Staff and Institutional Factors Associated with Substandard Care in the Management of Postpartum Hemorrhage.

A Rousseau,A Rousseau,A Rousseau,A Rousseau,A Rousseau,P Ravaud,P Ravaud,P Ravaud,P Ravaud,P Ravaud,P Ravaud,P Rozenberg,P Rozenberg,E Perrodeau,C Deneux-Tharaux,C Deneux-Tharaux,C Deneux-Tharaux

doi:10.1371/journal.pone.0151998

Abstract

Objectiveto identify staff and institutional factors associated with substandard care by midwives managing postpartum hemorrhage (PPH).MethodsA multicenter vignette-based study was e-mailed to a random sample of midwives at 145 French maternity units that belonged to 15 randomly selected perinatal networks. Midwives were asked to describe how they would manage two case-vignettes about PPH and to complete a short questionnaire about their individual (e.g., age, experience, and full- vs. part-time practice) and institutional (private or public status and level of care) characteristics. These previously validated case-vignettes described two different scenarios: vignette 1, a typical immediate, severe PPH, and vignette 2, a severe but gradual hemorrhage. Experts consensually defined 14 criteria to judge adherence to guidelines. The number of errors (possible range: 0 to 14) for the 14 criteria quantified PPH guideline adherence, separately for each vignette.Results450 midwives from 87 maternity units provided complete responses. Perfect adherence (no error for any of the 14 criteria) was low: 25.1% for vignette 1 and 4.2% for vignette 2. After multivariate analysis, midwives’ age remained significantly associated with a greater risk of error in guideline adherence in both vignettes (IRR 1.19 [1.09; 1.29] for vignette 1, and IRR 1.11 [1.05; 1.18] for vignette 2), and the practice of mortality and morbidity reviews in the unit with a lower risk (IRR 0.80 [0.64; 0.99], IRR 0.78 [0.66; 0.93] respectively). Risk-taking scores (IRR 1.41 [1.19; 1.67]) and full-time practice (IRR 0.83 [0.71; 0.97]) were significantly associated with adherence only in vignette 1.ConclusionsBoth staff and institutional factors may be associated with substandard care in midwives’ PPH management.

Highlights

Severe postpartum hemorrhage (PPH) is a leading cause of maternal mortality and morbidity worldwide [1,2,3] and represents 1% to 2% of deliveries in high-income countries [3,4,5]
Midwives’ age remained significantly associated with a greater risk of error in guideline adherence in both vignettes (IRR 1.19 [1.09; 1.29] for vignette 1, and incidence rate ratios (IRR) 1.11 [1.05; 1.18] for vignette 2), and the practice of mortality and morbidity reviews in the unit with a lower risk (IRR 0.80 [0.64; 0.99], IRR 0.78 [0.66; 0.93] respectively)
The incidence of PPH is increasing worldwide. [6,7,8,9,10] Hemorrhage accounts for 12% of pregnancy-related deaths in the United States [11,12] and 18% in France [13,14]

Summary

Introduction

Severe postpartum hemorrhage (PPH) is a leading cause of maternal mortality and morbidity worldwide [1,2,3] and represents 1% to 2% of deliveries in high-income countries [3,4,5]. [6,7,8,9,10] Hemorrhage accounts for 12% of pregnancy-related deaths in the United States [11,12] and 18% in France [13,14]. Factors related to medical care involve characteristics of the staff and of the institution and probably play a significant role in the poor translation of guidelines into clinical practice. They may constitute modifiable features in health systems

Objectives

Methods

Results