Doctor: Anne Rousseau
Title: Severe immediate postpartum hemorrhage: study of variations in management practice. Analysis of organizational and personal determinants
Supervisors: Philippe Ravaud, Patrick Rozenberg
Doctoral school: ED 393 Epidemiology and Biomedical Information Sciences, Université Paris Cité
Date of thesis defense: 2016
Jury: Marie-Victoire Senat, Loïc Josseran, Corinne Alberti, Gérard Bréart, Philippe Ravaud, Patrick Rozenberg
Postpartum Hemorrhage (PPH) still represents the leading cause of maternal morbidity and mortality in France. A high rate of severe morbidity and mortality results from a high incidence of severe PPH. The PPH worsening to severe PPH can be explained by different factors: factors related to women, pregnancy and childbirth and / or factors related to PPH management. The quality of this management cannot be evaluated independently of either the environment in which it is given or the characteristics of caregivers who provide them.
Observational studies have partially assessed the potential determinants of the quality of care for PPH management.
The objective of this PhD thesis was to develop and validate a methodology to study discrepancies with good practices and to assess determinants related to the organization of care and / or caregivers.
At first, we developed and validated dynamic case-vignettes with several steps, as tool assessing quality of PPH management.
Then we used these case-vignettes to study variations in PPH management among 450 French midwives. We showed variations in adherence to guidelines between and within maternity units and between different PPH situations. Adherence to guidelines was low for pharmacological management and especially for oxytocin use.
Finally, we investigated staff and institutional factors associated with substandard care. We showed both staff – i.e. age, experience, and level of risk taking – and institutional factors – mortality and morbidity reviews – may be associated with substandard care in midwives’ PPH management.
Our method proves to be a relevant way to complete the observational studies on the subject.