Using Criteria-Based Audit to Improve the Management of Postpartum Haemorrhage in a University Hospital in Eastern Ethiopia: A Before and After Study

Objectives: Postpartum haemorrhage, an excessive bleeding after childbirth, remains a leading cause of maternal mortality in low-resource settings. Improving the quality of postpartum haemorrhage care using audit and embedded quality improvement is essential for addressing this. A criteria-based audit, an objective, systematic and critical analysis of the quality of health care against a set of criteria, is essential for identifying appropriateness of care and areas for improvement in postpartum haemorrhage management. The aim of this study was to audit management of postpartum haemorrhage as quality assessment for postpartum haemorrhage care in a tertiary university hospital in eastern Ethiopia. 

Methods: In 2023, we repeated the criteria-based audit cycle conducted in 2019 to re-evaluate management of postpartum haemorrhage using the same previously co-created eight audit criteria. Two midwives and one consultant obstetrician independently reviewed each woman's medical records to assess whether a criterion was met or not. Findings were compared with the 2019 reports using a chi-square test and discussed with birth attendants and administrators of the hospital to identify underlying factors and areas for improvement in postpartum haemorrhage care. 

Results: Of 55 medical records reviewed, fulfilment of the audit criteria ranged from 24% (13/55) for fluid input and output monitoring to 100% (55/55) for documenting woman's history and general clinical conditions at admission, and haemoglobin measurement. Compared with the previous audit, where only 6.7% (3/45) women met all the audit criteria, there was substantial increase in proportion in the current audit as 22% (12/55) cases met all the criteria (p = 0.03). Lack of template for a postpartum haemorrhage management, refresher training, postpartum haemorrhage emergency kit, adherence to postpartum haemorrhage management guideline and adequate blood for transfusion were identified as major barriers to providing optimal postpartum haemorrhage care. 

Conclusions: Just over one in five women met the local audit criteria for postpartum haemorrhage management, and major barriers to providing the best possible care persist. These results highlights the need to develop a postpartum haemorrhage management template, availing blood for transfusion, providing low-dose high frequency (refresher) training and drills for staff, and enhancing documentation and record keeping in the hospital for improving quality of postpartum haemorrhage management to stop preventable deaths and sequelae from postpartum haemorrhage.