Background / Program Overview
Postpartum hemorrhage (PPH) is associated with nearly a quarter of all maternal deaths worldwide, making it the leading direct cause of maternal mortality.
While a lack of blood supply has been deemed an issue in PPH cases
, the specific obstacles towards obtaining blood in facilities with access to blood products have yet to be detailed in a manner that can inform interventions to improve timely access. In 2004, given the critical need for access to safe blood products, the Malawi Government established the MBTS in accordance with WHO guidelines to create a store of blood products under strict measures of quality control.
With the creation of the MBTS, Hospitals have the responsibility of collecting blood from the centralized service, cross-matching blood products for specific patients and issuing as needed. This qualitative study aimed to understand the factors that affect timely and adequate access to blood and blood products for obstetric emergencies and uncover potential solutions in 2 hospitals connected to the Malawi Blood Transfusion Service (MBTS) in Malawi.
Design
This study was a cross-sectional study that used a grounded theory approach. Data was collected through In-Depth Interviews (IDIs) with a variety of key stakeholders across the blood supply and delivery chain. Figure 1 depicts the pipeline of various stakeholders involved in the blood delivery process. Table 1 presents the cadres of stakeholders interviewed and the number interviewed from each cadre. Qualitative data were collected from key informants at three main locations: Queen Elizabeth Central Hospital (QECH) a large urban referral hospital; Mulanje District Hospital (MDH), a rural hospital in Southern Malawi; and MBTS.
Figure 1: Key stakeholders involved in the blood supply and delivery pipeline. Numbers represent those interviewed from each stakeholder group.
Impact
Table 1: Number of IDIs conducted with various cadre in each study site.
|
Stakeholder
|
Number of interviews conducted
|
|
POLICY
|
4
|
|
FACILITY (QECH and MDH combined)
|
25
|
|
Clinicians
|
17
|
|
Laboratory Technicians
|
3
|
|
Ward Attendants and Lab Assistants (Porters)
|
5
|
|
MBTS (Malawi Blood Transfusion Service)
|
4
|
|
OTHER
|
14
|
|
Drivers
|
3
|
|
Blood Recipients
|
4
|
|
Donors
|
7
|
|
Total
|
47
|
The criteria for interview selection, depending on stakeholder group, included working at the respective study site for at least 6 months, recently having worked in the QECH or MDH maternity wards, provided regional supervision to labor and delivery services, or having treated a patient with PPH in the past 6 months that required transfusion. Only those PPH patients who had received a blood transfusion were included in this study. Interviews were conducted by research assistants with experience in qualitative data collection, who were recruited and participated in a 5-day training workshop. The study leadership team provided ongoing supervision throughout the data collection process and continuous mentoring.
Implementation Guidelines
Through this process, we were able to map the pathway from diagnosis of PPH to delivery of blood product. Figure 2 depicts the numerous steps to delivery of blood product within a facility.
Figure 2: Facility-level blood pathway once need for transfusion is recognized.
The data collected in this study were categorized into five overlying themes that impact the provision of blood products to patients with PPH:
- Availability of blood products: Lack of adequate blood supply is the most significant barrier to access for PPH patients. Currently, MBTS heavily depends on school children for blood donations--a dependency that resulted in severe supply deficits during COVID-19 school shutdowns. Participants also noted that the cultural belief that donating blood is only necessary when a close relative needs a transfusion has significantly hindered the tendency of the general population to donate blood.
- Transport of blood products or transfer of patients to target sites: Issues with transportation lie in the availability of vehicles to transport the blood from the MBTS to the facility as well as the distance between MBTS and the rural district hospitals. Transportation of blood units is also a problem from the facility “blood bank” to the hospital ward. In addition to delays transporting blood, there can also be a delay transporting patients when blood transfusion is not available at the health facility they delivered at.
- MBTS resources and procedures: The logistical and administrative burdens of the MBTS impact the provision of blood supply for PPH patients. Recruiting and retaining voluntary blood donors is another issue noted by study participants.
- Hospital/maternity ward clinical policies and procedures for accessing blood products: Participants discussed the importance of risk assessment of patients to avoid either over burdening or delaying requests. Turnaround time can be affected by whether or not the member of the healthcare team sent to collect the blood waits at the laboratory and how rapidly laboratory personnel prepare the blood unit or blood product upon receiving the sample. The delay in hemoglobin drop often seen in the early stages of PPH can also cause delays in blood allocation because laboratory workers receive instructions to only dispense emergency blood supply in states of low hemoglobin. Participants also referenced incomplete blood request forms and ordering of the wrong blood products as critical issues that affect the emergency response.
Communication between health cadres: The blood delivery pipeline is impacted by miscommunication between health cadres involved in the delivery process. Communication was noted to be most impacted by the lack of functioning phone lines between the maternity department and the laboratory. Poor documentation in handover books can also lead to delays in PPH treatment, as key details such as vitals and general appearance may be omitted. It was also noted that advanced communication between hospital laboratories and MBTS, and regular meetings between hospital laboratories and the maternity unit are key to avoiding misunderstandings that may lead to mishaps.
Lessons Learned
- Greater efforts are needed to encourage voluntary blood donation.
- Improved systems to transport blood and/or patients needing blood are necessary.
- Lack of funding in a resource-limited setting affects the success of a centralized blood bank.
- Generalized strengthening of emergency response protocols (accurate completion of laboratory forms, timely sample delivery to the lab, prioritization of delivered samples, preparation of blood units in a timely manner, and on-time pick-up of prepared blood units) will help address barriers to access.
- More standardized communication between ward and blood service providers and within ward providers will expedite the transmission of important information.
Participants noted the following possible solutions for overcoming the identified barriers:
- Implementing nationwide sensitization and media campaigns that would encourage more people to donate
- Allowing family blood donors or hospital-based blood banks in order to complement blood supply from MBTS
- Having a designated vehicle for blood delivery to improve turnaround time.
- Installing a designated lab unit near the maternity unit
- Creating a multi-stakeholder developed PPH protocol, including details regarding form completion, transport, sample prioritization and delivery, and so forth
- Having joint meetings between the maternity unit and hospital laboratory to encourage ongoing communication and feedback rather than only communicating during a stressful emergency response
Limitations:
- The use of purposive sampling, while critical for its role in finding knowledgeable participants, may have resulted in sampling bias
- MDH was chosen as a study site due to its location and PPH burden and may not be representative of other district hospitals
- An MBTS member is a co-investigator for this study, thus providing an additional potential source of bias. This was addressed through independent data collection and data analysis conducted by the University of Malawi and UCSF researchers
- Study data were collected during the COVID-19 pandemic, which has had a significant impact on blood supply worldwide and likely exacerbated, or possibly even introduced, obstacles identified within the blood delivery pipeline
Implications for Future Work
Our findings suggest that stakeholders throughout the blood supply and delivery pipeline are aware of its critical importance in treating postpartum hemorrhage, have constructive suggestions, and are keen to implement interventions that can improve timely access to this life saving resource. While some of the identified obstacles require investment in infrastructure, many of the proposed solutions could be implemented without significant additional resources– an important finding for research limited settings. Furthermore, until the MBTS has adequate resources to sustainably increase the blood supply across the country, stakeholders may need to consider a decentralized alternative for blood supply collection and distribution.
- We have only one organization which deals with blood donation, which distributes blood to hospitals, so if that organization says it has no blood then we have nowhere else to go to get blood, the end result is that patients die due to lack of blood [Midwife Nurse, CMU, QECH]
- The only time that we are communicating is only when we want blood, but there are challenges that they have that they would have liked to actually talk to us… or there are challenges that we have but there haven’t been meetings whereby we can actually talk about those things.
Stand-out statistics:
- Postpartum haemorrhage (PPH) is associated with nearly a quarter of all maternal deaths worldwide, making it the leading direct cause of maternal mortality.
- While many of the discovered obstacles could be resolved by investment in infrastructure, many of the proposed solutions could be implemented without significant additional resources– a critical finding for research limited settings.
