Open Access Research article

The development of quality indicators for the prevention and management of postpartum haemorrhage in primary midwifery care in the Netherlands

Marrit Smit1*, Susanne IC Sindram1, Mallory Woiski2, Johanna M Middeldorp1 and Jos van Roosmalen13

Author Affiliations

1 Department of Obstetrics, Leiden University Medical Centre, Albinusdreef 2, Leiden, 2300 RC, The Netherlands

2 Department of Obstetrics, University Medical Centre St Radboud, Geert Grooteplein-Zuid 10, Nijmegen, 6500 HB, the Netherlands

3 Department of Medical Humanities, EMGO Institute VU University Medical Center, van der Boechorststraat 7, Amsterdam, 1081 BT, The Netherlands

For all author emails, please log on.

BMC Pregnancy and Childbirth 2013, 13:194  doi:10.1186/1471-2393-13-194

Published: 20 October 2013



At present, there are no guidelines on prevention and management of postpartum haemorrhage in primary midwifery care in the Netherlands. The first step towards implementing guidelines is the development of a set of quality indicators for prevention and management of postpartum haemorrhage for primary midwifery supervised (home) birth in the Netherlands.


A RAND modified Delphi procedure was applied. This method consists of five steps: (1) composing an expert panel (2) literature research and collection of possible quality indicators, (3) digital questionnaire, (4) consensus meeting and (5) critical evaluation. A multidisciplinary expert panel consisting of five midwives, seven obstetricians and an ambulance paramedic was assembled after applying pre-specified criteria concerning expertise in various domains relating to primary midwifery care, secondary obstetric care, emergency transportation, maternal morbidity or mortality audit, quality indicator development or clinical guidelines development and representatives of professional organisations.


After literature review, 79 recommendations were selected for assessment by the expert panel. After a digital questionnaire to the expert panel seven indicators were added, resulting in 86 possible indicators. After excluding 41 indicators that panel members unanimously found invalid, 45 possible indicators were assessed at the consensus meeting. During critical evaluation 18 potential indicators were found to be overlapping and two were discarded due to lack of measurability.


A set of 25 quality indicators was considered valid for testing in practice.

Quality indicators; Postpartum haemorrhage; Midwifery; Delphi technique; Home birth; The Netherlands