Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. The Cochrane Pregnancy and Childbirth Group produced more than 650 Cochrane Reviews after its establishment as the first Cochrane Review Group, 30 years ago. Several relate to postpartum haemorrhage, and these were added to in November 2023, with a new review of qualitative research, which was also supported by the Cochrane Effective Practice and Organisation of Care Group. In this podcast, Martha Vazquez Corona, talks with corresponding author Meghan Bohren, head of the Gender and Women's Health Unit at the University of Melbourne in Australia, about this qualitative evidence synthesis and its findings.

Martha: Hello Meghan. First of all, can you tell us a bit about postpartum haemorrhage? What is it and how does it affect women globally?

Meghan: Hello Martha. Postpartum haemorrhage is when women experience excessive blood loss after birth. It's the leading cause of maternal mortality worldwide, with almost all deaths occurring in low- and middle-income countries and is such a major problem that the World Health Organization recommends that all women giving birth are offered uterotonics to try to prevent it.
However, most women with postpartum haemorrhage have no identifiable risk factors. This means that careful monitoring of blood loss during and after labour is critical for early detection and intervention if needed; and fortunately Cochrane reviews have shown that effective interventions are available, including uterotonics, tranexamic acid, intravenous fluids, and uterine massage.

Martha: So why is it important to have this Cochrane review of qualitative research on the prevention, detection and management of postpartum haemorrhage, to sit alongside those Cochrane reviews of intervention effectiveness?

Meghan: Well, even though there are effective interventions to prevent, detect, and manage postpartum haemorrhage, these are not well implemented, especially in low- and middle-income countries. Qualitative research can help us to understand the reasons for this and we know from existing research and programming across maternal health that women's personal preferences and values influence their decisions to access facility-based childbirth services. This makes it very important to understand women's perceptions and experiences of postpartum haemorrhage, in order to assess the influences of individual and community-level factors. We were also interested to understand challenges and opportunities that health workers and other health system stakeholders had that may influence care provision.
Collectively, synthesising this evidence will help researchers and policymakers to identify critical gaps in the implementation of recommended practices for postpartum haemorrhage.

Martha: And what does the evidence you found say about the perceptions and experiences of postpartum haemorrhage?

Meghan: Well, we identified 67 studies meeting our eligibility criteria, and sampled 43 of these for inclusion in the analysis. The 43 studies were conducted in 26 countries, with 31 taking place in low- or middle-income countries. The studies mostly included the perspectives of women, family or community members, and both facility- and community-based health workers.

Martha: Thanks. That sounds like a good range of research. Tell us about the key findings, starting with those around community beliefs.

Meghan: We found that cultural beliefs around postpartum bleeding influenced women's and community perspectives about postpartum haemorrhage. For example, in many communities, bleeding during and after childbirth was considered "normal" and necessary to restore and cleanse the woman's body after pregnancy and birth. Some communities believed that postpartum haemorrhage was caused by supernatural powers or evil spirits. This means that when women gave birth at home or in communities, cultural beliefs around blood loss could lead to delays in seeking life-saving care for the woman.

Martha: And what about the perspective of health workers working in a health facility?

Meghan: In health facilities, health workers often had difficulty estimating the amount of blood loss after birth. They found that quantifying the amount of blood lost was complex and a contentious change of practice for health workers.
If women did experience postpartum haemorrhage, the health workers identified common challenges in managing postpartum haemorrhage which included insufficient staffing, stressful working conditions, insufficient training, and lack of medication and supplies. These challenges lead to delays in timely management of postpartum haemorrhage.
There were also a few strategies that health workers highlighted as helpful in improving detection and management of postpartum haemorrhage. These include team-based simulation training to bring together health workers of different cadres, such as midwives and obstetricians. This type of training helped the care team to develop a shared mental model to help them work quickly, efficiently, and amicably as a team.

Martha: And last but not least, what did you find about women's experiences of surviving a postpartum haemorrhage?

Meghan: The most common theme was that women described experiencing postpartum haemorrhage as painful, embarrassing and traumatic. Their partners and family members likewise found the experience stressful.
Some women described dissatisfaction with their level of involvement in decision-making for postpartum haemorrhage management, whereas other women felt that health workers were better placed to make decisions. However, women who had hysterectomies for severe postpartum haemorrhage management strongly believed that rich discussion and informed consent was critical, given the lasting physical and emotional consequences of hysterectomy.

Martha: Thank you for that. So, what's your take home message about the prevention, detection and management of postpartum haemorrhage

Meghan: Our qualitative evidence synthesis highlights how improving the prevention, detection, and management of postpartum haemorrhage is underpinned by a complex system of roles and behaviours of women, community members, and health workers. Considering these broader issues when designing interventions to improve postpartum haemorrhage is critical.
To help with this, we wrapped up the qualitative evidence synthesis with some prompts to help programme managers, policymakers, researchers, and other stakeholders to identify and address factors affecting implementation and scale-up of interventions to improve prevention, detection, and management of postpartum haemorrhage.

Martha: Thank you so much Meghan. If listeners would like to read the review, how can they get a hold of it?

Meghan: Thanks Martha, it's available online. If they go to cochranelibrary.com and type "qualitative evidence synthesis and postpartum haemorrhage" into the search box, they will get a link to it.