what are midwives in ethiopia doing to reduce pph complications

• Journal List
• Int J Womens Health
• v.13; 2021
• PMC8273907

Int J Womens Health. 2021; 13: 663–669.

Assessment of Postpartum Hemorrhage in a Academy Hospital in Eastern Ethiopia: A Cross-Sectional Study

Sinetibeb Mesfin

¹Schoolhouse of Nursing and Midwifery, Higher of Wellness and Medical Sciences, Haramaya University, Harar, Ethiopia

Merga Dheresa

^oneSchool of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Federal democratic republic of ethiopia

Sagni Girma Fage

ⁱSchool of Nursing and Midwifery, Higher of Health and Medical Sciences, Haramaya University, Harar, Ethiopia

Abera Kenay Tura

¹Schoolhouse of Nursing and Midwifery, Higher of Wellness and Medical Sciences, Haramaya University, Harar, Federal democratic republic of ethiopia

²Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands

Received 2021 January two; Accepted 2021 Jun 23.

Abstract

Objective

Despite implementation of different strategies, postpartum hemorrhage (PPH) continued to account for a substantial proportion of maternal deaths in Federal democratic republic of ethiopia. The objective of this study was to appraise the magnitude of PPH and its associated factors among women who gave birth in a university infirmary in eastern Ethiopia from 1 to 31 March 2020.

Methods

An institution-based cross-sectional written report was conducted. A review of 653 randomly selected medical records of all deliveries from 1 March 2018 to 29 February 2020 in Hiwot Fana Specialized University Hospital (HFSUH), a academy hospital in eastern Ethiopia, was conducted. Data were nerveless on sociodemographic characteristics, obstetric and reproductive wellness conditions, and presence of PPH. Information were coded, checked for completeness and entered using EpiData 3.ane and exported to SPSS xx for analysis. Results were expressed using frequencies, tables and figures. Binary and multiple logistic regression were fitted to identify factors associated with PPH and associations were described using adapted odds ratio (aOR) forth with 95% confidence intervals (CI). Associations with p<0.05 in the multivariable logistic regression were declared as statistically significant.

Results

From a total of 642 (98.3%) women included in this study, 83 (12.nine%; 95% CI 10.four–15.6) had PPH. Maternal historic period >35 years (aOR = 3.08; 95% CI one.56, 6.07), no antenatal care (aOR = 3.65; 95% CI 1.97, 6.76), history of PPH (aOR = 4.18; 95% CI 1.99, viii.82), and existence grand multigravida (aOR = 3.33; 95% CI 1.14, 9.74) were significantly associated with having PPH.

Conclusion

A loftier proportion of women who gave birth in HFSUH experienced PPH. Prevention and direction of PPH should focus on improving antenatal care and prioritize grand multigravida, older women, and women with a previous history of PPH.

Keywords: magnitude, morbidity, bloodshed, postpartum hemorrhage, PPH

Introduction

Postpartum hemorrhage (PPH), defined as blood loss over 500 mL afterwards vaginal delivery or more than 1000mL later a cesarean section, is a major crusade of maternal morbidity and bloodshed.¹ Information technology is estimated that every 10 minute a woman dies of PPH, contributing to the majority of deaths from obstetric hemorrhage.^{2 , 3} Although deaths from PPH may occur outside health intendance facilities as a issue of high habitation deliveries, a significant number occur in hospitals, where constructive emergency care has the potential to salvage lives.⁴ In Africa, where maternal mortality is exponentially higher than other regions, PPH has an fifty-fifty more profound role.^{v , half-dozen}

From 2013 to 2018, 41–51% of all maternal deaths in Federal democratic republic of ethiopia were attributed to hemorrhage, mainly PPH.^seven In addition to the high maternal bloodshed from PPH, thousands of women survive from PPH and continue to suffer from its debilitating consequences.^eight PPH is associated with long- and short-term health issues: chronic affliction, disability, increased risk of expiry and/or poor growth and development of child, and vital organ failure.⁹ Focusing on the number of deaths or complications may underestimate the burden of PPH, as majority of non-severe forms remain unreported in majority of databases or studies.

Low resource settings like Ethiopia have high PPH also characterized past loftier fatality charge per unit. Proportion of PPH in Ethiopia ranges from 5.8–16.6% based on the written report settings, study pattern or nature of study^10–13 In a national cross-department report, PPH was constitute to have the highest example fatality rate among all the direct obstetric complications in Ethiopia.^xiv PPH is more than probable among women with macrosomia, those who had histroy of PPH, previous cesarean, abnormal placentation, prolonged third stage of labor, hypertensive disorders of pregnancy, soft tissue lacerations or induction of labor.^15–17 Agile direction of the tertiary phase of labor is the most effective strategy for prevention of PPH.¹⁸

Given the chance of nether reporting among studies because of the focus on deaths or severe forms of morbidity from PPH,^{xix , 20} studies focusing on the overall morbidity from PPH are essential to reveal the burden of the problem for designing advisable preventive services and planning for resource allocation. However, there is express data on burden of PPH, particularly among women surviving complications. The objective of this written report was to appraise magnitude of PPH and its associated factors in Hiwot Fana Specialized University Hospital (HFSUH), eastern Ethiopia.

Methods

Written report Setting and Population

The written report was conducted in HFSUH, a third academy infirmary in eastern Federal democratic republic of ethiopia, located in Harar town, 526 km from Addis Ababa, the upper-case letter. HFSUH is the major referral hospital in eastern Ethiopia and is affiliated with the College of Health and Medical Sciences of Haramaya University. A 201 bedded hospital and on transformation to a one thousand-bedded hospital during the report period, the hospital serves equally a referral hospital 24/vii for more than than five million inhabitants in eastern Ethiopia. In addition to giving bones medical intendance for patients, HFSUH serves every bit the primary referral centre of care for specialized medical, obstetric, gynecologic and pediatric illnesses, amidst others. During the study menstruum, the section of obstetrics and gynaecology was run by four consultants, eight resident obstetricians and gynecologists and 31 nurse (midwives).

An institution based cross-exclusive study was conducted from 1–31 March 2020. All women who gave birth in HFSUH constituted the source population. All women who gave birth in the hospital from 1 March 2018 to 29 February 2020 were the study population. The identity of women who gave birth in the hospital was adamant from commitment registers, admission and discharge logbooks, and operation theater records. All women admitted in the infirmary from one March 2018 to 29 February 2020 were included if their cards contain complete information almost their obstetric conditions, including PPH-related management. Charts with incomplete data were excluded.

The sample size was calculated by using unmarried proportion formula with 95% conviction interval (CI), margin of error 3% and proportion of PPH (16.7%) from the written report conducted in Southern Ethiopia.¹² Later on considering a 10% not-response charge per unit, the final sample size was 653. Using the women's medical registration numbers (MRNs) during the study period (north = 8431), a sampling frame was prepared and entered to the computer to generate random samples.

Measurement and Statistical Analysis

Data were collected through review of medical records by five trained BSc midwives using a semi-structured information extraction form developed from different literature.^{10 , 11 , 13} Information on sociodemographic characteristics, pregnancy and obstetrics history, current labor- and delivery-related information, and PPH related questions were collected. The questionnaire was pre-tested on 33 deliveries outside the written report period before the data drove and the adequacy of the checklist was evaluated and appropriate modifications were made.

Presence of PPH, divers equally having a clinical diagnosis of PPH on the medical tape or reported excess blood loss as per the WHO 2018,ⁱ presence of sign and symptoms of hypovolemia, a decline of ten% or more in the baseline hematocrit level regardless of the route of commitment,²¹ was considered as the dependent variable whereas sociodemographic characteristics, obstetrics-related (post- and ante-partum) factors, and labor and commitment-related factors were investigated equally independent variables. The nerveless data were coded, cleaned and entered in to EpiData three.i and exported to SPSS twenty for analysis. Descriptive statistics such every bit uncomplicated frequencies, measures of cardinal tendency and measures of dispersion were used. Binary logistic regression was done to identify association betwixt independent variables and PPH and variables with p-≤0.25 were included in the multivariable analysis afterward checking for multicollinearity. The Hosmer-Lemeshow test was used to test model fitness. An adjusted odds ratio (aOR) with 95% CI was used to describe factors associated with PPH and level of statistical significance was declared at p<0.05.

Ethical Considerations

This study was conducted in accordance with the Helsinki Declaration for research involving human subjects.²² In add-on, ethical clearance was obtained from the Institutional Wellness Research Ethics Review Commission of Higher of Health and Medical Sciences, Haramaya University, Ethiopia (ref no: IHRERC 059). Informed consent was obtained from the principal medical officer of the hospital. Data were nerveless using anonymous forms and no individual identifier information was nerveless or analyzed. The collected questionnaire was locked and was accessible but to the research team.

Results

Sociodemographic Atmospheric condition

Of 653 medical records reviewed, 642 (98.iii%) were eligible and included in the analysis: 11 incomplete records were excluded. The mean age of participants was 27.26 (±5.half dozen) years. Majority of the participants were 20- to 34-years-old (72.6%), multigravida (59.8%), gave nativity vaginally (86.three%), received antenatal care (60.6%), and urban residents (59.5%) (Table i).

Tabular array one

Sociodemographic Characteristics of Women Who Gave Nativity in HFSUH, Federal democratic republic of ethiopia, 2020 (due north =642)

Variable	Category	Frequency	Pct (%)
Age	< 20 years	88	xiii.7
	20–34 years	466	72.half dozen
	≥ 35years	88	13.seven
Residence	Urban	363	56.5
	Rural	279	43.v
Gravidity	1	191	29.eight
	ii–4	295	46
	≥five	156	24.2
Parity	1	190	29.half dozen
	two–4	384	59.8
	≥5	68	10.6
Gestational age	< 37 weeks	37	5.8
	37–41 weeks	571	88.9
	≥ 42 weeks	34	v.three
ANC follow upward	Yes	492	76.6
	No	150	23.4
History of previous PPH	Yes	51	7.ix
	No	591	92.1
History of previous CS	Yeah	twoscore	vi.two
	No	602	93.viii
Complications	Yes	207	32.two
	No	435	67.8
Onset of labor	Spontaneous	551	85.8
	Induced	91	14.2
Labor augmented (n = 551)	Yes	39	7.1
	No	512	92.ix
Duration of labor	≥24 Hours	37	5.8
	<24 hours	599	94.two
Obstructed labor	Yes	28	4.4
	No	614	95.half dozen
Mode of delivery	Vaginal	554	86.3
	C/Southward	88	13.vii
Episiotomy (northward = 554)	Yep	82	14.viii
	No	472	85.2
Active third stage of labor direction (north=554)	Yes	539	97.iii
	No	xv	2.seven
Prolonged third stage labor (n=554)	Yeah	29	5.two
	No	525	94.8
Received blood after delivery	Yes	43	six.vii
	No	599	93.iii

A total of 207 (32.2%) women had developed some complications, pregnancy-induced hypertension (24.ii%) followed past prolonged labor (17.nine%) (Effigy i).

Distribution of complication in pregnancy and childbirth among mothers who gave birth at HFSUH, Eastern Federal democratic republic of ethiopia, 2020 (n = 642).

Magnitude of PPH and its Associated Factors

A total of 83 (12.9%; 95% CI; ten.iv–15.vi) of women had PPH. Uterine atony (49.4%), retained membrane (xix.three%) and genital trauma (12%) were the leading causes of PPH. History of PPH, ANC status, parity, and age were independently associated with PPH. Women with history of PPH were 4.18 times (aOR = 4.18; 95% CI 1.99, eight.82) more likely to develop PPH equally compared to women with no history of PPH. Women with no ANC follow upward were 3.65 times (aOR = 3.65; 95% CI 1.97, half dozen.76) more likely to develop PPH than their counterparts. The odds of having PPH was iii.33 (aOR = 3.33; 95% CI 1.14, 9.74) among grand multigravida women compared to primigravida. In addition, older women (>35 years) were iii.08 times (aOR=3.08; 95% CI 1.56,half dozen.07) more likely to develop PPH compared to women aged 20- to 34-years-old (Table 2).

Table 2

Factors Associated with PPH Amid Women Who Gave Nascence in HFSUH, Eastern Ethiopia, 2020 (n =642)

Variable		PPH		cOR (95% CI)	aOR (95% CI)
		Yep (%)	No (%)
Residence	Urban	37 (x.two)	326 (89.8)	one.00	1.00
	Rural	46 (16.5)	233 (83.v)	ane.74 (1.09,2.77)	0.95 (0.52,1.74)
History of PPH	Yes	23 (45.1)	28 (54.9)	vii.27 (3.94,13.42)	4.18 (1.99,eight.82) **
	No	60 (10.2)	531 (89.8)	one.00	1.00
ANC follow up	Yes	41 (8.iii)	451 (91.7)	1.00	1.00
	No	42 (28.0)	108 (72.0)	4.27 (ii.65,6.91)	3.65 (i.97,half dozen.76) **
Gestational age	<37 weeks	iii (seven.5)	37 (92.5)	0.49 (0.15,1.65)	0.77 (0.21,2.89)
	37–41 weeks	79 (14.0)	485 (86.0)	1.00	one.00
	≥42 weeks	1 (2.six)	37 (97.4)	0.17 (0.22,1.23)	0.22 (0.28,one.68)
Complication	Yes	22 (10.6)	185 (89.4)	0.73 (0.43,1.22)	0.69 (0.37,ane.29)
	No	61 (14.0)	374 (86.0)	i.00	i.00
Age	<xx years	1 (1.1)	87 (98.ix)	0.112 (0.015,0.83)	0.19 (0.23,one.72)
	20–34years	43 (9.iii)	420 (90.7)	1.00	1.00
	≥35years	39 (42.ix)	52 (57.ane)	7.33 (iv.35,12.32)	three.08 (i.56,6.07) **
Elapsing of labor	≥24 hour	9 (23.one)	30 (76.9)	two.12 (0.97,4.64)	2.22 (0.78,vi.34)
	<24 hour	74 (12.4)	523 (87.6)	1.00	1.00
Gravidity	1	6 (3.6)	185 (96.4)	1.00	1.00
	2–4	33 (11.ii)	262 (88.8)	3.88 (1.6,ix.46)	2.37 (0.89,half dozen.35)
	≥5	44 (28.2)	112 (71.viii)	12.1 (5.001,29.iii)	3.33 (i.fourteen,nine.74) *

Discussion

In this study, we assessed the magnitude of PPH and its associated factors among women who gave birth in a university hospital in eastern Ethiopia. We plant that slightly more than than one in ten women who gave birth in the hospital during the study menses developed PPH. Women with history of PPH, >35-years-old, who did not attend ANC, and g multigravida were more likely to develop PPH.

Our finding is in line with findings reported in Sri Lanka (12.3%) and Tanzania (11.9%).^{17 , 23–26} But it is lower than findings from Southern Federal democratic republic of ethiopia (16.6%), Pakistan (21.three%), and Cameroon (23.6%).^{12 , 17 , 23–26} In addition, it is higher than findings from Dessie (five.eight%), Debre Tabor (7.6%), Bedele (9.69%) in Ethiopia, Uganda (9%) and Nippon (eight.7%).^{10 , 11 , 13 , 17 , 26} Given that our study is conducted in a 3rd referral infirmary where bulk of women with complications are treated, our finding is expected to be college. In improver, differences due to sample size, inclusion criteria or quality of documentation might be related to these differences. Moreover, magnitude of PPH may vary between and within geographical regions every bit a result of variation in diagnosis, quality of documentation or due to subjective estimation of blood loss).^{17 , 23–26}

We found that women with history of PPH were more likely to experience PPH than their counterparts^sixteen indicating the importance of counseling women about recurrence of PPH in subsequent pregnancies. Coinciding with previous findings, PPH was more likely among women with no ANC follow up.^10–xiii Although not all risks of PPH could exist identified during prenatal visits or predictable, ANC may serve every bit an opportunity to screen, diagnose and manage identified risk factors. Additionally, we institute that PPH was more probable amid older women, a finding besides supported in previous studies from Senegal, Mali, the WHO multi country survey, Ethiopia (Bedele and Southern Ethiopia).^{x , 12 , 27 , 28} Equally maternal historic period increases, pregnancy complications like uterine atony, gestational diabetes, pre-eclampsia, placenta previa, caesarean section, placental abruption which cause PPH also accept a great take chances to occur.²⁸ Similarly, 1000 multigravida (≥v) women were more likely to develop PPH in line with the finding from Cameroon.^{xvi , 25} Repeated stretching of muscle fibers may lead to loss of muscle tone that results in uterine atony which is the leading crusade of PPH.²⁹

The loftier burden of PPH in our study indicates the importance of auditing the ceremoniousness of obstetric direction in HFSUH.³⁰ Given that PPH management in the study hospital is found to exist inadequate—weak vital sign monitoring, performing typing and cross-matching of blood, and fluid intake/output nautical chart maintenance—interventions to preclude further complications and/or deaths from PPH should be instituted. With the already established effectiveness of tranexamic acid in the prevention of PPH^{31 , 32} or reducing the gamble of deaths,³³ it should be considered for employ.

In conclusion, we found high proportion of women developing PPH compared to like settings. We too found that PPH is more probable amid women with prior history of PPH, >35-years-erstwhile, had no ANC, and grand multigravida. Screening history of PPH during ANC consultation or labor and delivery, and encouraging women to seek ANC is essential to identify women at risk of PPH to initiate close follow up and management. In improver to assessing burden of PPH (which was the primary objective of our study), a thorough of appropriateness and timeliness of direction for patients is essential to avert the high maternal deaths attributed to PPH in the eastern Ethiopia and beyond.

Acknowledgments

We would similar to thank Hiwot Fana Specialized University Hospital administrators for facilitation of the study. Nosotros are also grateful to the supervisors and information collectors for their support.

Funding Statement

The work was funded by Haramaya Academy every bit part of a MSc study to SM. The organization has no role in the design, collection, analysis or interpretation of data or the decision to submit for publication.

Authorship Contributions

All authors contributed to data analysis, drafting or revising the article, take agreed on the journal to which the article will be submitted, gave concluding approval of the version to exist published, and agree to exist answerable for all aspects of the work.

Disclosure

The authors study no conflicts of interest in this work.

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