Using Criteria-Based Audit to Improve the Management of Postpartum Haemorrhage in Resource Limited Countries: A Case Study of Malawi

  • Eugene J. KongnyuyEmail author
  • Grace Mlava
  • Nynke van den Broek


Objective The goal of this study was to assess and improve the management of postpartum haemorrhage (PPH) in maternity units in Malawi. The main objective was to determine whether criteria-based audit can improve adherence to standards for the management of PPH. Methods We used a before-and-after design and univariate statistics for data analysis. A retrospective review of 40 consecutive cases of PPH was conducted in eight hospitals and the results compared with standards for PPH, established based on World Health Organisation manuals. Results of the audit were presented to healthcare providers who made and implemented recommendations for improvement. A re-audit (45 cases) was conducted 3 months later. Results There was a significant improvement in adherence to three standards: typing and cross-match carried out (65.0% vs. 84.4%; P = 0.034), patient’s hematocrit or haemoglobin established (67.5% vs. 86.7%; P = 0.029), and fluid intake/output chart maintained (0.0% vs 33.3%; P < 0.001). There was no significant change in close monitoring of vital signs (32.5% vs. 53.3%, P = 0.065) and case fatality rate (10.0% vs. 6.7%, P = 0.702), intravenous access achieved and intravenous fluids administered (100.0% vs. 97.8%; P = 0.735), and oxytocic drugs administered (100.0% vs. 95.6%; P = 0.357). Conclusion Introduction of criteria-based audit can improve the management of postpartum haemorrhage in countries with limited resources. Future studies should consider using larger sample size to evaluate the effect of criteria-based audit on mortality.


Standards Postpartum haemorrhage Criteria-based audit Obstetric emergency complication Malawi 



We wish to acknowledge the Health Foundation for providing financial support for this study. Thanks to maternity and administrative staff of all the hospitals that participated in this study.

Authors’ Contributions

E. J. Kongnyuy: Conception, design, drafting of the protocol, analysis, interpretation and write-up of all versions of the manuscript. G. Mlava and N. van den Broek: Critically reviewed the final manuscript for important intellectual content.


  1. 1.
    World Health Organisation. (2003). Managing complications of pregnancy and childbirth: A guide for midwives and doctors. Geneva: WHO.Google Scholar
  2. 2.
    Dolea, C., AbouZahr, C., & Stein, C. (2003). Global burden of maternal haemorrhage in the year 2000. Geneva: Evidence and Information for Policy, World Health Organisation.Google Scholar
  3. 3.
    World Health Organisation. (2005). The World Health Report: Make every mother and child count. Geneva: WHO.Google Scholar
  4. 4.
    Khan, K. S., Wojdyla, D., Say, L., Gülmezoglu, A. M., & Van Look, P. F. (2006). WHO analysis of causes of maternal death: A systematic review. Lancet, 367(9516), 1066–1074. doi: 10.1016/S0140-6736(06)68397-9.PubMedCrossRefGoogle Scholar
  5. 5.
    Selo-Ojeme, D. O., & Okonofua, F. E. (1997). Risk factors for primary postpartum haemorrhage. A case control study. Archives of Gynecology and Obstetrics, 259(4), 179–187. doi: 10.1007/BF02505330.PubMedCrossRefGoogle Scholar
  6. 6.
    B-Lynch, C., Keith, L. G., Lalonde, A. B., & Karoshi, M. (Eds.). (2006). A textbook of postpartum haemorrhage: A comprehensive guide to evaluation, management and surgical intervention. Kirkmahoe: Sapiens Publishing.Google Scholar
  7. 7.
    Mahajan, N. N., Mahajan, K. N., & Soni, R. N. (2006). Reducing postpartum hemorrhage in Vietnam: Assessing the effectiveness of active management of third-stage labor. Journal of Obstetrics and Gynaecology Research, 32(5), 489–496. doi: 10.1111/j.1447-0756.2006.00436.x.CrossRefGoogle Scholar
  8. 8.
    National Statistical Office (Malawi), ORC Macro. (2005). 2004 Malawi demographic and health survey. Calverton: ORC Macro, Maryland.Google Scholar
  9. 9.
    van den Broek, N. R., Rogerson, S. J., Mhango, C. G., Kambala, B., White, S. A., & Molyneux, M. E. (2000). Anaemia in pregnancy in southern Malawi: Prevalence and risk factors. BJOG, 107(4), 445–451. doi: 10.1111/j.1471-0528.2000.tb13260.x.PubMedCrossRefGoogle Scholar
  10. 10.
    Ratsma, Y. E. (2001). Why more mothers die: Confidential enquiry into institutional maternal deaths in the southern region of Malawi. Blantyre, Malawi: National Safemotherhood Prohect.Google Scholar
  11. 11.
    Weeks, A. D., Alia, G., Ononge, S., Mutungi, A., Otolorin, E. O., & Mirembe, F. M. (2003). Introducing criteria based audit into Ugandan maternity units. BMJ (Clinical Research Ed), 327, 1329–1331. doi: 10.1136/bmj.327.7427.1329.CrossRefGoogle Scholar
  12. 12.
    Graham, W., Wagaarachchi, P., Penney, G., McCaw-Binns, A., Antwi, K. Y., & Hall, M. H. (2000). Criteria for clinical audit of the quality of hospital-based obstetric care in developing countries. Bulletin of the World Health Organization, 78(5), 614–620.PubMedGoogle Scholar
  13. 13.
    Wagaarachchi, P. T., Graham, W. J., Penney, G. C., McCaw-Binns, A., Yeboah Antwi, K., & Hall, M. H. (2001). Holding up a mirror: Changing obstetric practice through criterion-based clinical audit in developing countries. International Journal of Gynaecology and Obstetrics: The Official Organ of the International Federation of Gynaecology and Obstetrics, 74(2), 119–130. doi: 10.1016/S0020-7292(01)00427-1. discussion 131.Google Scholar
  14. 14.
    Kongnyuy, E. K., Hofman, J., Mlava, G., Mhango, C., van den Broek, N. (2008). Availability, utilisation and quality of basic and comprehensive emergency obstetric care services in Malawi. Maternal and Child Health Journal, [Epub ahead print].Google Scholar
  15. 15.
    Kongnyuy, E. J., & van den Broek, N. (2008). Criteria for clinical audit of women friendly care and providers’ perceptions in Malawi. BMC Pregnancy and Childbirth, 8(1), 28. doi: 10.1186/1471-2393-8-28.PubMedCrossRefGoogle Scholar
  16. 16.
    Ministry of Health and Population (Malawi), JHPIEGO. (2001). Malawi National Reproductive Health Services Delivery Guidelines. Lilongwe: Ministry of Health and Population, Malawi.Google Scholar
  17. 17.
    World Health Organisation. (2005). Integrated management of pregnancy and childbirth series (IMPAC). Geneva: WHO (retrieved 20 April 2007)
  18. 18.
    Lewison, H. (1994). Power at local level. Modern Midwife, 4(11), 14–16.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Eugene J. Kongnyuy
    • 1
    Email author
  • Grace Mlava
    • 2
  • Nynke van den Broek
    • 1
  1. 1.Child and Reproductive Health GroupLiverpool School of Tropical MedicineLiverpoolUK
  2. 2.The Health Foundation ConsortiumLilongweMalawi

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