Development of a complex quality improvement intervention for timely blood transfusions for the management of post-partum haemorrhage in Africa

分娩后的灾难性出血-产后出血-是全世界母亲死亡的主要原因。它在撒哈拉以南非洲等贫困地区尤其成问题，每年造成近5万人死亡。当一个女人有严重的产后出血，她往往需要输血，最好在一个小时内，生存。然而，需要血液的妇女并不总能及时得到血液，这是由于许多因素造成的，首先是社区由于恐惧和耻辱而不愿献血，妇女在需要时不寻求产妇护理，卫生设施工作人员不知道妇女在出生后何时需要血液，以及血液不安全或不可获得。这些问题不仅必须在输血设施（提供输血的设施）和血库解决，而且必须在社区解决。我们正在提议进行一项主要研究，旨在克服整个卫生系统的障碍，增加在提供输血的卫生设施分娩的人数，并改善血液供应和及时使用，以控制产后出血。然而，一些开发工作是必要的，以设计最好的主要研究可能。这项早期研究将使我们能够确定加纳和乌干达积极开展输血或充当血库的卫生设施，并了解这些卫生设施和社区在为产后出血妇女及时输血方面面临的关键问题。在每个国家，将通过与来自10个使用设施或血库的工作人员、48-64名社区成员以及来自国家输血服务机构和卫生部的4-5名代表交谈，了解提供高质量输血服务的障碍。然后，我们将召开全国性会议，让当地的献血者社区成员、献血机构和血库的工作人员、国家输血服务机构和卫生部的工作人员参与进来，这样他们就可以为主要研究的设计提供投入。这些会议将协调利益相关者对为产后出血妇女提供输血的障碍的了解，以指导主要研究活动。在主要的研究中，社区成员和使用血液的设施或血库工作人员将参与质量改进，确定问题，并创建和实施解决方案，以克服这些障碍。这些过程将被记录下来，以帮助建立可扩展的解决方案“包”，可以在全国范围内实施，以提高输血服务的质量。利益相关者的意见将有助于设计可行且受试者可接受的主要研究干预措施。此外，这些投入对于设计在研究资助结束后继续进行的干预措施非常重要。这种持续性的一部分将来自已经在使用设施和血库的领导能力范围内工作的导师的参与，而不是来自研究团队的外部促进者，他们将在整个干预过程中为这些设施提供领导和支持。总体而言，将加强包括社区在内的较低层次卫生系统之间的联系，以增加在使用卫生设施的分娩，特别是对最需要的妇女，并提高输血的及时性和质量。

Catastrophic bleeding after childbirth-post-partum haemorrhage-is a leading cause of deaths among mothers worldwide. It is especially problematic in poor regions, such as Sub-Saharan Africa, where it causes almost 50,000 deaths each year. When a woman has severe post-partum haemorrhage, she often needs a blood transfusion, ideally within one hour, to survive. However, blood does not always get to the women who need it, when they need it. This is because of many factors, starting from communities' reluctance to donate blood due to fear and stigma, women not seeking maternity care when they need it, health facility staff not recognising when a woman needs blood after birth, and blood not being safe or available. These problems must be tackled not only at transfusing facilities (facilities that provide blood transfusions) and blood banks, but in communities too. We are proposing a main study that aims to overcome barriers across the health system to increase births in health facilities that provide transfusions and to improve the supply and timely use of blood for the management of post-partum haemorrhage. However, some developmental work is necessary to design the best main study possible. This early-phase study will allow us to identify health facilities in Ghana and Uganda that are actively carrying out blood transfusions, or serving as blood banks, and to understand the key problems that these health facilities and communities face when it comes to providing timely blood transfusions for women with post-partum haemorrhage. In each country, information about barriers to providing high quality blood transfusion services will be obtained by speaking with staff from10 transfusing facilities or blood banks, 48-64 community members, and 4-5 representatives from the national blood transfusion services and the ministries of health. We will then convene national meetings to engage local stakeholders-community members, transfusing facility and blood bank staff, and staff from national blood transfusion services and ministries of health-so that they can input into the design of the main study. These meetings will harmonise stakeholders' knowledge of these barriers to providing transfusions for women with post-partum haemorrhage to guide the main study's activities. In the main study, community members and transfusing facility or blood bank staff will engage in quality improvement-identifying problems and creating and implementing solutions to these-to overcome those barriers. These processes will then be documented to help build scalable "packages" of solutions that can be implemented nationally to improve the quality of blood transfusion services. Stakeholder inputs will help design a main study intervention that will be feasible and acceptable to participants. Further, these inputs will be important for designing an intervention that will continue after the study funding has finished. Part of this continuation will come from the involvement of mentors who are already working within a leadership capacity with transfusing facilities and blood banks, rather than external facilitators from the study team, who will provide leadership and support to these facilities throughout the intervention. Overall, there will be enhanced links across the lower tiers of the health system, including communities, to increase childbirth in transfusing facilities, especially for women who most need it, and to improve the timeliness and quality of blood transfusions.