Healthcare Workers' Perspectives on the E-MOTIVE Postpartum Haemorrhage Bundle in Tanzania: A Qualitative Study of Implementation Facilitators and Challenges.

Background: The World Health Organization proposed a clinical care bundle as a first response for postpartum haemorrhage (PPH), a leading cause of maternal deaths. A large trial was conducted to evaluate its effectiveness, with Tanzania among the participating countries. We explored the experiences of healthcare workers during the early implementation of this bundle within the broader trial. Methods: An exploratory qualitative study was conducted to understand the early implementation experiences of the PPH bundle. We held six focus group discussions (FGDs) with healthcare workers, clinical leads designated as champions, and research nurses from all six facilities that implemented the intervention in Tanzania. A d-eductive qualitative thematic analysis was performed using the Consolidated Framework for Implementation Research to structure our findings. We reported on four domains: the intervention and its implementation, individual attributes, and the inner and outer contexts. Results: Healthcare workers reported positive experiences during implementation of the PPH first-response bundle. The innovation included several known components: calibrated drape for early detection, on-site training, facility audits, champions and the PPH care bundle comprising uterine massage, oxytocics, tranexamic acid and intravenous fluids. Individual participants appreciated the multi-component strategies that addressed chronic issues, including the lack of objective measurement of blood loss, inadequate skills, and supply shortages. Additionally, local clinical leads who served as champions increased local ownership and accountability. Facility-level challenges included staff rotation and a lack of clear communication, particularly when managing at-risk women. The availability of external support for training, supplies, and drugs required to administer the bundle, along with strong support from the districts and regional health management teams, enhanced the adoption and implementation process. Conclusion: The components of the bundle and the implementation strategies were well received and perceived as reducing the risk of severe postpartum haemorrhage and potentially saving lives. The perceived successes were contributed by the interconnectedness of the different strategies used. Facilities and countries aiming to scale need to harness these strategies that target the health system. In addition, there is a need to strengthen local facility audits, document and address chronic challenges affecting staff dynamics and supplies. District, regional and national leadership in adopting and integrating new clinical practices are key.