The Magnitude and Maternal Outcome of Primary Postpartum Hemorrhage among Mothers Who Received Postnatal Care at Alemata General Hospital, Northern Ethiopia: A Cross-sectional Study

Introduction

The term "primary postpartum hemorrhage" (PPH) refers to blood loss that occurs within 24 hours of giving birth and involves either blood loss of 1000 ml or more or blood loss that is accompanied by hypovolemia-related signs or symptoms (1). It is the significant cause of maternal mortality, accounting for one-quarter of all maternal deaths worldwide (2-3), and many experiences acute and long-term serious morbidities and disabilities such as anemia, organ failure, coagulopathy, complications of multiple blood transfusions, peripartum hysterectomy and loss of fertility, postpartum sepsis, longer hospital stay, and a psychological sequel, as well as poor growth and development of their children (2, 4-6).

Although PPH occurs worldwide, most maternal deaths as a result of PPH occur in middle and low-income countries (7, 8). PPH is a major cause of maternal morbidity and mortality, accounting for about one-third of all pregnancy-related deaths in Africa and Asia (9). The average magnitude rate of postpartum hemorrhage was approximately 6% in the globe and about 10.5% in Africa (10). The commonest etiology of primary PPH is uterine atony (2, 5), (11-13).

In Ethiopia, the maternal mortality rate (MMR) is high at the national and 25-30% is attributed to PPH (10) but Postnatal care (PNC) service usage is among the lowest of all maternal and child health care services in the health care delivery system and the most neglected period for the provision of quality care (14).

The main thing in the adverse outcomes associated with hemorrhage is the delay in detecting it and taking an appropriate intervention and it could be avoided through the use of timely and appropriate management (15- 16). Interventions like routine use of active management of the third stage of labor (AMTSOL) (15-18), providing immediate PNC, and encouraging all delivering women to stay in the health institution during the first 24 hours of delivery could play a great role in reducing or avoiding postpartum hemorrhage and associated complications (14).

Although data for the causes of maternal deaths are necessary to inform strategies to improve the maternal health care delivery system (16), it has been a challenge due to the scarcity of consistent and accurate data on maternal mortality specifically in middle and low-income country settings where maternal mortality is high (7). Thus it is very crucial to assess the magnitude of postpartum hemorrhage and the maternal outcome so that policies and strategies will be designed accordingly to end or minimize the mortality and morbidity of women due to postpartum hemorrhage and its complication. Data related to PPH in Ethiopia particularly in the study area is scarce. Therefore, this study aimed to assess the magnitude and maternal outcome of primary postpartum hemorrhage among mothers who receive postnatal care at Alemata general hospital, Northern Ethiopia, and come up with possible recommendations. Determining the magnitude and maternal outcomes of primary PPH would help health care providers, stakeholders, and policymakers create initiatives to enhance the health care service utilization of women to lessen the burden of primary PPH and its consequences.

Materials and Methods

An institutional-based cross-sectional study using retrospective chart review design was employed at Alemata general hospital from January 1st to 5th, 2020. The retrospective record review, also known as medical record review, patient record review, clinical record review, or retrospective chart review and is a well-established research design in which obtaining prerecorded, patient-centered data are thoroughly reviewed to answer one or more research questions or clinical queries (17). Alemata general hospital is located in the southern zone of Tigray region 666 km away from Addis Ababa and 180 kilometers from Mekelle, the capital city of the region. In Alemata town, there is one general hospital, one health center, and private clinics. According to the southern zone health department report, the hospital gives services to a population of more than 59,915 people with different departments like medical, surgical, pediatrics, and obstetrics and gynecology. Maternity services along with other services are available in the hospitals. 

Charts of all mothers who received postpartum care in Alemata general hospital from January 1 to December 30, 2019, made up the study population. Incomplete Maternal charts were excluded from the study.

The sample size was determined by using a single population proportion formula n = (Zα/2)² P (1 − P)/d² with the assumption of 7.6% of the population proportion of magnitude of PPH in the previous study (19), confidence interval of 95%, the marginal error of 4%, and adding 10% non-response rate finally gave us a sample size of 185. The sampled mothers’ chart was selected using systematic random sampling.

Data were collected from the client's medical record review technique by using a pretested structured and standardized checklist and it was prepared after reviewing different works of literature. Three BSc degree holder midwives were recruited to collect the data. The questionnaire had two parts which were the socio-demographic and obstetrical & gynecological part.

 A pretest was conducted among 10% of the sample size at a nearby hospital (Woldia General Hospital) which was not included in the study to see the appropriateness of the tool and feedback was incorporated accordingly. The one-day training was given to the data collector and supervisor on general information on the objective of the study, techniques of sampling, and data collection. In addition to this, data was checked before and after the data, entry stage to verify its completeness and double data entry was done.

Primary PPH- were all postnatal mothers diagnosed as having primary PPH by attending health care providers and documented on the chart during the study period.

The collected data was checked manually for completeness and consistency. After then, the data were coded, cleaned, and entered into Epi data, software version-4.6.0.0. Finally, the data was analyzed using SPSS Version-23. Findings were summarized and presented using figures and tables.

Ethical clearance was obtained from the institutional review board (IRB) of Mekelle University, which certifies that the study was performed per the ethical standards. An official letter obtained from the Tigray regional health bureau was submitted to each hospital and data was collected after permission was obtained from the medical director of the hospital. Anonymity and confidentiality were maintained by excluding personal identifiers from the data collection tool and the records of the study were kept strictly confidential.

Results

Socio‑demographic characteristics

A total of 185 mothers’ charts were reviewed with a response rate of 100%. The mean age and standard division of the study participants were 27.7 and 6.2 respectively. It was found that only 6.5% of the mothers were in the age group of 15-20 years. Two-thirds of the women (68.6%) belonged Tigray ethnic group. Moreover, the majority of mothers (64.6%) were from rural backgrounds (Table 1).

Obstetric and gynecological history of the study participants of a total of 185 mothers, 16 (8.6%) of mothers were diagnosed with primary PPH. Among mothers who had developed PPH, 37.6% were in the age group of 30-34 and 87.5% were from rural residences. Among mothers whose charts were reviewed, 66.5% of them were multiparous (had given birth two to four times).

Moreover, the majority (88.6%) of study participants had ANC follow-up, were institutional delivery and about 88.6% of study participants had received AMTSOL (Table 2).

Causes of primary postpartum hemorrhage

According to this study, the most common cause of postpartum hemorrhage was uterine atony (50.0%) followed by retained placenta (25.0%) and genital tract trauma (18.75%) (Figure 1).

Feto-maternal complication secondary to primary postpartum hemorrhage

This finding revealed that three fourth of patients had complications associated with PPH and the most common complication encountered was maternal vital sign (V/S) derangement (falling blood pressure and raising of heart rate) (68.8%), followed by postpartum anemia (56.3%). There was no observed maternal death in our study sample. It was also found that 2.1% of patients had stillbirth which indicates that the cause of PPH was a uterine rupture (Table 3).

Discussion

Postpartum hemorrhage is a significant cause of maternal morbidity and mortality worldwide. Women in low and middle income countries have an increase likelihood of severe PPH and of dying from PPH related consequences. However, information related to PPH is scarce in developing countries in general. So this study aimed to assess the magnitude and maternal outcome of postpartum hemorrhage among mothers who received postpartum care at Alemata general hospital. Accordingly, the current study found that the magnitude of postpartum hemorrhage was 16 (8.6%) which is in line with studies done in Uganda (20) and Japan (21). This report was also comparable with a study conducted in Debre Tabor General hospital (18) and Bedele hospital (22) and with the average magnitude of PPH in Africa (10).

However, the finding of the current study showed a lower rate of PPH compared with the previous studies conducted in Gondar town (23) and southern Ethiopia (24). The difference could be due to the difference in study period and improvement in the utilization of maternal health care services through time.

Similarly, the rate of PPH in this study was lower than those of earlier studies done in Pakistan (25) and Cameroon (26). The discrepancy might be due to the variation in blood loss estimation between countries, since in the current study setting there are no standard methods for quantifying the amount of blood loss after child birth. The variation might also be due to the difference in the data recording and documentation system.  The current study used PPH cases which was diagnosed by the attending clinician so there might be underestimation and under reported of the case.

On the other hand,  the result of the current study with respect to the rate of PPH was higher than studies conducted in Zimbabwe (2), Egypt (5), Nigeria (11) and Afghanistan (12). The possible reason for the difference may be sample size differences, obstetrics factors, socio-demographic differences, and study area and the maternal health services delivering system (accessibility) and variation in blood loss estimation between countries. The current study was carried out on small sample sizes and most of the mothers were from rural and multipara.

According to this study, the most common cause of postpartum hemorrhage was uterine atony followed by retained placenta and genital tract trauma. This is in line with different studies, where atonicity was the most common cause of PPH (2,5,11-13,24), followed by the retained placenta as the second most common cause of PPH (3). However, this is in contrast to a study conducted in Nigeria, which identified retained placenta and placental tissue were the major causes of PPH (27). So based on the findings of this study, we can infer that the active management of the third stage of labor with uterotonics can reduce the occurrence of postpartum hemorrhage.

In our study, the commonest complication encountered in patients with PPH was maternal vital sign derangement followed by anemia. This finding is in line with a study conducted in Egypt that showed that 67.5% of patients have a moderate degree of shock.

Moreover, the current study revealed that 6.3% of the patient had a hysterectomy. This is consistent with a study done in Afghanistan (12) which reported that 6% of the patient had a hysterectomy.

In contrast to previous studies conducted in Zimbabwe (2) and Afghanistan (12) which revealed maternal death due to PPH, there was no recorded maternal death in this study. The majority of PPH cases seemed to be early detected and quickly stopped soon after diagnosis before the patients lost too much blood and risked maternal life. Rapid recognition and early diagnosis of PPH is important for successful management and favorable outcome.

The study might not be a true representative of the population since the study was institution-based and used chart review methodology. Since we used secondary data, there might be missed cases and variables.

Conclusion

The magnitude of primary postpartum hemorrhage in the study setting was found to be 16 (8.6%). The current study concludes that the magnitude of primary PPH in this study area is approximately similar to the average magnitude of PPH in Africa. Other findings such as causes of primary PPH and maternal morbidity data also agree with most national and international studies on this topic. Although there was no recorded maternal death in this study, it was responsible for serious postpartum morbidities. So special emphasis should be given to the universal use of AMTSOL for all labors and timely detection and appropriate management of complications related to childbirth to avoid or decrease postpartum hemorrhage occurrence and its associated complications.

Acknowledgements

The authors are very thankful to the data collectors for their active participation in the data collection process.

Conflicts of interest

Authors declared no conflicts of interest.