Background
Worldwide postpartum hemorrhage (PPH) is the main cause of severe maternal morbidity (SMM). A recent study in the United States estimated PPH to be responsible for almost half of the cases of SMM (47,6%) [
1]. Globally the incidence of PPH is estimated around 10,5% and in high resource countries an increasing trend in PPH incidence has been seen [
2]. For example, in The Netherlands the incidence increased from 3% in 2003 to 8% in 2011 in second line care [
3].
A review on PPH guideline adherence found that 38% of the women with ≥1500 ml blood loss received substandard care [
4]. Substandard health care is often suggested as a possible cause for inadequate reduction of morbidity [
5‐
7]. It seems that evidence-based guidelines are not optimally adhered to, leading to substandard care and a gap between evidence-based medicine and clinical application [
8].
Guideline dissemination without a tailored implementation strategy to improve spread among professionals and adherence to guidelines is often ineffective [
9]. A review evaluating implementation strategies within the field of obstetrics concludes that a prospective identification of efficient strategies and barriers to change is necessary to improve clinical practice guideline implementation [
10]. The strategy choice needs to be tailored to the setting for best possible results, consisting of the right tools to increase guideline adherence. In this paper we describe the development of an implementation strategy for a high resource obstetric setting to improve guideline adherence regarding postpartum hemorrhage.
Discussion
We developed a tailored strategy to improve adherence to the evidence-based guideline on PPH care within secondary and tertiary care hospitals in the Netherlands. The strategy is based on current care, a barrier analysis and literature. A strategy with 3 stop moments was developed starting in the third trimester of the pregnancy and lasting till the end of the third stage of delivery. Tools used during the three stop moments are a checklist for risk assessment, patient empowerment tools and a time-out closely to the start of the second stage of delivery, with a PPH preventive care bundle incorporated in the time-out. Furthermore a checklist for PPH treatment was developed in case the blood loss exceeded 500 ml postpartum.
Safety checklists, such as the surgical safety checklists, have been derived from aviation and other high-risk industries where they have shown to be effective in reduction of adverse events. The Institute of Medicine published in 1999 the renowned report “To err is human” on medical errors, patient safety and the development of safety systems [
31]. They made recommendations to reduce the reliance on human memory and to implement systems that standardize and simplify processes. A checklist is such a system that forces a time-out to summarize the situation and to prepare the professionals for what is coming. It facilitates leadership and open communication, and reduces reliance on memory and the number of omitted procedures. Various types of surgical safety checklists have proven that these systems can be translated to the medical field and successfully reduce complications [
21,
22,
24]. A delivery is an acute process where we heavily rely on the memory of the professionals, and where the room for error is large. A recent review on obstetric checklist development confirmed the need to standardize work in the maternity and labor ward, and listed PPH as 6th in their top ten areas that have high priority on checklist development [
32].
Involving patients in the perinatal care process creates a shared responsibility and creates opportunity for women to take the lead in the creation of their own care plan. In 2010 an advisory committee (“pregnancy and birth”) of the Dutch Ministry of Health has written a report with advice on how to approach pregnancy and childbirth healthcare from a current and reliable perspective [
33]. The aim of the report is to improve (perinatal) health, not solely with the women are sick but in general thus preventing sickness, and to reduce health inequalities. The committee states seven cornerstones, two of which are related to patient empowerment (mother and child in the lead and well informed pregnant patients with shared responsibility). To reach this level of involvement of patients listening to patients and their needs is essential. Including patients in the barrier analysis gave us the opportunity to listen to patients carefully, leading to tools that are actually wanted by patients and filling the current information gap in perinatal care.
Currently, there is a discussion, outside the field of obstetrics, about the added effectiveness of multi-faceted strategies over single-faceted strategies. Although earlier reviews claimed that combinations of many different interventions are often effective [
34,
35], Grimshaw found that a higher number of intervention components was not related to higher effectiveness [
36].. It seems plausible that combined interventions are only more effective than single interventions, if these address different barriers at different levels. This is also the conclusion of Chaillet et al. [
10] Their review shows that in the field of obstetrics multi-faceted strategies are more effective, with the prerequisite that each strategy facet is targeted at its own barrier. Furthermore they showed that a prospective identification of the barriers would enhance its effectiveness, a recurrent finding in reviews on strategy effectiveness [
10,
34,
35]. We have created such a multi-faceted, tailor-made strategy with each separate tool developed to address specific barriers.
The framework of our strategy to improve the provision of optimal PPH care in high resource settings is based on barriers found among professionals and patients from the Netherlands, optimizing the strategy for the Dutch setting. However, we believe that the barriers are rather universal, and the framework would thus be applicable in similar obstetric setting in other countries. We detailed the contents of the individual tools in accordance with the Dutch national PPH guideline, international guidelines and literature. As the focus of guideline committees per country can differ, and (conflicting) evidence in literature sometimes leaves room for interpretation, guidelines can vary between countries, organizations and in time. Developing a strategy that is flexible to content and thus adjustable to updates or different surroundings allows it to be constant up-to-date and adaptable for other high-resource countries. As the strategy is low in development cost and maintenance, it could be applicable in low-resource countries, though this still needs to be investigated.
The main strength of our strategy is the fact that it is tailor-made to the field of PPH. Professionals in the field suggested the barriers and facilitators, which most likely facilitates the acceptance of the strategy in a clinical setting.
Limitations of any strategy development lie within the scarce amount of knowledge available for strategy selection. It is known that tailor-made strategies perform better, yet there is no explicit model prescribing which strategy or tool is to be expected most effective in a certain setting. Furthermore limitations of our study are the fact that it is created developed based on barriers found in a high income country, thus limiting the generalization towards lower income countries. Also, our literature search on strategy development evidence was a systematic comprehensive search.
The aim of this article is to describe the process of development, however at this point we need more evidence as to rather the strategy will indeed improve adherence to the guidelines, and ultimately decrease the PPH incidence. Therefore the next steps are testing the feasibility and effectiveness of the strategy in the clinical practice. Before setting up a large randomized controlled trial to evaluate the effectiveness of the trial, a feasibility trial has to be conducted. In such a feasibility trial, the strategy has to be evaluated on usability, time consummation and possible points for improvement. Additionally, an indication towards possible effectiveness and costs can be received. This will allow for optimization of the strategy before testing its cost−/effectiveness in a robust study design.