Abstract
BackgroundPostpartum hemorrhage (PPH) is the leading cause of maternal mortality in low-income countries, and is the most common direct cause of maternal deaths in Madagascar. Studies in Madagascar and other low-income countries observe low provider adherence to recommended practices for PPH prevention and treatment. Our study addresses gaps in the literature by applying a behavioral science lens to identify barriers inhibiting facility-based providers’ consistent following of PPH best practices in Madagascar.MethodsIn June 2019, we undertook a cross-sectional qualitative research study in peri-urban and rural areas of the Vatovavy-Fitovinany region of Madagascar. We conducted 47 in-depth interviews in 19 facilities and five communities, with facility-based healthcare providers, postpartum women, medical supervisors, community health volunteers, and traditional birth attendants, and conducted thematic analysis of the transcripts.ResultsWe identified seven key behavioral insights representing a range of factors that may contribute to delays in appropriate PPH management in these settings. Findings suggest providers’ perceived low risk of PPH may influence their compliance with best practices, subconsciously or explicitly, and lead them to undervalue the importance of PPH prevention and monitoring measures. Providers lack clear feedback on specific components of their performance, which ultimately inhibits continuous improvement of compliance with best practices. Providers demonstrate great resourcefulness while operating in a challenging context with limited equipment, supplies, and support; however, overcoming these challenges remains their foremost concern. This response to chronic scarcity is cognitively taxing and may ultimately affect clinical decision-making.ConclusionsOur study reveals how perception of low risk of PPH, limited feedback on compliance with best practices and consequences of current practices, and a context of scarcity may negatively affect provider decision-making and clinical practices. Behaviorally informed interventions, designed for specific contexts that care providers operate in, can help improve quality of care and health outcomes for women in labor and childbirth.
Highlights
Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in low-income countries, and is the most common direct cause of maternal deaths in Madagascar
Identified barriers to adequate implementation of evidence-based interventions recommended by World Health Organization (WHO) guidelines such as AMTSL range from healthcare system and supply issues, to insufficient knowledge due to lack of awareness or access to guidelines, in addition to numerous contextual and interpersonal influencing factors [9, 12, 14]. These assessments rarely focus on the psychological drivers of health care provider behavior and how their environments, including structural constraints, physical context, and social influence, may shape how they provide care and their adherence to known clinical protocols. Our study addresses this discrepancy in the literature by employing a behavioral science lens to identify barriers that inhibit facility-based providers from following best practices for postpartum hemorrhage (PPH) prevention and management in Madagascar
Interviews with providers and other stakeholders familiar with their working context revealed seven specific insights about behavioral barriers inhibiting providers’ consistent adherence to best practices for PPH, in addition to important contributing features from their environment. Not all of these insights apply to all providers, they represent a range of factors contributing to delays in PPH detection or ineffective management in the study settings
Summary
Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in low-income countries, and is the most common direct cause of maternal deaths in Madagascar. Studies in Madagascar and other lowincome countries observe low provider adherence to recommended practices for PPH prevention and treatment. While the majority of births currently take place outside of facilities, improving rates of institutional delivery [4] suggests that facility-based providers will play an increasingly important role in reducing maternal mortality from postpartum hemorrhage (PPH). A national assessment of 303 health facilities in Madagascar found that direct causes contributed to 84% of maternal deaths reviewed, with PPH the most common direct cause, followed by preeclampsia/eclampsia, obstructed labor, and infection [6].
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