Objectives: Describe management of severe postpartum haemorrhages (PPH) and its compliance with national guidelines and identify determinants of non-optimal care.
Patients and method: Population-based cohort study of 1379 women with severe PPH due to uterine atony after vaginal delivery, conducted in 106 French maternity units between December 2004 and November 2006. Severe PPH was defined by a peripartum haemoglobin drop of 4g/dL or more, blood loss of 1000 mL or more, hysterectomy, or transfer to intensive care for PPH. The frequency of each recommended procedure for the management of PPH was described. Associations between quality of care and both individual and institutional characteristics were assessed by univariate analysis and multivariate logistic regression.
Results: Management of severe PPH was not optimal in 65.9% of cases. The recommended components that were applied least often were administration of second line uterotonics, and transfusion of patients with a low haemoglobin. After adjustment for individual characteristics, the risk of either non- or suboptimal care was significantly higher in non-university public maternity units (aOR 2.62 [95% CI: 1.49-4.54]) compared with university hospital units, in units with fewer than 2000 annual deliveries (aOR 2.32 [95% CI: 1.49-3.57]), and in units without an obstetrician always present (aOR 1.96 [95% CI: 1.26-3.03]).
Conclusions: Management practices for severe PPH can be improved, to an extent that varies by component of care and type of hospital. A qualitative approach should help to identify the individual and organizational factors explaining why guidelines are not fully applied.
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