ABSTRACT
What is already known about the topic? * The gravimetric method estimates the blood loss volume by weighing sanitary materials used during the labour process (i.e., gauze, sheets, swabs, pads, etc.) before and after being contaminated by the blood. * In clinical practice, the weight difference (in grams) is considered as 'blood loss volume' for ease of measurement and reported in millilitres without any formal conversion of units of weight to volume. * The benefits of the gravimetric method have been reported previously. What this paper adds * An online training programme is effective in increasing midwives' knowledge and awareness of the gravimetric method for postpartum blood loss assessment. * The midwives found the gravimetric method simple to adopt in clinical practice, which increased their confidence in detecting postpartum haemorrhage. * The midwives encountered some barriers while implementing the gravimetric method and provided strategies to mitigate the issues raised. BACKGROUND Postpartum haemorrhage (PPH) is defined as "a blood loss of 500 ml or more within 24 hours after birth1'?-3'" while severe PPH is "blood loss greater than or equal to 1000 ml within 24 hours.2'?-1'" Severe PPH is associated with one or more of the following conditions: blood transfusion, transcatheter arterial embolisation, arterial ligation, uterine surgery, hysterectomy, long-term psychological impact, or even maternal death.3"5 As a life-threatening condition,4 postpartum haemorrhage is estimated to account for 27% of maternal deaths worldwide6 and 30% of maternal deaths in Indonesia.7 In Indonesia, this percentage has remained stable from 2012 to 20ig.7,8 Postpartum haemorrhage diagnosis relies in part on the accuracy of blood loss assessment.9,10 A delay in PPH management may lead to poor outcomes which is often caused by a delayed diagnosis of PPH.11 Rosmaria et al. found that 94% of Indonesian midwives involved in that study did not routinely assess blood loss volume.10 Moreover, there is currently no recommended gold standard for assessing blood loss to help PPH diagnosis.1213 Blood loss can be measured using a number of methods, including colourimetric,14 photometric,15 semi-automatic,16,17 mathematical formulas,18 computer-based mathematical modelling,19 and radioisotope dilution methods.20 Nevertheless, most of them are complicated and impractical to apply in a real-life midwifery practice.18 The most common method used to estimate blood loss by health professionals worldwide is a visual method due to its ease of use, and can be easily and quickly done at various levels of health facilities.9,18,21 Despite the benefits of this method, it has been found to be inaccurate, in particular when there are higher levels of blood loss.10-15,18,22 Therefore, Bose et al. (2006) and Schorn (2010) suggested replacing visual checks with a more accurate measure for assessing blood loss volume.15,22 The gravimetric method (GM) has been recommended due to its accuracy and relative simplicity of use.23,24 This method is an assessment carried out by weighing all maternity pads before and after being exposed to blood, followed by calculating the weight difference.9,25,26 It is an evidence-based method of blood loss assessment, and evidence suggests that it may help in the diagnosis and management of PPH by providing a more accurate assessment of blood loss, therefore improving patient safety27 However, this method is not routinely used by Indonesian midwives.10 No previous research was identified that explored the evaluation of training midwives in the GM and exploring barriers and facilitators to the implementation in practice.