Postpartum Haemorrhage The Cause Of Maternal Death

1.1 Background to the study 

Maternal mortality has been and still continues to be a public health problem particularly in developing countries. It is made more tragic because women die in the process of performing the essential physiologic function of childbearing and in efforts to fulfill their natural role of perpetuating the human race. According to WHO (2005), maternal mortality is the death of a woman while pregnant or within 42 days of termination of a pregnancy irrespective of the duration or site of the pregnancy from any cause related to or aggravated by the pregnancy or its management but not from accidental causes. 

Recent evidence from World Health Organization, (2012) estimated that postpartum haemorrhage of all etiologies accounts for 25% of the maternal deaths worldwide. However, statistics from the same organization showed disparity in the documentation of findings as record could reach as high as 40% in South East Asia, Latin America and some countries in Africa. Postpartum haemorrhage is responsible for about 50% of maternal mortality in Guatemala and Afghanistan (Miller & Martin, 2008). Every year, a total number of 529,000 women died due to complications of pregnancy and childbirth (Ojengbede, Morhason, Galadanti, Meyer, Nsima, & Gamin, 2010). Similarly, statistics has shown that 358,000 women lose their lives due to negative outcome of pregnancy and delivery (WHO, 2010). 

According to Adesokan (2010), PPH is excessive bleeding from the genital tract after the birth of a baby up to 6 weeks which is in excess of 500mls or any amount sufficient enough to cause cardiovascular collapse which is dangerous to the life of the woman. According to Reynders Sentennm, Tjalma and Jacquemyn, (2016) majority of these maternal deaths occur within the first four hours after birth. They occur as a result of either lack of or poor management of the stage three of labour by skilled midwives and birth attendants, most pregnant women are liable postpartum haemorrhage. Therefore midwives need to possess the knowledge and skill in third stage management of labour, recognize asses, treat excessive blood loss and prevent postpartum haemorrhage.

Postpartum haemorrhage is a killer, and also one of the obstetric complications with established and effective intervention through the use of a low technology device referred to as Non-Pneumatic Anti-Shock Garment or life wrap. NASG is a device in form of a lower bottom suit of an articulated neoprene with Velcro parts which gives lower body circumferential counter pressure that supplies blood to the vital organs of the body, thus reversing hypovolemic shock and decreasing postpartum haemorrhage. Evidence suggests that this promising technology helps overcome further damage and plays a part in sophisticated modern care units by stabilizing women whilst waiting for definitive haemorrhage therapies such as blood transfusion and surgeries. In Nigeria, the maternal mortality is estimated to be 545/100,000 live births (National Demography & Health Survey 2012). Indeed, the country has been ranked as the number two country (after India) with the highest absolute number of maternal death in the world. The causes of maternal mortality were reported in percentages as post partum haemorrhage (23%), infections (13%), unsafe abortion (13%), eclampsia (12%), obstructed labor (8%), other direct causes (8%) and indirect causes 20% (FMOH, 2017). Indirect causes such as malaria, anaemia, HIV/AIDS and cardiovascular disease complicate pregnancy or are aggravated by it (WHO, 2015).

Postpartum hemorrhage (PPH) is the common cause of obstetric haemorrhage and the leading cause of maternal death in Nigeria, as one in four maternal deaths is due to it (FMOH, 2017). According to the World Health Organization (WHO, 2010), PPH is defined as bleeding from the genital tract of 500 ml or more within the first 24 hours of delivery of the baby. Bleeding after delivery is normal; however excessive bleeding is often fatal. Uterine atony, which is the failure of the uterus to properly contract after delivery, is the commonest cause, accounting for about 90% cases of PPH (Chelmow, 2012). Other causes of PPH include tear in the cervix or vaginal tissue, uterine rupture, retained placenta or membrane, blood clotting disorders such as disseminated intravascular coagulation accounting for 10% of cases (FMOH, 2017).

The International Federation of Obstestrics and Gynaecology/International Council of Midwives (FIGO/ICM, 2016) recommended the use of active management of the third stage of labour (AMTSL) to prevent post partum haemorrhage. It involves the administration of a drug that causes the uterus to contract known as uterotonics, controlled cord traction only when a skilled attendant is present at birth and uterine massage after delivery of the placenta. Injectable uterotonics, which include ergometrine, oxytocin and syntometrine are the conventional drugs used and also remain the first line drug for prevention and treatment of PPH. However, these drugs are heat-sensitive when exposed to hot climates over long period of time which means they need to be refrigerated in order to maintain their potency. This may be difficult in low-resource settings or rural areas where electricity supply is very erratic and may be ineffective at preventing PPH and maternal mortality, sufficiently for Nigeria’s quest to accelerate pace towards MDG-5 target (FMOH, 2017).

Misoprostol, another uterotonic that is available in tablet form, was thus approved by the Federal Ministry of Health in 2007 for the prevention and treatment of PPH (FMOH, 2007). It has since been in increased use in obstetric and gynaecological practice, including the treatment of post partum haemorrhage. This is because it is relatively inexpensive, has alternative routes of administration (rectally, orally, and sublingually), is easy to store and is stable in field condition, has long shelf life of about 3 years and is easy to use with or without a skilled attendant (Prata, 2005). These characteristics make it very important and useful in  rural settings where the efficacy of the other uterotonics (and injection safety) are not assured and the skilled birth attendants to administer the latter are even in short supply.

FIGO and ICM (2005), jointly recommend that in the absence of safe injection, oral misoprostol should be administered to prevent and treat postpartum haemorrhage by a skilled birth attendant especially in rural areas. Therefore, there is need to promote misoprostol as an effective and easily administered drug for the prevention of PPH, and to ensure its ready availability in all settings where deliveries take place in the country especially in  Primary health care facilities. This is because Primary Health Centres (PHCs) are the basic health care units in the country, and  are located  mainly in the  rural communities where other  categories of health facilities are few. Women needing delivery care first present in PHCs, and only when they experience severe complications are they referred to secondary or tertiary levels of care (Okonofua, 2010). However, this study is aimed at determining the knowledge of the predisposing factors contributing to postpartum hemorrhage among women which makes it for difficult treatment and management of post partum hemorrhage when it occurs. 

1.2 Objectives of the study

The general objective of this study is to investigate the knowledge on the predisposing factors contributing to postpartum hemorrhage among women. Specifically, the study seeks to;

1. Determine the knowledge of predisposing risk factors associated with postpartum hemorrhage among women.

2. Determine the level of knowledge of drugs used in the prevention and treatment of postpartum hemorrhage among women.

3. Determine the use of preventive drugs in the management and treatment of post partum hemorrhage among women.

4. Identify factors influencing proper use and management of healthy lifestyle for the prevention and treatment of postpartum hemorrhage. 

1.3 Keywords

Postpartum heamorrhage, Pregnancy, Death, Maternal death, Women.