, five were qualitative and three used mixed-methods. The included studies were of mixed methodological quality. Of the nine studies reporting outcomes beyond five years after birth, only two quantitative studies and one qualitative study had a follow-up period longer than ten years. Seven studies reported outcomes or experiences for partners. The evidence indicated that women with PPH were more likely to have persistent physical and psychological health problems after birth compared with women who did not have a PPH. These problems, including PTSD symptoms and cardiovascular disease, may be severe and extend for many years after birth and were more pronounced after a severe PPH, as indicated by a blood transfusion or hysterectomy. There was limited evidence about outcomes for partners after PPH, but conflicting evidence of association between PTSD and PPH among partners who witnessed PPH. CONCLUSION This review explored existing evidence about longer-term physical and psychological health outcomes among women who had a primary PPH in high income countries, and their partners. While the evidence about health outcomes beyond five years after PPH is limited, our findings indicate that women can experience long lasting negative impacts after primary PPH, including PTSD symptoms and cardiovascular disease, extending for many years after birth. PROSPERO REGISTRATION PROSPERO registration number: CRD42020161144.
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Affiliation(s)
- Su Mon Latt
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Fiona Alderdice
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Madeline Elkington
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Mahkawnghta Awng Shar
- Health and Nutrition Specialist, United Nations International Children Fund, Myanmar
| | - Jennifer J. Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Rachel Rowe
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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Kwong LT, Wong SF, So PL. Menstrual, fertility and psychological impacts after uterine compression sutures for postpartum hemorrhage: a prospective cohort study. BMC Pregnancy Childbirth 2023; 23:217. [PMID: 36991358 DOI: 10.1186/s12884-023-05530-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/20/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND Uterine compression suture is an important conservative surgical technique in managing atonic postpartum hemorrhage. In this study, we aim to evaluate the subsequent menstrual, fertility and psychological outcomes after uterine compression sutures. METHODS This was a prospective cohort study between 2009 and 2022 conducted in a tertiary obstetric unit (6000 deliveries per year) in Hong Kong SAR. Women with primary postpartum hemorrhage successfully treated with uterine compression sutures were followed-up in postnatal clinic for two years after delivery. Data on menstrual pattern were collected during each visit. Psychological impact after uterine compression suture was assessed using a standardized questionnaire. Subsequent pregnancies were identified by territory-wide computer registry and telephone interviews. Women with postpartum hemorrhage treated with uterotonic agents only were chosen as controls. RESULTS In our cohort (n = 80), 87.9% of women had return of menses within six months after delivery. Regular monthly cycle was observed in 95.6% of women. Majority of women reported similar menstrual flow (75%), menstrual days (85.3%) and no change in dysmenorrhea status (88.2%) as compared before. Among eight (11.8%) women who reported hypomenorrhea after uterine compression sutures, two cases of Asherman's syndrome were diagnosed. Among 23 subsequent pregnancies (16 livebirths), no significant differences in outcome were observed except more omental or bowel adhesions (37.5% vs. 8.8%, p = 0.007), recurrence of hemorrhage (68.8% vs. 7.5%, p < 0.001) and repeated compression sutures (12.5% vs. 0%, p = 0.024) were seen in women with previous compression sutures. Over half of the couple declined future fertility after uterine compression sutures with 38.2% of women recalled unpleasant memories and 22.1% reported life-long adverse impact especially tokophobia. CONCLUSION Majority of women with history of uterine compression sutures had similar menstruation and pregnancy outcomes as compared to those who did not have sutures. However, they had higher intrapartum risk of visceral adhesions, recurrence of hemorrhage and repeated compression sutures next pregnancy. Furthermore, couple could be more susceptible to negative emotional impact.
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Affiliation(s)
- Lee Ting Kwong
- Department of Obstetrics and Gynecology, Tuen Mun Hospital, Tuen Mun, Hong Kong.
| | - Sai Fun Wong
- Department of Obstetrics and Gynecology, Tuen Mun Hospital, Tuen Mun, Hong Kong
| | - Po Lam So
- Department of Obstetrics and Gynecology, Tuen Mun Hospital, Tuen Mun, Hong Kong
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Rosvig L, Steffensen E, Brogaard L, Hvidman L, Kierkegaard O, Kjeldsen AC, Taastrøm K, Uldbjerg N, Lou S. Women and partners' experience of major postpartum haemorrhage: a qualitative study. BJOG 2023. [PMID: 36852514 DOI: 10.1111/1471-0528.17440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/04/2023] [Accepted: 01/23/2023] [Indexed: 03/01/2023]
Abstract
OBJECTIVE To examine women and their partners' experience of major postpartum haemorrhage (PPH). DESIGN A qualitative interview study. SETTING Two Labour and Delivery Units in Denmark. POPULATION Women who experienced major PPH (≥1 litre within 2 hours after vaginal birth). METHODS Semi-structured interviews were conducted with 15 women and nine partners (nine joint interviews, six individual interviews). Interviews were analysed using thematic analysis. MAIN OUTCOME MEASURES A qualitative description of women and their partners' experiences. RESULTS Three major themes were identified. (1) 'From birth to emergency' included factors that increased concern in women and their partners, such as 'incomprehensible' medical terminology, a tense atmosphere, and alarm call. Transfer to the operating theatre was experienced as the most devastating part of major PPH. (2) 'Feeling safe during an emergency' described factors that supported the women and their partners' management of the situation such as brief explanations from a few healthcare professionals and reassurance that the healthcare professionals were in control of the situation. The pain was experienced as severe, but acceptable. (3) 'Family unity challenged' described how family bonding was supported by positioning the partner at the head of the bed and by keeping the baby on the woman's chest. CONCLUSIONS Several factors such as small gestures from healthcare professionals and appropriate organisation of the PPH can make a difference to the woman and her partner's experience of major PPH. Particularly, efforts that support family bonding are greatly valued by women and their partners.
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Affiliation(s)
- L Rosvig
- Department of Obstetrics and Gynaecology, Horsens Regional Hospital, Horsens, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - E Steffensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark
| | - L Brogaard
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
| | - L Hvidman
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
| | - O Kierkegaard
- Department of Obstetrics and Gynaecology, Horsens Regional Hospital, Horsens, Denmark
| | - A C Kjeldsen
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
| | - K Taastrøm
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
| | - N Uldbjerg
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - S Lou
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,DEFACTUM - Public Health & Health Services Research, Aarhus, Denmark
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Kothari A, Bruxner G, Dulhunty JM, Ballard E, Callaway L. Dads in Distress: symptoms of depression and traumatic stress in fathers following poor fetal, neonatal, and maternal outcomes. BMC Pregnancy Childbirth 2022; 22:956. [PMID: 36550457 PMCID: PMC9773585 DOI: 10.1186/s12884-022-05288-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND This study aims to explore the prevalence of symptoms of depression and traumatic stress in fathers in the setting of poor fetal, neonatal, and maternal outcomes. METHODS A prospective mixed-methods study was conducted at an outer metropolitan public teaching hospital in Brisbane, Australia, with quantitative results presented here. Subjects included 28 fathers whose male partners had experienced pregnancy or childbirth complicated by a significant congenital abnormality or aneuploidy, termination of pregnancy, fetal death in-utero, stillbirth, admission to the neonatal intensive care unit or special care nursery or significant maternal morbidity, such as a postpartum haemorrhage or an emergency postpartum hysterectomy. These experiences were classified into two groups: anticipatory (time to prepare) and sudden (no warning). The fathers were screened using the Edinburgh Postnatal Depression Scale (EPDS) and the Impact of Events Scale-Revised (IES-R) to assess subjective distress at 2-3 weeks (timepoint 1) and 3-4 months (timepoint 2) after the event. RESULTS Data for both the EPDS and IES-R scales was available for 26 fathers (92.9%) at timepoint 1 and for 15 fathers (53.6%) at timepoint 2. High overall EPDS scores (≥10) were noted in 16/27 (59.3%) fathers at timepoint 1 and 6/15 fathers (40.0%) at timepoint 2. High overall IES-R scores ≥33 were noted in 12/26 (46.2%) fathers at timepoint 1 and 4/15 fathers (26.7%) at timepoint 2. A higher percentage of fathers who experienced anticipatory events had EPDS and IES-R score above these cut-offs at timepoint 1 (8/13 or 61.5%) compared to those experiencing sudden events (8/14 or 57.1%), however, percentages were similar between groups at time point 2 (2/7 or 28.6%% and 4/8 or 50.0%, respectively). More fathers who experienced anticipatory events had IES-R scores ≥33 at timepoint 1 (7/13 or 53.8%) compared to those experiencing sudden events (5/14 or 38.0%). CONCLUSION Our study indicates high rates of distress in fathers exposed to poor fetal, neonatal, and maternal outcomes, which can persist for months after the event. Increased support for fathers in this setting may be required to prevent poor mental health. Further research on the long-term effects of these adverse events is warranted.
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Affiliation(s)
- A. Kothari
- grid.490424.f0000000406258387Redcliffe Hospital, Anzac Avenue, Redcliffe, Queensland 4020 Australia ,grid.1003.20000 0000 9320 7537The University of Queensland, Brisbane, Queensland Australia
| | - G. Bruxner
- grid.490424.f0000000406258387Redcliffe Hospital, Anzac Avenue, Redcliffe, Queensland 4020 Australia ,grid.1003.20000 0000 9320 7537The University of Queensland, Brisbane, Queensland Australia
| | - J. M. Dulhunty
- grid.490424.f0000000406258387Redcliffe Hospital, Anzac Avenue, Redcliffe, Queensland 4020 Australia ,grid.1003.20000 0000 9320 7537The University of Queensland, Brisbane, Queensland Australia
| | - E. Ballard
- grid.1049.c0000 0001 2294 1395QIMR Berghofer Medical Research Institute, Brisbane, Queensland Australia
| | - L. Callaway
- grid.1003.20000 0000 9320 7537The University of Queensland, Brisbane, Queensland Australia ,grid.416100.20000 0001 0688 4634The Royal Brisbane and Women’s Hospital, Brisbane, Queensland Australia
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"It's a lot of pain you've got to hide": a qualitative study of the journey of fathers facing traumatic pregnancy and childbirth. BMC Pregnancy Childbirth 2022; 22:434. [PMID: 35610624 PMCID: PMC9128289 DOI: 10.1186/s12884-022-04738-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 05/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aims to explore the emotional and behavioural responses and coping strategies of fathers or expectant fathers who faced a significant traumatic event during a partner's pregnancy, labour, or the postpartum period. METHODS This prospective qualitative study of 24 fathers was conducted at a public teaching hospital in Brisbane, Australia. 'Traumatic pregnancy' was defined as a pregnancy complicated by life-threatening or severe risk to the mother and the fetus, termination of pregnancy, intrauterine fetal death or stillbirth. Semi-structured interviews of participants were conducted 3-4 months after the traumatic event. An initial qualitative analysis with automatic coding was performed using Leximancer and later followed by a six-phase manual thematic analysis. RESULTS A pregnancy-related traumatic event had significant mental and physical impacts on fathers. Participants' reactions and coping strategies were varied and influenced by their background history, pre-existing vulnerabilities, and the gap between expectation and reality. Most fathers described a fluctuating state between their needs 'not being met' and 'being met'. These needs were conceptualised using Maslow's hierarchy and Calman's gap theory to construct a composite thematic model to depict the universal requirements of men facing a traumatic pregnancy or childbirth. CONCLUSIONS A greater understanding of the needs of men and gaps in their care is urgently needed. A targeted effort is required to make maternity services father-inclusive. This approach may assist in preventing long term consequences on fathers, partners, and their children.
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Sweeney L, Lanz D, Daru J, Rasijeff AMP, Khanom F, Thomas A, Harden A, Green L. Deferred consent in emergency obstetric research: findings from qualitative interviews with women and recruiters in the ACROBAT pilot trial for severe postpartum haemorrhage. BMJ Open 2022; 12:e054787. [PMID: 35508349 PMCID: PMC9073399 DOI: 10.1136/bmjopen-2021-054787] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The ACROBAT pilot trial of early cryoprecipitate for severe postpartum haemorrhage used deferred consent procedures. Pretrial discussions with a patient and public involvement group found mixed views towards deferred consent. This study aimed to build an understanding of how the deferred consent procedures worked in practice, to inform plans for a full-scale trial. SETTING Qualitative interview study within a cluster-randomised pilot trial, involving four London maternity services. PARTICIPANTS Individual interviews were conducted postnatally with 10 women who had received blood transfusion for severe postpartum haemorrhage and had consented to the trial. We also interviewed four 'recruiters'-two research midwives and two clinical trials practitioners who conducted trial recruitment. RESULTS Consent procedures in the ACROBAT pilot trial were generally acceptable and the intervention was viewed as low risk, but most women did not remember much about the consent conversation. As per trial protocol, recruiters sought to consent women before hospital discharge, but this time pressure had to be balanced against the need to ensure women were not approached when distressed or very unwell. Extra efforts had to be made to communicate trial information to women due to the exhaustion of their recovery and competing demands for their attention. Participant information was further complicated by explanations about the cluster design and change in transfusion process, even though the consent sought was for access to medical data. CONCLUSION Our findings indicate that deferred consent procedures raise similar concerns as taking consent when emergency obstetric research is occurring-that is, the risk that participants may conflate research with clinical care, and that their ability to process trial information may be impacted by the stressful nature of recovery and newborn care. A future trial may support more meaningful informed consent by extending the window of consent discussion and ensuring trial information is minimal and easy to understand. TRIAL REGISTRATION NUMBER ISRCTN12146519.
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Affiliation(s)
| | - Doris Lanz
- Barts Research Centre for Women's Health, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Jahnavi Daru
- Barts Research Centre for Women's Health, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Annika M P Rasijeff
- Blizard Institute, Queen Mary University of London, London, UK
- Katie's Team Patient and Public Advisory Group, Barts Research Centre for Women's Health, Queen Mary University of London, London, UK
| | - Farzana Khanom
- Katie's Team Patient and Public Advisory Group, Barts Research Centre for Women's Health, Queen Mary University of London, London, UK
| | | | - Angela Harden
- School of Health Sciences, City University of London, London, UK
| | - Laura Green
- Blizard Institute, Queen Mary University of London, London, UK
- Barts Health NHS Trust, London, UK
- NHS Blood and Transplant, London, UK
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Bazirete O, Nzayirambaho M, Umubyeyi A, Karangwa I, Evans M. Risk factors for postpartum haemorrhage in the Northern Province of Rwanda: A case control study. PLoS One 2022; 17:e0263731. [PMID: 35167600 PMCID: PMC8846539 DOI: 10.1371/journal.pone.0263731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 01/26/2022] [Indexed: 12/04/2022] Open
Abstract
Background Postpartum haemorrhage (PPH) remains a major global burden contributing to high maternal mortality and morbidity rates. Assessment of PPH risk factors should be undertaken during antenatal, intrapartum and postpartum periods for timely prevention of maternal morbidity and mortality associated with PPH. The aim of this study is to investigate and model risk factors for primary PPH in Rwanda. Methods We conducted an observational case-control study of 430 (108 cases: 322 controls) pregnant women with gestational age of 32 weeks and above who gave birth in five selected health facilities of Rwanda between January and June 2020. By visual estimation of blood loss, cases of Primary PPH were women who changed the blood-soaked vaginal pads 2 times or more within the first hour after birth, or women requiring a blood transfusion for excessive bleeding after birth. Controls were randomly selected from all deliveries without primary PPH from the same source population. Poisson regression, a generalized linear model with a log link and a Poisson distribution was used to estimate the risk ratio of factors associated with PPH. Results The overall prevalence of primary PPH was 25.2%. Our findings for the following risk factors were: antepartum haemorrhage (RR 3.36, 95% CI 1.80–6.26, P<0.001); multiple pregnancy (RR 1.83; 95% CI 1.11–3.01, P = 0.02) and haemoglobin level <11 gr/dL (RR 1.51, 95% CI 1.00–2.30, P = 0.05). During the intrapartum and immediate postpartum period, the main causes of primary PPH were: uterine atony (RR 6.70, 95% CI 4.78–9.38, P<0.001), retained tissues (RR 4.32, 95% CI 2.87–6.51, P<0.001); and lacerations of genital organs after birth (RR 2.14, 95% CI 1.49–3.09, P<0.001). Coagulopathy was not prevalent in primary PPH. Conclusion Based on our findings, uterine atony remains the foremost cause of primary PPH. As well as other established risk factors for PPH, antepartum haemorrhage and intra uterine fetal death should be included as risk factors in the development and validation of prediction models for PPH. Large scale studies are needed to investigate further potential PPH risk factors.
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Affiliation(s)
- Oliva Bazirete
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- * E-mail:
| | | | - Aline Umubyeyi
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
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Wikkelsø AJ, Secher EL, Edwards H. General or regional anaesthesia for postpartum haemorrhage-A national population-based cohort study. Acta Anaesthesiol Scand 2022; 66:103-113. [PMID: 34582572 DOI: 10.1111/aas.13987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/03/2021] [Accepted: 09/13/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Anaesthesia is required to assist the treatment of postpartum haemorrhage (PPH) when manual removal of the placenta or emptying of the uterine cavity is required. The choice between general or regional anaesthesia may depend upon factors such as existing epidural, airway, hypovolaemia, and tradition. METHODS Data from a randomized controlled trial of PPH (FIB-PPH) was used to reveal differences between delivery centres. In addition, national data of 5,601 PPH procedures requiring anaesthesia during 2010-2015 was collected from the Danish Medical Birth Registry, the National Danish Patient Registry, and the Danish Anaesthesia Database. The aim is to describe the variation in choice of anaesthesia for treatment of PPH. RESULTS Data from the randomized trial showed large differences in practice between centres not explained by physiological factors. Using national Danish registry data, we show that large delivery centres as compared to small centres prefer regional anaesthesia for PPH procedures in opposed to general anaesthesia. Sevoflurane was used despite it causing uterine relaxation. The use of general anaesthesia was associated with younger parturients, larger blood loss, and larger Body-Mass Index. Aspiration was recorded in one case (0.02%). In the postoperative care-unit general anaesthesia was associated with a shorter stay, but also higher pain score at admission. CONCLUSION Practice varies immensely between delivery centres with large centres preferring regional anaesthesia. Difference in practice might be explained by level of experience, here large centres might be more confident using regional anaesthesia. Knowledge is being extrapolated from literature on caesarean sections. Future studies should address the optimal choice of anaesthesia for PPH procedures.
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Affiliation(s)
- Anne J. Wikkelsø
- Department of Anaesthesia and Intensive Care Medicine Herlev Hospital Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Medicine Bispebjerg Hospital Copenhagen Denmark
| | - Erik L. Secher
- Department of Anaesthesia and Intensive Care Medicine Rigshospitalet Copenhagen Denmark
| | - Hellen Edwards
- Department of Obstetrics and Gynaecology Herlev Hospital Copenhagen Denmark
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10
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van Steijn ME, Scheepstra KWF, Zaat TR, van Rooijen DE, Stramrood CAI, Dijksman LM, Valkenburg-van den Berg AW, Wiltenburg W, van der Post JAM, Olff M, van Pampus MG. Severe postpartum hemorrhage increases risk of posttraumatic stress disorder: a prospective cohort study. J Psychosom Obstet Gynaecol 2021; 42:335-345. [PMID: 32180491 DOI: 10.1080/0167482x.2020.1735343] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
PURPOSE To evaluate whether severe postpartum hemorrhage (PPH) is a risk factor for posttraumatic stress disorder (PTSD). Severe PPH can be experienced as a traumatic event. PTSD leads to negative mental health effects. Knowing risk factors for PTSD during childbirth offers opportunities for early interventions, which may prevent the development of PTSD. MATERIALS AND METHODS In this prospective study, we compared two groups of participants; women with ≥2000 mL of blood loss (severe PPH, patients) and women with ≤500 mL of blood loss (controls). Participants were screened for PTSD using the PCL-5 four to six weeks after delivery. Positive screening was followed by the CAPS-5 to diagnose PTSD. RESULTS We included 187 PPH patients and 121 controls. Median PCL-5 scores were higher for PPH patients (5.0) than controls (4.0, p = 0.005). Thirteen PPH patients (7.0%) and two controls (1.7%) scored ≥32 on the PCL-5, indicative of probable PTSD (OR 4.45, 95% CI 0.99-20.06, p = 0.035). Significant more PPH patients than controls met criteria for a clinical diagnosis of PTSD on the CAPS-5 (n = 10, 5.6% vs n = 0, 0.0%; p = 0.007). CONCLUSIONS There is a significant and clinically relevant increased risk for developing PTSD after severe PPH. Gynecologists and midwives are advised to screen for PTSD at postpartum follow-up visits to prevent long-term negative mental health effects. CLINICAL TRIAL REGISTRATION NL50273.100.14.
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Affiliation(s)
- Minouk E van Steijn
- Department of Obstetrics and Gynecology, OLVG, Amsterdam, the Netherlands.,Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Karel W F Scheepstra
- Department of Psychiatry, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Tjitske R Zaat
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | | | - Claire A I Stramrood
- Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Lea M Dijksman
- Department of Epidemiology and Statistics, St Antonius Hospital, the Netherlands
| | | | - Welmoed Wiltenburg
- Department of Obstetrics and Gynecology, Westfriesgasthuis, the Netherlands
| | - Joris A M van der Post
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Miranda Olff
- Department of Psychiatry, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Arq Psychotrauma Expert Group, Diemen, The Netherlands
| | - Maria G van Pampus
- Department of Obstetrics and Gynecology, OLVG, Amsterdam, the Netherlands
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11
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Paternal and maternal long-term psychological outcomes after uterine artery embolization for severe post-partum hemorrhage. Sci Rep 2021; 11:13990. [PMID: 34234162 PMCID: PMC8263630 DOI: 10.1038/s41598-021-92847-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 06/15/2021] [Indexed: 02/02/2023] Open
Abstract
This study intend to compare the long-term psychological impact (depression, post-traumatic stress disorder) on both partners between patients that underwent uterine artery embolization (UAE) for post-partum hemorrhage (PPH) and uneventful deliveries. Women who experienced severe PPH treated by UAE in our institution between 2003 and 2013 were identified in our obstetrical database. These cases were matched to controls with uneventful deliveries. Matching criteria were maternal age, parity, ethnicity, year of delivery, birthweight, gestational age and mode of delivery. Patients and their partners completed validated questionnaires measuring post-traumatic stress (TSQ), as well as depression symptoms (MINI). A total of 63 cases of PPH and 189 matched controls (1:3) participated in a study exploring gynecological and obstetrical outcomes. With a mean of 8 years post-index delivery, patients after PPH showed increased risk of depression (p = 0.015) and post-traumatic stress disorder (22.2% versus 4.8%, p < 0.005) compared to controls. PPH remains strongly associated with post-traumatic stress disorder, even after adjustment for depression (adjusted odds ratio 5.1; 95% confidence intervals 1.5–17.5). Similarly, partners of patients with PPH showed a propensity to depression (p = 0.029) and post-traumatic stress disorder (11.5% versus 1.5%, p = 0.019). In conclusion, both women and their partners are at increased risk of long-term psychological adverse outcomes after PPH. Couples may benefit from psychological support.
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12
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Schreurs A, Lier M, Koning D, Brals C, De Boer MA, Lambalk CB, De Wit M, Mijatovic V. Severe psychological impact and impaired quality of life after a spontaneous haemoperitoneum in pregnancy in women with endometriosis and their partners. Facts Views Vis Obgyn 2021; 13:159-168. [PMID: 34184845 PMCID: PMC8291980 DOI: 10.52054/fvvo.13.2.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background Spontaneous Haemoperitoneum in Pregnancy (SHiP) is a rare, but life-threatening complication of pregnancy that occurs predominantly in the third trimester of pregnancy and is associated with adverse pregnancy outcomes. Recently the largest case series in literature was published describing 11 Dutch cases of SHiP in women with endometriosis. Purpose To investigate experiences, psychological impact, and quality of life after SHiP. Methods A mixed-methods study was performed in women with a history of SHiP and their partners, including all known cases in the Netherlands between 2007 to 2015. Semi-structured in-depth interviews were organized between 2016 and 2017 and analysed thematically with a framework approach. Participants were asked to complete questionnaires investigating the impact of the event (Impact of Event Scale) and Quality of Life (RAND-36). Results Out of a total of 11 known cases, 7 women agreed for be individually interviewed. From these, all women described a freeze response at the moment of SHiP, combined with either an anxious reaction or a survival mode mind-set. All women received psychological help after SHiP. Still, the feeling of not being heard by the medical staff was present in all women. Other themes such as postpartum period, bonding with their child, effect on daily life, reviving the event, and future pregnancies were also identified in the interviews. In regard to their partners, 3 were interviewed, hence no saturation was achieved. Finally, the questionnaires showed lower Quality of Life and an impact score of ≥ 8/10. Conclusion SHiP had a profound impact on women and their partners. Dedicated psychological help should be offered to all women after experiencing SHiP.
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van der Scheer JW, Woodward M, Ansari A, Draycott T, Winter C, Martin G, Kuberska K, Richards N, Kern R, Dixon-Woods M. How to specify healthcare process improvements collaboratively using rapid, remote consensus-building: a framework and a case study of its application. BMC Med Res Methodol 2021; 21:103. [PMID: 33975550 PMCID: PMC8111055 DOI: 10.1186/s12874-021-01288-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 04/21/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Practical methods for facilitating process improvement are needed to support high quality, safe care. How best to specify (identify and define) process improvements - the changes that need to be made in a healthcare process - remains a key question. Methods for doing so collaboratively, rapidly and remotely offer much potential, but are under-developed. We propose an approach for engaging diverse stakeholders remotely in a consensus-building exercise to help specify improvements in a healthcare process, and we illustrate the approach in a case study. METHODS Organised in a five-step framework, our proposed approach is informed by a participatory ethos, crowdsourcing and consensus-building methods: (1) define scope and objective of the process improvement; (2) produce a draft or prototype of the proposed process improvement specification; (3) identify participant recruitment strategy; (4) design and conduct a remote consensus-building exercise; (5) produce a final specification of the process improvement in light of learning from the exercise. We tested the approach in a case study that sought to specify process improvements for the management of obstetric emergencies during the COVID-19 pandemic. We used a brief video showing a process for managing a post-partum haemorrhage in women with COVID-19 to elicit recommendations on how the process could be improved. Two Delphi rounds were then conducted to reach consensus. RESULTS We gathered views from 105 participants, with a background in maternity care (n = 36), infection prevention and control (n = 17), or human factors (n = 52). The participants initially generated 818 recommendations for how to improve the process illustrated in the video, which we synthesised into a set of 22 recommendations. The consensus-building exercise yielded a final set of 16 recommendations. These were used to inform the specification of process improvements for managing the obstetric emergency and develop supporting resources, including an updated video. CONCLUSIONS The proposed methodological approach enabled the expertise and ingenuity of diverse stakeholders to be captured and mobilised to specify process improvements in an area of pressing service need. This approach has the potential to address current challenges in process improvement, but will require further evaluation.
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Affiliation(s)
- Jan W van der Scheer
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge, CB2 0AH, UK.
| | - Matthew Woodward
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge, CB2 0AH, UK
| | - Akbar Ansari
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge, CB2 0AH, UK
| | - Tim Draycott
- Department of Translational Health Services, University of Bristol, Bristol, UK
- PROMPT Maternity Foundation, Women and Children's Health, North Bristol NHS Trust, Westbury on Trym, UK
| | - Cathy Winter
- PROMPT Maternity Foundation, Women and Children's Health, North Bristol NHS Trust, Westbury on Trym, UK
| | - Graham Martin
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge, CB2 0AH, UK
| | - Karolina Kuberska
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge, CB2 0AH, UK
| | - Natalie Richards
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge, CB2 0AH, UK
| | - Ruth Kern
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge, CB2 0AH, UK
| | - Mary Dixon-Woods
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge, CB2 0AH, UK
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Parry-Smith W, Okoth K, Subramanian A, Gokhale KM, Chandan JS, Humpston C, Coomarasamy A, Nirantharakumar K, Šumilo D. Postpartum haemorrhage and risk of mental ill health: A population-based longitudinal study using linked primary and secondary care databases. J Psychiatr Res 2021; 137:419-425. [PMID: 33774536 DOI: 10.1016/j.jpsychires.2021.03.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 03/06/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
There is a gap in the literature investigating the impact of obstetric complications on subsequent mental ill health outcomes. The aim of this study was to establish the association between post-partum haemorrhage (PPH) and mental ill health. We conducted a retrospective open cohort study utilizing linked primary care (The Health Improvement Network (THIN)) and English secondary care (Hospital Episode Statistics (HES)) databases, from January 1, 1990 to January 31, 2018. A total of 42,327 women were included: 14,109 of them were exposed to PPH during the study period and 28,218 unexposed controls were matched for age and date of delivery. Hazard ratios (HRs) for mental illness among women with and without exposure to PPH were estimated after controlling for covariates. Women who had had PPH were at an increased risk of developing postnatal depression (adjusted HR: 1·10, 95%CI: 1·01-1·21) and post-traumatic stress disorder (PTSD) (adjusted HR: 1·17, 95%CI: 0·73-1·89) compared to women unexposed to PPH. When restricting the follow-up to the first year after childbirth, the adjusted HR for PTSD was 3·44 (95% CI 1·31-9·03). No increase in the overall risk was observed for other mental illnesses, including depression (adjusted HR: 0·94, 95%CI: 0·87-1·01), severe mental illness (adjusted HR: 0·65, 95%CI: 0·40-1·08, p = 0·239) and anxiety (adjusted HR: 0·99, 95%CI: 0·90-1·09). PPH is associated with a significant increase in the risk of developing postnatal depression and PTSD in the first year after delivery. Active monitoring for mental illness should form an integral part of the follow-up in women who suffered a PPH.
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Affiliation(s)
- William Parry-Smith
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Department of Obstetrics and Gynaecology, Shrewsbury and Telford NHS Trust, Princess Royal Hospital, Telford, Shropshire, UK.
| | - Kelvin Okoth
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | | | - Joht Singh Chandan
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
| | - Clara Humpston
- Institute for Mental Health, University of Birmingham, Birmingham, UK
| | - Arri Coomarasamy
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Krishnarajah Nirantharakumar
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK; Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Dana Šumilo
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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15
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Elmir R, Schmied V. A qualitative study of the impact of adverse birth experiences on fathers. Women Birth 2021; 35:e41-e48. [DOI: 10.1016/j.wombi.2021.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 01/03/2021] [Accepted: 01/04/2021] [Indexed: 11/27/2022]
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16
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Bell SF, Kitchen T, John M, Scarr C, Kelly K, Bailey C, James K, Watkins A, Macgillivray E, Edey T, Greaves K, Volikas I, Tozer J, Sengupta N, Francis C, Collis R, Collins P. Designing and implementing an all Wales postpartum haemorrhage quality improvement project: OBS Cymru (the Obstetric Bleeding Strategy for Wales). BMJ Open Qual 2020; 9:e000854. [PMID: 32273281 PMCID: PMC7326295 DOI: 10.1136/bmjoq-2019-000854] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 03/06/2020] [Accepted: 03/20/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Postpartum haemorrhage (PPH) contributes to substantial maternal morbidity. Research into PPH has led to improvements in care which have been incorporated into the Obstetric Bleeding Strategy for Wales. INTERVENTION A national quality improvement team supported local teams in implementing multiple interventions including risk assessment, objective measurement of blood loss, multiprofessional assessment (at the bedside at 1000 mL blood loss) and point-of-care (POC) testing of coagulation to guide blood product resuscitation during PPH. The project was rolled out to all 12 obstetric units in 2017. The interventions were reinforced by an All Wales Guideline, PPH proforma and standardised training. A national database, biannual audits, and patient and staff surveys reported process and outcome measures. RESULTS Process measures: during 2017, there was an increase in the percentage of maternities with documented risk assessment (0%-76%), objective measurement of blood loss (52%-88%) and POC testing for coagulation for PPH ≥1500 mL (38%-59%). Maternity staff survey indicated that 94% were aware of the project and 87% stated that it had changed their unit's management of PPH. Interim outcome measures: the incidence (95% CI) of PPH ≥2500 mL per 1000 maternities in 2017 was 6.03 (5.23-6.95). The annual number of women receiving any red blood cell transfusion, level 3 intensive care admission and hysterectomy for PPH was 19.7 (18.2 to 21.3), 0.702 (0.464 to 1.06) and 0.255 (0.129 to 0.504) per 1000 maternities, respectively. CONCLUSIONS A high level of project awareness across Welsh maternity units has been achieved. Measurement of blood loss was reported to be the most important early change in practice, while PPH documentation and POC testing continue to be embedded. Combining qualitative and quantitative measures to inform implementation has improved project delivery and allowed teams to adapt to local contexts.
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Affiliation(s)
- Sarah Frances Bell
- Anaesthesia and Critical Care, University Hospital of Wales, Cardiff, UK
| | - Thomas Kitchen
- Anaesthesia and Critical Care, University Hospital of Wales, Cardiff, UK
| | - Miriam John
- Emergency Medicine, Aneurin Bevan University Health Board, Newport, UK
| | - Cerys Scarr
- Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, UK
| | - Kevin Kelly
- Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Rhyl, UK
| | - Christopher Bailey
- Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Rhyl, UK
| | - Kathryn James
- Anaesthesia and Critical Care, University Hospital of Wales, Cardiff, UK
| | | | | | - Tracey Edey
- Midwifery, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | | | - Ingrid Volikas
- Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Rhyl, UK
| | - James Tozer
- Anaesthesia and Critical Care, Aneurin Bevan University Health Board, Newport, UK
| | - Niladril Sengupta
- Obstetrics and Gynaecology, Betsi Cadwaladr University Health Board, Rhyl, UK
| | - Claire Francis
- Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, UK
| | - Rachel Collis
- Anaesthesia and Critical Care, University Hospital of Wales, Cardiff, UK
| | - Peter Collins
- Haematology, University Hospital of Wales, Cardiff, UK
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Prevalence and predictors of primary postpartum hemorrhage: An implication for designing effective intervention at selected hospitals, Southern Ethiopia. PLoS One 2019; 14:e0224579. [PMID: 31671143 PMCID: PMC6822730 DOI: 10.1371/journal.pone.0224579] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 10/16/2019] [Indexed: 11/29/2022] Open
Abstract
Background Primary postpartum hemorrhage is the leading cause of maternal mortality worldwide. Ethiopia has made significant progress in maternal health care services. Despite this, primary postpartum hemorrhage continues to remain the leading cause of maternal mortality in Ethiopia. This study aimed to assess the prevalence and predictors of primary postpartum hemorrhage among mothers who gave birth at selected hospitals in the Southern Ethiopia. Methods An institution-based cross-sectional study was employed from March 2–28, 2018. Four hundred and twenty-two study participants were obtained using the consecutive sampling method. A structured interviewer-administered questionnaire and chart review were used to collect data. Data were entered into Epi-data version 3.1 and analyzed using SPSS version 22. Multivariable logistic regression were used to determine the predictors of primary postpartum hemorrhage with 95% CI and p-value < 0.05. Results The overall prevalence of primary postpartum hemorrhage was 16.6%. Mothers aged 35 and above [AOR = 6.8, 95% CI (3.6, 16.0)], pre-partum anemia [AOR = 5.3, 95% CI (2.2, 12.8)], complications during labor [AOR = 1.8, 95% CI (2.8, 4.2)], history of previous postpartum hemorrhage [AOR = 2.7, 95% CI (1.1, 6.8)] and instrumental delivery [AOR = 5.3, 95% CI (2.2, 12.8)] were significant predictors of primary postpartum hemorrhage. Conclusion Primary postpartum hemorrhage is quite common in the study area. Mothers aged 35 and above, complications during labor, history of previous postpartum hemorrhage, and instrumental delivery were predictors of primary postpartum hemorrhage. Since postpartum hemorrhage being relatively common, all obstetrics unit members should be prepared to manage mothers who experience it.
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18
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Grönvall M, Tikkanen M, Paavonen J, Loukovaara M, Stefanovic V. Is there an association between postpartum hemorrhage, interventional radiology procedures, and psychological sequelae? J Matern Fetal Neonatal Med 2019; 34:1792-1796. [PMID: 31389295 DOI: 10.1080/14767058.2019.1649389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Postpartum hemorrhage (PPH) may cause post-traumatic psychological sequelae. Interventional radiology procedures (IRP) have been established in the management of PPH when conventional management fails. IRP is also used prophylactically in women who are at high risk for PPH in pregnancies with abnormally invasive placentation. We sought to determine if there is an association between PPH, IRP, and psychological sequelae. OBJECTIVES Seventy-three women who underwent IRP due to PPH or were at high risk for PPH. METHOD A structured questionnaire was sent to all women. RESULTS Overall 49 women returned the questionnaire. Two-thirds of the women developed psychological sequelae and one-third reported a lack of professional support. Nine women had symptoms of post-traumatic stress disorder. Psychological sequelae were not associated with a volume of bleeding, whether or not hysterectomy was performed, or whether the IRP was performed as an emergency procedure or prophylactically. However, women who had elective IRP and no hysterectomy performed had significantly less fear of death compared to the rest of the study population. CONCLUSIONS We observed a high rate of psychological sequelae associated with IRP. Lack of proper professional support may have contributed to the development of post-traumatic psychological sequelae suggesting a need for debriefing in such women.
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Affiliation(s)
- Maiju Grönvall
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Minna Tikkanen
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jorma Paavonen
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mikko Loukovaara
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Vedran Stefanovic
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Finlayson K, Downe S, Vogel JP, Oladapo OT. What matters to women and healthcare providers in relation to interventions for the prevention of postpartum haemorrhage: A qualitative systematic review. PLoS One 2019; 14:e0215919. [PMID: 31067245 PMCID: PMC6505942 DOI: 10.1371/journal.pone.0215919] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 04/10/2019] [Indexed: 12/02/2022] Open
Abstract
Background 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. Methods 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. Results 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. Conclusions 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.
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Affiliation(s)
- Kenneth Finlayson
- University of Central Lancashire, Research in Childbirth and Health (ReaCH) Group, Preston, Lancashire, United Kingdom
- * E-mail:
| | - Soo Downe
- University of Central Lancashire, Research in Childbirth and Health (ReaCH) Group, Preston, Lancashire, United Kingdom
| | - Joshua P. Vogel
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
- Maternal and Child Health Program, Burnet Institute, Melbourne, Australia
| | - Olufemi T. Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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20
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Semasaka JPS, Krantz G, Nzayirambaho M, Munyanshongore C, Edvardsson K, Mogren I. "Not taken seriously"-A qualitative interview study of postpartum Rwandan women who have experienced pregnancy-related complications. PLoS One 2019; 14:e0212001. [PMID: 30759136 PMCID: PMC6373944 DOI: 10.1371/journal.pone.0212001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 01/25/2019] [Indexed: 11/18/2022] Open
Abstract
Background There is limited knowledge on the women’s experiences of pregnancy-related complications in Rwanda. This study aimed to investigate women’s experiences and perceptions of specific complications during pregnancy and delivery and the consequences of these complications on postpartum health and family situation. Methods Data were collected through individual in-depth interviews (N = 15). Participants who experienced complications such as postpartum haemorrhage, caesarean section due to prolonged labour/dystocia, pre-eclampsia, or fistula and who were 13–24 months postpartum were invited to participate in the study in July 2015. Interviews were held in Kinyarwanda, digitally recorded, transcribed verbatim, translated into English, and analysed using qualitative content analysis. Results Most participants reported that they were previously unaware of the complications they had developed, and they claimed that at discharge they should have been better informed about the potential consequences of these complications. Most participants blamed the health care system as the cause of their problems due to the provision of inadequate care. Participants elaborated different strategies for coping with persistent health problems. Pregnancy-related complications negatively affected participants’ economic situation due to increased health care expenses and lowered income because of impaired working capacity, and participants expressed fear of encountering the same pregnancy-related health problems during future pregnancies. Conclusions The findings of this study demonstrate how participants felt that inadequate health care provision during pregnancy, delivery, and the postpartum period was the source of their problems. Participants reported different coping strategies to improve their respective life situation despite persistent health problems. Women’s individual postpartum experiences need to be considered and actions taken at the policy level and also by the local community, in terms of the quality of antenatal and postpartum care services, and in sensitizing the local community about the existence of these complications and preparing the community to support the affected women.
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Affiliation(s)
- Jean Paul Sengoma Semasaka
- Department of Clinical Sciences, Obstetrics and Gynaecology, Umeå University, Umeå, Sweden.,University of Rwanda College of Medicine and Health Sciences School of Public Health, Kigali, Rwanda
| | - Gunilla Krantz
- Department of Community Medicine and Public Health, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Manasse Nzayirambaho
- University of Rwanda College of Medicine and Health Sciences School of Public Health, Kigali, Rwanda
| | - Cyprien Munyanshongore
- University of Rwanda College of Medicine and Health Sciences School of Public Health, Kigali, Rwanda
| | - Kristina Edvardsson
- Department of Clinical Sciences, Obstetrics and Gynaecology, Umeå University, Umeå, Sweden.,Judith Lumley Centre, La Trobe University, Melbourne, Australia
| | - Ingrid Mogren
- Department of Clinical Sciences, Obstetrics and Gynaecology, Umeå University, Umeå, Sweden.,Judith Lumley Centre, La Trobe University, Melbourne, Australia
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Vallin E, Nestander H, Wells MB. A literature review and meta-ethnography of fathers’ psychological health and received social support during unpredictable complicated childbirths. Midwifery 2019; 68:48-55. [DOI: 10.1016/j.midw.2018.10.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 09/24/2018] [Accepted: 10/16/2018] [Indexed: 11/29/2022]
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Houghton G, Kingdon C, Dower M, Shakur-Still H, Alfirevic Z. What women think about consent to research at the time of an obstetric emergency: a qualitative study of the views of a cohort of World Maternal Antifibrinolytic Trial participants. BJOG 2018; 125:1744-1753. [PMID: 29911309 PMCID: PMC6283048 DOI: 10.1111/1471-0528.15333] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2018] [Indexed: 12/30/2022]
Abstract
Objective The World Maternal Antifibrinolytic (WOMAN) Trial was the first in the UK to use the option of waiver of informed consent at the time of an obstetric emergency. This qualitative study aimed to investigate participants’ views of the acceptability of the recruitment methods used. Design Qualitative study using in‐depth interviews with women who did and did not give consent at the time of their recruitment to the WOMAN Trial. Setting Highest UK recruitment site for the WOMAN Trial (129/569). Interviews were conducted in participants’ homes. Population About 40 of the 129 women who were recruited to the WOMAN Trial at one UK site were invited to take part, 15 women were interviewed. Methods Qualitative, interview study. Main outcome measures Facilitators and barriers to successful recruitment during obstetric emergencies. Guidance for future researchers. Results Findings revealed that what is important is not so much the consent process used or a signature on a form, but the way in which consent is obtained. Clinicians who successfully negotiate consent to research during childbirth emergencies engage in a ‘humane choreography’ of words and actions. This emphasises the importance of prompt decision‐making and treatment, while respecting the woman's personal situation and experience. Conclusions Our findings do not support a single pathway to consent in the context of an obstetric emergency. Women understand that consent to research in an emergency is complex. Clinicians’ skills in considering the clinical, ethical, and emotional aspects within the context of the clinical emergency can hamper or promote women's satisfaction. Tweetable abstract Study reports on women's views of consent to research in an obstetric emergency. Plain Language Summary Study reports on women's views of consent to research in an obstetric emergency.
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Affiliation(s)
- G Houghton
- Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - C Kingdon
- School of Community Health and Midwifery, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - M Dower
- Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - H Shakur-Still
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - Z Alfirevic
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool Women's NHS Foundation Trust, Liverpool, UK
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Posttraumatic stress disorder related to postpartum haemorrhage: A systematic review. Eur J Obstet Gynecol Reprod Biol 2018; 225:214-220. [PMID: 29747143 DOI: 10.1016/j.ejogrb.2018.04.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 04/10/2018] [Indexed: 11/23/2022]
Abstract
In some cases childbirth leads to negative psychological responses such as posttraumatic stress disorder (PTSD). Postpartum hemorrhage (PPH) is a common and major complication of childbirth, which occasionally requires emergency hysterectomy in severe cases. Patients often describe these complications as a traumatic experience. It is unknown whether PPH is a risk factor for developing PTSD. In this systematic review we summarize the current knowledge about the association between PPH with or without emergency hysterectomy and posttraumatic stress symptoms or PTSD. If PPH is a risk factor for PTSD, this will allow adequate preventive measures with the aim to reduce the long-term effects and socioeconomic problems associated with PTSD. To conduct this review MEDLINE, EMBASE, Web of Science, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, Cochrane Library and PsycINFO databases were searched for publications between January 1986 and October 2017. Manuscripts evaluating the association between PPH and peripartum emergency hysterectomy and PTSD or posttraumatic stress symptoms were included. Fifty-two articles met the criteria for full-text review. Seven articles were included in this review. Five studies focused on the association between PPH and PTSD and two studies evaluated the association between emergency hysterectomy and PTSD. Three studies found no association between PPH and PTSD. Two studies reported a higher risk of developing PTSD or posttraumatic stress symptoms after PPH. Two studies reported a higher risk of developing PTSD after emergency hysterectomy. Meta-analysis was not possible due to the heterogeneity of these studies. Based on the results of these studies there may be an association between PPH and PTSD. Secondly, it seems likely that an association exists between emergency postpartum hysterectomy and PTSD, but the strength of this conclusion is limited by the small amount of studies included.
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de Visser SM, Kirchner CA, van der Velden BG, de Wit AC, Dijkman A, Huisjes AJ, Middeldorp JM, Moonen-Delarue D, van Dillen J, Vandenbussche FP, Hulscher ME, Scheepers HC, Woiski MD, Hermens RP. Major obstetric hemorrhage: Patients’ perspective on the quality of care. Eur J Obstet Gynecol Reprod Biol 2018; 224:146-152. [DOI: 10.1016/j.ejogrb.2018.03.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/15/2018] [Accepted: 03/19/2018] [Indexed: 10/17/2022]
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