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

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