Variations in Postpartum Hemorrhage Management among Midwives: A National Vignette-Based Study

PLoS One. 2016 Apr 4;11(4):e0152863. doi: 10.1371/journal.pone.0152863. eCollection 2016.

Abstract

Objective: To assess variations in adherence to guidelines for management of postpartum hemorrhage (PPH) among midwives.

Methods: A multicentre vignette-based study was e-mailed to a random sample of midwives from 145 maternity units in France. They were asked to describe how they would manage the PPH described in 2 case-vignettes. These previously validated case-vignettes described 2 different scenarios for severe PPH. Vignette 1 described a typical immediate, severe PPH and vignette 2 a less typical case of severe but gradual PPH. They were constructed in 3 successive steps and included multiple-choice questions proposing several types of clinical practice options at each step. An expert consensus defined 14 criteria for assessing adherence to guidelines issued by the French College of Obstetricians and Gynecologists in 2004 in the midwives' responses. We analyzed the number of errors among the 14 criteria to quantify the level of adherence.

Results: We obtained 450 complete responses from midwives from 87 maternity units. The rate of complete adherence (no error for any of the 14 criteria) was low: 25.1% in vignette 1 and 4.2% in vignette 2. The error rate was higher for pharmacological management, especially oxytocin use, than for non-pharmacological management and communication-monitoring-investigation. Adherence to guidelines varied substantially between and within maternity units, as well as between the vignettes for the same midwives.

Conclusion: Reponses to case-vignettes demonstrated substantial variations in PPH management and especially individual variations in adherence to guidelines. Midwives should participate in continuous and individualized training.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Clinical Competence
  • Cross-Sectional Studies
  • Disease Management
  • Female
  • France / epidemiology
  • Guideline Adherence
  • Humans
  • Midwifery* / standards
  • Postpartum Hemorrhage / diagnosis*
  • Postpartum Hemorrhage / epidemiology
  • Postpartum Hemorrhage / therapy*
  • Pregnancy
  • Public Health Surveillance

Grants and funding

This trial was supported by a research grant from the Département à la Recherche Clinique Ile-de-France, Assistance Publique–Hôpitaux de Paris, which also sponsored the study (PHRC-AOR13212). The study sponsor did not participate in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Authors had full access to all the data and had final responsibility for the decision to submit for publication.