Effectiveness of care bundles for prevention and treatment of postpartum hemorrhage: a systematic review - 21/02/24
Abstract |
Objective |
Care bundles are a promising approach to reducing postpartum hemorrhage–related morbidity and mortality. We assessed the effectiveness and safety of care bundles for postpartum hemorrhage prevention and/or treatment.
Data Sources |
We searched MEDLINE, Embase, Cochrane CENTRAL, Maternity and Infant Care Database, and Global Index Medicus (inception to June 9, 2023) and ClinicalTrials.gov and the International Clinical Trials Registry Platform (last 5 years) using a phased search strategy, combining terms for postpartum hemorrhage and care bundles.
Study Eligibility Criteria |
Peer-reviewed studies evaluating postpartum hemorrhage–related care bundles were included. Care bundles were defined as interventions comprising ≥3 components implemented collectively, concurrently, or in rapid succession. Randomized and nonrandomized controlled trials, interrupted time series, and before-after studies (controlled or uncontrolled) were eligible.
Methods |
Risk of bias was assessed using RoB 2 (randomized trials) and ROBINS-I (nonrandomized studies). For controlled studies, we reported risk ratios for dichotomous outcomes and mean differences for continuous outcomes, with certainty of evidence determined using GRADE. For uncontrolled studies, we used effect direction tables and summarized results narratively.
Results |
Twenty-two studies were included for analysis. For prevention-only bundles (2 studies), low-certainty evidence suggests possible benefits in reducing blood loss, duration of hospitalization, and intensive care unit stay, and maternal well-being. For treatment-only bundles (9 studies), high-certainty evidence shows that the E-MOTIVE intervention reduced risks of composite severe morbidity (risk ratio, 0.40; 95% confidence interval, 0.32–0.50) and blood transfusion for bleeding, postpartum hemorrhage, severe postpartum hemorrhage, and mean blood loss. One nonrandomized trial and 7 uncontrolled studies suggest that other postpartum hemorrhage treatment bundles might reduce blood loss and severe postpartum hemorrhage, but this is uncertain. For combined prevention/treatment bundles (11 studies), low-certainty evidence shows that the California Maternal Quality Care Collaborative care bundle may reduce severe maternal morbidity (risk ratio, 0.64; 95% confidence interval, 0.57–0.72). Ten uncontrolled studies variably showed possible benefits, no effects, or harms for other bundle types. Nearly all uncontrolled studies did not use suitable statistical methods for single-group pretest-posttest comparisons and should thus be interpreted with caution.
Conclusion |
The E-MOTIVE intervention improves postpartum hemorrhage–related outcomes among women delivering vaginally, and the California Maternal Quality Care Collaborative bundle may reduce severe maternal morbidity. Other bundle designs warrant further effectiveness research before implementation is contemplated.
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Key words : care bundles, complex interventions, evidence synthesis, maternal health, maternal morbidity, maternal mortality, maternal outcomes, obstetric complications, postpartum haemorrhage, systematic reviews
Plan
The authors report no conflict of interest. |
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J.P.V. is supported by an Australian National Health and Medical Research Council Emerging Leadership Investigator Grant. This review was financially supported by the United Nations Development Programme/United Nations Population Fund /United Nations Children’s Fund/World Health Organization (WHO)/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland. As this systematic review was commissioned to provide evidence for a WHO guideline, we sought inputs from WHO/HRP staff on the review protocol. However, they did not contribute to review execution, analysis, or interpretation. |
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This protocol did not require human or animal ethics approval. |
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All data relevant to the study are included in the article and its supplemental files. |
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