Provider Insights on Health System Bottlenecks in Postpartum Hemorrhage Management in Malawi: A COM-B and CoP-E-MOTIVE Framework Analysis

Authors

  • Martha Kamanga Department of Midwifery, School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Lilongwe campus, Malawi Author
  • Elizabeth Chodzadza Department of Midwifery, School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Lilongwe campus, Malawi Author
  • Alexander Mboma Department of Midwifery, School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Lilongwe campus, Malawi Author
  • Tamanda Mgawi Department of Midwifery, School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Lilongwe campus, Malawi Author
  • Felistas Chiundira Department of Nursing, School of Nursing, Kamuzu University of Health Sciences, Lilongwe campus, Malawi Author
  • Edna Mandala Department of Community Health, School of Nursing, Kamuzu University of Health Sciences, Lilongwe campus, Malawi Author
  • Gaily Lungu Department of Midwifery, School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Lilongwe campus, Malawi Author
  • Felister Kapalamula Department of Midwifery, School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Lilongwe campus, Malawi Author
  • Chimwemwe Msowoya Department of Neonatal Health, School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Lilongwe campus, Malawi Author
  • Fikile Khangamwa Singano Department of Midwifery, School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Lilongwe campus, Malawi Author
  • Charity Kabondo Department of Midwifery, School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Lilongwe campus, Malawi Author
  • Abigail Kazembe Department of Neonatal Health, School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Lilongwe campus, Malawi Author

DOI:

https://doi.org/10.47363/JWHMR/2025(4)129

Keywords:

Postpartum Hemorrhage, Maternal Health, Emergency Obstetric Care, Health Systems, Referral, Malawi , Qualitative Study

Abstract

Background: Postpartum hemorrhage (PPH) remains the leading cause of maternal mortality globally and in Malawi, where it accounts for 20.4% of all
maternal deaths. Despite high facility birth rates (91%), quality gaps in early recognition, timely intervention, and adherence to guidelines persist. The
PPH Community of Practice (CoP) -E-MOTIVE approach, a bundle of evidence-based interventions supported by behavioural change strategies from the
COM-B model, emphasizes capability, opportunity, and motivation for improving PPH outcomes.

Methods: This qualitative study, part of the Advancing Postpartum Hemorrhage Care (APPHC) initiative, explored provider perspectives on PPH management in Malawi. In-depth interviews were conducted with 85 frontline healthcare providers across 25 facilities in four districts. Data were thematically analyzed using the COM-B framework and mapped to E-MOTIVE bundle implementation strategies.

Results: Barriers to effective PPH management included:
•     Capability: Limited knowledge and skills, lack of self-efficacy, and absence of structured simulation practice.
•     Opportunity: Stock-outs of essential commodities, poor referral systems, workflow inefficiencies, and inadequate staffing.
•     Motivation: Low engagement, absence of champions, and fear of blame. Proposed E-MOTIVE strategies included simulation-based team learning, peer-assisted refresher training, MOTIVE emergency kits, calibrated drapes with trigger lines for early detection, local champions, and actionable feedback loops.

Conclusion: Applying the COM-B lens to PPH care in Malawi reveals that closing the gap between guidelines and practice requires both health system strengthening and targeted behavioural interventions. Embedding the PPH CoP-E-MOTIVE bundles with capacity building, resource facilitation, and motivation-enhancing strategies could reduce PPH-related mortality.

Author Biographies

  • Martha Kamanga, Department of Midwifery, School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Lilongwe campus, Malawi

    Martha Kamanga, Associate Professor, Kamuzu University of Health Sciences, School of Maternal, Neonatal & Reproductive health, Midwifery Department, P/Bag 1, Lilongwe, Malawi.

  • Elizabeth Chodzadza, Department of Midwifery, School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Lilongwe campus, Malawi

    Martha Kamanga, Associate Professor, Kamuzu University of Health Sciences, School of Maternal, Neonatal & Reproductive health, Midwifery Department, P/Bag 1, Lilongwe, Malawi.

  • Alexander Mboma, Department of Midwifery, School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Lilongwe campus, Malawi

    Martha Kamanga, Associate Professor, Kamuzu University of Health Sciences, School of Maternal, Neonatal & Reproductive health, Midwifery Department, P/Bag 1, Lilongwe, Malawi. 

  • Tamanda Mgawi, Department of Midwifery, School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Lilongwe campus, Malawi

    Martha Kamanga, Associate Professor, Kamuzu University of Health Sciences, School of Maternal, Neonatal & Reproductive health, Midwifery Department, P/Bag 1, Lilongwe, Malawi. 

  • Felistas Chiundira, Department of Nursing, School of Nursing, Kamuzu University of Health Sciences, Lilongwe campus, Malawi

    Martha Kamanga, Associate Professor, Kamuzu University of Health Sciences, School of Maternal, Neonatal & Reproductive health, Midwifery Department, P/Bag 1, Lilongwe, Malawi.

  • Edna Mandala, Department of Community Health, School of Nursing, Kamuzu University of Health Sciences, Lilongwe campus, Malawi

    Martha Kamanga, Associate Professor, Kamuzu University of Health Sciences, School of Maternal, Neonatal & Reproductive health, Midwifery Department, P/Bag 1, Lilongwe, Malawi.

  • Gaily Lungu, Department of Midwifery, School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Lilongwe campus, Malawi

    Martha Kamanga, Associate Professor, Kamuzu University of Health Sciences, School of Maternal, Neonatal & Reproductive health, Midwifery Department, P/Bag 1, Lilongwe, Malawi.

  • Felister Kapalamula, Department of Midwifery, School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Lilongwe campus, Malawi

    Martha Kamanga, Associate Professor, Kamuzu University of Health Sciences, School of Maternal, Neonatal & Reproductive health, Midwifery Department, P/Bag 1, Lilongwe, Malawi.

  • Chimwemwe Msowoya, Department of Neonatal Health, School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Lilongwe campus, Malawi

    Martha Kamanga, Associate Professor, Kamuzu University of Health Sciences, School of Maternal, Neonatal & Reproductive health, Midwifery Department, P/Bag 1, Lilongwe, Malawi.

  • Fikile Khangamwa Singano, Department of Midwifery, School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Lilongwe campus, Malawi

    Martha Kamanga, Associate Professor, Kamuzu University of Health Sciences, School of Maternal, Neonatal & Reproductive health, Midwifery Department, P/Bag 1, Lilongwe, Malawi.

  • Charity Kabondo, Department of Midwifery, School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Lilongwe campus, Malawi

    Martha Kamanga, Associate Professor, Kamuzu University of Health Sciences, School of Maternal, Neonatal & Reproductive health, Midwifery Department, P/Bag 1, Lilongwe, Malawi. 

  • Abigail Kazembe, Department of Neonatal Health, School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Lilongwe campus, Malawi

    Martha Kamanga, Associate Professor, Kamuzu University of Health Sciences, School of Maternal, Neonatal & Reproductive health, Midwifery Department, P/Bag 1, Lilongwe, Malawi.

Downloads

Published

2025-11-25

Issue

Vol. 4 No. 5 (2025): Volume 4 Issue 5

Section

Articles