Midwives’ Voices on Postpartum Hemorrhage: An Exploratory Qualitative Study

Midwives’ Voices on Postpartum Hemorrhage: An Exploratory Qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Midwives’ Voices on Postpartum Hemorrhage: An Exploratory Qualitative Study Nafiye Dutucu, Sena Dilek AKSOY, Resmiye ÖZDİLEK This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7987833/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background: This study aimed to explore midwives' experiences, perceptions, and recommendations concerning the prevention, diagnosis, and management of postpartum hemorrhage (PPH). Methods: An exploratory qualitative design was employed, using semi-structured, in-depth interviews. The study was conducted in public hospitals and maternity units across Türkiye. Seventeen midwives with direct experience in postpartum hemorrhage management participated in the study. Data were collected through individual interviews and were analyzed thematically following Braun and Clarke’s framework. Verbatim transcripts were coded, categorized, and synthesized into overarching themes. Results: Five main themes emerged: (1) clinical preparedness and response capacity, (2) health system and access barriers, (3) team dynamics and crisis management, (4) training and policy gaps, and (5) facilitative strategies. Midwives reported challenges such as equipment shortages, delays in accessing physicians, and role ambiguity during emergencies. They also emphasized training needs, inadequate antenatal education, and weak family planning policies. Conversely, facilitators such as hemorrhage kits, planned blood reserves, and mentorship from experienced staff were perceived as valuable in strengthening care. Conclusion: Midwives play a pivotal role in the early recognition and management of PPH. However, systemic barriers and limited professional authority frequently hinder timely interventions. Strengthening midwives’ competencies through regular simulation-based training, ensuring the availability of essential resources, and strengthening midwifery roles within health policies can improve the prevention and management of postpartum hemorrhage and promote maternal safety. Clinical trial number Not applicable. Crisis intervention health services accessibility midwifery postpartum hemorrhage qualitative research Background Pregnancy and childbirth are critical periods that may involve life-threatening complications, among which postpartum hemorrhage (PPH) remains a leading cause of maternal mortality and morbidity (Kalu & Chukwurah, 2022a ; Richardson et al., 2022 ; WHO et al., 2019). Globally, an estimated 200 women die every hour from complications related to PPH (Finlayson et al., 2019 ; Say et al., 2014 ). Uterine atony, the most common cause of PPH, accounts for 58–90% of cases. Although once considered primarily a problem of developing countries, recent evidence indicates that PPH incidence is also increasing in developed countries (Flood et al., 2018 ; Gallos et al., 2019 ). As a medical emergency, PPH requires immediate intervention to prevent maternal death, yet timely recognition and appropriate management can substantially reduce its impact (WHO, 2019 ). According to data from the Turkish Statistical Institute, the maternal mortality rate in 2018 was 13.6 per 100,000 live births, with hemorrhage accounting for approximately 20% of maternal deaths (TURKSTAT, 2021; Yıldırım & Şahin, 2021 ). In the literature, minor PPH is defined as blood loss of 500–1000 ml, while major PPH refers to blood loss exceeding 1000 ml (Kalu & Chukwurah, 2022a ). Evidence suggests that the incidence of morbidity, particularly related to major PPH, has risen in recent years (Flood et al., 2019 ; Merriam et al., 2018 ). Depending on its severity, PPH can lead to hypovolemic shock, multiple organ failure, and maternal death, especially when compounded by preexisting anemia or delayed and ineffective management (Agarwal et al., 2021 ; Escobar et al., 2022b; Omotayo et al., 2021 ). Preventing predisposing factors such as anemia during pregnancy, ensuring proper management of the first and second stages of labor, actively managing the third stage, and particularly the timely and effective use of uterotonic agents are critical strategies to reduce the incidence of PPH (Escobar et al., 2022b; Gonzalez-Brown & Schneider, 2020 ; WHO, 2019 ). Timely diagnosis, effective intervention, and management of PPH remain major challenges, particularly in low- and middle-income countries (Akter et al., 2020 ). In the past five years, several systematic reviews on PPH management strategies have suggested that preventive approaches may be more effective than treatment alone (Akter et al., 2020 ; Carr et al., 2022 ; Ferrari et al., 2022 ; Masuzawa et al., 2018 ). As PPH is a critical determinant of maternal mortality, research on its prevention and management continues to grow. However, a comprehensive predictive model that can improve prognosis has yet to be established (Carr et al., 2022 ). Understanding the perceptions and experiences of key stakeholders—including healthcare professionals, women, and family members—is therefore essential for improving the recognition and management of PPH (Akter et al., 2020 ). Qualitative research can provide unique insights into these perspectives and contribute to the development of feasible, acceptable, and effective strategies and policies for timely and appropriate PPH interventions. Multiple interacting factors hinder the prevention, early detection, and management of PPH (Higgins et al., 2019 ), and identifying these factors through quantitative data alone has limitations. Recognizing these influences can provide valuable evidence to inform the design of new strategies. Emerging evidence-based approaches can improve the implementation of existing PPH strategies or enhance current practices that are difficult to change (Akter et al., 2020 ). Midwives play a central role in this process, and their experiences and perceptions are especially important. Methods Aim This study aimed to explore in depth and thematically the experiences, perceptions, and recommendations of midwives regarding the prevention, diagnosis, and management of postpartum hemorrhage (PPH) using a qualitative approach. Design A qualitative research design was employed, which emphasizes individuals’ experiences of a phenomenon and is widely used in health research (Neubauer et al., 2019). This approach enabled a detailed exploration of midwives’ perspectives and suggestions concerning the prevention, diagnosis, and management of PPH. In-depth individual interviews were chosen as the method of data collection. The study was reported in accordance with the Standards for Reporting Qualitative Research (SRQR) (O’Brien et al., 2014). The semi-structured interview form used in this study was developed by the researchers based on an extensive review of the relevant literature. To ensure content validity, the form was reviewed by six experts specializing in qualitative research in the fields of obstetric nursing and midwifery, and revisions were made in line with their feedback. Setting and sampling Participants were recruited through snowball sampling between June 2023 and December 2024, following the necessary institutional permissions and informed consent procedures. Snowball sampling, also known as chain sampling, is a non-probability technique in which participants recruit other potential participants from their network (Naderifar et al., 2017; Parker et al., 2019). Data collection began at a public hospital in western Türkiye, where an invitation announcement was shared in the hospital’s online midwife groups. The first participant was interviewed, and subsequent participants were recruited via referrals through the snowballing process. Interviews continued until data saturation was reached, i.e., when no new information emerged, consistent with recommendations in the literature (Naeem et al., 2024; Saunders et al., 2018). Data saturation was achieved with a total of 17 participants. Data collection Data were collected using a participant information form and a semi-structured interview guide developed by the researchers for individual in-depth interviews. The participant information form included five items addressing age, marital status, educational background, and professional experience. The semi-structured interview guide comprised seven main questions exploring midwives’ experiences with the prevention, diagnosis, and management of postpartum hemorrhage. Each question was reviewed and refined with input from three midwife researchers experienced in qualitative methods. Sample questions included: “Please describe your experiences with preventing postpartum hemorrhage at your institution.” “Please describe your experiences with diagnosing postpartum hemorrhage at your institution.” “Please describe your experiences with managing postpartum hemorrhage at your institution.” Interviews were conducted outside participants’ working hours. Appointments were scheduled in advance according to participants’ convenience regarding time and location. All interviews were conducted face-to-face by the same researcher and lasted approximately 30–45 minutes. Audio recordings of the interviews were made with participants’ consent. At the end of each interview, participants were invited to listen to and confirm the recordings. The verbal data were then transcribed verbatim, and participants were asked to verify the accuracy of the transcriptions. Data analysis The audio-recorded interviews were transcribed verbatim using word processing software to facilitate content analysis. A qualitative content analysis approach, as described by Graneheim and Lundman (2004), was employed to gain deeper insights into participants’ perceptions and attitudes (Graneheim & Lundman, 2004; Lindgren et al., 2020). Using the semi-structured interview questions as a guide, each researcher independently identified meaningful units and recurring expressions relevant to the research questions and study aim. These expressions were then analyzed inductively to generate categories and overarching themes. Two researchers who had not conducted the interviews collaboratively reviewed and refined the meaningful expressions, categories, and themes to reach consensus. In cases where agreement could not be reached, the researcher who conducted the interviews was consulted. This process ensured that the creation and naming of categories and themes were achieved through collective agreement among the research team. Finally, the qualitative data were cross-checked and organized using a trial version of MAXQDA24 (VERBI Software) to enhance the rigor and accuracy of the analysis. Validity, reliability, and rigor The study rigorously adhered to the criteria for trustworthiness proposed by Lincoln and Guba, which include credibility, transferability, dependability, and confirmability (Lincoln et al., 1985). Participant validation was employed to enhance credibility and ensure the accuracy of the identified themes. Specifically, each participant listened to the audio recordings after their interviews and confirmed the accuracy of the transcriptions. All participants verified that the information accurately reflected their statements. During interviews, participants were encouraged to provide detailed and clear accounts of their perceptions and attitudes. The reliability of the study was estimated using the formula suggested by Miles and Huberman, which calculates the percentage of agreement: Reliability = Agreement / (Agreement + Disagreement) × 100. According to Miles and Huberman, an agreement rate between 80% and 90% is considered adequate for reliability (Miles & Huberman, 2021). In this study, a reliability rate exceeding 90% was achieved, demonstrating the dependability of the qualitative data. Credibility was further strengthened through reflexivity (Darawsheh, 2014; Kalu & Chukwurah, 2022b). A consistent research design was maintained throughout the study, and strategies to enhance reliability were systematically applied. The use of a semi-structured interview guide for all interviews helped participants focus on the topic and contributed to the credibility, transferability, and confirmability of the study (Adeoye‐Olatunde & Olenik, 2021; Horton et al., 2004). Ethical Considerations Prior to the initiation of the study, ethical approval was obtained from the Kocaeli University Non-Interventional Ethics Committee, Turkey (Approval Number: GOKAEK-2022/21.22; Project Number: 2022/356). Written permission was also secured from the healthcare institution where the study was conducted. All participants provided both verbal and written informed consent for participation and for the use of audio recording devices. The study was conducted in full accordance with the ethical principles of the Declaration of Helsinki (as revised in 2013) and approved by the aforementioned ethics committee. Results Participants’ characteristics The mean age of the participants was 33.65±8.34 years (min.: 24; max.: 51) years. Participants' characteristics about age, marital status, education level, total work experience, and previous emergency obstetric care training are presented in Table 1. Table 1. Some demographic and professional characteristics of the participants (n=17) Participants Age (years) Marital status Education Work experience as a midwife (year) Previous emergency obstetric care training Participant 1 26 Single Undergraduate 4 No Participant 2 40 Married Undergraduate 15 Yes Participant 3 30 Married Undergraduate 4 No Participant 4 28 Married Undergraduate 6 No Participant 5 26 Married Undergraduate 2 No Participant 6 43 Married Undergraduate 25 Yes Participant 7 38 Married Undergraduate 17 Yes Participant 8 33 Single Postgraduate 10 Yes Participant 9 30 Single Postgraduate 8 Yes Participant 10 28 Single Undergraduate 3 No Participant 11 27 Single Postgraduate 6 Yes Participant 12 24 Single Undergraduate 2 No Participant 13 24 Single Undergraduate 2 No Participant 14 39 Married Undergraduate 7 Yes Participant 15 38 Married Undergraduate 17 Yes Participant 16 51 Single High school 32 Yes Participant 17 47 Married Undergraduate 27 Yes Participants' Views on Their Experiences with Postpartum Hemorrhage In this study, in-depth interviews with 17 midwives were analyzed using thematic analysis. Five main themes emerged, reflecting participants’ experiences with the prevention, diagnosis, and management of postpartum hemorrhage (PPH). The main themes, along with their corresponding categories, codes, and representative participant statements, are summarized in Table 2. Table 2. Midwives' Experiences with Preventing, Diagnosing, and Managing Postpartum Hemorrhage: Themes, Categories, Codes, and Participant Statements (n=17) Themes Categories Codes Participant Quotations Clinical preparedness and response capacity Resource Access Medication and equipment access I have access to a Bakri balloon, but we do not have the large syringes we use to fill it quickly. I have to get those, too. I have to collect everything from somewhere else.” (P10) Supply shortages and the difficulty of use “Fibrinogen has just arrived. Provision of the supplies used for postpartum hemorrhage is also very important. These need to be prepared in advance and readily available.” (P10) Clinical Competence and Training Clinical intervention adequacy We only have the authority to perform the procedure manually. We remove the placenta, and the bleeding stops there. But when the doctor is not accessible, sometimes seconds matter.” (P15) A lack of emergency obstetrics training Everyone working in a healthcare facility should be knowledgeable about emergency obstetrics. This training should not be online or optional; it should be mandatory, accessible to everyone.” (P10) Postpartum hemorrhage diagnosis and intervention training “Postpartum hemorrhage training should definitely be provided for the delivery room and obstetrics wards.” (P8) Health system and access barriers Physician Access and Decision-Making Processes Delays in accessing physicians “I had trouble accessing the doctor directly… You can manage postpartum hemorrhage, but in cases like rest placenta, you may not have access to a doctor directly. When you contact them, it takes time to arrive, which makes us very nervous…” (P1) Inadequate on-call shift system “The doctor is on-call shift at home. I'm the only midwife on call, gathering supplies and administering treatments. But the doctor arrives late because of the on-call shift at home, and the process takes longer.” (P10) Physician-centered decision-making “We do whatever the doctor says. Despite the risks predicted by the midwives, pregnant women who need to be referred are sometimes kept here. This is because the doctor makes the decision, and we can only guide them.” (P2) “The biggest problem here is the doctor's decision. We only provide information, but they make the decision. We have no authority.” (P7) Follow-Up and Coordination Gaps Pregnancies with no follow-up “Sometimes a patient comes to us, and we find out that she has not seen a doctor in nine months. These patients are like suicide bombers; you never know when they will bleed. Unfortunately, there are many pregnant women these days who are not followed up.” (P15) “We cannot see the results in primary care data. Patients seem to be unfollowed, but they say they have been followed up elsewhere. Because there's no information sharing, we cannot take precautions.” (P8) Failure to classify at-risk pregnancies This pregnant woman has not been followed up at our hospital. Even though she was anemic in the primary care unit, she was not classified as at-risk. She gave birth here, but she was actually in the high-risk group. Primary care should be more meticulous. (P1) A lack of information sharing "Primary, secondary, and tertiary care units need to meet on a common platform. For example, there may be a common file recording blood values, and we can also see it." (P1) Team dynamics and crisis management Team Structure and Coordination Gaps Personnel shortage "The biggest problem with postpartum hemorrhage is the lack of staff. During a shift, I was left alone with a patient bleeding after a C-section. There was no other midwife to support me." (P10) Role ambiguities "There should be only one person managing a case. When everyone is saying different things at the same time, it creates chaos. Then, it becomes unclear who is doing what." (P3) A lack of harmony "The team is not always in the same harmony. While one's provision of supplies is slow, another's priorities are different. This lack of shared perception of urgency creates problems." (P10) Crisis and Traumatic Experiences Experiences of severe bleeding "One pregnant woman experienced atony after a c-section. She did not respond to any medication. Finally, the bleeding was stopped by placing a tube. There was significant blood loss." (P1) Risk of maternal loss "In one case, the patient lost so much blood that the risk of losing the mother was very high. It was a very traumatizing experience." (P1) Midwives' helplessness “The doctor was on call during a bleeding case, and I was the only midwife on duty. I had to calm the patient, administer treatments, and gather supplies. Being alone was a huge problem.” (P10) Training and policy gaps Training Gaps Need for in-service training “Knowledge and education are very important… People need to improve themselves. You cannot practice without knowing the theory. That's why in-service training should be conducted more regularly.” (P15) Inadequate antenatal education “To raise informed patients, we absolutely must refer them to pregnancy schools. Iron use and risky pregnancies should be explained more comprehensively in pregnancy schools.” (P3) A lack of education for men and women “Lack of follow-up, ignorance, and lack of education are the most significant problems. When both men and women are not well-informed, pregnancies tend to be unplanned.” (P1) “In a patriarchal society, men do not favor contraception, and when women are uneducated, they resort to primitive methods. This increases unplanned pregnancies and postpartum bleeding.” (P1) Reproductive Health and Policy Gaps A lack of awareness of fertility control “The majority of the pregnant women coming here are multiparous. Limiting births would be preventative, but we cannot restrict reproduction. Awareness-raising is essential.” (P1) Weak family planning policies “Family planning is seriously inefficient. It's limited to just distributing condoms. This absolutely needs to be expanded. Pregnant women do not know what to expect.” (P4) Facilitative strategies Organizational Preparedness Hemorrhage kits “We prepare a postpartum hemorrhage kit. When I'm called for help from the obstetrics and gynecology department, I take that kit with me from the delivery room. This way, we do not have to hunt for supplies. This provides a significant convenience.” (P10) Planned blood reserves “Our hospital did not have enough blood reserves, so we had to request blood from another hospital. This process took a long time. If we had a planned blood reserve, the intervention could have been done much faster.” (P13) Experience Sharing and Support Mentorship by experienced staff “Experience in bleeding prevention is very important. Having seen many cases before allows us to quickly identify the source of bleeding. This experience is the biggest enabler for us.” (P16) Theme 1: Clinical Preparedness and Response Capacity Midwives highlighted that one of the most critical barriers to effective postpartum hemorrhage (PPH) management was difficulty accessing necessary supplies and medications. Participants reported losing valuable time gathering equipment, which hindered timely intervention and made controlling bleeding more challenging. One participant described this issue by expressing a lack of preparation during the intervention as follows: “ I have access to a Bakri balloon, but we do not have the large syringes we use to fill it quickly. I have to get those, too. I have to collect everything from somewhere else.” (P10) Delays were also attributed to unfamiliarity with newly introduced materials. As one midwife noted: “Fibrinogen has just arrived. Provision of the supplies used for postpartum hemorrhage is also very important.” (P10) Limited authority to perform certain interventions was another significant challenge. Midwives reported that when physicians were unavailable, critical seconds were lost, potentially jeopardizing patient outcomes. One participant stated: “ We only have the authority to perform the procedure manually... But when the doctor is not accessible, sometimes seconds matter .” (P15) Finally, gaps in emergency obstetrics and PPH training were strongly emphasized. Participants recommended that training should be mandatory, regularly scheduled, and accessible to all staff rather than optional or online-only. One midwife summarized this need as follows: " This training should not be online or optional; it should be mandatory, accessible to everyone .” (P10) Theme 2: Health System and Access Barriers Midwives emphasized that structural barriers within the healthcare system significantly affected the management of postpartum hemorrhage (PPH). Delays in accessing physicians and inadequacies in the emergency call system were reported to result in lost time during critical interventions. One participant described this challenge as follows: “ I had trouble accessing the doctor directly… and when you contact them, it takes time to arrive, which makes us very nervous …” (P1) Similarly, another participant stated that midwives were left alone. “ The doctor is on-call shift at home. I'm the only midwife on call ... the process takes longer .” (P10) Physician-centered decision-making processes further constrained midwifery practice. Although midwives recognized when at-risk pregnancies required referral, the decision-making authority rested solely with physicians, limiting their ability to intervene directly (P2, P7). Another major challenge identified was the lack of pregnancy follow-up and coordination across care levels. Midwives reported that pregnancies without consistent monitoring carried a “suicide bomber” risk of PPH (P15). Inaccurate classification of high-risk pregnancies and the absence of information sharing between primary, secondary, and tertiary care units were cited as serious gaps. One participant highlighted the need for better system integration as follows: " If there were a file recording blood values on a common platform, we could see it too ." (P1) Theme 3: Team Dynamics and Crisis Management Midwives emphasized that one of the most challenging aspects of postpartum hemorrhage (PPH) management was team coordination and dynamics during crises. Staff shortages were highlighted as a major barrier, with midwives often required to manage severe bleeding alone, limiting their capacity to respond effectively. One participant described this challenge: “During a shift, I was left alone with a patient bleeding after a C-section. There was no other midwife to support me." (P10) Role ambiguity further impeded effective teamwork. Participants noted that when multiple team members followed different instructions simultaneously during hemorrhage interventions, it led to confusion and disorganization. One midwife explained: “ It becomes unclear who is doing what… The result is sheer chaos ” (P3). The inability to maintain consistent team harmony was identified as another factor that slowed interventions and reduced their effectiveness. Traumatic experiences during crises also had a profound emotional impact on midwives. Participants described the intense blood loss, the high risk of maternal death, and the burden of sole responsibility as particularly distressing. One participant expressed the emotional burden experienced by saying, “ She lost so much blood. The risk of losing the mother was immense. It was a very traumatizing experience .” (P1) Similarly, midwives working alone reported having to simultaneously administer treatment and calm the patient, creating immense pressure. Theme 4: Training and Policy Aspects Participants highlighted that deficiencies in education constituted a significant barrier to the effective management of postpartum hemorrhage (PPH). Both theoretical and practical training were considered inadequate, with midwives emphasizing the need for ongoing updates through structured, regular in-service training. As one participant noted: “ Knowledge and education are very important… Practice cannot be done without understanding the theory. Therefore, in-service training should be conducted more regularly.” (P15) Participants also considered inadequate education among pregnant women as a risk factor that increased postpartum hemorrhage. One participant (P3) stated that referring pregnant women to pregnancy schools and raising awareness about medication use and risky pregnancies would be a preventative approach. Participants reported that the lack of education of both women and men led to unplanned pregnancies, which in turn increased the risk of hemorrhage. One participant emphasized the social dimension by saying, “ Lack of follow-up, ignorance, and lack of education are the most important problems. When both women and men lack awareness, pregnancies become unplanned. ” (P1) On the policy side, deficiencies in family planning services and inadequate fertility control were highlighted. Participants stated that preventing multiparous pregnancies was important, but current policies failed to meet this need. One participant emphasized the gap in current policies in the following way: “ Family planning is seriously inefficient. It's limited to just distributing condoms. This absolutely needs to be expanded .” (P4) Theme 5: Facilitative Strategies Despite the challenges encountered in managing postpartum hemorrhage (PPH), midwives identified several organizational and experience-based practices that facilitated timely and effective interventions. The most frequently mentioned strategy was the use of postpartum hemorrhage kits. Participants emphasized that having a pre-prepared kit, rather than gathering supplies during an emergency, significantly reduced delays. One participant highlighted this practice: " We prepare a postpartum hemorrhage kit... so we don't have to hunt for supplies ." (P10) Planned blood reserves were also described as a critical facilitator. Rapid access to blood prevented delays in life-saving interventions. As one midwife stated: "If there were planned blood reserves, the intervention could be performed much faster ." (P13) Midwives also stated that mentorship by experienced staff provided significant support in hemorrhage management. The ability of experienced healthcare professionals to respond quickly to cases instilled confidence in the team and facilitated proper implementation. One participant explained the importance of experience as follows: “ Having seen many cases before allows us to quickly recognize the source of bleeding .” (P16) Discussion This study explored the challenges midwives encountered in preventing, diagnosing, and managing postpartum hemorrhage (PPH) and highlighted potential solutions across five key themes that closely align with real-world practice. Our findings demonstrated that gaps in clinical preparedness and response capacity, limited physician access and referral system inefficiencies, weaknesses in team dynamics and crisis management, training and policy deficiencies, and the presence of facilitating practices all directly impacted PPH outcomes. These findings are consistent with the 2023 World Health Organization (WHO) guidelines, which emphasize a standardized approach to hemorrhage assessment—such as quantitative blood loss (QBL)—and the implementation of evidence-based, packaged initial responses by the clinical team (World Health Organization, 2023 ). Within the preparedness dimension, midwives frequently cited delays in accessing equipment and medications, as well as suboptimal organization of materials, as barriers to timely intervention. Such challenges underscore why the “readiness” domain is considered essential in international quality improvement packages. For instance, the AIM (Alliance for Innovation on Maternal Health) Obstetric Hemorrhage Patient Safety Bundle (2022 update) mandates the availability of a hemorrhage cart or kit, standardized checklists, and stage-based protocols in every unit to ensure consistent and timely execution of diagnostic and treatment steps (Adams & Meadows, 2022 ; Alliance for Innovation on Maternal Health, 2022 ). Similarly, the CMQCC (California Maternal Quality Care Collaborative) Toolkit v3.0 recommends repeated risk assessments, adherence to medication protocols—including the appropriate use of tranexamic acid—and detailed guidance for blood transfusions. Implementation of these structured packages has been associated with significant reductions in severe maternal morbidity due to hemorrhage in California (California Department of Public Health, 2021 ). Access and system-related challenges identified in this study demonstrated that delays in on-call physician availability and referral processes could postpone critical interventions, particularly during the first hours of postpartum hemorrhage, thereby increasing mortality risk. The 2023 WHO PPH Roadmap emphasizes the importance of legislating midwife competencies, strengthening referral and transportation systems, ensuring a reliable supply of quality-assured consumables and medications, and implementing task-sharing strategies to reduce such barriers (Sexual and Reproductive Health and Research [SRH], 2023; Williams et al., 2024 ). Similarly, the 2024 International Confederation of Midwives (ICM) Core Competencies Framework defines midwives’ responsibilities to include coordinating evidence-based practices both independently and within teams, maintaining accurate recording and communication, and initiating timely consultation and referral processes as part of professional standards (International Confederation of Midwives, 2024 ). Within this context, the development of integrated information-sharing platforms between primary care and hospitals, alongside standardized referral criteria, is critical to mitigate vulnerabilities associated with “unfollowed” or high-risk pregnancies, as observed in our findings (SRH, 2023). Regarding team dynamics and crisis management, our results indicated that staffing shortages, role ambiguity, and communication breakdowns contributed to confusion and inefficiency during hemorrhage events. Existing literature supports that structured, team-based simulation and clear task allocation improve both process indicators—such as timely medication administration and protocol adherence—and clinical outcomes. For example, a prospective intervention study in Tanzania showed a significant reduction in PPH incidence following simulation-based training (Nelissen et al., 2017 ). Scenario guides and checklists, as included in the CMQCC package, can clarify roles within local teams and establish a field-appropriate command-and-control system during emergencies (California Department of Public Health, 2021 ). In line with these recommendations, the WHO PPH Roadmap identifies scaling up practical teamwork and simulation training within obstetric emergency teams as a priority action to enhance preparedness and reduce adverse outcomes (SRH, 2023). In terms of education and policy, gaps in in-service training identified by midwives were consistent with current international guidelines. The FIGO (International Federation of Gynecology and Obstetrics) 2022 guidelines emphasize the correct and early use of uterotonics for both prophylaxis and treatment, along with stepwise management of PPH (Escobar et al., 2022a). The WHO 2023 assessment and treatment package further underscores the standardization of diagnostic thresholds and the use of initial response packages, including uterotonics, uterine massage or compression, and balloon tamponade (World Health Organization, 2023 ). Tranexamic acid has become a key component of the initial response, with strong recommendations to administer 1 g intravenously within three hours of bleeding onset, followed by a second 1 g dose 30 minutes later if necessary (International Federation of Gynecology and Obstetrics, 2021 ; World Health Organization, 2017 ). Dissemination of these recommendations is essential to enable midwives to initiate timely, evidence-based interventions, particularly when immediate physician access is limited. Finally, facilitative practices, including pre-prepared hemorrhage kits or carts, planned blood reserves, and mentorship by experienced staff, emerged in our findings as tangible strategies that improve field-level response. These elements are also recognized as unit-level standards in the AIM and CMQCC materials (Alliance for Innovation on Maternal Health, 2022 ; California Department of Public Health, 2021 ). Additional strategies, such as quantitative blood loss (QBL) risk assessment, establishment of rapid response teams, and shared decision-making through post-event review, further contribute to coordinated and effective management. In conclusion, midwives’ experiences in this study align closely with current evidence: improving PPH outcomes depends not only on individual clinical skills but on ensuring a robust institutional cycle encompassing readiness, diagnosis, response, and post-event learning. Based on these findings, we recommend (i) standardization of localized PPH protocols and hemorrhage carts, aligned with AIM and CMQCC recommendations; (ii) support for the initial response package, including uterotonics, tranexamic acid, and balloon tamponade, accompanied by midwifery competence and ongoing training; (iii) establishment of a culture of regular, multidisciplinary simulation and post-event learning; and (iv) strengthening of referral, supply, and data-sharing infrastructures in accordance with the WHO Roadmap. Implementing these measures has the potential to improve clinical outcomes, enhance maternal safety, and reduce the psychosocial burden on healthcare teams managing PPH. Strengths and Limitations This study captured midwives’ experiences of postpartum hemorrhage (PPH) directly, allowing participants to express their perspectives in their own words and addressing clinical, system, team, educational, and policy dimensions from a multifaceted perspective. Inclusion of midwives from different institutions enhanced the diversity of experiences and provided unique contributions to the literature. However, the study has some limitations. It was conducted in a specific region, which limits the generalizability of the findings. The data were based on participants’ subjective experiences and may reflect perceptual differences. Additionally, the exclusive focus on midwives’ perspectives excludes the insights of other healthcare professionals involved in PPH management. Conclusions This study provided a comprehensive perspective on the challenges midwives encounter in preventing, diagnosing, and managing postpartum hemorrhage (PPH), as well as the practical solutions they implement. The findings indicate that deficiencies in clinical preparation, delays in physician access, communication breakdowns within teams, inadequate in-service training, and policy gaps negatively affect the effectiveness of hemorrhage management. Conversely, facilitative practices identified by midwives—such as the use of pre-prepared postpartum hemorrhage kits, planned blood reserves, and mentorship by experienced staff—offer practical strategies to enhance both the safety and efficiency of PPH care. These results highlight the need to strengthen midwives' competencies, expand regular simulation training, and develop family planning policies. Overall the study highlights areas requiring improvement not only in clinical care practices but also at the healthcare system and policy levels. Empowering midwives and removing systemic barriers is critical for improving maternal safety. Declarations Acknowledgements We sincerely thank all the midwives who participated in the study and shared their experiences. We are also grateful to the institutional officials who contributed to the study and to all healthcare professionals who provided support. Authors’ contributions Nafiye Dutucu: Conceptualization, Methodology, Formal Analysis, Resources, Data Curation, Writing – Original Draft, Writing – Review & Editing, Supervision, Project Administration. Sena Dilek Aksoy: Conceptualization, Methodology, Investigation, Resources, Data Curation, Writing – Original Draft, Writing – Review & Editing, Visualization. Resmiye Özdilek: Formal Analysis, Resources, Data Curation, Writing – Review & Editing, Visualization. Funding The authors received no financial support for the research, authorship, and/or publication of this article. Data availability The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate Ethical approval was obtained from the Kocaeli University Non-Interventional Ethics Committee (Approval Number: GOKAEK-2022/21.22; Project Number: 2022/356). 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How phenomenology can help us learn from the experiences of others. Perspect. Med. Educ. 8, 90–97. https://doi.org/10.1007/S40037-019-0509-2 O’Brien, B.C., Harris, I.B., Beckman, T.J., Reed, D.A., Cook, D.A., 2014. Standards for reporting qualitative research. Acad. Med. 89, 1245–1251. https://doi.org/10.1097/ACM.0000000000000388 Omotayo, M.O., Abioye, A.I., Kuyebi, M., Eke, A.C., 2021. Prenatal anemia and postpartum hemorrhage risk: A systematic review and meta-analysis. J. Obstet. Gynaecol. Res. 47, 2565–2576. https://doi.org/10.1111/jog.14834 Parker, C., Scott, S., Geddes, A., 2019. Snowball sampling. https://doi.org/10.4135/9781526421036831710 Richardson, J., Hollier-Hann, G., Kelly, K., Chiara Alvisi, M., Winter, C., Cetin, I., Draycott, T., Harvey, T., Visser, G.H.A., Yip Sonderegger, Y.L., Perroud, J., 2022. A study of the healthcare resource use for the management of postpartum haemorrhage in France, Italy, the Netherlands, and the UK. Eur. J. Obstet. Gynecol. Reprod. Biol. 268, 92–99. https://doi.org/10.1016/j.ejogrb.2021.11.432 Saunders, B., Sim, J., Kingstone, T., Baker, S., Waterfield, J., Bartlam, B., Burroughs, H., Jinks, C., 2018. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual. Quant. 52, 1893–1907. https://doi.org/10.1007/s11135-017-0574-8 Say, L., Chou, D., Gemmill, A., Tunçalp, Ö., Moller, A.B., Daniels, J., Gülmezoglu, A.M., Temmerman, M., Alkema, L., 2014. Global causes of maternal death: A WHO systematic analysis. Lancet Glob. Heal. 2, 323–333. https://doi.org/10.1016/S2214-109X(14)70227-X Sexual and Reproductive Health and Research (SRH), 2023. A roadmap to combat postpartum haemorrhage between 2023 and 2030 [WWW Document]. World Heal. Organ. URL https://www.who.int/publications/i/item/9789240081802 Türkiye İstatistik Kurumu, 2021. Sürdürülebilir Kalkınma Göstergeleri , 2010-2019. Türkiye İstatistik Kurumu Haber Bülteni. WHO, UNICEF, UNFPA, UNPD, 2019. Maternal mortality in 2000-2017, Internationally comparable MMR estimates by the Maternal Mortality Estimation Inter-Agency Group (MMEIG). Data from Civ. Regist. vital Stat. Syst. Available 1–10. Williams, C.R., Adnet, G., Gallos, I.D., Coomarasamy, A., Gülmezoglu, A.M., Islam, M.A., Rushwan, S., Widmer, M., Althabe, F., Oladapo, O.T., 2024. Research agenda for ending preventable maternal deaths from postpartum haemorrhage: a WHO research prioritisation exercise. BMJ Glob. Heal. 9, e015342. https://doi.org/10.1136/bmjgh-2024-015342 World Health Organization, 2023. WHO recommendations on the assessment of postpartum blood loss and use of a treatment bundle for postpartum haemorrhage. World Health Organization, Geneva. World Health Organization, 2017. WHO recommendation on tranexamic acid for the treatment of postpartum haemorrhage [WWW Document]. World Heal. Organ. URL https://www.ncbi.nlm.nih.gov/books/NBK493072/table/executivesummary.t1/ Yıldırım, A.D., Şahin, N.H., 2021. Anne Ölümlerinin Önlenmesi: Uluslararası Bakım ve İzlem Modelleri. Jinekoloji-Obstetrik ve Neonatoloji Tıp Derg. https://doi.org/10.38136/jgon.842685 Additional Declarations No competing interests reported. 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Globally, an estimated 200 women die every hour from complications related to PPH (Finlayson et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Say et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Uterine atony, the most common cause of PPH, accounts for 58\u0026ndash;90% of cases. Although once considered primarily a problem of developing countries, recent evidence indicates that PPH incidence is also increasing in developed countries (Flood et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Gallos et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). As a medical emergency, PPH requires immediate intervention to prevent maternal death, yet timely recognition and appropriate management can substantially reduce its impact (WHO, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAccording to data from the Turkish Statistical Institute, the maternal mortality rate in 2018 was 13.6 per 100,000 live births, with hemorrhage accounting for approximately 20% of maternal deaths (TURKSTAT, 2021; Yıldırım \u0026amp; Şahin, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In the literature, minor PPH is defined as blood loss of 500\u0026ndash;1000 ml, while major PPH refers to blood loss exceeding 1000 ml (Kalu \u0026amp; Chukwurah, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2022a\u003c/span\u003e). Evidence suggests that the incidence of morbidity, particularly related to major PPH, has risen in recent years (Flood et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Merriam et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Depending on its severity, PPH can lead to hypovolemic shock, multiple organ failure, and maternal death, especially when compounded by preexisting anemia or delayed and ineffective management (Agarwal et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Escobar et al., 2022b; Omotayo et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Preventing predisposing factors such as anemia during pregnancy, ensuring proper management of the first and second stages of labor, actively managing the third stage, and particularly the timely and effective use of uterotonic agents are critical strategies to reduce the incidence of PPH (Escobar et al., 2022b; Gonzalez-Brown \u0026amp; Schneider, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; WHO, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTimely diagnosis, effective intervention, and management of PPH remain major challenges, particularly in low- and middle-income countries (Akter et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In the past five years, several systematic reviews on PPH management strategies have suggested that preventive approaches may be more effective than treatment alone (Akter et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Carr et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ferrari et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Masuzawa et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). As PPH is a critical determinant of maternal mortality, research on its prevention and management continues to grow. However, a comprehensive predictive model that can improve prognosis has yet to be established (Carr et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Understanding the perceptions and experiences of key stakeholders\u0026mdash;including healthcare professionals, women, and family members\u0026mdash;is therefore essential for improving the recognition and management of PPH (Akter et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Qualitative research can provide unique insights into these perspectives and contribute to the development of feasible, acceptable, and effective strategies and policies for timely and appropriate PPH interventions. Multiple interacting factors hinder the prevention, early detection, and management of PPH (Higgins et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), and identifying these factors through quantitative data alone has limitations. Recognizing these influences can provide valuable evidence to inform the design of new strategies. Emerging evidence-based approaches can improve the implementation of existing PPH strategies or enhance current practices that are difficult to change (Akter et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Midwives play a central role in this process, and their experiences and perceptions are especially important.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eAim\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study aimed to explore in depth and thematically the experiences, perceptions, and recommendations of midwives regarding the prevention, diagnosis, and management of postpartum hemorrhage (PPH) using a qualitative approach.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDesign\u003cbr\u003e\u003c/em\u003eA qualitative research design was employed, which emphasizes individuals\u0026rsquo; experiences of a phenomenon and is widely used in health research (Neubauer et al., 2019). This approach enabled a detailed exploration of midwives\u0026rsquo; perspectives and suggestions concerning the prevention, diagnosis, and management of PPH. In-depth individual interviews were chosen as the method of data collection. The study was reported in accordance with the Standards for Reporting Qualitative Research (SRQR) (O\u0026rsquo;Brien et al., 2014).\u003c/p\u003e\n\u003cp\u003eThe semi-structured interview form used in this study was developed by the researchers based on an extensive review of the relevant literature. To ensure content validity, the form was reviewed by six experts specializing in qualitative research in the fields of obstetric nursing and midwifery, and revisions were made in line with their feedback.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSetting and sampling\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were recruited through snowball sampling between June 2023 and December 2024, following the necessary institutional permissions and informed consent procedures. Snowball sampling, also known as chain sampling, is a non-probability technique in which participants recruit other potential participants from their network (Naderifar et al., 2017; Parker et al., 2019). Data collection began at a public hospital in western T\u0026uuml;rkiye, where an invitation announcement was shared in the hospital\u0026rsquo;s online midwife groups. The first participant was interviewed, and subsequent participants were recruited via referrals through the snowballing process. Interviews continued until data saturation was reached, i.e., when no new information emerged, consistent with recommendations in the literature (Naeem et al., 2024; Saunders et al., 2018). Data saturation was achieved with a total of 17 participants. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData collection\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData were collected using a participant information form and a semi-structured interview guide developed by the researchers for individual in-depth interviews. The participant information form included five items addressing age, marital status, educational background, and professional experience.\u003c/p\u003e\n\u003cp\u003eThe semi-structured interview guide comprised seven main questions exploring midwives\u0026rsquo; experiences with the prevention, diagnosis, and management of postpartum hemorrhage. Each question was reviewed and refined with input from three midwife researchers experienced in qualitative methods. Sample questions included:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Please describe your experiences with preventing postpartum hemorrhage at your institution.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Please describe your experiences with diagnosing postpartum hemorrhage at your institution.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Please describe your experiences with managing postpartum hemorrhage at your institution.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eInterviews were conducted outside participants\u0026rsquo; working hours. Appointments were scheduled in advance according to participants\u0026rsquo; convenience regarding time and location. All interviews were conducted face-to-face by the same researcher and lasted approximately 30\u0026ndash;45 minutes. Audio recordings of the interviews were made with participants\u0026rsquo; consent. At the end of each interview, participants were invited to listen to and confirm the recordings. The verbal data were then transcribed verbatim, and participants were asked to verify the accuracy of the transcriptions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe audio-recorded interviews were transcribed verbatim using word processing software to facilitate content analysis. A qualitative content analysis approach, as described by Graneheim and Lundman (2004), was employed to gain deeper insights into participants\u0026rsquo; perceptions and attitudes (Graneheim \u0026amp; Lundman, 2004; Lindgren et al., 2020). Using the semi-structured interview questions as a guide, each researcher independently identified meaningful units and recurring expressions relevant to the research questions and study aim. These expressions were then analyzed inductively to generate categories and overarching themes. Two researchers who had not conducted the interviews collaboratively reviewed and refined the meaningful expressions, categories, and themes to reach consensus. In cases where agreement could not be reached, the researcher who conducted the interviews was consulted. This process ensured that the creation and naming of categories and themes were achieved through collective agreement among the research team. Finally, the qualitative data were cross-checked and organized using a trial version of MAXQDA24 (VERBI Software) to enhance the rigor and accuracy of the analysis.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eValidity, reliability, and rigor\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study rigorously adhered to the criteria for trustworthiness proposed by Lincoln and Guba, which include credibility, transferability, dependability, and confirmability (Lincoln et al., 1985). Participant validation was employed to enhance credibility and ensure the accuracy of the identified themes. Specifically, each participant listened to the audio recordings after their interviews and confirmed the accuracy of the transcriptions. All participants verified that the information accurately reflected their statements. During interviews, participants were encouraged to provide detailed and clear accounts of their perceptions and attitudes. The reliability of the study was estimated using the formula suggested by Miles and Huberman, which calculates the percentage of agreement: Reliability = Agreement / (Agreement + Disagreement) \u0026times; 100. According to Miles and Huberman, an agreement rate between 80% and 90% is considered adequate for reliability (Miles \u0026amp; Huberman, 2021). In this study, a reliability rate exceeding 90% was achieved, demonstrating the dependability of the qualitative data. Credibility was further strengthened through reflexivity (Darawsheh, 2014; Kalu \u0026amp; Chukwurah, 2022b).\u003c/p\u003e\n\u003cp\u003eA consistent research design was maintained throughout the study, and strategies to enhance reliability were systematically applied. The use of a semi-structured interview guide for all interviews helped participants focus on the topic and contributed to the credibility, transferability, and confirmability of the study (Adeoye‐Olatunde \u0026amp; Olenik, 2021; Horton et al., 2004).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrior to the initiation of the study, ethical approval was obtained from the Kocaeli University Non-Interventional Ethics Committee, Turkey (Approval Number: GOKAEK-2022/21.22; Project Number: 2022/356). Written permission was also secured from the healthcare institution where the study was conducted. All participants provided both verbal and written informed consent for participation and for the use of audio recording devices. The study was conducted in full accordance with the ethical principles of the Declaration of Helsinki (as revised in 2013) and approved by the aforementioned ethics committee.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eParticipants\u0026rsquo; characteristics\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean age of the participants was 33.65\u0026plusmn;8.34 years (min.: 24; max.: 51) years. Participants\u0026apos; characteristics about age, marital status, education level, total work experience, and previous emergency obstetric care training are presented in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Some demographic and professional characteristics of the participants (n=17)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"622\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWork experience as a midwife (year)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious emergency obstetric care training\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eParticipant 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eSingle\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eUndergraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eParticipant 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eUndergraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e15\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eParticipant 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eUndergraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eParticipant 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eUndergraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e6\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eParticipant 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eUndergraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eParticipant 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eUndergraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e25\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eParticipant 7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eUndergraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e17\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eParticipant 8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003ePostgraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e10\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eParticipant 9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003ePostgraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e8\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eParticipant 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;Single\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eUndergraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eParticipant 11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003ePostgraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e6\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eParticipant 12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eUndergraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eParticipant 13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eUndergraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eParticipant 14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eUndergraduate\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e7\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eParticipant 15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eUndergraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e17\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eParticipant 16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e32\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eParticipant 17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eUndergraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e27\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u0026apos; Views on Their Experiences with Postpartum Hemorrhage\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, in-depth interviews with 17 midwives were analyzed using thematic analysis. Five main themes emerged, reflecting participants\u0026rsquo; experiences with the prevention, diagnosis, and management of postpartum hemorrhage (PPH). The main themes, along with their corresponding categories, codes, and representative participant statements, are summarized in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Midwives\u0026apos; Experiences with Preventing, Diagnosing, and Managing Postpartum Hemorrhage: Themes, Categories, Codes, and Participant Statements (n=17)\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"959\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategories\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCodes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant Quotations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eClinical preparedness and response capacity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eResource Access\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eMedication and equipment access\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003eI have access to a Bakri balloon, but we do not have the large syringes we use to fill it quickly. I have to get those, too. I have to collect everything from somewhere else.\u0026rdquo; (P10)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eSupply shortages and the difficulty of use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Fibrinogen has just arrived. Provision of the supplies used for postpartum hemorrhage is also very important. These need to be prepared in advance and readily available.\u0026rdquo; (P10)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eClinical Competence and Training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eClinical intervention adequacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003eWe only have the authority to perform the procedure manually. We remove the placenta, and the bleeding stops there. But when the doctor is not accessible, sometimes seconds matter.\u0026rdquo; (P15)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eA lack of emergency obstetrics training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003eEveryone working in a healthcare facility should be knowledgeable about emergency obstetrics. This training should not be online or optional; it should be mandatory, accessible to everyone.\u0026rdquo; (P10)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003ePostpartum hemorrhage diagnosis and intervention training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Postpartum hemorrhage training should definitely be provided for the delivery room and obstetrics wards.\u0026rdquo; (P8)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eHealth system and access barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003ePhysician Access and Decision-Making Processes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eDelays in accessing physicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I had trouble accessing the doctor directly\u0026hellip; You can manage postpartum hemorrhage, but in cases like rest placenta, you may not have access to a doctor directly. When you contact them, it takes time to arrive, which makes us very nervous\u0026hellip;\u0026rdquo; (P1)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eInadequate on-call shift system\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The doctor is on-call shift at home. I\u0026apos;m the only midwife on call, gathering supplies and administering treatments. But the doctor arrives late because of the on-call shift at home, and the process takes longer.\u0026rdquo; (P10)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003ePhysician-centered decision-making\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;We do whatever the doctor says. Despite the risks predicted by the midwives, pregnant women who need to be referred are sometimes kept here. This is because the doctor makes the decision, and we can only guide them.\u0026rdquo; (P2)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The biggest problem here is the doctor\u0026apos;s decision. We only provide information, but they make the decision. We have no authority.\u0026rdquo; (P7)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFollow-Up and Coordination Gaps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003ePregnancies with no follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes a patient comes to us, and we find out that she has not seen a doctor in nine months. These patients are like suicide bombers; you never know when they will bleed. Unfortunately, there are many pregnant women these days who are not followed up.\u0026rdquo; (P15)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;We cannot see the results in primary care data. Patients seem to be unfollowed, but they say they have been followed up elsewhere. Because there\u0026apos;s no information sharing, we cannot take precautions.\u0026rdquo; (P8)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eFailure to classify at-risk pregnancies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003eThis pregnant woman has not been followed up at our hospital. Even though she was anemic in the primary care unit, she was not classified as at-risk. She gave birth here, but she was actually in the high-risk group. Primary care should be more meticulous. (P1)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eA lack of information sharing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Primary, secondary, and tertiary care units need to meet on a common platform. For example, there may be a common file recording blood values, and we can also see it.\u0026quot; (P1)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eTeam dynamics and crisis management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eTeam Structure and Coordination Gaps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003ePersonnel shortage\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;The biggest problem with postpartum hemorrhage is the lack of staff. During a shift, I was left alone with a patient bleeding after a C-section. There was no other midwife to support me.\u0026quot; (P10)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eRole ambiguities\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;There should be only one person managing a case. When everyone is saying different things at the same time, it creates chaos. Then, it becomes unclear who is doing what.\u0026quot; (P3)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eA lack of harmony\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;The team is not always in the same harmony. While one\u0026apos;s provision of supplies is slow, another\u0026apos;s priorities are different. This lack of shared perception of urgency creates problems.\u0026quot; (P10)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eCrisis and Traumatic Experiences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eExperiences of severe bleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;One pregnant woman experienced atony after a c-section. She did not respond to any medication. Finally, the bleeding was stopped by placing a tube. There was significant blood loss.\u0026quot; (P1)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eRisk of maternal loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;In one case, the patient lost so much blood that the risk of losing the mother was very high. It was a very traumatizing experience.\u0026quot; (P1)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eMidwives\u0026apos; helplessness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The doctor was on call during a bleeding case, and I was the only midwife on duty. I had to calm the patient, administer treatments, and gather supplies. Being alone was a huge problem.\u0026rdquo; (P10)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eTraining and policy gaps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eTraining Gaps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eNeed for in-service training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Knowledge and education are very important\u0026hellip; People need to improve themselves. You cannot practice without knowing the theory. That\u0026apos;s why in-service training should be conducted more regularly.\u0026rdquo; (P15)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eInadequate antenatal education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;To raise informed patients, we absolutely must refer them to pregnancy schools. Iron use and risky pregnancies should be explained more comprehensively in pregnancy schools.\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eA lack of education for men and women\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Lack of follow-up, ignorance, and lack of education are the most significant problems. When both men and women are not well-informed, pregnancies tend to be unplanned.\u0026rdquo; (P1)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;In a patriarchal society, men do not favor contraception, and when women are uneducated, they resort to primitive methods. This increases unplanned pregnancies and postpartum bleeding.\u0026rdquo; (P1)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eReproductive Health and Policy Gaps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eA lack of awareness of fertility control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The majority of the pregnant women coming here are multiparous. Limiting births would be preventative, but we cannot restrict reproduction. Awareness-raising is essential.\u0026rdquo; (P1)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eWeak family planning policies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Family planning is seriously inefficient. It\u0026apos;s limited to just distributing condoms. This absolutely needs to be expanded. Pregnant women do not know what to expect.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eFacilitative strategies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eOrganizational Preparedness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eHemorrhage kits\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;We prepare a postpartum hemorrhage kit. When I\u0026apos;m called for help from the obstetrics and gynecology department, I take that kit with me from the delivery room. This way, we do not have to hunt for supplies. This provides a significant convenience.\u0026rdquo; (P10)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003ePlanned blood reserves\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Our hospital did not have enough blood reserves, so we had to request blood from another hospital. This process took a long time. If we had a planned blood reserve, the intervention could have been done much faster.\u0026rdquo; (P13)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eExperience Sharing and Support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eMentorship by experienced staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Experience in bleeding prevention is very important. Having seen many cases before allows us to quickly identify the source of bleeding. This experience is the biggest enabler for us.\u0026rdquo; (P16)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cem\u003eTheme 1: Clinical Preparedness and Response Capacity\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMidwives highlighted that one of the most critical barriers to effective postpartum hemorrhage (PPH) management was difficulty accessing necessary supplies and medications. Participants reported losing valuable time gathering equipment, which hindered timely intervention and made controlling bleeding more challenging. One participant described this issue by expressing a lack of preparation during the intervention as follows:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI have access to a Bakri balloon, but we do not have the large syringes we use to fill it quickly. I have to get those, too. I have to collect everything from somewhere else.\u0026rdquo;\u003c/em\u003e (P10)\u003c/p\u003e\n\u003cp\u003eDelays were also attributed to unfamiliarity with newly introduced materials. As one midwife noted:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Fibrinogen has just arrived. Provision of the supplies used for postpartum hemorrhage is also very important.\u0026rdquo;\u003c/em\u003e (P10)\u003c/p\u003e\n\u003cp\u003eLimited authority to perform certain interventions was another significant challenge. Midwives reported that when physicians were unavailable, critical seconds were lost, potentially jeopardizing patient outcomes. One participant stated:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eWe only have the authority to perform the procedure manually... But when the doctor is not accessible, sometimes seconds matter\u003c/em\u003e.\u0026rdquo; (P15)\u003c/p\u003e\n\u003cp\u003eFinally, gaps in emergency obstetrics and PPH training were strongly emphasized. Participants recommended that training should be mandatory, regularly scheduled, and accessible to all staff rather than optional or online-only. One midwife summarized this need as follows:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026quot;\u003cem\u003eThis training should not be online or optional; it should be mandatory, accessible to everyone\u003c/em\u003e.\u0026rdquo; (P10)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 2: Health System and Access Barriers\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMidwives emphasized that structural barriers within the healthcare system significantly affected the management of postpartum hemorrhage (PPH). Delays in accessing physicians and inadequacies in the emergency call system were reported to result in lost time during critical interventions. One participant described this challenge as follows:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI had trouble accessing the doctor directly\u0026hellip; and when you contact them, it takes time to arrive, which makes us very nervous\u003c/em\u003e\u0026hellip;\u0026rdquo; (P1) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSimilarly, another participant stated that midwives were left alone.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eThe doctor is on-call shift at home. I\u0026apos;m the only midwife on call ... the process takes longer\u003c/em\u003e.\u0026rdquo; (P10)\u003c/p\u003e\n\u003cp\u003ePhysician-centered decision-making processes further constrained midwifery practice. Although midwives recognized when at-risk pregnancies required referral, the decision-making authority rested solely with physicians, limiting their ability to intervene directly (P2, P7).\u003c/p\u003e\n\u003cp\u003eAnother major challenge identified was the lack of pregnancy follow-up and coordination across care levels. Midwives reported that pregnancies without consistent monitoring carried a \u0026ldquo;suicide bomber\u0026rdquo; risk of PPH (P15). Inaccurate classification of high-risk pregnancies and the absence of information sharing between primary, secondary, and tertiary care units were cited as serious gaps. One participant highlighted the need for better system integration as follows:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026quot;\u003cem\u003eIf there were a file recording blood values on a common platform, we could see it too\u003c/em\u003e.\u0026quot; (P1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 3: Team Dynamics and Crisis Management\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMidwives emphasized that one of the most challenging aspects of postpartum hemorrhage (PPH) management was team coordination and dynamics during crises. Staff shortages were highlighted as a major barrier, with midwives often required to manage severe bleeding alone, limiting their capacity to respond effectively. One participant described this challenge:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;During a shift, I was left alone with a patient bleeding after a C-section. There was no other midwife to support me.\u0026quot; (P10)\u003c/p\u003e\n\u003cp\u003eRole ambiguity further impeded effective teamwork. Participants noted that when multiple team members followed different instructions simultaneously during hemorrhage interventions, it led to confusion and disorganization. One midwife explained: \u0026ldquo;\u003cem\u003eIt becomes unclear who is doing what\u0026hellip; The result is sheer chaos\u003c/em\u003e\u0026rdquo; (P3). The inability to maintain consistent team harmony was identified as another factor that slowed interventions and reduced their effectiveness.\u003c/p\u003e\n\u003cp\u003eTraumatic experiences during crises also had a profound emotional impact on midwives. Participants described the intense blood loss, the high risk of maternal death, and the burden of sole responsibility as particularly distressing. One participant expressed the emotional burden experienced by saying, \u0026ldquo;\u003cem\u003eShe lost so much blood. The risk of losing the mother was immense. It was a very traumatizing experience\u003c/em\u003e.\u0026rdquo; (P1)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSimilarly, midwives working alone reported having to simultaneously administer treatment and calm the patient, creating immense pressure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 4: Training and Policy Aspects\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants highlighted that deficiencies in education constituted a significant barrier to the effective management of postpartum hemorrhage (PPH). Both theoretical and practical training were considered inadequate, with midwives emphasizing the need for ongoing updates through structured, regular in-service training. As one participant noted: \u0026ldquo;\u003cem\u003eKnowledge and education are very important\u0026hellip; Practice cannot be done without understanding the theory. Therefore, in-service training should be conducted more regularly.\u0026rdquo;\u003c/em\u003e (P15)\u003c/p\u003e\n\u003cp\u003eParticipants also considered inadequate education among pregnant women as a risk factor that increased postpartum hemorrhage. One participant (P3) stated that referring pregnant women to pregnancy schools and raising awareness about medication use and risky pregnancies would be a preventative approach. Participants reported that the lack of education of both women and men led to unplanned pregnancies, which in turn increased the risk of hemorrhage. One participant emphasized the social dimension by saying, \u0026ldquo;\u003cem\u003eLack of follow-up, ignorance, and lack of education are the most important problems. When both women and men lack awareness, pregnancies become unplanned.\u003c/em\u003e\u0026rdquo; (P1)\u003c/p\u003e\n\u003cp\u003eOn the policy side, deficiencies in family planning services and inadequate fertility control were highlighted. Participants stated that preventing multiparous pregnancies was important, but current policies failed to meet this need. One participant emphasized the gap in current policies in the following way:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eFamily planning is seriously inefficient. It\u0026apos;s limited to just distributing condoms. This absolutely needs to be expanded\u003c/em\u003e.\u0026rdquo; (P4)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 5: Facilitative Strategies\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite the challenges encountered in managing postpartum hemorrhage (PPH), midwives identified several organizational and experience-based practices that facilitated timely and effective interventions. The most frequently mentioned strategy was the use of postpartum hemorrhage kits. Participants emphasized that having a pre-prepared kit, rather than gathering supplies during an emergency, significantly reduced delays. One participant highlighted this practice:\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eWe prepare a postpartum hemorrhage kit... so we don\u0026apos;t have to hunt for supplies\u003c/em\u003e.\u0026quot; (P10)\u003c/p\u003e\n\u003cp\u003ePlanned blood reserves were also described as a critical facilitator. Rapid access to blood prevented delays in life-saving interventions. As one midwife stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;If there were planned blood reserves, the intervention could be performed much faster\u003c/em\u003e.\u0026quot; (P13)\u003c/p\u003e\n\u003cp\u003eMidwives also stated that mentorship by experienced staff provided significant support in hemorrhage management. The ability of experienced healthcare professionals to respond quickly to cases instilled confidence in the team and facilitated proper implementation. One participant explained the importance of experience as follows:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eHaving seen many cases before allows us to quickly recognize the source of bleeding\u003c/em\u003e.\u0026rdquo; (P16)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored the challenges midwives encountered in preventing, diagnosing, and managing postpartum hemorrhage (PPH) and highlighted potential solutions across five key themes that closely align with real-world practice. Our findings demonstrated that gaps in clinical preparedness and response capacity, limited physician access and referral system inefficiencies, weaknesses in team dynamics and crisis management, training and policy deficiencies, and the presence of facilitating practices all directly impacted PPH outcomes. These findings are consistent with the 2023 World Health Organization (WHO) guidelines, which emphasize a standardized approach to hemorrhage assessment\u0026mdash;such as quantitative blood loss (QBL)\u0026mdash;and the implementation of evidence-based, packaged initial responses by the clinical team (World Health Organization, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWithin the preparedness dimension, midwives frequently cited delays in accessing equipment and medications, as well as suboptimal organization of materials, as barriers to timely intervention. Such challenges underscore why the \u0026ldquo;readiness\u0026rdquo; domain is considered essential in international quality improvement packages. For instance, the AIM (Alliance for Innovation on Maternal Health) Obstetric Hemorrhage Patient Safety Bundle (2022 update) mandates the availability of a hemorrhage cart or kit, standardized checklists, and stage-based protocols in every unit to ensure consistent and timely execution of diagnostic and treatment steps (Adams \u0026amp; Meadows, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Alliance for Innovation on Maternal Health, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Similarly, the CMQCC (California Maternal Quality Care Collaborative) Toolkit v3.0 recommends repeated risk assessments, adherence to medication protocols\u0026mdash;including the appropriate use of tranexamic acid\u0026mdash;and detailed guidance for blood transfusions. Implementation of these structured packages has been associated with significant reductions in severe maternal morbidity due to hemorrhage in California (California Department of Public Health, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAccess and system-related challenges identified in this study demonstrated that delays in on-call physician availability and referral processes could postpone critical interventions, particularly during the first hours of postpartum hemorrhage, thereby increasing mortality risk. The 2023 WHO PPH Roadmap emphasizes the importance of legislating midwife competencies, strengthening referral and transportation systems, ensuring a reliable supply of quality-assured consumables and medications, and implementing task-sharing strategies to reduce such barriers (Sexual and Reproductive Health and Research [SRH], 2023; Williams et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Similarly, the 2024 International Confederation of Midwives (ICM) Core Competencies Framework defines midwives\u0026rsquo; responsibilities to include coordinating evidence-based practices both independently and within teams, maintaining accurate recording and communication, and initiating timely consultation and referral processes as part of professional standards (International Confederation of Midwives, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Within this context, the development of integrated information-sharing platforms between primary care and hospitals, alongside standardized referral criteria, is critical to mitigate vulnerabilities associated with \u0026ldquo;unfollowed\u0026rdquo; or high-risk pregnancies, as observed in our findings (SRH, 2023).\u003c/p\u003e\u003cp\u003eRegarding team dynamics and crisis management, our results indicated that staffing shortages, role ambiguity, and communication breakdowns contributed to confusion and inefficiency during hemorrhage events. Existing literature supports that structured, team-based simulation and clear task allocation improve both process indicators\u0026mdash;such as timely medication administration and protocol adherence\u0026mdash;and clinical outcomes. For example, a prospective intervention study in Tanzania showed a significant reduction in PPH incidence following simulation-based training (Nelissen et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Scenario guides and checklists, as included in the CMQCC package, can clarify roles within local teams and establish a field-appropriate command-and-control system during emergencies (California Department of Public Health, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In line with these recommendations, the WHO PPH Roadmap identifies scaling up practical teamwork and simulation training within obstetric emergency teams as a priority action to enhance preparedness and reduce adverse outcomes (SRH, 2023).\u003c/p\u003e\u003cp\u003e In terms of education and policy, gaps in in-service training identified by midwives were consistent with current international guidelines. The FIGO (International Federation of Gynecology and Obstetrics) 2022 guidelines emphasize the correct and early use of uterotonics for both prophylaxis and treatment, along with stepwise management of PPH (Escobar et al., 2022a). The WHO 2023 assessment and treatment package further underscores the standardization of diagnostic thresholds and the use of initial response packages, including uterotonics, uterine massage or compression, and balloon tamponade (World Health Organization, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Tranexamic acid has become a key component of the initial response, with strong recommendations to administer 1 g intravenously within three hours of bleeding onset, followed by a second 1 g dose 30 minutes later if necessary (International Federation of Gynecology and Obstetrics, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; World Health Organization, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Dissemination of these recommendations is essential to enable midwives to initiate timely, evidence-based interventions, particularly when immediate physician access is limited.\u003c/p\u003e\u003cp\u003eFinally, facilitative practices, including pre-prepared hemorrhage kits or carts, planned blood reserves, and mentorship by experienced staff, emerged in our findings as tangible strategies that improve field-level response. These elements are also recognized as unit-level standards in the AIM and CMQCC materials (Alliance for Innovation on Maternal Health, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; California Department of Public Health, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Additional strategies, such as quantitative blood loss (QBL) risk assessment, establishment of rapid response teams, and shared decision-making through post-event review, further contribute to coordinated and effective management.\u003c/p\u003e\u003cp\u003eIn conclusion, midwives\u0026rsquo; experiences in this study align closely with current evidence: improving PPH outcomes depends not only on individual clinical skills but on ensuring a robust institutional cycle encompassing readiness, diagnosis, response, and post-event learning. Based on these findings, we recommend (i) standardization of localized PPH protocols and hemorrhage carts, aligned with AIM and CMQCC recommendations; (ii) support for the initial response package, including uterotonics, tranexamic acid, and balloon tamponade, accompanied by midwifery competence and ongoing training; (iii) establishment of a culture of regular, multidisciplinary simulation and post-event learning; and (iv) strengthening of referral, supply, and data-sharing infrastructures in accordance with the WHO Roadmap. Implementing these measures has the potential to improve clinical outcomes, enhance maternal safety, and reduce the psychosocial burden on healthcare teams managing PPH.\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\u003cp\u003eThis study captured midwives\u0026rsquo; experiences of postpartum hemorrhage (PPH) directly, allowing participants to express their perspectives in their own words and addressing clinical, system, team, educational, and policy dimensions from a multifaceted perspective. Inclusion of midwives from different institutions enhanced the diversity of experiences and provided unique contributions to the literature.\u003c/p\u003e\u003cp\u003eHowever, the study has some limitations. It was conducted in a specific region, which limits the generalizability of the findings. The data were based on participants\u0026rsquo; subjective experiences and may reflect perceptual differences. Additionally, the exclusive focus on midwives\u0026rsquo; perspectives excludes the insights of other healthcare professionals involved in PPH management.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003e This study provided a comprehensive perspective on the challenges midwives encounter in preventing, diagnosing, and managing postpartum hemorrhage (PPH), as well as the practical solutions they implement. The findings indicate that deficiencies in clinical preparation, delays in physician access, communication breakdowns within teams, inadequate in-service training, and policy gaps negatively affect the effectiveness of hemorrhage management. Conversely, facilitative practices identified by midwives\u0026mdash;such as the use of pre-prepared postpartum hemorrhage kits, planned blood reserves, and mentorship by experienced staff\u0026mdash;offer practical strategies to enhance both the safety and efficiency of PPH care. These results highlight the need to strengthen midwives' competencies, expand regular simulation training, and develop family planning policies. Overall the study highlights areas requiring improvement not only in clinical care practices but also at the healthcare system and policy levels. Empowering midwives and removing systemic barriers is critical for improving maternal safety.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely thank all the midwives who participated in the study and shared their experiences. We are also grateful to the institutional officials who contributed to the study and to all healthcare professionals who provided support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNafiye Dutucu:\u0026nbsp;Conceptualization, Methodology, Formal Analysis, Resources, Data Curation, Writing \u0026ndash; Original Draft, Writing \u0026ndash; Review \u0026amp; Editing, Supervision, Project Administration.\u003c/p\u003e\n\u003cp\u003eSena Dilek Aksoy:\u0026nbsp;Conceptualization, Methodology, Investigation, Resources, Data Curation, Writing \u0026ndash; Original Draft, Writing \u0026ndash; Review \u0026amp; Editing, Visualization.\u003cbr\u003e\u0026nbsp;Resmiye \u0026Ouml;zdilek: Formal Analysis, Resources, Data Curation, Writing \u0026ndash; Review \u0026amp; Editing, Visualization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Kocaeli University Non-Interventional Ethics Committee (Approval Number: GOKAEK-2022/21.22; Project Number: 2022/356). All participants were informed about the purpose of the study and provided written and verbal consent before participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAdams, K.M., Meadows, A., 2022. Obstetric hemorrhage change package [WWW Document]. Alliance Innov. Matern. Heal. URL https://www.ihi.org/sites/default/files/2024-04/AIM-Patient-Safety-Bundles_Change-Package_Hemorrhage.pdf\u003c/li\u003e\n\u003cli\u003eAdeoye‐Olatunde, O.A., Olenik, N.L., 2021. Research and scholarly methods: Semi‐structured interviews. ACCP J. Am. Coll. Clin. 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(Rockv). 23, 1\u0026ndash;356. https://doi.org/10.3310/hta23090\u003c/li\u003e\n\u003cli\u003eGonzalez-Brown, V., Schneider, P., 2020. Prevention of postpartum hemorrhage. Semin. Fetal Neonatal Med. 25, 101129. https://doi.org/10.1016/j.siny.2020.101129\u003c/li\u003e\n\u003cli\u003eGraneheim, U.., Lundman, B., 2004. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ. Today 24, 105\u0026ndash;112. https://doi.org/10.1016/j.nedt.2003.10.001\u003c/li\u003e\n\u003cli\u003eHiggins, N., Patel, S.K., Toledo, P., 2019. Postpartum hemorrhage revisited: New challenges and solutions. Curr. Opin. Anaesthesiol. 32, 278\u0026ndash;284. https://doi.org/10.1097/ACO.0000000000000717\u003c/li\u003e\n\u003cli\u003eHorton, J., Macve, R., Struyven, G., 2004. Qualitative research: Experiences in using semi-structured interviews, in: The Real Life Guide to Accounting Research. 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BMC Pregnancy Childbirth 22, 1\u0026ndash;10. https://doi.org/10.1186/s12884-022-04804-x\u003c/li\u003e\n\u003cli\u003eKalu, F.A., Chukwurah, J.N., 2022b. Midwives\u0026rsquo; experiences of reducing maternal morbidity and mortality from postpartum haemorrhage (PPH) in Eastern Nigeria. BMC Pregnancy Childbirth 22, 474. https://doi.org/10.1186/s12884-022-04804-x\u003c/li\u003e\n\u003cli\u003eLincoln, Y.S., Guba, E.G., Pilotta, J.J., 1985. Naturalistic inquiry. Int. J. Intercult. Relations 9, 438\u0026ndash;439. https://doi.org/10.1016/0147-1767(85)90062-8\u003c/li\u003e\n\u003cli\u003eLindgren, B.-M., Lundman, B., Graneheim, U.H., 2020. Abstraction and interpretation during the qualitative content analysis process. Int. J. Nurs. Stud. 108, 103632. https://doi.org/10.1016/j.ijnurstu.2020.103632\u003c/li\u003e\n\u003cli\u003eMasuzawa, Y., Kataoka, Y., Fujii, K., Inoue, S., 2018. Manejo profil\u0026aacute;ctico de la hemorragia posparto en la tercera etapa del parto: una visi\u0026oacute;n general de revisiones sistem\u0026aacute;ticas. Syst. Rev. 7, 1\u0026ndash;24.\u003c/li\u003e\n\u003cli\u003eMerriam, A.A., Wright, J.D., Siddiq, Z., D\u0026rsquo;Alton, M.E., Friedman, A.M., Ananth, C. V., Bateman, B.T., 2018. Risk for postpartum hemorrhage, transfusion, and hemorrhage-related morbidity at low, moderate, and high volume hospitals. J. Matern. Neonatal Med. 31, 1025\u0026ndash;1034. https://doi.org/10.1080/14767058.2017.1306050\u003c/li\u003e\n\u003cli\u003eMiles, M.B., Huberman, A.M., 2021. Qualitative data analysis, 4th Editio. ed, Pegem Academy. Pegem Academy, Ankara. https://doi.org/10.14527/9786053181415\u003c/li\u003e\n\u003cli\u003eNaderifar, M., Goli, H., Ghaljaie, F., 2017. Snowball sampling: A purposeful method of sampling in qualitative research. Strides Dev. Med. 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Educ. 8, 90\u0026ndash;97. https://doi.org/10.1007/S40037-019-0509-2\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Brien, B.C., Harris, I.B., Beckman, T.J., Reed, D.A., Cook, D.A., 2014. Standards for reporting qualitative research. Acad. Med. 89, 1245\u0026ndash;1251. https://doi.org/10.1097/ACM.0000000000000388\u003c/li\u003e\n\u003cli\u003eOmotayo, M.O., Abioye, A.I., Kuyebi, M., Eke, A.C., 2021. Prenatal anemia and postpartum hemorrhage risk: A systematic review and meta-analysis. J. Obstet. Gynaecol. Res. 47, 2565\u0026ndash;2576. https://doi.org/10.1111/jog.14834\u003c/li\u003e\n\u003cli\u003eParker, C., Scott, S., Geddes, A., 2019. Snowball sampling. https://doi.org/10.4135/9781526421036831710\u003c/li\u003e\n\u003cli\u003eRichardson, J., Hollier-Hann, G., Kelly, K., Chiara Alvisi, M., Winter, C., Cetin, I., Draycott, T., Harvey, T., Visser, G.H.A., Yip Sonderegger, Y.L., Perroud, J., 2022. 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A roadmap to combat postpartum haemorrhage between 2023 and 2030 [WWW Document]. World Heal. Organ. URL https://www.who.int/publications/i/item/9789240081802\u003c/li\u003e\n\u003cli\u003eT\u0026uuml;rkiye İstatistik Kurumu, 2021. S\u0026uuml;rd\u0026uuml;r\u0026uuml;lebilir Kalkınma G\u0026ouml;stergeleri , 2010-2019. T\u0026uuml;rkiye İstatistik Kurumu Haber B\u0026uuml;lteni.\u003c/li\u003e\n\u003cli\u003eWHO, UNICEF, UNFPA, UNPD, 2019. Maternal mortality in 2000-2017, Internationally comparable MMR estimates by the Maternal Mortality Estimation Inter-Agency Group (MMEIG). Data from Civ. Regist. vital Stat. Syst. Available 1\u0026ndash;10.\u003c/li\u003e\n\u003cli\u003eWilliams, C.R., Adnet, G., Gallos, I.D., Coomarasamy, A., G\u0026uuml;lmezoglu, A.M., Islam, M.A., Rushwan, S., Widmer, M., Althabe, F., Oladapo, O.T., 2024. Research agenda for ending preventable maternal deaths from postpartum haemorrhage: a WHO research prioritisation exercise. BMJ Glob. Heal. 9, e015342. https://doi.org/10.1136/bmjgh-2024-015342\u003c/li\u003e\n\u003cli\u003eWorld Health Organization, 2023. WHO recommendations on the assessment of postpartum blood loss and use of a treatment bundle for postpartum haemorrhage. World Health Organization, Geneva.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization, 2017. WHO recommendation on tranexamic acid for the treatment of postpartum haemorrhage [WWW Document]. World Heal. Organ. URL https://www.ncbi.nlm.nih.gov/books/NBK493072/table/executivesummary.t1/\u003c/li\u003e\n\u003cli\u003eYıldırım, A.D., Şahin, N.H., 2021. Anne \u0026Ouml;l\u0026uuml;mlerinin \u0026Ouml;nlenmesi: Uluslararası Bakım ve İzlem Modelleri. Jinekoloji-Obstetrik ve Neonatoloji Tıp Derg. https://doi.org/10.38136/jgon.842685\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Crisis intervention, health services accessibility, midwifery, postpartum hemorrhage, qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-7987833/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7987833/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study aimed to explore midwives' experiences, perceptions, and recommendations concerning the prevention, diagnosis, and management of postpartum hemorrhage (PPH).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn exploratory qualitative design was employed, using semi-structured, in-depth interviews. The study was conducted in public hospitals and maternity units across Türkiye. Seventeen midwives with direct experience in postpartum hemorrhage management participated in the study. Data were collected through individual interviews and were analyzed thematically following Braun and Clarke’s framework. Verbatim transcripts were coded, categorized, and synthesized into overarching themes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFive main themes emerged: (1) clinical preparedness and response capacity, (2) health system and access barriers, (3) team dynamics and crisis management, (4) training and policy gaps, and (5) facilitative strategies. Midwives reported challenges such as equipment shortages, delays in accessing physicians, and role ambiguity during emergencies. They also emphasized training needs, inadequate antenatal education, and weak family planning policies. Conversely, facilitators such as hemorrhage kits, planned blood reserves, and mentorship from experienced staff were perceived as valuable in strengthening care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMidwives play a pivotal role in the early recognition and management of PPH. However, systemic barriers and limited professional authority frequently hinder timely interventions. Strengthening midwives’ competencies through regular simulation-based training, ensuring the availability of essential resources, and strengthening midwifery roles within health policies can improve the prevention and management of postpartum hemorrhage and promote maternal safety.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number \u003c/strong\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Midwives’ Voices on Postpartum Hemorrhage: An Exploratory Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-24 12:52:36","doi":"10.21203/rs.3.rs-7987833/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-30T06:23:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-29T09:35:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"274040307070873340699552445730973637581","date":"2025-12-10T17:43:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-10T10:48:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"11063255024810566366705186475107891238","date":"2025-12-10T08:57:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"127047141597174691489093832403737295621","date":"2025-11-22T16:16:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309246323226034042333488362821665592976","date":"2025-11-17T13:17:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-12T12:51:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-12T12:44:10+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-04T06:26:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-03T10:04:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-11-03T09:59:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bceaec10-512a-471b-8b8e-80ff25566747","owner":[],"postedDate":"November 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-17T14:23:29+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-24 12:52:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7987833","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7987833","identity":"rs-7987833","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}