,,O0,, '. OUK'OLtd 1991 (~) Longman Group

Midwifery

Postpartum haemorrhage: its contribution to maternal mortality Barbara E Kwast

Postpartum h a e m o r r h a g e is the major cause o f maternal mortality in the developing world. This paper presents the incidences and discusses the causes a n d strategies for its prevention. T h e p a p e r is based on one originally given at the I C M / W H O / U N I C E F pre-congress workshop in Kobe, Japan, Oct, 1990.

INTRODUCTION Every year half a million women die in pregnancy and childbirth (see Kwast, 1991). The major obstetric causes are haemorrhage, sepsis, pregnancy-induced hypertension (eclampsia), obstructed labour and illicit induced abortion. This paper considers postpartum haemorrhage. The direct and underlying causes are presented and strategies for its prevention are suggested. The case for having midwives competent in the treatment of postpartum haemorrhage is made.

The magnitude of the problem Obstetric haemorrhage is the biggest single cause of maternal deaths and accounts for the largest proportion (28%) in the developing world (Linpainter et al, 1982; Mola & Aitken, 1984; Abdullah et al, 1985; Farnot Cardosa, 1985; Rodriguez et al, 1985; Walker et al, 1986; Thaddeus & Maine, 1990). Selected community studies have shown that haemorrhage accounted Barbara E Kwast MCommH, PhD, SCM, MTD, Scientist, Maternal & Child Health, World Health Organization, 1211, Geneva, 27, Switzerland. Requests for offprints to BEK

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for 31% of direct obstetric deaths in Fiji (Bavadra et al, 1978), 54% in Manoufia, Egypt (Fortney et al, 1986) 12% in Addis Ababa (Kwast et al, 1986), 33% in Papua New Guinea (Mola & Aitken, 1984), 23% in Jamaica (Walker et al, 1986) and 22% in Bangladesh (Lindpainter et al, 1982). Haemorrhage claims 150000 maternal lives annually. More than half of these deaths occur in the countries of Middle South Asia, and a further 19% in countries of South East Asia. Obstetric haemorrhages rank among the first two major causes of maternal deaths in all regions except Middle South Asia where postpartum sepsis is the major killer. The highest maternal mortality from haemorrhage is in West Africa (233 haemorrhage deaths/100000 live births) and South East Asia (208 haemorrhage deaths/100000 live births) (WHO unpublished review, 1988). It is interesting to note that it is not only countries with high maternal mortality rates which have a large proportion of haemorrhagic deaths. For example, in China a recent study of 21 provinces found that 44% of all maternal deaths were from haemorrhage, giving an overall maternal mortality rate of 49/100000 live births (Zhang & Ding, 1986).

MIDWIFERY 65 Studies have shown that deaths f r o m postpartum h a e m o r r h a g e are the greatest cause of death f r o m obstetric h a e m o r r h a g e (Adetoro, 1987; Dutta, 1980; Mutambirwa, 1984) and this section will therefore deal with deaths f r o m this specific cause.

Definitions A postpartum h a e m o r r h a g e (PPH) is defined as the loss of 500ml or more o f blood f r o m the genital tract after delivery. This definition is internationally accepted (WHO, 1990), but it is an arbitrary figure. A Technical Working G r o u p convened by the World Health Organization (WHO) in J u n e 1989 (WHO, 1990), agreed that the threshold for making a diagnosis of PPH should stay at 500ml even though the diagnosis is a clinical diagnosis and the assessment of blood loss by m e a s u r e m e n t of collected blood is often significantly underestimated. This definition implies that any loss smaller than this is within normal limits and can therefore be tolerated without risk. This is certainly not the case in countries where severe anaemia is c o m m o n and the circulating red cell mass may be so reduced that a blood loss of 250 ml may be fatal (Lawson, 1967). W o m e n who have had a difficult operative delivery after a prolonged labour, women with eclampsia, women with an a n t e p a r t u m h a e m o r r h a g e and those with i n t r a p a r t u m sepsis may not tolerate a small p o s t p a r t u m blood loss. Such circumstances need special attention in the discussion of definitions of p o s t p a r t u m blood loss.

Primary PPH includes the occurrences o f bleeding within 24h of the delivery of the baby. Secondary PPH includes all cases of PPH occurring between 24 h after delivery of the baby and six week postpartum. T h e distinction between 'third stage haernorrhage' and 'haemorrhage occurring after delivery of the placenta' should be abandoned and all cases included under the heading primary PPH (WHO, 1990). T h e term retained placenta should be used to describe a situation in which the placenta has not been delivered within one h o u r after the birth of the baby.

Factors affecti ng postpartu m haemorrhage Obstetric and medical factors T h e risk of dying f r o m postpartum haemorrhage depends on the amount and rate of blood loss and on the state of health of the mother. No matter what the cause of the bleeding, death is always from one or m o r e of the following effects - shock, anaemia, sepsis, renal failure or brain damage. Sometimes death occurs long after the obstetric condition initially responsible for the h a e m o r r h a g e has ceased to exist. T h e causes of primary and secondary postpartum h a e m o r r h a g e are set out in Figure 1. While the causes of p o s t p a r t u m h a e m o r r h a g e are many as shown, the most frequent are retained placenta, associated with between a third and a half of deaths f r o m PPH, and uterine atony. A study f r o m Ilorin, Nigeria states the proportions as follows:

Fig. 1 Causes of primary and secondary postpartum haemorrhage (WHO, 1990).

Primary PPH

Secondary PPH

Retained placenta* Retained cotyledon

Chorioamnionitis* Retained placental tissue

Genital trauma (both spontaneous and iatrogenic e.g. instrumental delivery, episiotomy, 'gishiri' cut) Disseminated intravascular coagulation* Inversion of the uterus* *Associated with high case-fatality rate

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MIDWIFERY 1. uterine a t o n y - 47% 2. retained placenta or placenta tissue fragm e n t s - 18% 3. vaginal or cervical lacerations - 18%; 4. e p i s i o t o m y - 12%; 5. ruptured u t e r u s - 5% (Adetoro, 1989).

It is not always clear from reviews of the literature whether deaths from ruptured uterus have been excluded from haemorrhage deaths. Conditions that predispose to postpartum haemorrhage are shown in Figure 2. T h e predictive value of antenatal factors is generally low and only a minority of postpartum haemorrhages have a predisposing risk factor identifiable in the antenatal period. Some factors such as primiparity and grand multiparity are very common and constitute the majority of women who die from a PPH, but they are not very specific when used in screening. However, a woman with a large baby, a placenta praevia, a previous caesarean section or an intra-uterine death for two weeks or more is likely to experience a postpartum haemorrhage. The factor that seems particularly useful to identify women likely to have a PPH is a history o f previous third stage complication, when the

risk of PPH may be increased two or three times, and up to a quarter of multiparae having a PPH, have had one in a previous pregnancy (Hall et al, 1985). A study in Papua New Guinea stated that 71% of the women with a high risk factor for childbirth still gave birth at home (Lennox, 1984). It also described that women among a certain ethnic group were f o u n d to be remarkably poor at recalling complications of previous deliveries, particularly the (hird stage. T h e accuracy of prenatal history-taking has been found to be poor in many developing countries and the rate of detection of risk factors prenatally could be improved using an action-oriented prenatal card (Lennox, 1984). Health service factors Based on experience, some authors have estimated the modal interval from onset to death for major complications of pregnancy and delivery (Maine et al, 1987). The most important feature of these estimates is the gap between the modal time to death for postpartum haemorrhage (2 h) and for the major complications (12h). As was noted earlier, PPH is often the most common cause of maternal death, and a large proportion

Fig. 2 Conditions that predispose to postpartum haemorrhage (WHO, 1990).

Predating pregnancy

Arising antenatally

Arising during labour

Primiparity

Placenta praevia

Induced labour

Grand multiparity (5+)

Placenta praevia with previous caesarean section*

Prolonged-obstructed labour

Fibroids

Abruptio placentae

Precipitate labour

Idiopathic thrombocytopenic purpura*

Polyhydramnios

Forceps delivery

Von Willebrand's disease*

Multiple pregnancy

Caesarean section

Anaemia

Previous third stage complication

General/epidural anaesthesia

Intra-uterine death*

Chorioamnionitis*

Eclampsia

Disseminated intravascular coagulation*

Hepatitis * Associated with high case-fatality rate

MIDWIFERY

of women in developing countries live in rural areas and deliver at home. Consequently, unless there is some way to control PPH quickly, many women will continue to die. The importance of access to health facilities in preventing deaths from haemorrhage is illustrated by a study in China covering 21 provinces and urban districts where the proportion of deaths from this cause was over 50% from rural areas and 25% for urban areas where access to health facilities was more readily available (Zhang & Ding, 1986). Such rural-urban variations in maternal mortality were revealed in A n a n t h a p u r District, A n d h r a Pradesh, India (Bhatia, 1985). Furthermore, the study revealed intra-rural differentials with mortality levels four times higher in poorly developed villages. Confidential enquiries into maternal deaths in Columbia (Rodriguez et al, 1985), Malawi (Keller, 1987), Ethiopia (Kwast et al, 1989) and Jamaica (Walker et al, 1986), show similar reasons that contribute to haemorrhage deaths: - delays in manual removal of placenta in women with retained placenta; in starting adequate resuscitative measures, partly due to unavailability of blood or plasma expanders;

-delays

- faulty technique at caesarean section or too early episiotomy; - underestimation of blood loss and delay in calling a medical officer. Risk factors and the level o f care were identified by the Technical Working G r o u p in Postpartum Haemorrhage and are reflected in Figure 3. That maternal deaths from haemorrhage can be effectively prevented with adequate health facilities is demonstrated from the experience of Krian district in Malaysia. Before the adoption of the 'risk' approach, 60% of all maternal deaths were from haemorrhage and rupture of the uterus, or 21/35 deaths in 1976 1980. During 1981 - 1982 this declined dramatically to one haemorrhage death and no deaths from uterine rupture, bringing down the number of maternal deaths from 35 to only four (Yadav, 1982).

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S o c i o - e c o n o m i c status a n d c u l t u r a l factors

It is clear that maternal mortality and morbidity is higher among women of low socio-economic status (Myrdal, 1968: Oyakhire, 1980; Bhatia, 1985; Kwast et al, 1986). Economic status affects the use of health services. Many studies show that even though mortality rates are significantly higher among women who have not received prenatal care than a m o n g women who have, a considerable n u m b e r o f women who died from PPH had prenatal care but delivered at home and either died there or arrived moribund at hospital. The reasons for not using the health services for delivery are often more complex and go beyond economic constraints only. Factors influencing whether Bariba women in West Africa chose government midwives were role expectations for birth assistants and social and cultural differences (Sargent, 1982). In research on health services utilisation it has been found that often women and their families are not aware of risk factors associated with the major causes of maternal mortality (Lartson, 1987). This was reiterated by Bhatia (1985) who showed that 23% of rural and 9% of urban family members said that they were not aware of the seriousness of the woman's condition before death. O f the remaining families who understood the seriousness, a small proportion did not take action. Traditional childbirth practices do have implications for both the treatment and the occurrence of postpartum haemorrhage. In many countries both in Asia and Africa traditional birth attendants as well as the family look upon bleeding after delivery as normal and some would encourage the flow of 'bad blood' in the postnatal period (Nbevi & Njoki, 1982; Kargbo, 1984; Lartson, 1987). In Southern Africa, medicines may be given to encourage bleeding once a woman is discharged from hospital (Min & Ulin, 1981; Levitt et al, 1987). Traditional delivery attendants may use interventions during the third stage of labour to deliver a placenta in the absence of bleeding and these include manual removal of placenta, pulling on the cord, pressure applied to the abdomen or induce gagging by putting the woman's hair in her mouth. In many societies there are traditional remedies in

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MIDWIFERY

Fig. 3 Risk factors and the level of care (WHO, 1990). Domiciliary delivery (TBA)

Health Centre (nurse/midwife)

Referral Centre (doctor/obstetrician)

- e p i s i o t o m y mistimed

- induction o f l a b o u r

Risk factor

Treatment - failure to recognise and/ or treat: high risk pregnancies; genital t,'auma; excessive blood loss

- non-active m a n a g e m e n t - m i s m a n a g e m e n t of third stage

- instrumental of third stage or operative d e l i v e r y - m i s m a n a g e m e n t of third stage

- non-active m a n a g e m e n t of third stage

Supply - use of traditional medicines

- organisational constraints

- lack of blood - lack of qualified personnel

- inadequacies in quality of care

- lack of intravenous fluids including plasma e x p a n d e r s - i n a d e q u a t e operative facilities

Access - transportation difficulties - poor communication

- transportation difficulties - poor communication

the event of retained placenta and methods include the 'gourd method', the ' b r o o m method', 'vomiting method' and inducing sneezing (see Fig. 4). Excessive bleeding is usually recognised and traditional medicines are administered with often detrimental delays in transfer (Kargbo, 1984; Bhatia, 1981).

Problems related to midwifery education In order to prevent where possible and treat promptly a postpartum h a e m o r r h a g e which has occurred it is vital that midwives have had the necessary education about the topic if mortality f r o m this cause is to be reduced. T h e education should include the following:

1. A recognition of the need to know and understand the traditional beliefs regarding blood loss in the third stage, the traditional practices in the third stage and the interventions in case of retained placenta and PPH. Once this is understood health education p r o g r a m m e s can be designed to give information on the dangers of blood loss and the need to seek p r o m p t treatment. 2. A recognition of awareness of cultural gaps between midwives and the pregnant woman and her family. Once this difference is recognised strategies may be developed which can overcome these gaps so that provision of health care may be more effective.

MIDWIFERY 69 Fig. 4 Methods used by traditional midwives to remove the retained placenta (Ityavyar, 1984). Broom method:

Gourd method: Vomiting method: Sneezing method:

a new broom is placed in the lower abdomen of the woman, the traditional midwife pulls the abdomen towards the diaphragm with the aid of the broom, she then removes the broom and allows the abdomen to fall back into place helping to expel the placenta, the woman is given a gourd to inflate, the force and strain of this is assumed essential in expelling the placenta, a wooden spatula is pushed into the woman's mouth until she vomits, bitter pepper is poured onto a fire near the woman and the ensuing sneezing is thought to expel the placenta.

3. Midwives n e e d to be t a u g h t h o w to p r e s e n t h e a l t h e d u c a t i o n i n f o r m a t i o n to c o m m u n i ties in a m e a n i n g f u l m a n n e r . 4. Midwives m u s t be t a u g h t to follow-up p r e g n a n t w o m e n at h i g h risk o f PPH. 5. Midwives m u s t be t a u g h t how, a n d m u s t be c o m p e t e n t to u n d e r t a k e m a n u a l r e m o v a l o f placenta, m a n u a l c o n t r o l o f h a e m o r r h a g e a n d fluid r e p l a c e m e n t techniques. 6. Midwives s h o u l d be m a d e a w a r e o f the n e e d to set u p e m e r g e n c y p l a n s b e t w e e n T B A / A u x i l i a r i e s a n d t h e m i d w i f e to d e a l with h a e m o r r h a g e s w h e n t h e y arise. 7. Midwives m u s t take responsibility to i n f o r m the m o t h e r a n d t h e relatives a b o u t t h e risk o f deliveries s u b s e q u e n t to caesarean section, t h i r d stage complications, illness such as anaemia, h a e m o g l o b i n o p a t h i e s a n d h e l p t h e m with spacing o f f u t u r e p r e g n a n c i e s . U n f o r t u n a t e l y too few m i d w i f e t e a c h e r s have r e l e v a n t e x p e r i e n c e in r u r a l a r e a s a n d have little practical a p p r e c i a t i o n o f t h e p r o b l e m s faced by those qualifying f r o m the t r a i n i n g p r o g r a m m e s (see Kwast & Bentley, 1991). T h e t e a c h e r s have little contact with midwives p r a c t i s i n g O U T S I D E hospitals, a n d that is w h e r e m o s t midwives s h o u l d be w o r k i n g , if lives a r e to b e saved.

CONCLUSION P o s t p a r t u m h a e m o r r h a g e is t h e m o s t c o m m o n cause o f m a t e r n a l mortality. A l t h o u g h the u n d e r l y i n g causes are p o o r socio-economic status a n d lack o f access to h e a l t h facilities, available midwives c o m p e t e n t in t h e p r e v e n t i o n

a n d t r e a t m e n t o f P P H c o u l d d o m u c h to r e d u c e the incidence o f m o r t a l i t y f r o m this cause. T h i s necessarily i n c l u d e s a c h a n g e in the c o d e o f practice a n d r e g u l a t o r y m e c h a n i s m s w h e r e t h e r e a r e constraints to p e r f o r m essential obstetric care.

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Kargbo T K 1984 Traditional practices affecting the health of women and children in Africa. Paper presented to the seminar on traditional practices affecting the health of women and children in Africa, Dakar, Senegal Keller M E 1987 Maternal mortality at Kamuzu Central Hospital for 1985. Medical Quarterly, Journal of the Medical Association of Malawi 4(1): 13-16 Kwast B E 1991 Maternal mortality: the magnitude and the causes. Midwifery 7(1): 4--7 Kwast B E, Bentley J 1991 Introducing confident midwives: Midwifery Education - Action for Safe Motherhood. Midwifery 7(1): 8-19 Kwast B E, Rochat R W, Kidane Mariam W 1986 Maternal mortality in Addis Ababa, Ethiopia. Studies in Family Planning 17:288-301 Kwast B E, Bekele M, Yoseph et al 1989 Confidential enquiries into maternal deaths in Addis Ababa, Ethiopia 1981-1983. Journal of Obstetrics and Gynaecology of East and Central Africa 8:75-82 Lartson L I 1987 The trained traditional birth attendant: a study of her role in two cultures. Journal of Tropical Pediatrics 33:29-33 Lawson J B 1967 Obstetric haemorrhage In: Lawson J B, Stewart D B (eds) Obstetrics and Gynaecology in the Tropics. Edward Arnold, London Lennox C E 1984 Assessment of obstetric high risk factor in a developing country, Tropical Doctor July: 125-128 Levitt M J, Shrestha K R, McGinn E et al 1987 Influence of formal training on knowledge, attitude and practices of TBAs in Nepal. Paper presented at National Council for International Health Annual International Health Conference, Washington, DC, June 15 1987 Lindpainter L S e t al 1982 Maternity-related mortality in Matlab Thana, Bangladesh. Final Report of the Community Services Research Working Group, International Centre for Diarrhoeal Diseases Research, Bangladesh Maine D, Rosenfield A, Wallace M e t al 1987 Prevention of maternal mortality in developing countries: programme options and practical considerations. Centre for Population and Family Health, Columbia University, New York

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