Nursing Question

Description

NURS-FPX6016 – Prepare an evaluation (5–7 pages) of an existing QI initiative to determine if the initiative is effective.

This is part two of a three-part project. Part 1 will be attached as reference. This initiative will focus on prevention/reduction of postpartum hemorrhages and a labor and delivery unit.

I need to generate pre and post implementation data to illustrate the success of the initiative, as well as what the CDC’s views on maternal hemorrhage. (https://www.cdc.gov/media/releases/2022/p0919-pregnancy-related-deaths.html)

Joint Commission views: https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-51-proactive-prevention-of-maternal-death-from-maternal-hemorrhage/quick-safety-51-proactive-prevention-of-maternal-death-from-maternal-hemorrhage/#:~:text=Recent%20data%20indicate%20that%20rates,during%20the%20birth%20process%20or

Too often, discussions about quality health care, care costs, and outcome measures take place in isolation—various groups talking among themselves about results and enhancements. Nurses are critical to the delivery of high-quality, efficient health care. As a result, they must develop their skills in reviewing and evaluating performance reports. They also need to be able to communicate outcome measures related to quality initiatives effectively. Patient safety and positive institutional health care outcomes mandate collaboration among nursing staff members to ensure the integration of their perspectives in all quality care initiatives.

In the first assessment, you analyzed an adverse event or a near miss, and outlined a QI initiative to address it. This assessment will give you practice and the confidence to evaluate a quality care initiative in much the same way you might in your health care setting to help determine if the initiative is effective.

Too often, discussions about quality health care, care costs, and outcome measures take place in isolation—each group talking among themselves about results and enhancements. Because nurses are critical to the delivery of high-quality, efficient health care, it is essential that they develop the proficiency to review, evaluate performance reports, and be able to effectively communicate outcome measures related to quality initiatives. The nursing staff’s perspective and the need to collaborate on quality care initiatives are fundamental to patient safety and positive institutional health care outcomes.

Imagine you have been asked to prepare and deliver an analysis of an existing QI initiative at your workplace. The QI initiative you choose to analyze should be related to a specific disease, condition, or public health issue of personal or professional interest to you, or you may use the hospice information provided in the Vila Health: Data Analysis activity in this assessment. The purpose of the report is to assess whether the specific quality indicators point to improved patient safety, quality of care, cost and efficiency goals, and other desired metrics. Your target audience is nurses and other health professionals with specializations or interest in your chosen condition, disease, or public health issue.

In your report, you will:

Analyze a current QI initiative in a health care setting.
Identify what prompted implementation of the QI initiative.
Evaluate problems that arose during the initiative or problems that were not addressed.
Evaluate the success of a current QI initiative through recognized benchmarks and outcome measures as required to meet national, state, or accreditation requirements.
Identify the core performance measurements related to successful treatment or management of the condition.
Evaluate the impact of the quality indicators on the health care facility.
Incorporate interprofessional perspectives related to the success of actions used in the QI initiative as they relate to functionality and outcomes.
Recommend additional indicators and protocols to improve and expand outcomes of a current quality initiative.
Ensure your analysis conveys purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

Be sure to address all of the bullet points. You may also want to read the Quality Improvement Initiative Evaluation Scoring Guide to better understand the performance levels that relate to each grading criterion. Additionally, be sure to review the Guiding Questions: Quality Improvement Initiative Evaluation [DOCX] Download Guiding Questions: Quality Improvement Initiative Evaluation [DOCX]document for additional clarification about things to consider when creating your assessment.

Guiding Questions
Quality Improvement Initiative Evaluation
This document is designed to give you questions to consider and additional guidance to help you successfully complete the Quality Improvement Initiative Evaluation assessment. You may find it useful to use this document as a prewriting exercise, an outlining tool, or a final check to ensure you have sufficiently addressed all the grading criteria for this assessment. This document is a resource to help you complete the assessment. Do not turn in this document as your assessment submission.

Remember, you are analyzing a current QI initiative that is already in place. You are not creating a new QI initiative (Assessment 3).

Analyze a current quality improvement initiative in a health care setting.
● What prompted the implementation of the quality improvement initiative?
● What problems were not addressed?
● What problems arose from the initiative? Evaluate the success of a current quality initiative through recognized benchmarks and outcome measures.
● What benchmarks or outcome measures were used to evaluate success? Consider requirements for national, state, or accreditation standards.
● What was most successful? Incorporate interprofessional perspectives related to initiative functionality and outcomes.
● How does the interprofessional team contribute to the success of the QI initiative?
● What are the perspectives of interprofessional team members involved in the initiative?
● Who did you talk to? From what other professions? How did their input impact your analysis? Recommend additional indicators and protocols to improve and expand outcomes of a current quality initiative.
● What process or protocol changes would you recommend?
● What added technologies would improve quality outcomes?
● What outcome measures are missing, or could be added?

Convey purpose, in an appropriate tone and style, incorporating supporting evidence
and adhering to organizational, professional, and scholarly writing standards.
● Is your analysis logically structured?
● Is your analysis 5–7 double-spaced pages (not including title page and reference list)?
● Is your writing clear and free from errors?
● Does your analysis include both a title page and reference list?
● Did you use a minimum of four sources? Were they published within the last five years?
● Are they cited in current APA format throughout the analysis?

Your assessment should also meet the following requirements:

Length of submission: A minimum of five but no more than seven double-spaced, typed pages, not including the title page and References section.
Number of references: Cite a minimum of four sources of scholarly or professional evidence that support your evaluation, recommendations, and plans. Current source material is defined as no older than five years unless it is a seminal work. Review the Nursing Master’s Program (MSN) Library Guide for guidance.
APA formatting: Resources and citations are formatted according to current APA style. Review the Evidence and APA section of the Writing Center for guidance.

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

Competency 2: Plan quality improvement initiatives in response to routine data surveillance.
Recommend additional indicators and protocols to improve and expand outcomes of a quality initiative.
Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures.
Analyze a current quality improvement initiative in a health care setting.
Evaluate the success of a current quality improvement initiative through recognized benchmarks and outcome measures as required to meet national, state, or accreditation requirements.
Competency 4: Integrate interprofessional perspectives to lead quality improvements in patient safety, cost effectiveness, and work life quality.
Incorporate interprofessional perspectives related to the success of actions utilized in a quality improvement initiative as they relate to functionality and outcomes.
Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.
Convey purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

Unformatted Attachment Preview

Ansari et al. BMC Health Services Research
https://doi.org/10.1186/s12913-020-05342-y
(2020) 20:484
RESEARCH ARTICLE
Open Access
Quality of care in prevention, detection and
management of postpartum hemorrhage in
hospitals in Afghanistan: an observational
assessment
Nasratullah Ansari1* , Farzana Maruf1,2, Partamin Manalai1,3, Sheena Currie4, Mohammad Samim Soroush5,
Sher Shah Amin6, Ariel Higgins-Steele7, Young Mi Kim4, Jelle Stekelenburg8,9, Jos van Roosmalen1 and
Hannah Tappis4
Abstract
Background: Hemorrhage is the leading cause of maternal mortality worldwide and accounts for 56% of maternal
deaths in Afghanistan. Postpartum hemorrhage (PPH) is commonly caused by uterine atony, genital tract trauma,
retained placenta, and coagulation disorders. The purpose of this study is to examine the quality of prevention,
detection and management of PPH in both public and private hospitals in Afghanistan in 2016, and compare the
quality of care in district hospitals with care in provincial, regional, and specialty hospitals.
Methods: This study uses a subset of data from the 2016 Afghanistan National Maternal and Newborn Health
Quality of Care Assessment. It covers a census of all accessible public hospitals, including 40 district hospitals, 27
provincial hospitals, five regional hospitals, and five specialty hospitals, as well as 10 purposively selected private
hospitals.
Results: All public and private hospitals reported 24 h/7 days a week service provision. Oxytocin was available in
90.0% of district hospitals, 89.2% of provincial, regional and specialty hospitals and all 10 private hospitals;
misoprostol was available in 52.5% of district hospitals, 56.8% of provincial, regional and specialty hospitals and in
all 10 private hospitals. For prevention of PPH, 73.3% women in district hospitals, 71.2% women at provincial,
regional and specialty hospitals and 72.7% women at private hospital received uterotonics. Placenta and
membranes were checked for completeness in almost half of women in all hospitals. Manual removal of placenta
was performed in 97.8% women with retained placenta. Monitoring blood loss during the immediate postpartum
period was performed in 48.4% of women in district hospitals, 36.9% of women in provincial, regional and specialty
hospitals, and 43.3% in private hospitals. The most commonly observed cause of PPH was retained placenta
followed by genital tract trauma and uterine atony.
(Continued on next page)
* Correspondence: [email protected]
1
Athena Institute, Faculty of Science, Vrije Universiteit, Amsterdam, the
Netherlands
Full list of author information is available at the end of the article
© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article’s Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
Ansari et al. BMC Health Services Research
(2020) 20:484
Page 2 of 9
(Continued from previous page)
Conclusion: Gaps in performance of skilled birth attendants are substantial across public and private hospitals.
Improving and retaining skills of health workers through on-site, continuous capacity development approaches and
encouraging a culture of audit, learning and quality improvement may address clinical gaps and improve quality of
PPH prevention, detection and management.
Keywords: Afghanistan, Postpartum hemorrhage, Quality of care, Maternal health, Emergency obstetric care
Background
Obstetric hemorrhage is the leading cause of maternal
mortality worldwide. It contributes to nearly one-third
of all maternal deaths globally, the majority taking place
in low-income countries [1]. An estimated 12% of postpartum hemorrhage (PPH) survivors will suffer from
long- lasting, severe complications [2]. Contributing factors are many and often rooted in deficiencies in the
health system, human resource capacity and supplies of
commodities [3]. Homebirths without skilled birth attendants (SBAs), late transfer to health facilities with emergency obstetric care and the low-quality of care in these
facilities are also contributing factors [4]. Furthermore,
geographical, social and economic barriers limit
women’s access to health services [5].
In Afghanistan, obstetric hemorrhage accounts for
56% of maternal deaths [6]. Afghanistan has one of the
world’s highest maternal mortality ratios, estimated at
638 per 100,000 live births [7]. More than half (51%) of
all births in Afghanistan take place at home without
skilled attendants and only 43% of women give birth in
public health facilities and 5% in private facilities [8]. Although Afghanistan has made substantial gains in the
last 15 years in coverage of maternal health services and
facility births as well as health system performance, further progress is still needed, especially with regard to the
quality of basic and comprehensive emergency obstetric
and newborn care [9, 10].
National health policies have prioritized quality improvement of maternal health care with respect to the
major causes of maternal deaths, such as PPH [11].
National clinical guidelines to prevent, detect and
manage PPH, based on the World Health Organization’s (WHO) recommendations, are available in the
country; however, data on compliance with these national guidelines are scarce. WHO’s indicators for
quality of prevention and management of PPH, such as
uterotonics utilization, are not included in Afghanistan’s
health information system [12]. Although an emergency
obstetric and newborn care study in 2010 showed that the
majority of hospitals had essential supplies and equipment
and 85% of SBAs had received training on prevention of
PPH before 2010, the present status of hospital readiness
and SBA practices for prevention, detection and management of PPH in hospitals is unknown [13].
The purpose of this study is to examine the quality of
prevention, detection and management of PPH in both
public and private hospitals in 2016, and compare the
quality of care in district hospitals with care in provincial, regional, and specialty hospitals.
Methods
Study design
The 2016 Afghanistan National Maternal and Newborn
Health Quality of Care Assessment is a cross-sectional
national survey. The assessment was designed to examine health facility readiness for basic and comprehensive
emergency maternal and newborn care, and to assess
quality of routine antenatal care (ANC), childbirth and
postpartum care as well as management of selected obstetric and newborn complications. The focus of this
study is on prevention, detection and management of
PPH in public and private hospitals.
Five data collection tools (see online supplementary
materials) were used: 1) facility inventory and record reviews to verify availability of medications, supplies, human resources, infrastructure and recordkeeping; 2)
interviews to collect information on SBAs’ practices and
constraints faced in the provision of labor and postnatal
care; 3) labor and delivery observation checklists; 4)
postnatal care observation checklists; and 5) PPH case
management observation checklists.
Observation checklists were based on WHO guidelines
and adapted from tools used in conducting quality of
care assessments in other countries [14], in Demographic and Health Survey service provision assessments
[15], and in emergency obstetric and newborn care assessments, supported by the Averting Maternal Death
and Disability program [16]. The tools were developed
in English and translated to local languages, Dari and
Pashto.
Sample
The study includes a census of all accessible public hospitals with an average of five or more births per day reported in the national health management information
system for 2015: 40 district hospitals, 27 provincial hospitals, five regional hospitals, and five specialty hospitals.
District hospitals provide primary healthcare and general
medical and surgical services closer to the community.
Ansari et al. BMC Health Services Research
(2020) 20:484
They are typically staffed by midwives, nurses, anesthesiologists, junior medical officers and surgeons. Provincial
hospitals provide more sophisticated services for diagnosing and treating various conditions. Provincial hospitals support the use of some specialist doctors in the
capital of the provinces. In addition to above, regional
and specialty hospitals are tertiary hospitals that provide
more advanced specialized care. Regional hospitals are
located in five different regions. Specialty hospitals are
mostly located in capital Kabul [17]. According to the
Ministry of Public Health (MoPH), all hospitals should
provide comprehensive emergency obstetric and neonatal care for 24 h per day and 7 days per week [11, 17].
Two additional district hospitals reported an average of
five or more births per day in 2015 but were not accessible due to insecurity at the time of data collection. Ten
private hospitals with an average of at least five births
per day (two in each of Afghanistan’s five most densely
populated provinces) were purposively sampled to provide a snapshot of services in the private sector.
Page 3 of 9
collectors were in a safe location with internet access.
Logic, skip and consistency checks were built into the
program, and data collectors were trained to review records for missing or inconsistent answers before
submission.
Data analysis
Descriptive statistics were used to analyze indicators of
interest and 2 tests were used for differences in hospitals’ readiness and SBAs’ performance on prevention and
detection of PPH by hospital type. Stata® software version 15 was used for all statistical analysis with a type I
error of 0.05. Data from private hospitals are based on
purposively nonrandom sampling and not compared
with the public health facilities.
Observations of PPH case management data were analyzed based on the causes of PPH and type of interventions. Interventions included administration of
uterotonics, uterine massage, intravenous fluids, blood
transfusion, additional procedures and case recording in
clinical logbooks.
Data collection, sites and procedures
Data collectors were 32 experienced female doctors and
midwives who received technical updates on maternal
and newborn health care and training on data collection
techniques with a focus on clinical observation, data
quality assurance, research ethics and CommCare software (Dimagi, Cambridge, MA, USA).
Data collection was completed in a 2–3-day visit to
each hospital between May and August 2016. Each hospital in-charge was informed about the purpose of the
assessment and the data collection process by the data
collectors upon arrival. In each district hospital teams of
three data collectors interviewed up to five SBAs on day
duty. In each provincial, regional and specialty hospital
data collectors interviewed up to five SBAs on day duty
and five SBAs on night duty. Data collectors observed
up to five vaginal births in each district hospital and up
to 10 in each provincial, regional and specialty hospital
(five during a day shift and five during a night shift).
Procedures from initial admission and client observation
through the first hour postpartum were documented in
labor and delivery checklists. Women’ examinations during postpartum ward rounds before discharge were documented in postpartum observation checklists. PPH
cases attended during facility assessment visits were observed, including women who may have given birth at
home.
Data collection was conducted using CommCare software loaded on Android tablets, with paper tools used as
backup in sites where use of tablets was considered a security risk or unacceptable to care providers or women.
Where paper tools were used, data from completed
checklists were entered into the software when data
Results
In district hospitals, 233 health providers were interviewed, in provincial, regional and specialty hospitals
315, and in private hospitals 48. The number of observations during the third stage of labor totaled 270 in district hospitals, 379 in provincial, regional and specialty
hospitals, and 33 in private hospitals. In the inpatient
postnatal ward, the number of observations for detection
of PPH was 188 in district hospitals, 214 in provincial,
regional and specialty hospitals, and 30 in private hospitals. PPH management was observed in 72 women in
various inpatient settings.
Characteristics of hospitals and health care providers
In all public and private hospitals, management reported
provision of services 24 h a day, 7 days per week. The
median number of births per month was 232 (142–
1233) in district hospitals, 558 (76–2157) in provincial,
regional and specialty hospitals, and 91 (8–218) in private hospitals. There was no statistically significant difference in caseload between the two types of public
hospitals.
Providing uterotonics for management of PPH in the
last 3 months was reported in 39 of 40 (97.5%) in district
hospitals, 35 of 37 (94.6%) in provincial, regional and
specialty hospitals, and 8 of 10 private hospitals. Meanwhile, 30 (75.0%) district hospitals, 36 (97.3%) provincial,
regional and specialty hospitals, and seven private hospitals provided blood transfusion for maternity care.
Provision of blood transfusion was higher in provincial,
regional and specialty hospitals than in district hospitals
(p = 0.019) (Table 1).
Ansari et al. BMC Health Services Research
(2020) 20:484
Page 4 of 9
Table 1 Characteristics of public and private hospitals included in assessment
Characteristics of Hospitals
Facility Type
District Hospitals n = 40
Provincial, Regional & Specialty Hospitals
n = 37
p-value
Private Hospitals n = 10
Number (%) of hospitals providing uterotonic
to manage PPH cases in the past 3 months
39 (97.5%)
35 (94.6%)
0.577
8 (80.0%)
Number (%) of hospitals having performed
blood transfusion for maternity care in the past 3 months
30 (75.0%)
36 (97.3%)
0.019
7 (70.0%)
Characteristics of health care providers
District Hospitals (n = 233 SBA)
Provincial, Regional, & Specialty Hospitals
(n = 315 SBA)
p-value
Private Hospitals (n = 48 SBA)
Number (%) of SBAs having received training
on basic emergency obstetric
and newborn care in the past 3 years
43 (18.5%)
88 (27.9%)
0.044
16 (33.3%)
Number (%) of SBAs having received training
on use of misoprostol for prevention
and/or management of postpartum
hemorrhage in the past 3 years
26 (11.2%)
54 (17.1%)
0.223
11 (22.9%)
In district hospitals, 43 of 233(18.5%) SBAs, in provincial, regional and specialty hospitals 88 of 315 (27.9%)
SBAs and in private hospitals 16 of 48 (33.3%) SBAs received emergency obstetric and neonatal care (EmONC)
training in the past 3 years. The number of SBAs trained
on EmONC was higher in provincial, regional and specialty hospitals than in district hospitals (p = 0.044)
(Table 1).
Availability of medicines and guidelines for prevention
and management of PPH
Oxytocin was available in 36 of 40 (90.0%) district hospitals, in 33 of 37 (89.2%) provincial, regional and specialty
hospitals and all ten private hospitals. Misoprostol was
available in 21 of 40 (52.5%) district hospitals, in 21 of
37 (56.8%) provincial, regional and specialty hospitals,
and in all ten private hospitals (Table 2).
Less than half of the public hospitals (19 of 40 [47.5%]
district hospitals, 16 of 37 [43.2%] provincial, regional
and specialty hospitals) and 5 of 10 private hospitals had
guidelines for EmONC (Table 2).
Observation of prevention and detection practices of PPH
during childbirth and immediate postpartum care
Among the births observed, 198 of 270 (73.3%) women
in district hospitals, 270 of 379 (71.2%) women in
provincial, regional and specialty hospitals and 24 of 33
(72.7%) women in private hospitals received uterotonics
for prevention of PPH during the third stage of labor.
Oxytocin was the most frequently used uterotonic in all
hospitals. In 119 of 270 (44.1%) district hospitals, in 184
of 379 (48.6%) provincial, regional and specialty hospitals
and in 16 of 33 (48.5%) private hospitals women received
uterotonics within 1 min after birth (Table 3).
Uterine tone was checked within 15 min after birth
in 135 of 270 (50.0%) women in district hospitals,
165 of 379 (47.4%) women in provincial, regional and
specialty hospitals and 13 of 33 (37.1%) in private
hospitals. Placenta and membranes were checked for
completeness in 135 of 270 (50.0%) women in district
hospitals, 207 of 379 (54.6%) in provincial, regional
and specialty hospitals and 17 of 33 (51.5%) in private
hospitals. More women in provincial, regional and
specialty hospitals [285 of 379 (75.2%)] and in private
hospitals (25 of 33; 75.8%) than in district hospitals
(185 of 270; 68.5%) (p = 0.039) had their perineum
and vagina checked for tears.
In the inpatient postnatal ward, the proportion of
women examined for excessive bleeding during postpartum ward rounds in district hospitals (91 of 188; 48.4%)
was significantly higher than in provincial, regional and
specialty hospitals (79 of 214; 36.9%) (p = 0.019]. In
Table 2 Availability of guidelines and medicines for prevention and management of PPH at the point of care
Items available in the delivery room (%)
Facility Type
District Hospitals
n = 40
Provincial, Regional & Specialty Hospitals
n = 37
p-value Private Hospitals,
n = 10
19 (47.5%)
16 (43.2%)
0.369
5 (50.0%)
Intravenous solutions: Ringers lactate, D5%NS, or NS 35 (87.5%)
infusion
34 (91.9%)
0.376
9 (90.0%)
Injectable oxytocin
36 (90.0%)
33 (89.2%)
0.261
10 (100.0%)
Misoprostol
21 (52.5%)
21 (56.8%)
0.799
10 (100.0%)
Injectable ergometrine/methergine
24 (60.0%)
24 (64.9%)
0.457
8 (80.0%)
Guidelines for emergency obstetric and newborn
care
Ansari et al. BMC Health Services Research
(2020) 20:484
Page 5 of 9
Table 3 SBA performance observed for prevention and detection of PPH in hospital
PREVENTION PRACTICES
District
Hospitals
Provincial, Regional &
Specialty Hospitals
Number (%) of observations during third stage of labor
n = 270
n = 379
Uterotonic administered
Oxytocin
pPrivate Hospitals
value
n = 33
198 (73.3%)
270 (71.2%)
0.211
24 (72.7%)
188 (69.6%)
264 (70.0%)
0.297
21 (63.6%)
Misoprostol
2 (0.7%)
0 (0.0%)
1 (3.0%)
Ergometrine
0 (0.0%)
1 (0.3%)
0 (0.0%)
Recorded type not observed
8 (4.0%)
5 (1.4%)
Uterotonic administered within one minute
119 (44.1%)
184 (48.6%)
0.121
2 (8.3%)
DETECTION PRACTICES
District
Hospitals
Provincial, Regional &
Specialty Hospitals
pPrivate Hospitals
value (n = 38)
Number (%) of observation during third stage of labor and
immediately postpartum
n = 270
n = 379
Uterus checked immediately following the delivery of the placenta
203 (75.2%)
266 (70.2%)
16 (48.5%)
n = 33
0.369
23 (69.7%)
17 (51.5%)
Placenta and membranes checked for completeness
135 (50.0%)
207 (54.6%)
0.524
Perineum and vagina checked for tears
185 (68.5%)
285 (75.2%)
0.039 25 (75.8%)
Vital signs checked within 15 min
92 (34.1%)
102 (27.5%)
0.115
11 (33.4%)
Uterus palpated within 15 min
135 (50.0%)
165 (47.4%)
0.424
13 (37.1%)
Number (%) of observations in inpatient postnatal ward
n = 188
n = 214
pn = 30
value
Client examined for excessive vaginal bleeding
91 (48.4%)
79 (36.9%)
0.019 13 (43.3%)
Client examination includes
Taking pulse
81 (43.1%)
58 (27.1%)
0.002 16 (53.3%)
Taking blood pressure
141 (75.0%)
149 (69.6%)
0.065
Checks fundus and massage if soft
129 (68.6%)
104 (48.6%)
< 21 (70.0%) 0.001 private hospitals this proportion was 43.3% (13 of 30) women (Table 3). Observation of management of PPH in hospitals A total of 72 women with hemorrhage were observed. One woman had antepartum hemorrhage and in three women, insufficient data were available to classify their conditions. Those four women were excluded from the analysis. Of 68 women with PPH, 14 had homebirths and seven of them had hemorrhagic shock on admission. Two women gave birth on the way to hospital and one of them arrived in hemorrhagic shock. Fifty-two women gave birth in the hospitals and 11 of them developed hemorrhagic shock. No maternal death occurred. Files of 46 of 68 women could be traced in the clinical logbooks. Active management of the third stage of labor (AMTSL) had been observed in 37 of 52 (71.2%) women who gave birth in hospital; 35 received 10 International Units (IU) of oxytocin, one received 15 IU oxytocin, and one 800 μg misoprostol. Fifteen of 52 (28.8%) women 23 (76.7%) were not observed during labor and delivery, or did not receive AMTSL. The most commonly observed cause of PPH was retained placenta (46 of 68; 67.6%) followed by genital tract trauma (12/68; 17.6%) and uterine atony (10/68; 14.7%). Eleven women with retained placenta also had genital tract injury (Table 4). For management of PPH, uterotonics were administered in 9 of 10 women with uterine atony and 34 of 46 (74%) women with retained placenta cases. Oxytocin was given to 7 of 10 and misoprostol was given to 2 of 10 women with uterine atony. For management of retained placenta, oxytocin was administered in 25 of 46 (54%) and misoprostol 9 of 46 (20%) women. However, the oxytocin doses varied widely from less than 40 IU to 40 IU or more and misoprostol from less than 800 μg to 800 μm or more. Uterine massage was performed in all women with uterine atony and 40 of 46 (87%) women with retained placenta. All women who were in shock (19 of 68; 28%) received IV fluids and 12 of 19 (63.1%) women received a blood transfusion. Ansari et al. BMC Health Services Research (2020) 20:484 Page 6 of 9 Table 4 Observation of Management of PPH in Hospitals Causes of PPH Total Type of Intervention Uterine atony n = 10 (%) Genital Tract tears n = 12 (%) Retained placentaa n = 46 (%) n = 68 (%) Uterotonics (excluding AMSTL) 9 (90%) 6 (50%) 34 (74%) 49 (72%) Oxytocin Less than 40 IU 7 (70%) 2 (17%) 25 (54%) 34 (50%) 3 (30%) 1 (8%) 17 (37%) 21 (31%) 40 IU or more 4 (40%) 1 (8%) 4 (9%) 9 (13%) not documented – – 4 (9%) 4 (6%) Misoprostol 2 (20%) 4 (33%) 9 (20%) 15 (22%) Less than 800 μg – 2 (17%) 4 (9%) 6 (9%) 800 μg or more 1 (10%) 1 (8%) 3 (7%) 5 (7%) not documented 1 1 2 4 Uterine massage Yes 10 (100%) 10 (83%) 40 (87%) 60 (88%) No – 2 (17%) 5 (11%) 7 (10%) not documented – – 1 1 Yes 9 (90%) 10 (83%) 42 (91%) 61 (90%) No 1 (10%) 2 (17) 4 (9%) 7 (10%) IV fluids Blood transfusion Yes 2 (20%) 2 (17%) 14 (30%) 18 (26%) 1 unit or less 2 (20%) 2 (17%) 8 (17%) 12 (18%) 2 units or more – – 3 (7%) 3 (4%) unknown – – 3 3 Additional Procedure Bimanual compression 3 (30%) 1 (8%) 5 (11%) 9 (13%) Aortic compression 3 (30%) – 6 (13%) 9 (13%) Genital tract tears repair N/A 10 (83%) 6 (13%) 16 (24%) Removal of retained placenta/products N/A N/A 45 (98%) 45 (66%) Tranexamic acid 2 (20%) 1 (8%) 1 (2%) 4 (6%) Hysterectomy – 1 (8%) 1 (2%) 2 (3%) Yes 9 (90%) 7 (58%) 30 (65%) 46 (68%) No 1 (10%) 5 (42%) 16 (35%) 22 (32%) Recorded as PPH case in the logbook Note: all women’s outcome = alive a Eleven women with retained placenta also had a perineal laceration Bimanual compression of the uterus (9 of 68; 13.2%) and aortic compression (9 of 68; 13.2%) were observed for management of PPH. Genital tract tears were repaired in 16 of 23 (69.5%) women. Hysterectomy was performed in two cases. One woman was diagnosed with placenta accreta and subtotal hysterectomy was performed; she received two and half units of blood and 4000 ml IV fluids. Discussion Numerous gaps in practices of SBAs with respect to prevention, detection and management of PPH were found in all hospitals. Although most facilities had oxytocin, various health facilities faced shortages of other supplies and medicines required for prevention and management of PPH. Oxytocin is a drug of choice in prevention of PPH during third stage of labor and plays a central role in management of PPH [18]. Oxytocin was available in the majority of public and all private hospitals; however, a few public hospitals faced potentially serious shortages of oxytocin. Challenges in the supply chain in those hospitals could be the main reason. Misoprostol is included as a “special drug” for prevention of PPH in the MoPH Essential Drug List [19], but it is tightly controlled. Approximately half of all different hospitals had misoprostol in the labor room and there were no statistically significant differences between these hospital types. Ansari et al. BMC Health Services Research (2020) 20:484 Surprisingly, all private hospitals had misoprostol in the labor room. It may be caused by private sector’s independent procurement mechanisms. Despite clear recommendations in the MoPH Reproductive, Maternal, Newborn Child and Adolescent Health Strategy 2017– 2021 [11], public facilities still rely on a supply list issued in Essential Package for Hospitals Services issued in 2005, which does not include misoprostol [17]. WHO recommends use of misoprostol for prevention and management of PPH if oxytocin is unavailable or the bleeding does not respond to oxytocin [18]. It is critical for MoPH policy makers to review and improve the oxytocin supply chain, shift misoprostol from the special drug list to the essential drug list, and make both oxytocin and misoprostol available to address the shortage of commodities in all hospitals. All women should receive uterotonics, preferably oxytocin as a component of AMTSL for prevention of PPH [18]. In our study, more than half (51%) women did not receive uterotonics within 1 min after birth as per WHO’s recommendations [18]. In a study covering six countries in sub-Saharan Africa, almost all women received oxytocin; however, similar to our study, only 52% received oxytocin within 1 min after birth [14]. Unfortunately, uterotonic administration for prevention of PPH in both public and private hospitals is relatively low in Afghanistan, leaving women at risk of PPH even within health facilities. Early detection of PPH as per standard guidelines include checking placenta for completeness, uterine tone, excessive bleeding and genital tract tears [20]. Often SBAs did not check the placenta for completeness, monitor the uterine tone and vital signs after birth, or examine women for excessive bleeding during the immediate postpartum period in all public and private hospitals. Checking for genital tract tears was not performed in about one-quarter of births observed in public hospitals; provincial, regional and specialty hospitals, however, were performing slightly better than district hospitals. In a study in Madagascar, similar gaps were found in performance of health providers [21]. Early detection of PPH requires skilled care and rigorous monitoring; maternal monitoring appears to be weak in hospitals in Afghanistan, endangering women’s lives. Supportive strategies are needed to ensure SBAs take time to include evidence-based practices for detection of obstetric complications in routine care for every woman. In observations of PPH management, we found that retained placenta was the most common cause of PPH; however, generally, uterine atony is the most frequent cause [22]. Most likely, our finding is explained by underreporting of PPH due to atony since blood loss is not measured regularly. Page 7 of 9 SBA performance during PPH management was inadequate. Uterotonics were not used in all PPH cases. Uterotonic dosage varied and did not adhere to national guidelines. Gaps in PPH management practices of SBAs are also common in other low-resource settings. For example in Kenya, health care providers missed repair of genital tract tears in a number of PPH cases [23]. In Tanzania, providers correctly followed the initial steps of PPH management, such as uterotonic administration, uterine massage, and initiation of IV fluid. They were, however, less consistent in adherence to other standard protocols for management of PPH [24]. A number of factors affect the performance of SBAs in provision of quality of care. These include lack of training opportunities, increased workload, poor supervision, low salaries, poor living conditions and lack of equipment and supplies [25]. Gaps in practices of SBAs in our study could be caused by lack of capacity building opportunities and a weak system to ensure provider competencies. We found that access to training to improve knowledge and skills in EmONC was limited for most SBAs, and fewer SBAs in district hospitals received training as compared to SBAs in provincial, regional and specialty hospitals in the past 3 years. This was in contrast to 2010, when most SBAs had recently received training on EmONC, including AMTSL and management of PPH in all types of public facilities [13].. Inadequacy of training could be related to lack of financial resources in Afghanistan. The national health accounts studies in 2011 and 2014 showed that expenditure on education and training for health providers was more than 50% lower in 2014 compared to 2011 [26, 27]. Considering scarcity of financial resources, innovative and cost-effective capacity development approaches should be reviewed and adopted. For instance, a recent study in Ghana indicates that lowdose, high-frequency training through on-site learning and practice, supported by mentors, decreases newborn mortality and intra-partum stillbirths and retains the knowledge and skills of health providers for longer than a year [28]. The low-dose, high-frequency training approach has proven to be cost effective [29]. In addition, evidence suggests that obstetric simulation-based training can reduce the incidence of PPH and improve the performance of providers in PPH management [30]. Policy makers and public health managers should review the existing MoPH human resource development strategy and adopt recent evidence-based, cost-effective and on-site capacity building approaches to effectively transfer learning and retain knowledge and skills of SBAs. Attention to documentation of clinical care and increased accountability for quality of care at all levels of the health system can also drive quality improvement efforts. Ansari et al. BMC Health Services Research (2020) 20:484 This assessment has several methodological limitations. Although the study sample was national in scope, it was not designed to provide a representative sample of private hospitals. Therefore, readiness and quality of care in public hospitals cannot be compared with private hospitals. In addition, findings can only be generalized to district hospitals with at least five births per day, not all district hospitals. We cannot link specific providers to case observations in the study dataset—interviews provide a picture of availability of guidelines and medicines in hospitals, observations provide a picture of observed care. Although efforts were made to ensure multiple providers were observed over a course of 2 days, the same provider may have been observed with multiple clients. There may be influence of the Hawthorne effect in observations of provider performance [31]. The study may therefore give an underestimation of gaps in providing inappropriate care. Despite these limitations, this is the first country-wide assessment that included direct observation of prevention, detection and management of PPH in hospitals in Afghanistan. Moreover, it is the first study of any kind to assess quality of PPH prevention, detection and management in private facilities in Afghanistan. Conclusions Numerous gaps in quality of care for prevention, detection and management of PPH exist in all hospitals with limited differences between district hospitals and provincial, regional and specialty hospitals in Afghanistan. Progress towards national and global development goals for improvement of maternal health will require dedicated efforts to improve prevention, detection and management of PPH in Afghanistan. Improving quality of care should be top priority for policy makers, health managers and service providers to reduce the high risks of maternal mortality and morbidity and meet