{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T00:15:40Z","timestamp":1789690540716,"version":"4.0.1"},"reference-count":18,"publisher":"Oxford University Press (OUP)","issue":"3","license":[{"start":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T00:00:00Z","timestamp":1787616000000},"content-version":"vor","delay-in-days":55,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,7,8]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Severe postpartum haemorrhage (PPH) remains a leading and largely preventable cause of maternal morbidity and mortality worldwide. Delayed recognition, inappropriate fluid replacement, and suboptimal clinical management contribute to adverse outcomes. Clinical audit can identify deficiencies in care and stimulate quality improvement. In the Netherlands, a nationwide perinatal audit system enables multidisciplinary review of maternity care to enhance collaboration and optimize clinical practice. This study reports the first nationwide audit of severe PPH management in the Netherlands and aims to identify improvable care factors and draw lessons for clinical care.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>In the Netherlands, perinatal audit is nationally coordinated and based on a set of periodic clinical themes. In 2020\u20133, one such theme was severe PPH, defined as blood loss of \u22652500\u2009ml in the first 24\u2009h after birth or blood loss requiring hysterectomy. Local multidisciplinary audit sessions were held within \u2018perinatal cooperation groups\u2019, comprised maternity care professionals working within a region. During audit sessions, anonymized case reports were reviewed, and areas for improvement of clinical care were identified and documented. Audit findings were analysed quantitatively to group improvable care factors regarding clinical management provided to women sustaining severe PPH. In addition, narrative excerpts from audit reports were used descriptively to provide context to the findings.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>In 116 women sustaining severe PPH, the audit revealed 234 improvable care factors, mostly related to nonadherence to guidelines and standards (47.8%), organization of care (22.3%), and communication and documentation between care professionals and patients (17.1%). Common issues included absence or ambiguity of local management protocols, unclear allocation of responsibilities among team members, limited capacity in terms of staffing and available labour rooms, and incomplete communication and documentation around referral between\/within echelons. Nearly half of the improvable care factors were stated by local audit panellists to be likely or possibly associated with severe PPH.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Audit of PPH care revealed several areas for improvement in the Netherlands, including ensuring sufficient staffing and labour room capacity and updating of national and local management protocols.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/intqhc\/mzag119","type":"journal-article","created":{"date-parts":[[2026,8,24]],"date-time":"2026-08-24T11:26:13Z","timestamp":1787570773000},"source":"Crossref","is-referenced-by-count":0,"title":["Lessons learned from nationwide perinatal audit of severe postpartum haemorrhage in the Netherlands"],"prefix":"10.1093","volume":"38","author":[{"ORCID":"https:\/\/orcid.org\/0009-0005-8319-2355","authenticated-orcid":false,"given":"Lisa","family":"Broeders","sequence":"first","affiliation":[{"name":"Department of Obstetrics and Gynaecology, Leiden University Medical Centre , 2333 ZA Leiden,","place":["The Netherlands"]},{"name":"Perined , 3528 BL Utrecht,","place":["The Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-7485-4735","authenticated-orcid":false,"given":"Steven V","family":"Koenen","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynaecology, Fam\/ETZ , 5000 LC Tilburg,","place":["The Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-9578-3718","authenticated-orcid":false,"given":"Nicole","family":"de Vocht","sequence":"additional","affiliation":[{"name":"Perined , 3528 BL Utrecht,","place":["The Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9890-9145","authenticated-orcid":false,"given":"Thomas","family":"van den Akker","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynaecology, Leiden University Medical Centre , 2333 ZA Leiden,","place":["The Netherlands"]},{"name":"Athena Institute, Faculty of Science, VU University Amsterdam , 1081 HV Amsterdam,","place":["The Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3751-2950","authenticated-orcid":false,"given":"Ageeth N","family":"Rosman","sequence":"additional","affiliation":[{"name":"Perined , 3528 BL Utrecht,","place":["The Netherlands"]},{"name":"Department of Healthcare Studies, Rotterdam University of Applied Sciences , 3011 WN Rotterdam,","place":["The Netherlands"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,8,25]]},"reference":[{"key":"2026091719525263500_mzag119-B1","doi-asserted-by":"publisher","first-page":"e323","DOI":"10.1016\/S2214-109X(14)70227-X","article-title":"Global causes of maternal death: a WHO systematic analysis","volume":"2","author":"Say","year":"2014","journal-title":"Lancet Glob Health"},{"key":"2026091719525263500_mzag119-B2","volume-title":"WHO Recommendations for the Prevention and Treatment of Postpartum Haemorrhage","author":"World Health Organization","year":"2012"},{"key":"2026091719525263500_mzag119-B3","doi-asserted-by":"publisher","DOI":"10.1111\/1471-0528.14178","article-title":"Prevention and management of postpartum haemorrhage","volume":"124","author":"Mavrides","year":"2017","journal-title":"BJOG"},{"key":"2026091719525263500_mzag119-B4","author":"World Health Organization","year":"2023"},{"key":"2026091719525263500_mzag119-B5","doi-asserted-by":"publisher","first-page":"e0250373","DOI":"10.1371\/journal.pone.0250373","article-title":"The Italian obstetric surveillance system: implementation of a bundle of population-based initiatives to reduce haemorrhagic maternal deaths","volume":"16","author":"Donati","year":"2021","journal-title":"PLoS One"},{"key":"2026091719525263500_mzag119-B6","doi-asserted-by":"publisher","first-page":"999","DOI":"10.1016\/j.bpobgyn.2008.08.004","article-title":"Epidemiology of postpartum haemorrhage: a systematic review","volume":"22","author":"Carroli","year":"2008","journal-title":"Best Pract Res Clin Obstet Gynaecol"},{"key":"2026091719525263500_mzag119-B7","doi-asserted-by":"publisher","first-page":"583","DOI":"10.1093\/intqhc\/mzr042","article-title":"Clinical audit: a useful tool for reducing severe postpartum haemorrhages?","volume":"23","author":"Dupont","year":"2011","journal-title":"Int J Qual Health Care"},{"key":"2026091719525263500_mzag119-B8","doi-asserted-by":"publisher","first-page":"1201","DOI":"10.3109\/00016340903280990","article-title":"The Dutch perinatal audit project: a feasibility study for nationwide perinatal audit in the Netherlands","volume":"88","author":"de Reu","year":"2009","journal-title":"Acta Obstet Gynecol Scand"},{"key":"2026091719525263500_mzag119-B9","doi-asserted-by":"publisher","first-page":"1034","DOI":"10.1136\/adc.88.12.1034","article-title":"The confidential enquiry into maternal and child health (CEMACH)","volume":"88","author":"Weindling","year":"2003","journal-title":"Arch Dis Child"},{"key":"2026091719525263500_mzag119-B10","doi-asserted-by":"publisher","first-page":"65","DOI":"10.1016\/S0301-2115(99)00135-9","article-title":"Perinatal audit on avoidable mortality in a Dutch rural region: a retrospective study","volume":"88","author":"de Reu","year":"2000","journal-title":"Eur J Obstet Gynecol Reprod Biol"},{"key":"2026091719525263500_mzag119-B11","doi-asserted-by":"publisher","first-page":"195","DOI":"10.1186\/1472-6963-12-195","article-title":"The implementation of unit-based perinatal mortality audit in perinatal cooperation units in the northern region of the Netherlands","volume":"12","author":"van Diem","year":"2012","journal-title":"BMC Health Serv Res"},{"key":"2026091719525263500_mzag119-B12","doi-asserted-by":"publisher","first-page":"215","DOI":"10.1186\/s12884-015-0638-5","article-title":"Classification of substandard factors in perinatal care: development and multidisciplinary inter-rater agreement of the Groningen-system","volume":"15","author":"van Diem","year":"2015","journal-title":"BMC Pregnancy Childbirth"},{"key":"2026091719525263500_mzag119-B13","doi-asserted-by":"publisher","first-page":"272","DOI":"10.1186\/s12884-015-0707-9","article-title":"Influencing factors for high quality care on postpartum haemorrhage in the Netherlands: patient and professional perspectives","volume":"15","author":"Woiski","year":"2015","journal-title":"BMC Pregnancy Childbirth"},{"key":"2026091719525263500_mzag119-B14","doi-asserted-by":"publisher","first-page":"450","DOI":"10.1111\/aogs.14321","article-title":"Nationwide confidential enquiries into maternal deaths because of obstetric hemorrhage in the Netherlands between 2006 and 2019","volume":"101","author":"Ramler","year":"2022","journal-title":"Acta Obstet Gynecol Scand"},{"key":"2026091719525263500_mzag119-B15","doi-asserted-by":"publisher","first-page":"527","DOI":"10.1136\/archdischild-2021-322891","article-title":"Severe neonatal hyperbilirubinaemia: lessons learnt from a national perinatal audit","volume":"107","author":"van der Geest","year":"2022","journal-title":"Arch Dis Child Fetal Neonatal Ed"},{"key":"2026091719525263500_mzag119-B16","doi-asserted-by":"publisher","first-page":"100179","DOI":"10.1016\/j.eurox.2023.100179","article-title":"Lessons learned in cases of late preterm mortality in the Netherlands: Results from nationwide perinatal audits, a mixed method study","volume":"17","author":"Baauw","year":"2023","journal-title":"Eur J Obstet Gynecol Reprod Biol X"},{"key":"2026091719525263500_mzag119-B17","doi-asserted-by":"publisher","first-page":"e664","DOI":"10.1002\/hsr2.664","article-title":"Lessons learned from the perinatal audit of uterine rupture in the Netherlands: a mixed-method study","volume":"5","author":"Rosman","year":"2022","journal-title":"Health Sci Rep"},{"key":"2026091719525263500_mzag119-B18","doi-asserted-by":"publisher","first-page":"e003421","DOI":"10.1136\/bmjoq-2025-003421","article-title":"Evaluation of a tailored implementation strategy for audit-generated improvements in perinatal care","volume":"14","author":"van der Woerdt-Eltink","year":"2025","journal-title":"BMJ Open Qual"}],"container-title":["International Journal for Quality in Health Care"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/intqhc\/advance-article-pdf\/doi\/10.1093\/intqhc\/mzag119\/70784352\/mzag119.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/intqhc\/article-pdf\/38\/3\/mzag119\/70784352\/mzag119.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/intqhc\/article-pdf\/38\/3\/mzag119\/70784352\/mzag119.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T23:52:59Z","timestamp":1789689179000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/intqhc\/article\/doi\/10.1093\/intqhc\/mzag119\/8770361"}},"subtitle":[],"editor":[{"given":"Anthony","family":"Staines","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,7]]},"references-count":18,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2026,7,8]]}},"URL":"https:\/\/doi.org\/10.1093\/intqhc\/mzag119","relation":{},"ISSN":["1353-4505","1464-3677"],"issn-type":[{"value":"1353-4505","type":"print"},{"value":"1464-3677","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,7]]},"published":{"date-parts":[[2026,7]]},"article-number":"mzag119"}}