Prevalence and predictors of primary postpartum hemorrhage: An implication for designing effective intervention at selected hospitals, Southern Ethiopia

PLoS ONE, Volume 14, No. 10, Year 2019

Interpretation

Background Primary postpartum hemorrhage is the leading cause of maternal mortality worldwide. Ethiopia has made significant progress in maternal health care services. Despite this, primary postpartum hemorrhage continues to remain the leading cause of maternal mortality in Ethiopia. This study aimed to assess the prevalence and predictors of primary postpartum hemorrhage among mothers who gave birth at selected hospitals in the Southern Ethiopia. Methods An institution-based cross-sectional study was employed from March 2–28, 2018. Four hundred and twenty-two study participants were obtained using the consecutive sampling method. A structured interviewer-administered questionnaire and chart review were used to collect data. Data were entered into Epi-data version 3.1 and analyzed using SPSS version 22. Multivariable logistic regression were used to determine the predictors of primary postpartum hemorrhage with 95% CI and p-value < 0.05. Results The overall prevalence of primary postpartum hemorrhage was 16.6%. Mothers aged 35 and above [AOR = 6.8, 95% CI (3.6, 16.0)], pre-partum anemia [AOR = 5.3, 95% CI (2.2, 12.8)], complications during labor [AOR = 1.8, 95% CI (2.8, 4.2)], history of previous postpartum hemorrhage [AOR = 2.7, 95% CI (1.1, 6.8)] and instrumental delivery [AOR = 5.3, 95% CI (2.2, 12.8)] were significant predictors of primary postpartum hemorrhage. Conclusion Primary postpartum hemorrhage is quite common in the study area. Mothers aged 35 and above, complications during labor, history of previous postpartum hemorrhage, and instrumental delivery were predictors of primary postpartum hemorrhage. Since postpartum hemorrhage being relatively common, all obstetrics unit members should be prepared to manage mothers who experience it. It was an institution-based cross-sectional conducted in the Wachemo University Negist Eleni Mohammed Memorial General Hospital, Butajira Zonal Hospital and in the Worabe comprehensive Hospital from March 2–28, 2018. Source populations were all mothers who gave birth in the selected Hospitals during the study period and mothers who cannot able to communicator critically ill/sick at the time of data collection were excluded from the study. The single population proportion formula was used to determine sample size with the following assumptions: prevalence of primary postpartum hemorrhage was 50%, 95% confidence interval, marginal error 5% and 10% none response rate, the final sample size was 422. Three hospitals were selected purposely. From all hospitals, 422 participants were selected using a consecutive sampling technique till the calculated sample size was achieved. The allocation of the study participants to each hospital was based on the previous monthly deliveries (from hospital records). Data were collected using a pretested structured interviewer administered questionnaire and patient's chart reviewed, which was used to retrieve diagnosis of primary postpartum hemorrhage and mothers’ test results that could not be captured by the interview. Research questionnaire was developed based on the instruments that were applied in other related studies [11, 14, 24–26]. It was intended to collect data on sociodemographic variables, obstetric related characteristics (antepartum, intrapartum and postpartum events) and fetal factors. Three B.Sc. midwives, and one M.Sc. midwife were recruited for the data collection and supervision, respectively in each hospital. To ensure the quality of data collected from the study participants, at the beginning, a data collection questionnaire was pre-tested on 5%(21) of calculated sample size at the Halaba Zonal Hospital and necessary modifications were made based on gaps identified in the questionnaire. Data collectors and supervisors were trained for three days intensively on the study instrument and data collection procedure that includes the relevance of the study. The English questionnaire was translated first to the local language and translated back into English language by experts to check its consistency. The data collectors worked under close observation of the supervisors to ensure reliability to correct data collection procedures. In addition, supervisors and the principal investigators checked the filled questionnaires at the end of data collection every day for completeness. Furthermore, the data were carefully entered and cleaned before the beginning of the analysis. In this study the definition of clinical diagnosis PPH was obtained from the mothers’ card which was identified by birth attendants and was classified as: “yes” (having a clinical diagnosis of postpartum hemorrhage in the mothers’ card) or “no”. Such as antepartum hemorrhage, hypertension disorders during pregnancy, polyhydramnios, chorioamnionitis or/and others. Malpresentation, malposition, prolonged labour or obstructed labour, or/and others, (present = 1 or absent = 0). Data were entered using Epi-data version 3.1 and exported to statistical package social science (SPSS), version 22.0 software for analyses. Multivariable logistic regression was done for variables that have p-value ≤ 0.25 during the bivariate logistic regression analyses to identify the predictor of PPH and to control for potential confounders. The degree of association between independent, and dependent variables were assessed using odds ratio with 95% confidence interval. The P-value < 0.05 was considered as statistically significant. The Hosmer-Lemeshow goodness-of-fit statistic was used to check if the necessary assumptions for multivariable logistic regressions were fulfilled and the model had p-value > 0.05 which proved the model was good. Ethical approval was taken from the Institutional Review committee of Wachemo University. Formal letters were obtained from the Hadiya, Silte and Gurage zonal health office administration. Then, permission was obtained from each hospital authority before commencing the data collection. The participants were informed about purpose, procedures, potential risks and benefits of the study. Informed written consent was sought from selected participant to confirm willingness to participate in the study before the interview. To protect confidentiality, name was not included in the written questionnaire. The study participants also were ensured that refusal to consent or withdrawal from the study would not alter or put at risk their access to care.

AI Digest

Study Justification:

– Primary postpartum hemorrhage is the leading cause of maternal mortality worldwide.
– Despite progress in maternal health care services in Ethiopia, primary postpartum hemorrhage remains a significant issue.
– This study aimed to assess the prevalence and predictors of primary postpartum hemorrhage in selected hospitals in Southern Ethiopia.

Study Highlights:

– The study found that the overall prevalence of primary postpartum hemorrhage was 16.6%.
– Significant predictors of primary postpartum hemorrhage included mothers aged 35 and above, pre-partum anemia, complications during labor, history of previous postpartum hemorrhage, and instrumental delivery.
– The study highlights the importance of preparedness in managing mothers who experience postpartum hemorrhage.

Recommendations for Lay Reader:

– Mothers aged 35 and above should be closely monitored during childbirth to prevent postpartum hemorrhage.
– Pre-partum anemia should be identified and managed to reduce the risk of postpartum hemorrhage.
– Complications during labor should be promptly addressed to prevent postpartum hemorrhage.
– Mothers with a history of previous postpartum hemorrhage should receive special attention and care during childbirth.
– The use of instrumental delivery should be carefully considered to minimize the risk of postpartum hemorrhage.

Recommendations for Policy Maker:

– Enhance monitoring and surveillance systems to identify mothers at risk of postpartum hemorrhage.
– Strengthen antenatal care services to detect and manage pre-partum anemia.
– Improve access to emergency obstetric care to address complications during labor.
– Develop protocols and guidelines for managing mothers with a history of previous postpartum hemorrhage.
– Promote evidence-based practices in instrumental delivery to reduce the risk of postpartum hemorrhage.

Key Role Players:

– Obstetricians and gynecologists
– Midwives
– Nurses
– Hospital administrators
– Policy makers
– Maternal health program managers

Cost Items for Planning Recommendations:

– Training programs for healthcare providers on managing postpartum hemorrhage
– Equipment and supplies for emergency obstetric care
– Development and dissemination of protocols and guidelines
– Monitoring and surveillance systems for identifying at-risk mothers
– Antenatal care services for detecting and managing pre-partum anemia

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is relatively strong, but there are some areas for improvement. The study design, an institution-based cross-sectional study, provides valuable information on the prevalence and predictors of primary postpartum hemorrhage. The sample size calculation and selection process are clearly described. Data collection methods, including the use of a structured questionnaire and chart review, are appropriate. The statistical analysis, including multivariable logistic regression, is robust. However, there are a few areas that could be improved. First, the abstract does not provide information on the response rate or any potential biases in participant selection. Second, the abstract does not mention any limitations of the study. It would be helpful to include a brief discussion of potential limitations, such as generalizability or confounding factors. Finally, the abstract does not mention any recommendations for future research or implications for practice. It would be beneficial to include a sentence or two on how the findings can be used to improve interventions or maternal health care services.

Abstract

It was an institution-based cross-sectional conducted in the Wachemo University Negist Eleni Mohammed Memorial General Hospital, Butajira Zonal Hospital and in the Worabe comprehensive Hospital from March 2–28, 2018. Source populations were all mothers who gave birth in the selected Hospitals during the study period and mothers who cannot able to communicator critically ill/sick at the time of data collection were excluded from the study. The single population proportion formula was used to determine sample size with the following assumptions: prevalence of primary postpartum hemorrhage was 50%, 95% confidence interval, marginal error 5% and 10% none response rate, the final sample size was 422. Three hospitals were selected purposely. From all hospitals, 422 participants were selected using a consecutive sampling technique till the calculated sample size was achieved. The allocation of the study participants to each hospital was based on the previous monthly deliveries (from hospital records). Data were collected using a pretested structured interviewer administered questionnaire and patient's chart reviewed, which was used to retrieve diagnosis of primary postpartum hemorrhage and mothers’ test results that could not be captured by the interview. Research questionnaire was developed based on the instruments that were applied in other related studies [11, 14, 24–26]. It was intended to collect data on sociodemographic variables, obstetric related characteristics (antepartum, intrapartum and postpartum events) and fetal factors. Three B.Sc. midwives, and one M.Sc. midwife were recruited for the data collection and supervision, respectively in each hospital. To ensure the quality of data collected from the study participants, at the beginning, a data collection questionnaire was pre-tested on 5%(21) of calculated sample size at the Halaba Zonal Hospital and necessary modifications were made based on gaps identified in the questionnaire. Data collectors and supervisors were trained for three days intensively on the study instrument and data collection procedure that includes the relevance of the study. The English questionnaire was translated first to the local language and translated back into English language by experts to check its consistency. The data collectors worked under close observation of the supervisors to ensure reliability to correct data collection procedures. In addition, supervisors and the principal investigators checked the filled questionnaires at the end of data collection every day for completeness. Furthermore, the data were carefully entered and cleaned before the beginning of the analysis. In this study the definition of clinical diagnosis PPH was obtained from the mothers’ card which was identified by birth attendants and was classified as: “yes” (having a clinical diagnosis of postpartum hemorrhage in the mothers’ card) or “no”. Such as antepartum hemorrhage, hypertension disorders during pregnancy, polyhydramnios, chorioamnionitis or/and others. Malpresentation, malposition, prolonged labour or obstructed labour, or/and others, (present = 1 or absent = 0). Data were entered using Epi-data version 3.1 and exported to statistical package social science (SPSS), version 22.0 software for analyses. Multivariable logistic regression was done for variables that have p-value ≤ 0.25 during the bivariate logistic regression analyses to identify the predictor of PPH and to control for potential confounders. The degree of association between independent, and dependent variables were assessed using odds ratio with 95% confidence interval. The P-value 0.05 which proved the model was good. Ethical approval was taken from the Institutional Review committee of Wachemo University. Formal letters were obtained from the Hadiya, Silte and Gurage zonal health office administration. Then, permission was obtained from each hospital authority before commencing the data collection. The participants were informed about purpose, procedures, potential risks and benefits of the study. Informed written consent was sought from selected participant to confirm willingness to participate in the study before the interview. To protect confidentiality, name was not included in the written questionnaire. The study participants also were ensured that refusal to consent or withdrawal from the study would not alter or put at risk their access to care.

Materials

Innovations

Based on the provided information, here are some potential innovations that can be used to improve access to maternal health:

1. Telemedicine: Implementing telemedicine services can provide remote access to healthcare professionals, allowing pregnant women in rural or remote areas to receive medical advice, consultations, and monitoring without the need for travel.

2. Mobile health (mHealth) applications: Developing mobile applications that provide educational resources, appointment reminders, and personalized health information can empower pregnant women to take an active role in their own healthcare and improve access to important maternal health information.

3. Community health workers: Training and deploying community health workers who can provide basic prenatal care, health education, and referrals to pregnant women in underserved areas can help bridge the gap in access to maternal health services.

4. Transportation support: Establishing transportation networks or partnerships to provide affordable and reliable transportation options for pregnant women to reach healthcare facilities can help overcome geographical barriers and improve access to maternal health services.

5. Maternal health clinics: Setting up dedicated maternal health clinics in underserved areas can ensure that pregnant women have access to comprehensive prenatal care, including regular check-ups, screenings, and counseling services.

6. Mobile clinics: Utilizing mobile clinics equipped with medical professionals and necessary equipment to reach remote areas can bring maternal health services directly to communities that lack access to healthcare facilities.

7. Health information systems: Implementing robust health information systems that allow for the collection, analysis, and sharing of maternal health data can help identify areas with low access to care and inform targeted interventions to improve access.

8. Public-private partnerships: Collaborating with private healthcare providers and organizations to expand access to maternal health services can help leverage resources and expertise to reach more women in need.

9. Financial incentives: Providing financial incentives, such as subsidies or vouchers, to pregnant women who seek prenatal care and deliver at healthcare facilities can help reduce financial barriers and increase access to essential maternal health services.

10. Maternal health awareness campaigns: Conducting targeted awareness campaigns to educate communities about the importance of maternal health, available services, and the benefits of seeking care can help increase demand and utilization of maternal health services.

It is important to note that the specific context and needs of the community should be considered when implementing these innovations to ensure their effectiveness and sustainability.

AI Innovations Description

Based on the provided description, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Implement a comprehensive maternal health program: Develop and implement a comprehensive maternal health program that focuses on preventing and managing primary postpartum hemorrhage. This program should include training for healthcare providers on identifying and managing postpartum hemorrhage, as well as educating pregnant women on the signs and symptoms of postpartum hemorrhage and the importance of seeking immediate medical attention.

2. Strengthen healthcare infrastructure: Improve the infrastructure and resources in healthcare facilities to ensure timely and effective management of postpartum hemorrhage. This includes ensuring the availability of essential medical supplies, such as blood transfusion services, uterotonics, and surgical equipment, as well as establishing protocols and guidelines for the management of postpartum hemorrhage.

3. Enhance antenatal care services: Strengthen antenatal care services to identify and address risk factors for postpartum hemorrhage. This includes regular screening for anemia and other complications during pregnancy, as well as providing appropriate interventions and referrals for high-risk pregnancies.

4. Promote community awareness and engagement: Conduct community awareness campaigns to educate women and their families about the importance of antenatal care, skilled birth attendance, and early recognition of postpartum hemorrhage. Engage community leaders and local organizations to promote maternal health and encourage women to seek timely and appropriate care.

5. Improve data collection and monitoring: Establish a robust data collection and monitoring system to track the prevalence and predictors of postpartum hemorrhage. This will help identify trends, evaluate the effectiveness of interventions, and inform future strategies for improving access to maternal health services.

By implementing these recommendations, it is expected that access to maternal health services will be improved, leading to a reduction in the prevalence of primary postpartum hemorrhage and ultimately a decrease in maternal mortality rates in Ethiopia.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations for improving access to maternal health:

1. Strengthening antenatal care services: Increase the availability and accessibility of antenatal care services, including regular check-ups, screenings, and education on potential complications during pregnancy.

2. Enhancing emergency obstetric care: Improve the capacity of healthcare facilities to provide emergency obstetric care, including skilled birth attendance, blood transfusion services, and access to surgical interventions.

3. Promoting community-based interventions: Implement community-based programs that focus on raising awareness about maternal health, promoting early detection of complications, and encouraging timely referral to healthcare facilities.

4. Addressing socio-cultural barriers: Address socio-cultural factors that hinder access to maternal health services, such as gender inequality, traditional beliefs, and stigma associated with seeking healthcare during pregnancy and childbirth.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify specific indicators that measure access to maternal health, such as the number of antenatal care visits, percentage of skilled birth attendance, and availability of emergency obstetric care services.

2. Collect baseline data: Gather data on the current status of the selected indicators in the target population or region.

3. Introduce the recommendations: Implement the recommended interventions in the target population or region, ensuring proper implementation and monitoring.

4. Collect post-intervention data: After a defined period of time, collect data on the indicators again to assess the impact of the recommendations on improving access to maternal health.

5. Analyze the data: Compare the baseline data with the post-intervention data to determine the changes in the selected indicators. Use statistical analysis to assess the significance of the changes and identify any patterns or trends.

6. Evaluate the impact: Evaluate the impact of the recommendations by considering the changes in the selected indicators. Assess the effectiveness of each recommendation and identify areas for further improvement.

7. Adjust and refine: Based on the evaluation results, make adjustments and refinements to the recommendations as needed to optimize their impact on improving access to maternal health.

It is important to note that the specific methodology may vary depending on the context and resources available.

Author

Dima Health

Statistics:

Citations: 21

Identifiers:

DOI: 10.1371/journal.pone.0224579

Research Areas:

Health System and Policy, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cross Sectional Study, Grounded Theory, randomised-control-trial

Study Approach:

Quantitative