Postpartum Haemorrhage Prevention and Management: Midwives’ Knowledge, Self-Reported Competence and Observed Clinical Practice at Obstetrics and Gynaecology Department in Kenyatta National Hospital Kenya

Every year, thousands of women face a terrifying reality after giving birth: a sudden, heavy loss of blood. This condition, known as postpartum hemorrhage, is one of the leading causes of maternal death worldwide. The body can lose blood so quickly that it leads to shock and organ failure before help can arrive. Because of this, medical teams rely on a specific set of actions to prevent disaster. These actions include giving a medicine to make the uterus squeeze tightly, gently pulling on the umbilical cord to help the placenta come out, and massaging the uterus to keep it firm. These steps are not just suggestions; they are a life-saving routine that must happen within minutes of a baby's birth. In many hospitals, especially in low-resource settings, the success of this routine depends entirely on the midwives who are present at the bedside. They are the first line of defense, the ones who must recognize danger, act quickly, and coordinate care when seconds count.

Researchers at Kenyatta National Hospital in Kenya decided to look closely at how well midwives were actually performing these life-saving steps. They wanted to know if the knowledge these women learned in classrooms translated into real-world action when a baby was being born. The team gathered a large group of midwives to answer questions about what they knew and how confident they felt. Then, they did something rare and difficult: they quietly watched midwives working in the delivery room to see what they actually did. The goal was to compare what the midwives said they knew with what they were observed doing in the heat of the moment.

The study began by asking 114 midwives about their training and their knowledge. The results showed that these women knew the theory very well. More than 95 percent of them could correctly name the medicine needed to stop bleeding, and over 90 percent knew the correct way to pull the cord and massage the uterus. They also felt very confident in their abilities. When asked if they could identify the signs of bleeding or diagnose the problem on their own, more than 80 percent said yes. They believed they were ready to handle an emergency.

However, when the researchers moved from the questionnaire to the delivery room, the picture changed dramatically. They observed 22 midwives as they cared for women during the final stages of labor. The difference between what the midwives said they would do and what they actually did was stark. While nearly all the midwives knew they should give the bleeding-prevention medicine within one minute of the baby's birth, only two out of the 22 observed midwives actually did it that quickly. In most cases, the medicine was given late or not at all within that critical window. Similarly, while the midwives knew they should massage the uterus immediately after the placenta was delivered, this was done correctly in only a small fraction of the observations. In many cases, the massage was delayed or skipped entirely.

There were some bright spots in the observation. The midwives were very good at monitoring the firmness of the uterus and at gently pulling the cord to deliver the placenta. These tasks were performed correctly in almost every case they watched. Yet, the tasks that required immediate, time-sensitive action—like giving the medicine or massaging the uterus right away—were often missed. The researchers also noted that other important care steps, such as helping the mother choose a comfortable position or emptying her bladder, were not seen at all during the observations.

To understand why this gap existed between knowledge and action, the researchers spoke with the people in charge of the hospital wards. The midwives and their supervisors pointed to the heavy pressures of their daily work. They described being overwhelmed by the number of patients, dealing with fatigue, and facing shortages of essential supplies like medicine and blood products. They explained that even when they knew exactly what to do, the chaotic environment, the lack of staff, and the difficulty in getting equipment quickly made it hard to follow the perfect routine every single time. The study found that many midwives had not had a refresher training session in over three years, which meant their skills might have become rusty.

The researchers concluded that simply knowing the rules is not enough to save lives. The midwives at this hospital were not lacking in knowledge; they were struggling with the reality of their work environment. The study suggests that to truly improve safety, hospitals need to do more than just teach the theory. They need to provide regular practice sessions that simulate real emergencies, ensure that supplies are always within reach, and create systems that support the midwives when they are overwhelmed. The findings highlight that turning knowledge into action requires a supportive system, not just a knowledgeable individual. Without these changes, the gap between what a midwife knows and what she can do in an emergency will remain a dangerous barrier to saving mothers' lives.