Participants and hospitals

Table 2 provides the sociodemographic characteristics of participants and a description of the hospitals. Forty-five healthcare providers, consisting of 14 midwives, (one male; 13 females), 6 nurses (all females), 17 doctors (9 males; 8 females), and 8 managerial staff (4 males; 4 females) participated in the study. Their overall years of experience ranged from one year to 30 years (median=8 years) and time working at their hospital from 3 months to 26 years (median=4 years). All participants currently worked in a hospital in a clinical role (n=37) or in a managerial role (n=8). The managerial staff was senior clinical staff members, with responsibility for managing and overseeing a team of clinical staff responsible for PPH detection and management (i.e. in-charge midwifery or nurse matrons or head of obstetrics). The locations of the hospitals were 2 rural and 7 urban and the burden of PPH cases was categorised as either low (less than 50 cases per year), middle (between 51 and 99 cases per year) or high (more than 100 cases per year). The median duration of the interviews was 67 min (range 38–107 min).

Table 2 Sociodemographic characteristics of participants and description of hospitalsFindings

Overall, similar influences on bundle uptake were reported from participants across countries. In the narrative summary of the results below, we highlight any country-specific influences (i.e. reported by participants from one country only) or influences for which participants from different countries had contrasting views. The findings are presented in three sections corresponding to the stated research questions. Contextual differences and similarities across the 3-country settings are discussed throughout.

Research question (RQ)1: influences on current PPH detection and management

A total of 55 belief statements representing perceived barriers and enablers to current PPH detection and management were identified across 12 of the 14 TDF domains. No belief statements mapped to the TDF domains of optimism and intention. Table 3 presents a sub-sample of barriers and enablers identified within each TDF domain, for each country, with supporting quotes. These are summarised descriptively below, highlighting any cross-country differences and similarities within each domain. The full set of identified barriers and enablers within each domain is in Additional File 3.

Table 3 Summary of key barriers and enablers of PPH detection and management in Kenya, Nigeria and South AfricaEnvironmental context and resources

The influence of environmental context and resources was mixed across all countries. Provision of PPH care was facilitated by all hospitals being organised into separate wards or rooms for maternity care and by having guidelines, protocols, posters and/or charts related to PPH care displayed in some maternity wards across all countries. A common barrier was inconsistent supplies of drugs, particularly in Nigeria where women or their families often had to procure tranexamic acid themselves. Other barriers were delays in transporting women referred from lower-level hospitals to higher-level hospitals because of a lack of ambulances (all countries), unreliable blood supplies (only in Nigeria and South Africa), staff shortages to manage PPH emergencies (all countries) and lack of tools and equipment to measure blood loss (only in Nigeria and Kenya).

Skills

The influence of skills related to PPH detection and management was also mixed across all countries. Training on PPH received since midwifery, nursing or medical school was inconsistent, with some healthcare providers having received in-service training whilst others had no additional training since pre-service certification. Continuous training was seen as an enabler to keeping updated with new approaches and was recommended by participants in Kenya and South Africa. Participants reported more training for inexperienced or new staff was required in Kenya and Nigeria.

Knowledge

Participants across countries reported differing knowledge of definitions of PPH, different knowledge of guidelines, differing awareness of the signs and symptoms of a PPH and different steps constituting appropriate PPH management. These findings were often in contradiction to WHO guidelines. Participants reported recognising PPH as an obstetric emergency and felt that they were knowledgeable at appropriately detecting and managing PPH.

Behaviour regulation

For all countries, a key enabler was receiving feedback on current practice because it helps identify areas for improvement and in Kenya and South Africa existing strategies such as continuing education, hospital-specific protocols and having a PPH emergency kit reportedly helped to promote appropriate PPH care provision. In Kenya and Nigeria, a lack of information sharing between hospitals when referring women was a relevant hindrance to PPH management and monitoring of PPH clinical practice using audit and feedback was reported to be limited in all countries.

Beliefs about consequences

Despite PPH being the largest contributor to maternal mortality and described as a ‘common’ and ‘big issue’, participants in this study did not always perceive it to be as serious a concern compared to other maternal health issues. For all countries, negative consequences of current practice were delays in PPH detection because of a lack of an appropriate and objective measure of blood loss and late referrals from other hospitals to effectively manage PPH.

Social/professional role and identity

Midwives and nurses were most often the first responders to PPH, responsible for deciding when to call for help after observing a significant blood loss or a sudden onset of bleeding after birth in all countries. Midwives and doctors performed examinations to determine the cause of the blood loss and took vital signs to detect and confirm a PPH. Therefore, an important enabler was a good level of role clarity (individual and team) in all countries, division of tasks based on clinical role (in Nigeria and Kenya) and having a multi-disciplinary team managing a PPH (only reported in Kenya).

Emotion

Healthcare workers, particularly first responders, reported an association between some negative emotions such as panic and stress, they felt when managing a PPH with the unpredictability and potential for maternal mortality from PPH.

Social influence

The impact of social influence was mixed across countries. An enabler for some participants was teamwork, which they described could speed up and improve the management of PPH; therefore, it is necessary to appropriately manage PPH. In contrast, some participants believed PPH had to be detected and managed alone in some hospitals often because of staff shortages that were reported across all countries.

Memory, attention and decision-making

Memory, attention and decision-making influences were also mixed. In all countries, more attention was given to using guidelines to inform clinical care if international guidelines were adapted into hospital-based clinical guidelines. A common barrier in South Africa was that more consideration was given to vital signs (observing a decreasing blood pressure and an increasing pulse rate) than blood loss to detect a PPH, which may delay treatment. Participants often reported detecting PPH using visual blood loss estimation methods, such as looking at the amount of blood on linen or on the floor, using kidney dishes to collect blood or counting the number of blood-soaked linens or swabs. Decisions made during this period of diagnosis were sometimes unlikely to include any immediate treatment to manage the PPH. After diagnosing a PPH, management sometimes followed a 'wait and see’ approach, where clinicians would implement one treatment measure at a time and wait to see if the woman responded to it. The treatments mentioned as the primary or first-line treatments included uterine massage, oxytocic drugs (e.g. oxytocin and misoprostol) and IV fluids. Some of the reported current care conflicted with the evidence-based practice for PPH detection and management, for example not administering the dosage of oxytocin recommended by WHO guidelines.

Beliefs about capabilities

Beliefs about capabilities were a mixed influence, with healthcare providers reporting varying levels of confidence in detecting and managing PPH. In Nigeria, specific barriers were the need to cope with the rapid onset of PPH and abilities to detect and manage PPH with a woman not booked for birth in the hospital, because of having no details of the medical history of potential high-risk factors for PPH (compared to a woman booked to give birth in the hospital, who therefore has a medical history obtained).

Reinforcement

There were varying approaches to disciplinary procedures for the mismanagement of PPH across hospitals and countries. In Nigeria and Kenya, disciplinary procedures were considered a barrier to PPH detection and management; therefore, disciplinary actions were not required or recommended with more training being preferrable. One participant in South Africa expressed fears of punishment (i.e. disciplinary action taken) for failing to manage a PPH appropriately.

Goals

Across all countries, an enabler was that PPH was perceived to be of high importance because it can cause maternal deaths if not detected and managed appropriately.

RQ2: Potential influences on the future use of the E-MOTIVE bundle

Thirty-eight belief statements representing barriers and enablers to implementing the E-MOTIVE bundle were identified across nine TDF domains. No beliefs were mapped to the TDF domains of Behaviour Regulation, Optimism, Reinforcement, Goals and Emotion. Table 4 shows a full list of belief statements across TDF domains, classified as a barrier, an enabler or mixed across the three countries, alongside supporting quotes.

Table 4 List of TDF domain belief statements about factors potentially influencing uptake of the E-MOTIVE bundle In Kenya, Nigeria and South AfricaBeliefs about consequences

Collectively, the feedback received about introducing the E-MOTIVE bundle to clinical practice was positive across all countries. Many participants said that using the bundle had the potential to improve current PPH management and to reduce PPH morbidity and mortality in their hospitals or country. The perceived benefits of using the bundle were the accurate measurement of blood loss which could increase the effectiveness of PPH detection and consequently improve PPH management and reduce PPH mortality and morbidity. The bundled approach of using massage and oxytocin together was thought to be advantageous, although not including misoprostol as part of the bundle was a potential disadvantage because misoprostol is typically used in conjunction with oxytocin, especially where the latter was thought to have poor quality. Potential barriers were how the drape may limit women to only recumbent birth positions (lying flat on their back) and that counting of swabs placed in the drape may be time-consuming.

Environmental context and resources

The influence of environmental context and resources was mixed. An enabler was having a plentiful supply of oxytocin and IV fluids and having a large enough team to deliver the bundle as intended. A key barrier to bundle implementation was the limited availability of tranexamic acid in the maternity ward and in the wider hospital. Other barriers were an inadequate supply of and anticipated high ongoing cost of calibrated drapes, having poor quality oxytocin, bed type not suitable for using the calibrated drape, hospital prone to power cuts that could impede internal examinations and staff shortages.

Memory, attention and decision-making

Memory, attention and decision-making was an enabler because components of the bundle were already used independently, such as examinations to detect the cause of bleeding, uterine massage as the first-line treatment for PPH and oxytocin currently administered simultaneously with the uterine massage. An important barrier was that tranexamic acid was not routinely used (unless as a last resort when oxytocin had not worked). Despite an overall positive evaluation of the bundle, and a recognition that the majority of bundle elements were already used in current practice, there were concerns raised about how collecting blood loss in a calibrated drape would fit in with current practice.

Beliefs about capabilities

Confidence in performing different components of the bundle varied. Across all countries, participants reported feeling confident in their capability to give oxytocin, IV fluids and uterine massage, but there was varying confidence in examining the genital tract and this also varied across cadre, e.g. doctors were often more confident than midwives. Participants also did not feel confident in using a bundled approach and in giving tranexamic acid, specifically in Nigeria and Kenya where tranexamic acid was not routinely used for PPH management.

Skills and knowledge

Both skills and knowledge were reported to be a barrier to implementing the bundle, particularly a lack of education and skills around how to use components of the bundle that are not routinely used in current practice (e.g., a calibrated drape, tranexamic acid). A further barrier was a lack of understanding of the concept of a clinical care bundle and a need for further training on using a bundle approach.

Social/professional role and identity

There were mixed views about whether certain professional groups would be allowed to perform certain components of the bundle, for instance, whether in addition to doctors, midwives or nurses could perform genital tract examinations. A potential enabler of the overall use of the bundle was assigning roles and a need to work as a team.

Social influences

Social influence was a barrier to the massage and examination components of the bundle. Some women refuse to have an internal examination and staff have concerns about causing discomfort and pain to a woman when applying a uterine massage.

Intention

The influence of intention is a potential barrier, with reported concerns over buy-in (i.e. failure to see benefits) to the bundle approach over existing practice, because the majority of bundle elements are already being practised—albeit independently rather than bundled.

Overall, similar influences likely to facilitate or hinder the implementation of the E-MOTIVE care bundle were consistently found across all countries.

RQ3: Mapping of identified barriers and enablers to implementation interventions

Table 5 presents a mapping of identified barriers and enablers to potential intervention strategies to address these and improve current practice and maximise future bundle implementation. We proposed 5 implementation interventions to address the identified barriers and enablers: Calibrated Drape, E-MOTIVE training, E-MOTIVE champions, PPH emergency trolley/kit and Audit and Feedback. These interventions focus on increasing the competencies and motivation of staff to adopt E-MOTIVE and to address existing contextual and socio-cultural factors which could hinder the uptake and optimal delivery of E-MOTIVE. One strategy which is part of the E-MOTIVE bundle is a new blood collection measurement tool (i.e., a calibrated drape) that targets delays in PPH detection and inaccurate measurement of blood loss. Therefore, this requires specific training on how to use this new calibrated drape appropriately and includes broader education on the purpose of clinical care bundles, such as E-MOTIVE, and on recommended PPH management to address the identified areas of sub-optimal PPH care. Other barriers addressed by training include administering tranexamic acid, which is rarely used to treat mild PPH in Nigeria and Kenya and only prescribed by doctors in South Africa, inadequate team communication skills, breaking down any hierarchical clinical practices and reassuring midwives of their enhanced role in administering tranexamic acid where there is no specific local hospital protocol specifying that nursing staff can administer tranexamic acid.

Table 5 Identified barriers and enablers mapped to proposed implementation interventions using the BCW

Other interventions operate on a day-to-day basis to target any resistance to adopting E-MOTIVE by providing on-site leadership (e.g., E-MOTIVE champions) support to encourage and to demonstrate using the bundle. Also, to address the stress and anxiety often felt by staff when coping with a PPH, in particular in sourcing all necessary drugs and equipment by introducing a regularly stocked PPH-specific emergency trolley/kit to keep everything readily available in one place. At the hospital level, healthcare providers were encouraged to routinely use E-MOTIVE by monitoring uptake and subsequently give feedback to identify areas for further improvements (i.e., Audit and Feedback).