title: Staff and Institutional Factors Associated with Substandard Care in the Management of Postpartum Hemorrhage.
abstract: OBJECTIVE
  to identify staff and institutional factors associated with substandard care by midwives managing postpartum hemorrhage (PPH).
  
  
  METHODS
  A multicenter vignette-based study was e-mailed to a random sample of midwives at 145 French maternity units that belonged to 15 randomly selected perinatal networks. Midwives were asked to describe how they would manage two case-vignettes about PPH and to complete a short questionnaire about their individual (e.g., age, experience, and full- vs. part-time practice) and institutional (private or public status and level of care) characteristics. These previously validated case-vignettes described two different scenarios: vignette 1, a typical immediate, severe PPH, and vignette 2, a severe but gradual hemorrhage. Experts consensually defined 14 criteria to judge adherence to guidelines. The number of errors (possible range: 0 to 14) for the 14 criteria quantified PPH guideline adherence, separately for each vignette.
  
  
  RESULTS
  450 midwives from 87 maternity units provided complete responses. Perfect adherence (no error for any of the 14 criteria) was low: 25.1% for vignette 1 and 4.2% for vignette 2. After multivariate analysis, midwives' age remained significantly associated with a greater risk of error in guideline adherence in both vignettes (IRR 1.19 [1.09; 1.29] for vignette 1, and IRR 1.11 [1.05; 1.18] for vignette 2), and the practice of mortality and morbidity reviews in the unit with a lower risk (IRR 0.80 [0.64; 0.99], IRR 0.78 [0.66; 0.93] respectively). Risk-taking scores (IRR 1.41 [1.19; 1.67]) and full-time practice (IRR 0.83 [0.71; 0.97]) were significantly associated with adherence only in vignette 1.
  
  
  CONCLUSIONS
  Both staff and institutional factors may be associated with substandard care in midwives' PPH management.
authors.affiliation: Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France.|INSERM U1153, METHODS (Méthodes en évaluation thérapeutique des maladies chroniques) Research Unit. Paris Descartes-Sorbonne Paris Cité University, Paris, France.
authors.forename: A
authors.initials: A
authors.lastname: Rousseau
authors.affiliation: Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France.|Research unit EA 7285, Versailles-St Quentin University, Saint Quentin en Yvelines, France.
authors.forename: P
authors.initials: P
authors.lastname: Rozenberg
authors.affiliation: INSERM U1153, METHODS (Méthodes en évaluation thérapeutique des maladies chroniques) Research Unit. Paris Descartes-Sorbonne Paris Cité University, Paris, France.|Assistance Publique-Hôpitaux de Paris, Centre d'Epidémiologie Clinique, Hôpital Hôtel-Dieu, Paris, France.
authors.forename: E
authors.initials: E
authors.lastname: Perrodeau
authors.affiliation: INSERM U1153, EPOPé (Epidémiologie Obstétricale, Périnatale et Pédiatrique) Research Unit, Paris Descartes-Sorbonne Paris Cité University, Paris, France.
authors.forename: C
authors.initials: C
authors.lastname: Deneux-Tharaux
authors.affiliation: INSERM U1153, METHODS (Méthodes en évaluation thérapeutique des maladies chroniques) Research Unit. Paris Descartes-Sorbonne Paris Cité University, Paris, France.|Assistance Publique-Hôpitaux de Paris, Centre d'Epidémiologie Clinique, Hôpital Hôtel-Dieu, Paris, France.
authors.forename: P
authors.initials: P
authors.lastname: Ravaud
mesh_terms: D000328:Adult; D019468:Disease Management; D005260:Female; D019983:Guideline Adherence; D006268:Health Facilities; D006801:Humans; D008880:Midwifery; D009721:Nurse Midwives; D006473:Postpartum Hemorrhage / Q000628:therapy*; D012309:Risk-Taking