{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,8,31]],"date-time":"2025-08-31T20:40:03Z","timestamp":1756672803983,"version":"3.44.0"},"reference-count":13,"publisher":"BMJ","issue":"4","license":[{"start":{"date-parts":[[2022,12,5]],"date-time":"2022-12-05T00:00:00Z","timestamp":1670198400000},"content-version":"unspecified","delay-in-days":4,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open Qual"],"accepted":{"date-parts":[[2022,10,26]]},"published-print":{"date-parts":[[2022,12]]},"abstract":"<jats:p>This safety improvement project used quality improvement methods in a Comprehensive Emergency Obstetric and Newborn Care facility in Yemen, managed by an international humanitarian non-governmental organisation. It is responsible for about 6500 deliveries per annum. Following a local review of maternal deaths and serious incidents in 2020\u20132021, care for women with severe hypertensive disease in pregnancy and postpartum haemorrhage were highlighted as potential areas for improvement. These are also the two most common reasons recorded for maternal mortality in Yemen (and in many low-income countries worldwide). We also wanted to foster an open and honest safety culture within the department that encouraged learning from error.<\/jats:p>\n               <jats:p>We used an inclusive approach in designing the improvements, with change ideas collated via frontline doctors, midwives and nurses working in the maternity unit. Data were collected via manual audit, and through routinely collected data. We focused on the following measures: number of incidents reported per month, documentation quality of antihypertensive prescriptions, fluid restriction practices in women with severe pre-eclampsia, number of minutes taken to control severe hypertensive episodes, postpartum haemorrhage identification rates and tranexamic acid stock usage. We evaluated the efficacy of team simulation training through precourse and postcourse questionnaires.<\/jats:p>\n               <jats:p>We found demonstrable improvement in our measures relating to treatment of women with hypertensive disorders of pregnancy, and in postpartum haemorrhage identification and treatment. Team simulation training was a difficult intervention to sustain but was received well with positive results during our test session. Incident reporting showed a temporary increase, but this effect was not sustained.<\/jats:p>\n               <jats:p>We concluded that quality improvement methodology is a valuable tool even in challenged healthcare settings such as this one, in an active conflict zone. Behaviour change in team culture and safety culture is harder to sustain and demonstrate without a long-term strategy.<\/jats:p>","DOI":"10.1136\/bmjoq-2022-002013","type":"journal-article","created":{"date-parts":[[2022,12,5]],"date-time":"2022-12-05T10:21:49Z","timestamp":1670235709000},"page":"e002013","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Use of quality improvement methodology to improve care of women with hypertensive disease in pregnancy and haemorrhage in Yemen (low-income, high-insecurity setting)"],"prefix":"10.1136","volume":"11","author":[{"given":"Sabrina","family":"Das","sequence":"first","affiliation":[{"name":"Obstetrics and Gynaecology, Imperial College Healthcare NHS Trust, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Emtiaz","family":"Abdulwahid","sequence":"additional","affiliation":[{"name":"Taiz Houban Mother and Child Hospital, Medecins Sans Frontieres Operational Centre Amsterdam, Amsterdam, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Audrey","family":"Moisan","sequence":"additional","affiliation":[{"name":"Maternity Department, Centre Hospitalier de Mayotte, Mamoudzou, France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anna Kathrina","family":"De Jesus","sequence":"additional","affiliation":[{"name":"Paediatrics, San Juan De Dios Educational Foundation Inc, Pasay City, The Philippines"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2022,12,5]]},"reference":[{"key":"2025083113110206000_11.4.e002013.1","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s13031-020-00269-x","article-title":"Reproductive, maternal, newborn and child health service delivery during conflict in Yemen: a case study","volume":"14","author":"Tappis","year":"2020","journal-title":"Confl Health"},{"key":"2025083113110206000_11.4.e002013.2","unstructured":"UNHCR . Yemen operational report. Available: https:\/\/reporting.unhcr.org\/document\/1335 [Accessed 31 Jan 2022]."},{"key":"2025083113110206000_11.4.e002013.3","unstructured":"World Health Organization . Saving the lives of mothers and children: rising to the challenge in Yemen; 2013."},{"key":"2025083113110206000_11.4.e002013.4","doi-asserted-by":"publisher","DOI":"10.1186\/s12992-018-0389-y"},{"key":"2025083113110206000_11.4.e002013.5","doi-asserted-by":"crossref","first-page":"1169","DOI":"10.1007\/s00268-011-1084-9","article-title":"Quality of care in humanitarian surgery","volume":"35","author":"Chu","year":"2011","journal-title":"World J Surg"},{"key":"2025083113110206000_11.4.e002013.6","doi-asserted-by":"crossref","DOI":"10.3402\/gha.v6i0.20311","article-title":"Too complicated for the field? Measuring quality of care in humanitarian aid settings","volume":"6","author":"Kersten","year":"2013","journal-title":"Glob Health Action"},{"key":"2025083113110206000_11.4.e002013.7","unstructured":"Frankel A , Haraden C , Federico F , et al . A framework for safe, reliable, and effective care. white paper. Cambridge, MA: Institute for Healthcare Improvement and Safe & Reliable Healthcare, 2017."},{"key":"2025083113110206000_11.4.e002013.8","unstructured":"Langley GL , Moen R , Nolan KM , et al . The improvement guide: a practical approach to enhancing organizational performance. 2nd ed. San Francisco: Jossey-Bass Publishers, 2009."},{"key":"2025083113110206000_11.4.e002013.9","doi-asserted-by":"crossref","first-page":"1581","DOI":"10.1016\/S0140-6736(17)31947-5","article-title":"Tranexamic acid for post-partum haemorrhage in the woman trial","volume":"390","author":"Letson","year":"2017","journal-title":"Lancet"},{"key":"2025083113110206000_11.4.e002013.10","unstructured":"Das S . Training in Yemen: how positive workplace cultures impact staff and patients, 2021. Available: https:\/\/blogs.msf.org\/bloggers\/sabrina\/training-yemen-how-positive-workplace-cultures-impact-staff-and-patients;"},{"key":"2025083113110206000_11.4.e002013.11","unstructured":"Haidt J . The happiness hypothesis: putting ancient wisdom and philosophy to the test of modern science. Random House, 2006."},{"key":"2025083113110206000_11.4.e002013.12","unstructured":"Heath D , Heath C . Switch: how to change things when change is hard. Random House, 2011."},{"key":"2025083113110206000_11.4.e002013.13","unstructured":"Ibarra H , Scoular A . The leader as coach, 97. Harvard Business Review, 2019: 110\u20139."}],"container-title":["BMJ Open Quality"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjoq-2022-002013","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,31]],"date-time":"2025-08-31T20:11:07Z","timestamp":1756671067000},"score":1,"resource":{"primary":{"URL":"https:\/\/qir.bmj.com\/lookup\/doi\/10.1136\/bmjoq-2022-002013"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,12]]},"references-count":13,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2022,12,5]]},"published-print":{"date-parts":[[2022,12]]}},"alternative-id":["10.1136\/bmjoq-2022-002013"],"URL":"https:\/\/doi.org\/10.1136\/bmjoq-2022-002013","relation":{},"ISSN":["2399-6641"],"issn-type":[{"type":"electronic","value":"2399-6641"}],"subject":[],"published":{"date-parts":[[2022,12]]}}}