Impact of the Zero Maternal Death by Hemorrhage Strategy on health professionals’ self-perceived knowledge in managing postpartum hemorrhage

de Oliveira, Gilson Geraldo; Larissa Oliveira dos Santos, Mariana; Osanan, Gabriel Costa; Azevedo, George Dantas de; Freitas Júnior, Reginaldo Antônio de Oliveira

doi:10.61622/rbgo/2025rbgo25

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Original Article • Rev Bras Ginecol Obstet 47 • 2025 • https://doi.org/10.61622/rbgo/2025rbgo25 linkcopy

Impact of the Zero Maternal Death by Hemorrhage Strategy on health professionals’ self-perceived knowledge in managing postpartum hemorrhage

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective: This study aimed to evaluate the results of the Obstetric Hemorrhage Prevention and Management Course – Zero Maternal Death by Hemorrhage Strategy (0MMxH) among healthcare professionals before and after participation.

Methods: A quasi-experimental design was employed, assessing the educational intervention in a convenience sample of healthcare professionals who had participated in the 0MMxH at least one year prior. Participants completed a retrospective pre-post questionnaire sent via email, focusing on self-perceived knowledge levels and the adoption of best practices in postpartum hemorrhage (PPH) management.

Results: Out of 129 professionals who completed the 0MMxH training, 85 (65.9%) responded to the questionnaire. The percentages of respondents reporting no or low knowledge before and after the course were: shock index (52.8% to 0%, before and after, respectively), blood loss estimation (35.2% to 1.1%), care sequence for PPH (44.6% to 0%), rational use of crystalloids (37.5% to 1.1%), non-pneumatic anti-shock garment (83.5% to 3.4%), and damage control surgery (74.1% to 8.1%). These results indicate a significant improvement in self-perceived knowledge. After the course, the highest adoption rates of best practices were for shock index (83.5%), blood loss estimation (67.1%), and use of warm crystalloids (58.8%). However, gaps remained regarding non-pharmacological interventions for PPH management.

Conclusion: Participants reported improved knowledge on most topics covered by the 0MMxH. The program was recognized as a crucial factor in adopting effective PPH management practices, underscoring the importance of training in enhancing obstetric care.

Keywords
Medical education; Healthcare professionals; Health strategies; Postpartum hemorrhage; Maternal mortality

Initial assessment	Phase	N n(%)	L n(%)	+/- n(%)	H n(%)	VH n(%)	p-value*
PPH diagnosis	Pre	-	9(10.5)	39(45.9)	32(37.6)	5(5.9)	<0.001
PPH diagnosis	Post	-	1(1.2)	4(4.7)	33(38.8)	4(55.3)	<0.001
Methodology used to estimate blood loss in PPH	Pre	6(7.0%)	24(28.2)	40(47.0)	15(17.6)	-	0.001
Methodology used to estimate blood loss in PPH	Post	-	1(1.1)	3 (3.5)	40(47.0)	41(48.2)	0.001
Golden Hour concept in PPH	Pre	7(8.2%)	26(30.5)	25(29.4)	22(25.8)	5(5.8)	0.002
Golden Hour concept in PPH	Post	-	-	4(4.7)	34(40.0)	47(55.2)	0.002
Shock index in PPH	Pre	22(25.8%)	23(27.0)	24(28.2)	15(17.6)	1(1.1)	0.048
Shock index in PPH	Post	-	-	5 (5.8)	35(41.1)	45(52.9)	0.048
PPH prevention with oxytocin 10 IU IM injection	Pre	5 (5.8%)	13(15.2)	16(18.8)	23(27.0)	28(32.9)	0.014
PPH prevention with oxytocin 10 IU IM injection	Post	-	-	1(1.1)	19(22.3)	65(76.4)	0.014

Overall measures and pharmacological treatment	Phase	N n(%)	L n(%)	+/- n(%)	H n(%)	VH n(%)	p-value*
Care sequence for patients with PPH	Pre	16(18.8)	22(25.8)	27(31.7)	20(23.5)	-	0.003
Care sequence for patients with PPH	Post	-	-	6(7.0)	41(48.2)	38(44.7)	0.003
Uterine atony treatment including oxytocin, methylergometrine and misoprostol	Pre	1 (1.1)	10(11.7)	19(22.3)	28(32.9)	27(31.7)	< 0.001
	Post	-	-	3(3.5)	25(29.4)	57(67.0)	< 0.001
Use of tranexamic acid as adjuvant in PPH treatment	Pre	10(11.7)	12(14.1)	20(23.5)	25(29.4)	18(21.1)	0.001
Use of tranexamic acid as adjuvant in PPH treatment	Post	1(1.1)	-	5(5.8)	28(32.9)	51(60.0)	0.001
Rational use of crystalloids in hemostatic resuscitation of patients with PPH, avoiding a 3:1 ratio	Pre	6(7.0)	26(30.5)	31(36.4)	17(20.0)	5(5.8)	< 0.001
	Post	-	1 (1.1)	7(8.2)	37(43.5)	40(47.0)	< 0.001
Early blood transfusion indication based on clinical criteria	Pre	6(7.0)	22(25.8%)	30(35.2)	22(25.8)	5(5.8)	< 0.001
	Post	-	1(1.1)	8(9.4)	37(43.5)	39(45.8%)	< 0.001
Lethal triad in PPH: acidosis, hypothermia and coagulopathy	Pre	8(9.4)	19(22.3)	28(32.9)	20(23.5)	10(11.7)	< 0.001
Lethal triad in PPH: acidosis, hypothermia and coagulopathy	Post	-	-	9(10.5)	43(50.5)	33(38.8)	< 0.001

Non-pharmacological treatment	Phase	N n(%)	L n(%)	+/- n(%)	H n(%)	VH n(%)	p-value*
Use of non-pneumatic antishock garment as a transient method to control PPH (n=85)	Pre	46(54.1)	25(29.4)	11(12.9)	2(2.3)	1(1.1)	< 0.001
	Post	2(2.3)	1(1.1)	6(7.0)	43(50.5)	33(38.8)	< 0.001
Use of intrauterine balloon tamponade in uterine atony (n=85)	Pre	25(29.4)	28(32.9)	18(21.1)	12(14.1)	2(2.3)	0.024
	Post	2(2.3)	-	8(9.4)	39(45.8)	36(42.3)	0.024
Hemostatic sutures (n=85)	Pre	27(31.7)	17(20.0)	26(30.5)	11(12.9)	4(4.7)	< 0.001
Hemostatic sutures (n=85)	Post	1(1.1)	4(4.7)	11(12.9)	43(50.5)	26(30.5)	< 0.001
PPH management by placental acretism (n=85)	Pre	12(14.1)	20(23.5)	27(31.7)	23(27.0)	3(3.5)	0.001
PPH management by placental acretism (n=85)	Post	-	1(1.1)	8(9.4)	41(48.2)	35(41.1)	0.001
Damage control surgery in PPHP (pelvic packing using the vacuum dressing technique) (n=85)	Pre	34(40.0)	29(34.1)	18(21.1)	4 (4.7)	-	< 0.001
	Post	1(1.1)	6(7.0)	14(16.4)	47(55.2)	17(20.0)	< 0.001

Clinical PPH management practices	Reports that they already adopted the practice before participating in 0MMxH n(%)	Reports that they only started adopting the practice after participating in 0MMxH n(%)	n(%)
Revision of the perineum, vagina and episiotomy	79(92.9)	6(7.1)	85(100)
Use of misoprostol in the treatment of PPH	78(91.8)	7(8.2)	85(100)
Placental examination after delivery	74(87.1)	11(12.9)	85(100)
Uterine massage	74(87.1)	11(12.9)	85(100)
Placenta removal by controlled cord traction	68(80.0)	17(20)	85(100)
Bimanual uterine compression	56(65.9)	29(34.1)	85(100)
Use of tranexamic acid as adjuvant in pharmacological PPH treatment	54(63.5)	31(36.5)	85(100)
Routine IM administration of oxytocin as PPH prevention strategy	53(62.4)	32(37.6)	85(100)
Early blood transfusion based on clinical criteria	37(43.5)	48(56.5)	85(100)
Use of warm crystalloids for volume replacement	35(41.2)	50(58.8)	85(100)
Estimated postpartum blood loss (by any method)	28(32.9)	57(67.1)	85(100)
Shock index as clinical parameter of PPH	14(16.5)	71(83.5)	85(100)

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[TFN1] ^*
Wilcoxon t-test (5% significance level);

[TFN1a] N: None; L: Low; +/-: Neither high, nor low; H: High; VH: Very high