Postpartum haemorrhage in midwifery care in the Netherlands: validation of quality indicators for midwifery guidelines

Postpartum haemorrhage (PPH) is still one of the major causes of severe maternal morbidity and mortality worldwide. The rate of PPH has increased in recent years in many high income countries, including the United States, Canada, Australia, Norway, and Ireland [1]-[7]. In particular, PPH due to uterine atony has contributed to this rise, although the reasons for this remain unclear [3],[7]-[10].

In the Netherlands, the overall incidence of PPH, defined as blood loss >1000 mL within 24 hours after birth, is 6% and this number is rising [11],[12]. The definition of 1000 mL is often used in high-resource countries (such as the Netherlands) because a woman in good health can tolerate up to one liter of blood loss without showing early signs of shock.

Almost one third of Dutch women (32.7%) give birth in ‘primary care’ which is low risk care supervised by a midwife (99% of births) or general practitioner (1% of births). Of all births in primary care, 64% occur at home [12]. Of all women who give birth in primary midwifery care, the incidence of PPH is 3.4% [13]. There are various guidelines concerning prevention and management of PPH [14]-[16]. However, no guideline for PPH occurring in primary midwifery care in the Netherlands is available. In a primary care setting, limited hands-on assistance and the necessity of arranging ambulance transfer (in case of home birth) make the availability of a specific guideline for midwifery care essential. A set of 25 quality indicators for prevention and management of PPH in primary care has been developed by an expert panel consisting of midwives, obstetricians, ambulance personal and representatives of the Royal Dutch College of Midwives (KNOV) and the Dutch Society of Obstetrics and Gynecology (NVOG) [7]. This paper describes the performance of those quality indicators in clinical practice as an assessment tool for midwifery care and suitability for incorporation in a professional midwifery guideline. Validation is necessary to demonstrate the value of the set of indicators as an instrument for monitoring and improving prevention and management of PPH in primary care [17],[18].

Ethical clearance was granted by the Leiden University Medical Ethics Committee (P11.105).

Aim of this study was to assess the performance of the 25 quality indicators of PPH in primary midwifery care. After applying the indicators to each of the 94 cases, 11 indicators could be validated to measure care provided by midwives to prevent and manage PPH in primary care. Five of these (5/11) showed potential to be used to monitor improvement of the quality of care in our study.

PPH guideline development and implementation is an important (worldwide) topic as the incidence is still rising [23]. The present guidelines vary greatly per country, as evidence and background on which the guidelines are drawn upon differs (for example, the presence of primary midwifery care). And practical matters such as geographic landscape (e.g. road network) and proximity to hospital are of influence on the approach of PPH. This study forms an important step in the development of a guideline for prevention and management of PPH in primary midwifery care. An important strength of this study is the use of effective methods such as a RAND modified Delphi procedure and applying validated quality criteria (applicability, feasibility, adherence to the indicator and improvement potential) [18],[20],[21]. As we thoroughly followed these steps, these indicators are valid, usable in clinical practice and form an important basis in guideline development.

Blood loss over 2000 mL at time of referral is a rare phenomenon, especially in primary midwifery care and occurred in only three of our 94 cases. Further exploration of the indicators related to blood loss over 2000 mL is recommended with more cases of such high blood loss. Nine indicators were found not feasible. Information about the indicators was either partially or completely missing in case registration forms or medical files, suggesting documentation of midwives may need improvement. Further research is needed to explore whether specific care was not noted or care was indeed provided but not documented in the medical file. The remainder of 14 indicators (those who were found not feasible and/or applicable) were selected through a meticulous RAND modified Delphi procedure and therefore have potential to be incorporated in a guideline. They may not be suitable as tools for quality improvement in its present form. A larger study, however, may show improvement potential for these indicators. Although these items are not suitable as a quality tool in the present form, they should not be discarded in incorporating in a guideline, as they are validated [7]. Our small sample is a limitation of the study. A possible selection bias is another limitation. Only midwives who successfully finished the CAVE course reported cases. One can assume that these participants perform very well in case of PPH as they were recently trained. Further research should also include midwives, who did not participate in the CAVE training.

This is the first study describing quality indicators particularly for PPH in primary midwifery care in the Netherlands. Eleven out of 25 indicators were found to be suitable as an assessment tool for midwifery care of PPH and are therefore suitable for incorporation in a professional midwifery guideline.