Severe postpartum haemorrhage (PPH) is the main component of severe maternal morbidity in developed countries, and reducing its rate is a major challenge in obstetrics today. In France, PPH is the leading cause of maternal mortality, and data from the French Confidential Enquiries into maternal deaths show that 80% of deaths due to PPH might have been prevented by timely and appropriate care (1). The French College of Obstetrics & Gynaecology (CNGOF) issued the first national clinical guidelines on PPH prevention and management in France in November 2004 (2). However, the passive dissemination of guidelines is by itself insufficient to change professionals’ practices (3).

Clinical audit is a quality improvement process that seeks to improve patient care and outcomes by looking at current actual practices through the review of cases according to explicit criteria and uses the findings to modify the organisation and the content of care if necessary (4, 5). Few studies have assessed the impact of clinical audits in obstetrics (6,7,8), and none, to our knowledge, has focused specifically on PPH. Information on the feasibility of clinical audits of deliveries with severe PPH and the results that can be expected from this tool would be useful to clinicians (9).

The Pithagore6 trial was a cluster-randomised trial, with the maternity unit as the unit of randomisation, to evaluate a multifaceted educational intervention for reducing the rate of severe PPH. It included 106 French maternity units and finally found no significant difference in the severe PPH rate between the hospitals with the intervention and the control hospitals (10). The intervention included a clinical audit of deliveries with severe PPH in all maternity units in the intervention arm. Two of these hospitals decided to continue the clinical audit meetings on a regular basis. The objective of this report is to describe the change in the prevalence of severe PPH and in the quality of care provided in these cases after the implementation of routine audits in two hospitals with different levels and organisation of care.

A before-and-after survey was designed to assess the impact of the routine use of clinical audits.

The characteristics of parturient women did not change significantly from 2005 to 2008 in the level II unit, although in the level III unit, the rate of instrumental vaginal deliveries increased significantly, from 7.3% in 2005 to 10.5% in 2008, as did the rate of deliveries with PPH, from 4.0% of deliveries in 2005 to 6.1% in 2008 (Table 1). This global increase in the PPH annual rate resulted from the combination of a decrease in PPH after spontaneous and instrumental vaginal deliveries (from 2.0% to 1.85% and from 7.9% to 3.5%, respectively) and a concomitant significant increase in the PPH rate after caesarean deliveries, from 9.6% in 2005 to 20.4% in 2008.

A significant reduction in the prevalence of severe PPH occurred in both hospitals between 2005 and 2008, from 2.1% to 0.6% in the level II hospital and from 1.5% to 1.0% in the level III hospital (Table 2). In the level II unit, the prevalence of severe PPH decreased for both vaginal and caesarean deliveries. In the level III unit, on the other hand, the prevalence of severe PPH after vaginal deliveries fell significantly, but the prevalence after caesareans did not change.

The global quality of care provided to women with severe PPH improved in both units between 2005 and 2008, although the difference reached statistical significance only in the level III hospital (Table 3). The proportion of cases for which management was considered optimal increased from 47% to 73% in the level II unit and from 22% to 61% in the level III unit.

In both units in 2005, the main deviations from recommended care once PPH was diagnosed were no or delayed examination of the uterine cavity (57% in the level II and 74% in the level III unit), the absence of instrumental examinations of vagina and cervix (76% and 59% of severe PPH cases, respectively), and no or delayed administration of second-line uterotonics when uterine atony persisted (71% and 86%).

From 2005 to 2008, the proportion of deliveries with severe PPH that were managed consistently with the guidelines increased for all of the principal components, in both units. In particular, this improvement was statistically significant in both units for the components of care that were the most inappropriate in 2005.

This study shows that routine clinical audits can easily be implemented in obstetrics settings and that their regular performance is associated with an improvement in PPH-related practices and with a significant reduction in the prevalence of severe PPH.

Several limitations must be noted. First although the initial audit meeting was part of a research programme, the routine use of the audit that followed was a local initiative in both units, and the external validity of the results may thus be questionable. Our findings nonetheless suggest that clinical audits are a simple and potentially effective tool for units willing to assess and improve the care they provide.

The quality of care for PPH and the specific components of that care were analysed only in cases of severe PPH. A complete assessment of the audit impact would theoretically have required us to analyse practices in all cases of PPH, or in a representative sample of them, and not only in the most severe cases. These data, however, were not available. It is possible that the improvement in practices was actually greater than that observed in cases of severe PPH, since, by definition, the severe cases have worsened and are thus more likely to have received inappropriate care.

The inherent limitations of our observational design prevent this study from proving that the regular audits caused the reduction in the prevalence of severe PPH, and other factors external to the audit may have contributed to this decrease. Obstetrics professionals in France have been focusing on the issue of PPH since the late 1990s, and global improvement in PPH-related practices might have been underway as part of this national context and could explain the decrease in the prevalence of severe PPH found in the 2 units of our study. We consider this hypothesis seems unlikely, however. Firstly, passive dissemination of recommendations for clinical practice has repeatedly been shown to be insufficient to improve practices (11). Secondly, the dramatic reduction found here – with the prevalence of severe PPH after vaginal delivery divided by three -- seems unlikely to have happened in the absence of active intervention. Finally, a regional study in all maternity units of another French region showed no significant decrease in the rate of severe PPH during this time period (12). Another possible explanation of our results is that the proportion of women at risk for PPH decreased over time. However, neither the prevalence of PPH risk factors among parturient women nor the annual rate of all PPH decreased over this period. Indeed, an inverse trend was observed in the level III unit, where the rates of two important risk factors increased between 2005 and 2008: the number of instrumental deliveries and of women with previous caesareans. These changes may have contributed to the increase in the PPH rate. Under these circumstances, the reduction we observed in the prevalence of severe PPH suggests a decline in the proportion of the PPH that worsened and became severe, probably due to better management of early PPH. The specific PPH-related practices used as criteria for determining quality of care improved concomitantly. Finally, the implementation of routine audits was associated with a significant reduction in severe PPH in two different maternity units providing different levels of care in different settings. All these elements suggest that the organisation of regular clinical audits is likely to have had a positive effect on the prevalence of severe PPH.

Although there are reports of interventions aimed at improving the global quality of care delivered to mothers and children, or targeting other specific issues in obstetrics, previous studies of interventions to decrease the rate of severe PPH are scarce (13–14). Because those few tested the impact of complex or multifaceted interventions, they are not easily reproducible, and it is difficult to attribute the global effect to one component or another. Only one reported a significant reduction in the rate of severe PPH, obtained over a 3 year period in one centre (13). The present study provides a description of the routine use of one specific tool, the clinical audit, and our findings suggest it has a significant impact on the prevention of severe PPH through effective management of early bleeding. The precise description of the agenda of the audit meetings should make them easily reproducible in other units. In addition, the continuous monitoring of the prevalence of severe PPH and of the proportion of adequate care provides evidence that the audit’s impact is sustained over time.

A major strength of regular clinical audits is that they bring practitioners together frequently to discuss the management of severe cases and to define relevant improvement objectives appropriate to the local context and based on the audit’s findings (15). Severe PPH is a very pertinent event for clinical audits, because of the availability of management guidelines and its obviously multidisciplinary nature, involving midwives, obstetricians, and anaesthetists. Such multidisciplinary meetings with a facilitator team applying strategies to encourage collaboration, both at the meeting and during care, are likely to increase the audit activity and to improve care.

In our experience, the results that can be expected from a clinical audit meeting depend on several aspects of the audit process: institutional support, by treating participation in the meetings as actual working time; respect for the facilitator team and their leadership skills; consideration for every participant‘s words; objective assessment of care provided with the help of a standardised form; analysis of the mechanisms that led to the severe event, focused not on individual mistakes, but on understanding individual and collective decision-making processes; and conclusions expressed in terms of improvement strategies. In addition, long-term repetition of the audit appears necessary for it to improve practices and health outcomes. In the level III unit, clear improvement appeared only during the third year of audits. This finding is consistent with the previous report from Rizvi et al of an intervention to decrease the rate of severe PPH (13). This is also likely to explain why no significant improvement was obtained in the Pithagore6 trial where only one audit meeting took place (10): a single meeting is probably insufficient for identifying suboptimal care and its reasons and is certainly insufficient for verifying its improvement.

An interesting finding is the differential changes in the prevalence of severe PPH for vaginal and caesarean deliveries. Caesarean delivery is a recognized risk factor for severe PPH, and the baseline rates of severe PPH in 2005 were higher for caesarean than vaginal deliveries in both units. During the subsequent years and following the implementation of routine audits, the prevalence of severe PPH after vaginal delivery fell quite appreciably in both units. However, severe PPH at caesarean deliveries decreased only in the level II unit; it remained stable in the level III unit and these cases accounted for most of the severe PPH in 2008. The clinical guidelines for PPH management offer more detailed measures for dealing with bleeding after vaginal delivery; it is thus unsurprising that the audits might have had a greater impact on this type of PPH. The concomitant increase in the rate of all PPH after caesarean delivery found in the level III unit may indicate that the procedure itself was associated with a higher risk of bleeding in 2008 than in 2005. Although the mechanisms and management of PPH at caesarean deliveries include surgical issues that may be more difficult to standardise, the current continuous rise in caesarean rates indicates that guidelines focusing on the management of bleeding at caesarean delivery are needed.

The prevalence of severe PPH and the high proportion of inadequate management found at baseline in the two units of this study suggest that room for improvement exists. Because passive dissemination of guidelines does not change practices, specific interventions are required. One feasible tool is the regular clinical audit of severe PPH, and in this study, it was associated with a persistent reduction in the prevalence of severe PPH.

Contributed by Contribution to authorship

CD and CDT participated in the design and the implementation of the study, the collection and the analysis of the data and the drafting and revision of the paper.