Improving Postpartum Hemorrhage Management in a Rural Setting

The leading cause of maternal death worldwide is postpartum hemorrhage, followed by hypertensive disorders, infection, complications with delivery, and unsafe abortions. Globally, hundreds of women die every day in childbirth due to these causes, and in 2015, there were 45,000 maternal deaths in India alone, which accounted for 15% of all maternal deaths worldwide (about 45,000/303,000). Giving birth in rural and low-resource settings increases a woman's risk of dying in childbirth. In collaboration with the Shakti Krupa Charitable Trust, The University of Utah collected data at a rural hospital in Gujarat, India which demonstrated that birth attendants were lacking the confidence and skills necessary to recognize and manage postpartum hemorrhage. The aim of this quality improvement project was to provide training to hospital staff to ensure they are properly equipped to manage postpartum hemorrhage. In addition, the project sought to identify an appropriate staff member to facilitate periodic trainings at the site in an effort to promote sustainability. Simulation-based training was employed as an evidence-based method for training healthcare workers in managing obstetrical emergencies. Nurses (12) and ward boys (6) who care for women in labor and the postpartum period were trained in small groups with use of a local translator. A change in knowledge and skills was assessed by pre and post intervention questions adapted from Jhpiego's Helping Mothers Survive: Bleeding After Birth curriculum. The intervention was a simulation scenario created by PRONTO International that detailed a normal physiologic birth with postpartum hemorrhage due to uterine atony. This was followed by a debriefing session to facilitate learning and to discuss necessary and unnecessary steps in the management of the third stage of labor. Results indicate that there was an improvement in some participants' knowledge of postpartum hemorrhage recognition and management. Pre and post intervention median scores for nurses increased by 25% (from 61% to 86%). The median scores for ward boys increased by 14% (from 57% to 71%). Though the majority of scores increased, not all participants saw an increase in scores pre to post-test, and some saw a decrease. However, all participants who completed an evaluation felt the training methods were effective and the knowledge and skills they learned would be useful in providing care to mothers. Although future effectiveness of the training was not measurable due to time constraints, it is proposed that a demonstrable increase in staff's knowledge of postpartum hemorrhage and the opportunity to practice life-saving hand skills will decrease the incidence of maternal morbidity and mortality secondary to postpartum hemorrhage at this site in rural India. Identifying future trainers at the site was not achieved during the lifetime of this project due to lack of interest from staff, time, and leadership. Recommendations are given to create leadership at the site and to identify staff whose primary role is to promote quality care and continuous education, ensuring retention of necessary knowledge and hand skills for proper management of obstetrical emergencies.