September 20, 2025

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

MKMartha KamangaUniversity of Health Science CKCharity KabondoKamuzu Central Hospital FSFikile Khangamwa SinganoUniversity of Health Science

Key Points

Barriers to effective postpartum hemorrhage management include limited knowledge, skills, and staffing in Malawi.
In-depth interviews with 85 frontline healthcare providers unveiled significant gaps in capability and motivation regarding postpartum hemorrhage care.
Data were thematically analyzed using the COM-B framework, providing insights into the health system deficiencies affecting postpartum hemorrhage outcomes.
Embedding the PPH CoP-E-MOTIVE strategies with capacity building may enhance motivation and ultimately reduce maternal mortality.

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

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