A mixed-methods study of barriers and facilitators to the implementation of postpartum hemorrhage guidelines in Uganda

Int J Gynaecol Obstet. 2016 Jan;132(1):89-93. doi: 10.1016/j.ijgo.2015.06.047. Epub 2015 Sep 28.


Objective: To determine the level of adherence to postpartum hemorrhage clinical guideline recommendations and to explore context-specific barriers and facilitators to evidence-based obstetric care.

Methods: Using direct observation of deliveries at a Ugandan healthcare facility, a mixed-methods study was conducted between February and March 2014 to document practices related to the active management of the third stage of labor (AMTSL). The degree to which practice concurred with WHO postpartum hemorrhage guidelines was determined. Semi-structured interviews were conducted with maternal healthcare practitioners.

Results: Of 154 women, individual AMTSL, in the form of administering a uterotonic during the third stage of labor, controlled cord traction, or delayed cord clamping, occurred in 105 (68.2%), 119 (77.3%), and, of a subset of 60 patients, 37 (61.7%) individuals, respectively. However, only 18 of 53 (34.0%) individuals observed for receipt of all of the three AMTSL components received all of the essential elements of AMTSL. Three major themes influencing the uptake of evidence-based practice were identified through 18 interviews: healthcare system issues; current knowledge, awareness, and use of clinical guidelines; and healthcare practitioner attitudes to updating their clinical practice.

Conclusion: Overall guideline adherence was low. There is a need to address context-specific barriers to uptake, ensuring guideline implementation to reduce maternal mortality in low-resource settings.

Keywords: Evidence-based practice; Guideline adherence; Low-income countries; Maternal mortality; Postpartum hemorrhage; Qualitative research; Uganda.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Attitude of Health Personnel
  • Delivery, Obstetric / methods
  • Delivery, Obstetric / psychology*
  • Delivery, Obstetric / standards*
  • Female
  • Guideline Adherence*
  • Health Knowledge, Attitudes, Practice
  • Humans
  • Labor Stage, Third / psychology
  • Oxytocics / therapeutic use
  • Postpartum Hemorrhage / prevention & control*
  • Postpartum Hemorrhage / psychology
  • Postpartum Hemorrhage / therapy
  • Practice Guidelines as Topic*
  • Pregnancy
  • Qualitative Research
  • Research Design
  • Uganda
  • Young Adult


  • Oxytocics