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Managing obstetric bleeding in Wales: A qualitative evaluation of the OBS Cymru care bundle using Normalisation
Tanvi Rai1, Lisa E Hinton1, Rosa Mackay1
1Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom.
Insights
The Obstetric Bleeding Strategy (OBS) care bundle is now standard post-partum haemorrhage (PPH) care in Wales. Its proforma aids communication and role clarity, informing wider UK implementation.
Area of Science:
- Obstetrics
- Healthcare Implementation Science
- Patient Safety
Background:
- Post-partum haemorrhage (PPH) remains a major global cause of maternal mortality.
- The Obstetric Bleeding Strategy (OBS) care bundle was implemented in Wales in 2019 (OBS Cymru).
- A qualitative evaluation was conducted five years post-adoption to optimize UK-wide implementation.
Purpose of the Study:
- To qualitatively evaluate the implementation and normalization of the OBS care bundle in Welsh maternity units.
- To identify facilitators and barriers to OBS bundle use.
- To inform the optimization of OBS implementation across the UK.
Main Methods:
- Ethnographic observations and qualitative interviews with multidisciplinary teams (MDT) in four Welsh maternity units.
- Thematic analysis supported by Normalisation Process Theory.
- Evaluation of a care bundle five years after adoption.
Main Results:
- The OBS Cymru protocol is used daily, with MDT members reporting improved PPH management quality and safety.
- The supporting proforma acted as a 'boundary object,' clarifying roles and enhancing communication during PPH events.
- Standardization fostered shared PPH knowledge, though minor variations in practice existed due to staffing and caseload.
Conclusions:
- The OBS care bundle has become normalized as standard PPH care in Wales, despite minor variations.
- The proforma's centrality and the need for clearer staff role expectations were key insights.
- Findings inform implementation strategies for the ongoing OBS UK trial.
Background:
Post-partum haemorrhage (PPH) is one of the leading causes of maternal mortality and morbidity worldwide. The Obstetric Bleeding Strategy (OBS) care bundle for PPH management was adopted into Welsh national guidelines in 2019 (as OBS Cymru), and is currently being implemented across 36 sites in the rest of the UK through the OBS UK stepped-wedge cluster randomised controlled trial. We conducted a qualitative evaluation of the OBS care bundle five years after its adoption to inform plans for optimising its implementation across the UK.
Methods:
We conducted ethnographic observations, informal conversations and qualitative interviews with multidisciplinary teams (MDT) in four maternity units in Wales. Data were analysed thematically and using Normalisation Process Theory.
Results:
The OBS Cymru protocol was used daily and MDT members believe it improves the quality and safety of PPH management. The paper proforma supporting OBS Cymru was the 'boundary object' that kept the care bundle in view while clarifying individualised roles across the MDT during a PPH and prompting improved and continuous communication as bleeding progressed. The standardisation of processes through the care bundle was seen as enabling all staff with an overall knowledge of PPH care, while situating the prominence of their particular roles within a greater whole. Enacting the bundle in practice varied slightly across different settings, according to staffing structures (e.g., in delivery rooms versus theatre births) and caseload, and some residual tensions remained regarding expectations from different staff members and levels of support provided regarding OBS Cymru.
Conclusions:
Despite some small-scale variations, OBS care bundle has become normalised as standard PPH care in Wales. Insights from this evaluation, such as the centrality of the proforma in holding the bundle together, and need for greater clarity in staff role expectations, have informed implementation plans for the OBS UK trial.
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