title: Variations in Postpartum Hemorrhage Management among Midwives: A National Vignette-Based Study.
abstract: OBJECTIVE
  To assess variations in adherence to guidelines for management of postpartum hemorrhage (PPH) among midwives.
  
  
  METHODS
  A multicentre vignette-based study was e-mailed to a random sample of midwives from 145 maternity units in France. They were asked to describe how they would manage the PPH described in 2 case-vignettes. These previously validated case-vignettes described 2 different scenarios for severe PPH. Vignette 1 described a typical immediate, severe PPH and vignette 2 a less typical case of severe but gradual PPH. They were constructed in 3 successive steps and included multiple-choice questions proposing several types of clinical practice options at each step. An expert consensus defined 14 criteria for assessing adherence to guidelines issued by the French College of Obstetricians and Gynecologists in 2004 in the midwives' responses. We analyzed the number of errors among the 14 criteria to quantify the level of adherence.
  
  
  RESULTS
  We obtained 450 complete responses from midwives from 87 maternity units. The rate of complete adherence (no error for any of the 14 criteria) was low: 25.1% in vignette 1 and 4.2% in vignette 2. The error rate was higher for pharmacological management, especially oxytocin use, than for non-pharmacological management and communication-monitoring-investigation. Adherence to guidelines varied substantially between and within maternity units, as well as between the vignettes for the same midwives.
  
  
  CONCLUSIONS
  Reponses to case-vignettes demonstrated substantial variations in PPH management and especially individual variations in adherence to guidelines. Midwives should participate in continuous and individualized training.
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: D002983:Clinical Competence; D003430:Cross-Sectional Studies; D019468:Disease Management; D005260:Female; D005602:France / Q000453:epidemiology; D019983:Guideline Adherence; D006801:Humans; D008880:Midwifery / Q000592:standards; D006473:Postpartum Hemorrhage / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy*; D011247:Pregnancy; D062486:Public Health Surveillance