title: A mixed-methods study of barriers and facilitators to the implementation of postpartum hemorrhage guidelines in Uganda.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Medical School, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
authors.forename: Louise
authors.initials: L
authors.lastname: Braddick
authors.affiliation: Medical School, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
authors.forename: Victoria
authors.initials: V
authors.lastname: Tuckey
authors.affiliation: Medical School, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
authors.forename: Zan
authors.initials: Z
authors.lastname: Abbas
authors.affiliation: Birmingham Centre for Women's and Children's Health, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
authors.forename: David
authors.initials: D
authors.lastname: Lissauer
authors.affiliation: Birmingham Centre for Women's and Children's Health, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
authors.forename: Khaled
authors.initials: K
authors.lastname: Ismail
authors.affiliation: School of Health and Population Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
authors.forename: Semira
authors.initials: S
authors.lastname: Manaseki-Holland
authors.affiliation: Sanyu Africa Research Institute (SAfRI), University of Liverpool, UK and Uganda.
authors.forename: James
authors.initials: J
authors.lastname: Ditai
authors.affiliation: School of Health and Population Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand. Electronic address: tim.stokes@otago.ac.nz.
authors.forename: Tim
authors.initials: T
authors.lastname: Stokes
mesh_terms: D000293:Adolescent; D000328:Adult; D001291:Attitude of Health Personnel; D036861:Delivery, Obstetric / Q000379:methods / Q000523:psychology* / Q000592:standards*; D005260:Female; D019983:Guideline Adherence; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007749:Labor Stage, Third / Q000523:psychology; D010120:Oxytocics / Q000627:therapeutic use; D006473:Postpartum Hemorrhage / Q000517:prevention & control* / Q000523:psychology / Q000628:therapy; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D036301:Qualitative Research; D012107:Research Design; D014454:Uganda; D055815:Young Adult
chemical_list: D010120:Oxytocics
keywords: Evidence-based practice; Guideline adherence; Low-income countries; Maternal mortality; Postpartum hemorrhage; Qualitative research; Uganda