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Background: Reduction of maternal mortality and morbidity is a major global health priority. However, much remains unknown regarding factors associated with postpartum hemorrhage (PPH) among childbearing women in the Rwandan context. The aim of this study is to explore the influencing factors for prevention of PPH and early detection of childbearing women at risk as perceived by beneficiaries and health workers in the Northern Province of Rwanda. Methods: A qualitative descriptive exploratory study was drawn from a larger sequential exploratory-mixed methods study. Semi‐structured interviews were conducted with 11 women who experienced PPH within the 6 months prior to interview. In addition, focus group discussions were conducted with: women’s partners or close relatives (2 focus groups), community health workers (CHWs) in charge of maternal health (2 focus groups) and health care providers (3 focus groups). A socio ecological model was used to develop interview guides describing factors related to early detection and prevention of PPH in consideration of individual attributes, interpersonal, family and peer influences, intermediary determinants of health and structural determinants. The research protocol was approved by the University of Rwanda, College of Medicine and Health Sciences Institutional Ethics Review Board. Results: We generated four interrelated themes: (1) Meaning of PPH: beliefs, knowledge and understanding of PPH: (2) Organizational factors; (3) Caring and family involvement and (4) Perceived risk factors and barriers to PPH prevention. The findings from this study indicate that PPH was poorly understood by women and their partners. Family members and CHWs feel that their role for the prevention of PPH is to get the woman to the health facility on time. The main factors associated with PPH as described by participants were multiparty and retained placenta. Low socioeconomic status and delays to access health care were identified as the main barriers for the prevention of PPH. Conclusions: Addressing the identified factors could enhance early prevention of PPH among childbearing women. Placing emphasis on developing strategies for early detection of women at higher risk of developing PPH, continuous professional development of health care providers, developing educational materials for CHWs and family members could improve the prevention of PPH. Involvement of all levels of the health system was recommended for a proactive prevention of PPH. Further quantitative research, using case control design is warranted to develop a screening tool for early detection of PPH risk factors for a proactive prevention.
As part of a larger exploratory sequential mixed-methods study, we undertook phase one of the study with a qualitative descriptive design to develop a rich description of the phenomenon under study [16, 17]. This design was used to uncover daily participants’ experiences by remaining close to described or observed events [18]. To explore influencing factors for delivering PPH proactive preventive care from different perspectives, a social determinants approach to maternal deaths [19] and Social Ecological Model (SEM) [20] were used. The healthcare system in Rwanda reaches from the community to the national referral hospitals [21]. As illustrated by the Fig. 1, there are three levels of the healthcare system in Rwanda: (1) community health centers and health posts which constitute the primary level of healthcare, (2) district hospitals operating at the secondary level of healthcare, and (3) provincial referral hospitals, national referral hospitals and University Teaching Hospitals, serving as the tertiary and highest level of healthcare [21, 22]. Health care system in Rwanda. MOH*: Ministry of Health Recently, Rwandan Ministry of Health established a new level of health facility which is in between district hospital and health center, to relieve the challenge of delays in referral of obstetric cases and overcrowding at district hospitals. These facilities are called medicalized health centers [23]. The present study was conducted at primary and secondary levels of the health system in Rwanda. We reached out to the community by involving community members and community health workers (CHWs) in charge of maternal health. This study was conducted in three health facilities of the Northern Province of Rwanda. We included one health center, one medicalized health center and one district hospital. The selection criteria we used to choose facilities to be visited included their level of performance in maternal and newborn health, location (urban versus rural), and geographical accessibility of the health facilities to clients. The study sites were selected by the principal investigator and validated by the research committee. The selected district hospital serves a population of 444 387 in its catchment area, which also includes 24 health centers [24]. The Northern Province of Rwanda was purposively chosen for being in a rural area where some health centers are hard to access, and for its low uptake of antenatal and postnatal services among childbearing women [24]. Fifteen women were purposively selected for having experienced PPH within the six months immediately prior to data collection, being willing to participate, and being over 18 years old. The research team, in collaboration with the head of maternity at the facility, identified PPH cases from the birth register. For women who were discharged from the health facilities, the CHWs in charge of maternal health assisted to connect the research team with them for recruitment from the villages. Women who were still in hospital were given a verbal invitation by the researcher to participate. Women and their partners or close relatives who agreed to participate were given an appointment by the researcher for an interview at the nearest health facility. The inclusion criteria for relatives included being her husband or a close relative who was with her when PPH occurred. The final sample size of eleven women was reached when it was determined no new themes were emerging from the interviews and it was judged that sufficient data had been collected to address the study’s purpose [16]. Ten close relatives to the women from two health facilities responded to our invitation and were willing to participate (eight husbands and two close female relatives). CHWs in charge of maternal health living in the same village as the woman who experienced PPH were also invited to participate in this study since they are in control for not only maternal health but also for neonatal health in their respective villages. CHWs register women of reproductive age, encourage them to use maternal care services, go along with clients in labor from villages to the nearest health facility to be assisted by skilled birth attendants during labor and delivery [25]. The CHWs who participated in the present study were identified through the CHW coordinator who is a full time employee at the health facility. The researcher made a phone call to fourteen CHWs who were eligible, inviting them to participate in the study. Eleven female CHWs from the two health facilities responded to the invitation and were sent a text message specifying the venue and time for the focus group interview. A total of twenty-five health care providers working in maternity units of selected health facilities were also invited to participate, of whom fourteen (10 nurses, 3 midwives, 1 medical doctor) were eligible to participate in a focus group discussion (FGD). Correspondence to potential participants was in Kinyarwanda language. Participants were recruited using email or telephone messages. Inclusion criteria included: being a full-time and health care provider with at least one year’s experience of working in maternity, and ability to speak and read in either English or Kinyarwanda. In this study women and their relatives are considered as beneficiaries while health care professionals and CHWs in charge of maternal health are all considered as health workers. The research team consisted of members with expertise in qualitative research methodology, maternal health and health care. Apart from one research team member, all were female. The research team developed semi-structured interview guides in both English and Kinyarwanda, including one for each category of in-depth interviews (IDIs) and Focus Group Discussions (FGDs). The interview guides were translated back and forth by an independent professional translator, to confirm that the meaning and content of the questions of the original copy had not changed during the translation process. Verification of the translated instrument was also done by the research team to ensure its validity. The interview guide questions focused on five interrelated levels of SEM to facilitate identification and description of potential PPH influencing factors: individual, interpersonal, community, organizational, and policy/enabling environment [20]. Demographic data of participants was obtained using a demographic form during individual interviews. All participants chose to be interviewed in Kinyarwanda. The principal investigator conducted IDIs and FGDs. As the researcher is a Rwandan national, there were no language or cultural barriers with participants. Pretesting of the interview guides was conducted to improve validity in data collection procedures and interpretation of findings [26]. The pretest was done with participants not included in this study but sharing same inclusion criteria. This process assisted to determine the relevancy and appropriateness of the questions being asked, to assess wording and identify any difficulties. The pretest results indicated that conducting IDIs while a woman was still hospitalized, was not conducive for a free and open discussion. In fact, women were reluctant to talk about issues pertaining to their relationships with health care providers. Therefore, for the women who were still hospitalized at the health facilities included in this study, IDIs were scheduled on the day of their discharge. Prior to voluntarily participating in the study, participants were informed about the purpose of the study and provided with a letter of information and consent form for their signature. Anonymity and confidentiality were observed throughout the conduct of the study. After obtaining participants’ informed consent, all interviews were digitally audio-recorded with participants’ permission and transcribed verbatim by the researcher. Data collection took place over a period of three months from December 2018 to February 2019 in meeting rooms of the three selected health facilities. First, the researcher conducted one-to-one in-depth interviews with eleven women who had experienced PPH. Then, FGDs took place with the three groups of participants: (1) two FGDs with the partners and close relatives of the women, (2) two FGDs with CHWs and (3) three FGDs with health care providers. The duration of IDIs ranged between 45 and 60 minutes, while the FGDs lasted 45 to 90 minutes. To produce an in-depth understanding of early detection of women at risk of PPH and its prevention in relation to different contexts, field notes were taken by the researcher during and after data collection to capture all respondents’ nonverbal communications and other important information from the researcher observations. The combination of IDIs and FGDs was used to seek data completeness [27] in this study. Each method (IDIs and FGDs) revealed different information about prevention of PPH and contributed to a more comprehensive understanding. Integration of data involved moving back and forth between the data sets to discover data convergence and complementarity. After the number of IDIs and FGDs described above were completed, the participants’ responses had become repetitive, therefore it was determined that data saturation had been reached and recruitment ceased. The Table 1 illustrates number of participants in individual interviews and in focus groups discussions. Methods of data collection and participants in the qualitative study Data analysis was concurrently undertaken with data collection and was initiated after the completion of the first interview. NVivo Pro Version 12 was used to help organize the data for further analysis. To analyze findings from the present study, we used the six steps of inductive thematic analysis [28, 29]. As described by Braun and Clarke [28] we focused on interpreting and explaining what the study participants shared. Throughout this process the researcher considers whether the identified themes work in the context of the entire data set and refines the developed themes to ensure they are coherent and distinct from each other [30]. The transcripts were read while listening to the audio recordings to ensure accuracy and completeness. First, we read and re read the transcripts to become familiar with what was stated and to be immersed in the data, noting initial analytic observations. Second, we engaged in open line by line coding and assigned preliminary codes to the data in order to describe the content with interesting features across the entire data set. A coding guide was developed, consisting of all the codes or labels from the transcripts. Third, we proceeded to group familiar codes into preliminary themes which depicted the same ideas or concepts. The themes were discussed and agreed by the research team members through consensus. Ongoing analysis helped to refine the specifics of the themes then clear definitions and names for each theme were created. Finally we produced a report [29] on influencing factors for PPH prevention care from different perspectives. The research team worked in close collaboration throughout the data analysis process to discuss the codes and preliminary themes, and come to a consensus of the final emergent themes. Verbatim quotes were selected from the transcripts to illustrate main themes. To ensure rigor [31] of the present qualitative study, trustworthiness was established by observing the criteria suggested by Lincoln and Guba [32]: credibility, transferability, dependability and confirmability. To prepare for data collection, the interview guides were developed by the principal investigator after a literature search and critical discussion with the research committee members. The interview guide was initially pilot tested with three participants who are not included in the present study. For the credibility of data, we used investigator triangulation. For data quality checkup and consistency, reliability [33] was observed. Two transcripts from IDIs and one transcript from a FGDs were randomly selected by the principal investigator and shared with research team members to ensure that findings are based on participants’ responses rather than on researcher’s own preconceptions. The resulting comments were discussed and final decisions on codes and themes were made by group consensus. We also involved an independent researcher, with a master’s degree in public health to analyze a set of data while the principal investigator who conducted the interviews verified the consistency and fit of analyzed data with the original transcripts and audio records. Credibility of data was also ensured by data triangulation by using different methods and varying sources to collect data to develop a comprehensive understanding of factors affecting PPH prevention. IDIs and FGDs were conducted with different groups of people believed to have information about the topic under study. Data were gathered from three health facilities from the Northern Province of Rwanda offering different levels of health services to ensure greater representation of participants from various contexts and experiences. One medical doctor in charge of maternity unit was recruited to ensure that a wide range of insights were gained about the phenomenon. During data collection and analysis, to account for personal bias and maintain objectivity, the researcher used journal writing to highlight the researcher’s reflections on the research in progress. A verbal check was also made by the researcher during and at the end of each interview, asking the participant to confirm whether the researcher’s understanding of the provided information aligned with what the participant had meant to say. After data analysis, three participants (one from IDIs and two from FGDs) were contacted with a phone call to obtain feedback on the generated themes and categories. To ensure dependability, an audit trail was maintained to record the details of data collection, data analysis and the decisions made throughout the research process that led to the findings. This study was presented and assessed by the Institution Review Board at the College of Medicine and Health Sciences, University of Rwanda, and approval (No 313/CMHS IRB/2018) to carry out the study was granted in accordance with the applicable rules concerning the review of research ethics committee and informed consent.
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