Meeting demand-Obstetric hemorrhage and blood availability in Malawi, a qualitative study

Background Postpartum haemorrhage (PPH) is the leading cause of maternal mortality in Malawi. Despite the presence of a centralized institution supplying blood and blood products for hospitals across the country, a lack of timely blood transfusion has been identified as a critical barrier to successful PPH management. This study aims to understand the factors that affect the blood delivery pipeline and adequate access to blood products for postpartum haemorrhage patients. Methods Qualitative data were collected through in-depth interviews with key stakeholders across the blood delivery pipeline. Interviews were conducted from July 2020 to January 2021 at Queen Elizabeth Central Hospital and Mulanje District Hospital, a referral and district hospital respectively, as well as the Malawi Blood Transfusion Service. Line by line, open coding was used to perform a thematic analysis of the data using Nvivo and Atlas.ti software. Results Five key themes were identified: 1) Lack of blood availability due to an inadequate donor pool, 2) Transportation of blood products and PPH patients is impeded by distance to target sites and competing interests for blood delivery vehicles, 3) The Malawi Blood Transfusion Service has difficulty meeting demand for blood products due to inadequate funding and difficulty retaining blood donors, 4) Current PPH management protocols and practices lead to delays due to inconsistent guidelines on delivery and analysis of patient samples, and 5) Communication between health cadres is inconsistent and affected by a lack of adequate resources. Conclusions Barriers to timely blood transfusion for PPH patients exist across the blood delivery pipeline. While an investment of infrastructure would alleviate many obstacles, several solutions identified in this study can be implemented without additional resources, such as establishing joint department meetings to improve communication between health cadres. Ultimately, given a resource limited setting, it may be worth considering de-centralizing the blood supply. Methods are reported according to the Standards for Reporting Qualitative Research (SRQR) framework [12]. This study was a cross-sectional study that used a grounded theory approach to better understand the relationships and behaviors of groups identified as critical to blood supply access and distribution [13]. The study employs a constructivist research paradigm, wherein an understanding of the system came from ongoing discourse with those of relevant lived experience, ultimately resulting in a better-informed consensus of results [14]. Data were collected using In-Depth Interviews (IDIs) with a variety of key stakeholders across the blood supply and delivery chain. The research team was led by principal investigators from Malawi (authors S.E.N., A.S.M.) who have appointments at the Kamuzu University of Health Sciences (formally known as the University of Malawi, College of Medicine) and speak both English and Chichewa. Interviews were conducted by research assistants (RAs) with experience in qualitative data collection, who also speak both English and Chichewa to allow participants to be interviewed in the language of preference. The research assistants did not interact with participants prior to the study. RAs participated in a 5-day training prior to initiating interviews. The training included all aspects of study procedure. A pretest with mock interviews was conducted and informed adjustments to interview guides, which included removing questions that lacked purpose or clarity. Qualitative data were collected from key informants at three main locations: Queen Elizabeth Central Hospital (QECH), a large urban referral hospital, Mulanje District Hospital (MDH), a rural hospital in Southern Malawi, and MBTS. QECH, located in Blantyre, is the largest public hospital in Malawi, and serves as a referral location for complex obstetric cases. QECH is one of four regional referral hospitals in Malawi and is representative of the level of care and services provided at these hospitals. The Chatinkha Maternity Unit (CMU), located within QECH, is one of the busiest maternity units in Malawi, reporting over 11,000 deliveries per year. The most recent annual facility data (July 2018-June 2019) lists PPH as the leading cause of maternal deaths at QECH, resulting in 42% of the 463 maternal deaths, out of 11,253 total deliveries [15]. MDH is a rural district hospital located in Mulange, 80 km south of Blantyre, and was selected to represent district hospitals throughout the country which provide relatively limited services in comparison to regional referral hospitals. Nearly 7,000 live births and 20 maternal deaths were reported at MDH between July 2018—June 2019 [16]. The MBTS, headquarters located in Blantyre, collects blood through clinics at regional offices and mobile clinics for blood donor recruitment campaigns in schools, places of worship and workplaces. Under a mandate instituted by the government on MBTS’ inception in 2004, family member donations are only permitted at hospitals when blood is not available at MBTS. In 2019, the MBTS fulfilled approximately 71% of monthly demand at QECH (a monthly average of 959 blood units issued against 1342 requested) and 76% of demand at MDH (monthly average of 144 units issued against 188 requested). In 2020, MBTS fulfilled on average 63% of blood unit demand at QECH (monthly average of 836 units issued against 1322 requested) and 56% of monthly demand at MDH (average of 103 units issued against 183 requested). The initiation of this study was delayed due to the COVID-19 pandemic and was conducted during the first wave of the virus in Malawi. New coronavirus cases ranged from 33–2573 per month between the months of April 2020 and November 2020, with a total of 6044 new COVID-19 cases during this time period [17]. Participants were chosen for this study using purposive sampling to ensure that data was collected from a broad range of stakeholders across the blood supply and delivery spectrum. The sample size was based on the principle of data saturation [18]; while there is no fixed rule regarding sample size for qualitative studies, some authors have recommended a sample of at least 12 participants [18]. The criteria for interview selection, depending on stakeholder group, included working at the respective study site for at least 6 months, recently having worked at the QECH or MDH maternity wards, provided regional supervision to labor and delivery services, or having treated a patient with PPH in the past 6 months that required transfusion. Only those PPH patients who had received a blood transfusion were included in this study. Details regarding the number of IDIs conducted with each cadre and key stakeholder can be found in Table 1. In-depth interviews were conducted in either English or Chichewa language (the latter is the predominant language spoken in the study area), based on participant preference, from July 2020 to January 2021. The interview guide consisted of a standard set of questions asked across all interviews, with additional follow-up questions asked for clarity and elaboration based on participant response. Subjects were identified and invited to participate by the principal investigators. If interested, the participant agreed upon a date and location for the interview. Written consent was obtained before conducting the interview and all interviews were conducted in private rooms or offices to ensure privacy. IDIs were audio recorded with an electronic recorder and lasted approximately 30–60 minutes based on the content covered. The audio-taped sessions were transcribed by experienced transcribers who also translated the recordings into English. All personal identifiers in the transcripts were removed upon translation. The study leadership team provided ongoing supervision and continuous mentoring throughout the data collection process. Data were reviewed on an ongoing basis to ensure quality, and feedback was provided to data collectors as needed. Data were stored on an encrypted server at the Kamuzu University of Health Sciences with only investigators having access to password protected files. De-identified data were provided to the research support team at University of California San Francisco (UCSF) through an encrypted data-sharing platform. A combination of direct and conventional content analysis was employed, in which themes and corresponding codes were theorized in the early stages of data analysis while remaining codes emerged from the data itself [19]. A member of the data analysis team in Malawi (author G.M.) and a member of the research support team at UCSF (author R.F.S.) independently conducted line-by-line open coding of the transcribed interviews [20]. The list of codes and themes were evaluated by the research team throughout the analysis process to ensure that data were being appropriately captured. Data analysis was performed using the NVivo (author G.M.) and ATLAS.ti v8.1 (author R.F.S) software programs [21]. The study received ethical approval from the College of Medicine Research and Ethics Committee (COMREC) at the University of Malawi (currently the Kamuzu University of Health Sciences) with COMREC approval number P.04 /20 /3037. Participants received a detailed description of the study and provided written consent in advance of the interviews. All participants received a copy of the consent form for their records.