Risk factors of primary postpartum hemorrhage among postnatal mothers in the public hospital of southern Tigray, Ethiopia, 2019: a case-control study

doi:10.21203/rs.3.rs-1821260/v1

Background: Postpartum hemorrhage is the most common direct cause of maternal mortality and morbidity among them, primary postpartum hemorrhages are an enormous element. Although it has an incredible impact on maternal lifestyle, this is the most neglected area in Ethiopia and there aren’t studies achieved within the study area. The purpose of this study is to identify the risk factors of primary postpartum hemorrhage among postnatal mothers in public hospitals in southern Tigray, Ethiopia, 2019

Methods: Hospital-based unmatched case-control study design was conducted on 318 (106 case & 212 controls) postnatal mothers in public hospitals of Southern Tigray from January to October 2019. The data had been collected by using an interviewer-administered structured questionnaire and chart review. Bivariate and multivariable logistic regression models were used to identify the risk factors. P-value < 0.05 was considered for statically significance for both steps and an odds ratio with a 95% confidence level was used to see the strength of association.

Results: Abnormal third stage of labor [AOR = 5.86, 95%; CI:(2.55-13.43); P-value=000], Cesarean section [AOR= 5.61, 95%; CI: (2.79-11.30); p-value=0.000], lack of AMTOL [AOR=3.88; 95%; CI: (1.29 - 11.60); P= 0.015], absence of labor monitoring [AOR=3.82; 95%; CI: (1.31-11.09); P=0.014], Lack of antenatal care [AOR=2.76, 95%, CI: (1.13–6.75); P-value=0.026] and complications during pregnancy [AOR=2.79, 95%, CI; (1.34-5.83), P-value=0.006] were found to be risk factors of primary postpartum hemorrhage.

Conclusions: in this study complications and lack of maternal health interventions in the course of the antepartum and in the intrapartum period were found to be risk factors for primary postpartum hemorrhage. A strategy toward improving essential maternal health services and detecting and handling complications in a timely and proper manner will help to prevent primary postpartum hemorrhage.

Case-control

Ethiopia

Primary postpartum hemorrhage

Risk factors

Primary postpartum hemorrhage(PPH) is defined as blood loss from the genital tract of 500 mL or more following a normal vaginal delivery or 1,000 mL or more following a cesarean section within 24 hours of delivery (1–3). But defining PPH simply as the amount of blood loss is problematic, since the quantity of blood loss is much less important than the effect it has on the woman, and it has been advised that a clinically applicable definition takes into account, any blood loss sufficient to cause a physiologic change that threatens the woman’s life, a 10% drop in the hematocrit or requiring transfusion of blood products regardless of the route of delivery (4–6).

Postpartum hemorrhage is a major cause of maternal mortality and accounts for one-quarter of all maternal deaths (5,7) & serious morbidities such as severe anemia, complications of multiple blood transfusions, peripartum hysterectomy, loss of fertility and a psychological sequel including posttraumatic stress disorders as well as poor growth and development of their children (6,8,9).

Even though primary PPH occurs in all geographic regions, the majority of maternal deaths because of PPH take place in developing countries (10) and this disparity has been attributed to differences in access to reproductive health services, quality of care, including the availability of skilled personnel attending deliveries, appropriate equipment, and supplies and the timely receipt of needed interventions whilst obstetric emergencies arise (11,12). This disparity additionally shows that deaths from PPH are preventable and any intervention aimed at preventing PPH will reduce maternal mortality by more than one quarter (9).

Like many African countries, Ethiopia's maternal mortality ratio is high at the national level (13), with 412 deaths per 100,000 live births in the 2016 Ethiopian Demographic Health Survey(EDHS) (14) of which 25-30% are attributed to PPH (15).

Reducing maternal mortality is one of the hot agendas, globally and nationally; with the introduction of the Sustainable Development Agenda, by 2030 to reduce the global maternal mortality ratio to less than 70 per 100 000 live births, with no country having a maternal mortality rate of more than twice the global average (20). So identification of the gap and improving health care during pregnancy, childbirth and postpartum to end preventable maternal mortality such as death caused by PPH is an essential step closer to the achievement of this Goal.

Poverty and low level of educational continue to be the primary cause of PPH (5). The majority of women who developed PPH were either illiterate or had primary level education (9,21). The age group of 15-20 years was significantly associated with PPH indicating that teenagers were highly susceptible to bleeding postpartum after early marriage because the reproductive system was not fully developed & advanced maternal age had an indirect role in the development of PPH for parity and gravidity was expected to occur at older ages (9).

Relationships with male partners and the level of a husband's education are another factor that affects women's health, indicating that women may need to get their partner's permission before making decisions about their health care (22).

Grand multipara with obstetric performance is labeled as high risk (9,23,24). A history of postpartum hemorrhage (PPH) is also another known risk factor for PPH in subsequent pregnancies (21,25,26). According to a study done in Sweden, the risk of PPH in women with one prior affected pregnancy was roughly 3-fold higher, and about 6-fold higher after two prior affected pregnancies when compared to women without a history of PPH(27).

In a cohort study in Netherlands showed that the risk of postpartum hemorrhage is 1.53 times higher for pre-eclamptic women (28). Similarly, those who had eclampsia had 3.5 fold more experienced PPH than those without it (23). A study done in Norway, Libya and Zimbabwe also Showed that mothers with severe preeclampsia were more likely to have primary PPH (26,29,30).

Pre-existing (antepartum) anemia was one of the most frequent maternal risk factors for primary PPH; the likelihood of PPH increased among women with moderate to severe anemia (17,31,32). Besides, lack of antenatal care throughout pregnancy and inadequate birth interval were discovered to be risk factor for primary PPH (21,33). Similarly, a study carried out in Ethiopia revealed that non-utilization of ANC (AOR, 11.3, 95% CI, 4.2-30.2 was observed to be a predictor of PPH (6).

Repeated use of obstetric interventions like miscarriage, repeated CS, labor induction and augmentation, instrumental delivery and episiotomy may responsible for the increasing incidence of postpartum hemorrhage(2,6,18,34–37). Moreover, the duration of expulsive efforts was significantly associated with PPH(24,38).

Women with multiple pregnancies and macrosomic baby, polyhydramnios, or one with multiple fibroids were at increased risk for primary PPH as atonic type hemorrhage is common in a uterus that is overstretched (24), large placental size in multiple pregnancies increase the surface area for bleeding (18) and prolonged labor and cesarean delivery is common in macrocosmic group and it was associated with higher risks of perineal tear and increased bleeding volume (39,40).

There is frequently a link between a protracted third stage of labor and an elevated risk of PPH- related maternal morbidity and mortality(41). An abnormal third stage of labor and a retained placenta were the factors more significantly associated with both moderate and severe PPH (16,42). The third stage of labor longer than 18 minutes is associated with a high risk of PPH and the risk is six times higher after 30 minutes than before(43,44).

Induced abortions, child delivery at home or on the way, lack of labor monitoring by partograph(21), uterine fibroma (26), placenta previa(23), emergency or referral admission (9), perineal injury (16,45,46) were additional risk factors for the occurrence of primary PPH.
On the other hand, active management of the third stage of labor with uterotonics has been demonstrated to reduce the risk of PPH (3,5,9,21,47).

Understanding the relative contributions of various risk factors is crucial in general and assist policymakers and health care providers in designing current delivery protocols and setting priorities for a particular action in PPH case management (17,18). Therefore, it is the right time to conduct this study and come up with possible recommendations.

Conceptual framework

Fig 1 Conceptual framework on risk factors of primary postpartum hemorrhage

Study area and period

The study was conducted in public hospitals of Southern Tigray, Ethiopia from January to October 2019. Southern Zone is one of the seven zones in the region of Tigray regional state. The southern zone is bordered on the south and west by the Amhara region, on the north by southeastern zone and on the east by the Afar region and it is located around 172Kms south of Mekelle city and 600 Km north from Addis-Ababa capital city of Ethiopia. The zone has three general hospitals: Lemlem Karl Hospital, Alemata Hospital, and Korem Hospital and two Primary Hospitals (Mekoni and Adishu) and 34 health centers and 65 health posts. Maternity services along with other services are available in all of the hospitals.

Study design

A hospital-based unmatched case-control study design was conducted

Populations

Source population: All postnatal mothers who were admitted to the postnatal ward of public hospitals in Southern Tigray.
Study population: All postnatal mothers who were admitted to the postnatal ward of the public hospitals at Southern Tigray during the time of data collection.

Eligibility criteria

Inclusion criteria: Postnatal mothers who were admitted to the postnatal ward of the public hospitals of Southern Tigray during the time of data collection

Ascertainment of cases and controls

Cases- were all postnatal mothers diagnosed as having primary PPH by attending health care providers and admitted to the postnatal ward during the study period
Controls- were postnatal mothers without primary PPH confirmed by attending health care providers and admitted to the postnatal ward during the study period.

Sample size determination, and sampling technique

Sample size determination: The desired sample size for the study was determined using EPI INFO version 7.1 statistical software using the double population proportion formula for unmatched case-control by taking the previous history of PPH as a risk factor from the previous stud(26) where the proportion of exposure among cases was 8.3 % with OR 8.97, with the assumptions of a 95% confidence interval, an 80% power, and a 2:1 control to case ratio. Finally it gives a sample size of 318 (212 controls and 106 cases).

Sampling technique and procedure: all five public hospitals in the Zone were included in the study. According to a case flow during a 10-months period, the study hospitals received a proportionate share of the sample size (Cases and controls). Women with primary PPH who meet the inclusion criteria were recruited consequently as cases till the calculated sample size was attained; for every case, two women without primary PPH and on their 24-hours postpartum period who meet the inclusion criteria were chosen as controls during the study period. (Fig. 2)

Figure 2: Schematic representation of the sampling technique

Data collection tools and procedures

The data were collected through face to face interviews and a review of client's medical record using pretested structured questioners and a checklist. The questionnaire was developed after a review of different literatures and it included information related to the maternal socio-demographic condition, obstetric and gynecologic history, current pregnancy characteristics as well as intrapartum and postpartum events. Data were collected by seven BSC degree holder Midwives who were working in another health facility from January to October 2019 prospectively. Two BSC Health officer supervisors and a PI are in charge of overseeing the data collection procedure and ensuring the questionnaire for its completeness and consistency.

Data quality control and assurance

The questionnaire was created in English and translated into Tigrigna which is the local language of the study area. Then it was translated back into English by language experts to check for consistency. The questionnaire was reviewed by a senior researcher and the Pre-test was conducted ahead of the actual data collection at 10% of the sample size at a nearby hospital (Quiha General Hospital) which is not included in the study to see the appropriateness of the tool and feedbacks was incorporated accordingly. A three-day training was given to the data collector and supervisor on general information on the objective of the study, techniques of sampling and data collection methods. The principal investigator(PI) and two supervisors had site supervision to make sure that the data collection was going smoothly. The data was checked before and after the data entry stage to verify its completeness and double data entry was done.

Data Processing and analysis

The collected data were entered via Epi-Data version 4.6.0.0, and exported to SPSS version 23 software for analysis. Descriptive statistics were employed to organize, summarize and present the results using frequencies, percentages, or in the form of texts accordingly. Bivariate and Multivariate logistic regression models were used to identify the risk factors for the primary PPH. Variables having a p-value of less than 0.05 is considered as significant variables for both steps. An AOR with a 95% CI was considered to measure the strength of association between the outcome and independent variables. Texts and tables were used to present the overall findings.

Study Variables

Dependent variables: Primary postpartum hemorrhage

Independent variables

Socio-demographic characteristics: age, ethnicity, marital status, residence, educational level, occupation and husband's educational level.
Gynecological and obstetrical history: history of PPH, history of cesarean delivery, uterine pathology, history and type of abortions.
Characteristics of current pregnancy: Gravidity, parity, inter-pregnancy interval, ANC, multiple gestations, any complications occurred during pregnancy [Anemia, PIH, APH…]
Intrapartum and postpartum events: the way of admission, place of delivery, medicated therapy during labor (induction/augmentation), duration of labor, newborn birth weight, genital tract trauma, mode of delivery and monitoring during labor with Parthograph and after childbirth (like safe childbirth checklist), intrapartum complications

Definitions of terms

AMTSL: a prophylactic lifesaving intervention that is the administration of a uterotonics agent immediately after the birth of the baby
The prolonged third stage of labor: if not completed within 30 minutes of the birth of the baby with active management and 60 minutes with physiological management.
Labor not monitored with partograph: if the three components of Partograph were not filled out correctly or not documented to maternal chart at all.
Newborn birth weight- for twins and above the sum of all newborn birth weight
Anemia- HGB level below 11g/dL in the 1^st and 3^rd trimester and 10.5g/dL in the 2^nd trimester

5.1. Socio-demographic characteristics of the study participants

A total of 318 mothers (212 cases and 106 controls) were interviewed for this study and yielding a response rate of 100%. The mean ages for cases and controls were 29.77 years (SD 6.96 years) and 26.4 years (SD 5.8 years), respectively. There was no statically significant difference between cases and controls in the percentage of older age mothers (age ≥ 35), which was 17.9% vs 12.7% respectively. Moreover, more than half (54.7%) of respondents had attained either a low level of education or none at all. (Table 1)

Table 1 Socio-demographic characteristics of study participants with and without primary postpartum hemorrhage in the public hospital of Southern Tigray, Ethiopia, 2019

Variables

Categories

Cases

n (%)

Controls

n (%)

Total

N= 318

Age group (Year)

20-34

<20

=>35

79 (74.5)

8 (7.5)

19 (17.9)

173 (81.6)

12 (5.7)

27 (12.7)

252 (79.2)

20 (6.3)

46 (14.5)

Residence

Urban

Rural

35 (33.0)

71 (67.0)

84 (39.6)

128 (60.4)

119 (37.4)

199 (62.6)

Ethnicity

Tigray

Amhara

Afar

89 (84.0)

12 (11.3)

5 (4.8)

175 (82.5)

29 (13.7)

8 (3.7)

264 (83.0)

41 (12.9)

13 (4.1)

Religion

Orthodox

Muslim

88 (83.0)

18 (17)

166 (78.3)

46 (21.7)

254 (79.9)

64 (20.2)

Marital status

Currently in relationship

Not in relationship

103 (97.2)

3 (2.8)

204 (96.2)

8 (3.8)

307 (96.5)

11 (3.5)

Educational level

No education

Primary

Secondary

College and above

37 (34.9)

25 (23.6)

15 (14.2)

29 (27.4)

53 (25.0)

59 (27.8)

42 (19.8)

58 (27.4)

90 (28.3)

84 (26.4)

57 (17.9)

87 (27.4)

Occupation

Employed

Unemployed

21 (19.8)

85 (80.2)

62 (29.2)

150 (70.8)

83 (26.1)

235 (73.9)

Husband’s educational level

(N=307)

No education

Primary

Secondary

College and above

26 (25.2)

20 (19.4)

22 (21.4)

35 (34.00

39 (19.1)

45 (22.1)

34 (16.7)

86 (42.2)

65 (21.2)

65 (21.20

56 (18.2)

121 (39.4)

Not in a relationship = unmarried, divorced and widowed

Past Obstetrics and Gynecology history of the study participants

Two third (67.0 %) of the study participants were multiparous (had given birth 2-4 times) which was a comparable proportion among cases and controls (66.0% vs 67.5 %) respectively. About 12.9% of cases and 8.3 % of controls had a previous history of cesarean delivery with no statically significant difference(p=0.23). (Table 2)

Table 2 Obstetrics and Gynecologic history of study participants with and without primary postpartum hemorrhage in the public hospital of Southern Tigray, Ethiopia, 2019

Variable

Category

Cases

n (%)

Controls

n (%)

Total

N=318

Parity

Primipara

Multipara

Grand multipara

21 (19.8)

70 (66.0)

15 (14.2)

53 (25.0)

143 (67.5)

16 (7.5)

74 (23.3)

213 (67.0)

31 (9.7)

History of Abortion

Yes

No

25 (23.6)

81 (76.4)

43 (20.3)

169 (79.7)

68 (21.4)

250 (78.6)

Type of abortion (n=68)

Spontaneous

Induced

19 (76.0)

6 (24.0)

35 (81.4)

8 (18.6)

54 (79.4)

14 (20.6)

History of Cesarean delivery (n=244)

Yes

No

11 (12.9)

74 (87.1)

13 (8.2)

146 (91.8)

24 (9.8)

220 (90.2)

History of PPH (n=244)

Yes

No

7 (8.2)

78 (91.8)

8 (5.0)

151 (95.0)

15 (6.1)

229 (93.9)

Uterine abnormality

Yes

No

2 (1.9)

104 (98.1)

4 (1.9)

208 (98.1)

6 (1.9)

312 (98.1)

n (number), % (percent)

Current pregnancy characteristics of the study participants

The vast majority of pregnancies were singletons and the proportions of cases and controls were comparable (98.0% vs 97.6%) respectively. In contrast, about 89.6 % of study participants had ANC follow-up and the cases had a lower proportion (81.1%) when compared to controls (93.9%). Additionally, the proportions of complications during the current pregnancy among cases were nearly twice as high as the proportion among controls (24.5% vs 13.7%). (Table 3)

Table 3 Index pregnancy characteristics of study participants with and without primary postpartum hemorrhage in the public hospital of Southern Tigray, Ethiopia, 2019

Variable

Categories

Cases

n ( %)

Controls

n (%)

Total

N (%)

Inter-pregnancy interval (months) (n=244)

<24

>=24

29 (34.1)

56 (65.9)

45 (28.3)

114 (71.7)

74 (30.3)

170 (69.7)

Type of pregnancy

Singleton

Multiple

104 (98.1)

2 (1.9)

207 (97.6)

5 (2.4)

311 (97.8)

7 (2.2)

ANC visit

Yes

No

86 (81.1)

20 (18.9)

199 (93.9)

13 (6.1)

285 (89.6)

33 (10.4)

Frequency

<4

>=4

44 (51.2)

42 (48.8)

84 (42.2)

115 (57.8)

128 (44.9)

157 (55.1)

Complications during pregnancy (n=318)

Yes

No

26 (24.5)

80 (75.5)

29 (13.7)

183 (86.3)

55 (17.3)

263 (82.7)

Pregnancy Induced Hypertension(PIH) (55)

Yes

No

10 (38.5)

16 (61.5)

7 (24.1)

22 (75.9)

17 (30.9)

38 (69.1)

Anemia (n=55)

Yes

No

6 (23.1)

20 (76.9)

10 (34.5)

19 (65.5)

16 (29.1)

39 (70.9)

Antepartum Hemorrhage (APH) (n=55)

Yes

No

8 (30.8)

18 (69.2)

5 (17.2)

24 (82.8)

13 (23.6)

42 (76.4)

Others* (n=55)

Yes

No

2 (3.6)

24 (96.4)

7 (12.7)

22 (87.3)

9 (16.4)

46 (83.6)

Others*: [polyhydraminous =3; Congenital anomaly =4; Hyperemesis gravidarum=2]

Intrapartum and postpartum characteristics of the study participants

About 95.3% were institutional delivery and the remaining was either home or on the way to the institution and the proportion among cases was higher when compared to controls (8.5% vs 2.8%). Regardless of the category, the majority of study participants gave birth to infants to weighing between 2500 and 3999g. Abnormality on the 3^rd stage of labor was present in about 23.6% of cases and 6.6% of controls with a significant difference between the group (p=0.000). (Table 4)

Table 4: Intrapartum and postpartum characteristics of study participants with and without primary postpartum hemorrhage in the public hospital of Southern Tigray, Ethiopia, 2019

Variable

Categories

Cases n(%)

Controls n (%)

Total N=318

Place of Birth

Institutional

Non-Institutional

97 (91.5)

9 (8.5)

206 (97.2)

6 (2.8)

303 (95.3)

15 (4.7)

Type of admission

Non-referral

Referral

84 (79.2)

22 (20.8

186 (87.7)

26 (12.3)

270 (84.9)

48 (15.1)

Way of Labor initiated

Spontaneously

Induced

91 (85.8)

15 (14.2)

197 (92.9)

15 (7.1)

288 (90.6)

30 (9.4)

Gestational age (weeks)

(N=313)

Term

Preterm

Post-term

88 (84.6)

11 (10.6)

5 (4.8)

187 (89.5)

13 (6.2)

9 (4.3)

275 (87.9)

24 (7.7)

14 (4.5)

Mode of delivery

SVD

CS

Assisted vaginal delivery

67 (63.2)

34 (32.1)

5 (4.7)

178 (84.0)

25 (11.8)

9 (4.2)

245 (77.0)

59 (18.6)

14 (4.4)

FBW (grams)

(N=316)

2500-3999

<2500

=>4000

77 (74.0)

14 (13.5)

13 (12.5)

165 (77.8)

28 (13.2)

19 (9.0)

242 (76.6)

42 (13.3)

32 (10.1)

Labor Duration (hours)

<24

>=24

96 (90.6)

10 (9.4)

205 (96.7)

7 (3.3)

301 (94.7)

17 (5.3)

Labor monitored with Partograph

Yes

No

81 (76.4)

25 (23.6)

200 (94.3)

12 (5.7)

281 (88.4)

37 (11.6)

AMTSOL

Yes

No

86 (81.1)

20 (18.9)

204 (96.2)

8 (3.8)

290 (91.2)

28 (8.8)

Third stage prolonged

Yes

No

25 (23.6)

81 (76.4)

14 (6.6)

198 (93.4)

39 (12.3)

279 (87.7)

Perineal tear/lacerations

Yes

No

7 (6.6)

99 (93.4)

8 (3.8)

204 (96.2)

15 (4.7)

303 (95.3

Safe childbirth checklist

Yes

No

84 (79.2)

22 (20.8)

183 (86.3)

29 (13.7)

267 (84.00

51(16.0%)

Risk factors of primary postpartum Hemorrhage

The independent effect of different factors on a primary postpartum hemorrhage were examined. Binary logistic regression was used to evaluate the relationship between the independent variables with the occurrence of dependent variables. As a result, the model demonstrated a statically significant association of primary PPH and factors such as lack of ANC, pregnancy complications, place of birth, way of admission, induced labor, prolonged labor (>24 hours), cesarean delivery, mothers without documented parthograph, abnormalities in the third stage of labor and absence of AMTSOL.

Variables that were found to be associated with the dependent variable in the bivariate analysis (P < 0.05) were taken to the multivariable analysis. After adjusting for possible confounding factors in the multivariable logistic regression, third stage abnormality [AOR = 5.86, 95%; CI:(2.55 - 13.43); P-value=000], cesarean route of delivery [AOR= 5.61, 95%; CI: (2.79-11.30); p-value=0.000], non-use of AMTSOL [AOR=3.88; 95%; CI: (1.29 –1.60); P= 0.015], none utilization of parthograph [AOR=3.82; 95%; CI: (1.31 -11.09); P=0.014] and lack of ANC [AOR=2.76, 95%, CI: (1.13 – 6.75); P-value=0.026] and complications during pregnancy [AOR = 2.79, 95%, CI; (1.34 - 5.83) (1.22-7.99), P-value=0.006] were found to be independent predictors of primary PPH. (Table 5)

Table 5 Risk factors of primary postpartum hemorrhage among postnatal mothers in public hospital of Southern Tigray, Ethiopia, 2019

Variable

Cases

Controls

COR (95% CI)

AOR (95% CI)

P-Value

ANC visit

Yes

No

86 (81.1)

20 (18.9)

199 (93.9)

13 (6.1)

R

3.56 (1.69-7.48)

R

2.76 (1.13-6.75)

0.026

Complications

Yes

No

26 (24.5)

80 (75.5)

29 (13.7)

183 (86.3)

2.05(1.13- 3.70)

R

2.79 (1.34 - 5.83)

R

0.006

Place of Birth

Institutional

Non institutional

97 (91.5)

9 (8.5)

206 (97.2)

6 (2.8)

R

3.18 ( 1.10 - 9.20)

R

2.26 (0.92 - 5.56)

0.482

Way of admission

Non-referral

Referral

84 (79.2)

22 (20.8

186 (87.7)

26 (12.3)

R

1.87 (1.00- 3.49)

R

1.08 (0.42 - 2.22)

0.986

Way of Labor initiated

Spontaneously

Induced

91 (85.8)

15 (14.2)

197 (92.9)

15 (7.1)

R

2.50 (1.19-5.24)

R

2.37 (0.97- 5.79)

0.074

Mode of delivery

SVD

C/D

Assisted vaginal delivery

67 (63.2)

34 (32.1)

5 (4.7)

178 (84.0)

25 (11.8)

9 (4.2)

R

3.61 (2.00 - 6.50)

1.47 (0.47 - 4.56)

R

5.61 (2.79 - 11.30)

1.81 (0.49 - 6.60)

0.000

Labor Duration (hours)

<24

>=24

96 (90.6)

10 (9.4)

205 (96.7)

7 (3.3)

R

3.05 (1.12-8.25)

R

2.47 (.77 - 7.90 )

0.126

Labor monitored

Yes

No

81 (76.4)

25 (23.6)

200 (94.3)

12 (5.7)

R

5.14 (2.46-10.72)

R

3.82 (1.31 - 11.09)

0.014

Abnormal third stage

Yes

No

25 (23.6)

81 (76.4)

14 (6.6)

198 (93.4)

R

4.36( 2.16 - 8.82)

R

5.86 (2.55 - 13.43)

0.000

AMTOL

Yes

No

86 (81.1)

20 (18.9)

204 (96.2)

8 (3.8)

R

5.93 (2.51-13.98)

3.88 (1.29 - 11.60)

0.015

Primary PPH is the leading cause of maternal mortality and morbidity and understanding various risk factors and their relation with underlying causes can help us to be proactive in the management and prevention of PPH. So this study was intended to identify the relative contributions of different factors to the development of primary PPH.

In this study, the ANC was found to be an important predictor of primary PPH; the odds of non-utilization of the ANC was higher among cases compared to controls. This result is consistent with the prior study carried out at the Dessie referral hospital which found that women who didn’t have ANC follow-up were eleven times more likely develop PPH than those who did receive at least one follow-up (6). This finding also supported by a study done in Parakou and Nigeria (21,33) which concluded that lack of ANC was a risk factor for PPH. This may be because of mothers who don’t have ANC Visits are more likely to have undetected complications, non-institutional delivery which could be associated with the delay in health-seeking behavior, all predispose for primary PPH development.

Likewise, mothers who have complications during pregnancy (medical or obstetric) were at higher risk of developing primary PPH as compared with Mothers without complications which is congruent with a research findings from Parakou (21), Tanzania(32), Norway(26) Indonesia(23) and Japan (45). A potential mechanism might be due to the possibility that women with PIH might have hematological abnormalities like abnormal plasma clotting factors, inhibition of platelet activity leads to prolonged bleeding time and the use of magnesium sulfate facilitates blood loss via vasodilatation, a tocolytics effect predisposes to uterine atony, a major cause of PPH (45).

The results of this study also revealed that C/S increased the risk of Primary PPH by five times. This finding is comparable with a previous study conducted in Ethiopia, Uganda, and Mexico (6,18,37) which indicated that cesarean delivery was a risk factor for primary PPH across all deliveries. This result is also in agreement with a study conducted in Norway which showed that the risk of severe bleeding after a C/S was twice the risk of severe hemorrhage after vaginal deliveries (34). The possible reason for the fivefold risk caused by C/S might be most of the time cesarean birth is the last resort when another route of delivery is impossible and difficulties arise (such as placenta previa, dehiscence of previous CS scar, uterine rupture) and all this conditions predisposes to have a massive blood loss. Additionally, women undergoing C/S are at risk for several intraoperative complications, including hemorrhage and injury to adjacent organs (48). So in the decision-making process, less invasive methods should be tried initially if possible and the obstetrician must be ready to recognize and familiar with the management of these problems.

The strongest independent risk factor for primary PPH was an abnormal third stage of labor in this study. Odds of 3^rd stage abnormality were six times higher among cases as compared to controls. This is in line with a study done in Australia and Egypt (43,44). Similar to this, it has also been reported as an independent predictor of primary PPH from various research conducted in different regions of the globe (16,42). It is because longer the duration of the third stage, greater the blood loss (a logistic regression result revealed that for every five minutes duration before delivery of the placenta, bleeding increased by 40ml) (41).

This study also discovered that none-use of AMTSOL was a predictor of primary PPH in this study which is in agreement with results from different studies (17,28,36). Another comparative study likewise concluded that AMTSOL is associated with less blood loss as well as a shorter duration of the third stage compared with expectant management (41). The routine use of active management of the third stage of labor is also recommend by ICM, FIGO and WHO also as it lowers the incidence of PPH, the quantity of blood loss, and the need for blood transfusions (3,5,49,50).

Though AMTSOL is composed of life-saving components the contribution and effectiveness of individual components are still being studied, but the use of uterotonics found to be the most important factor (49,50).

The other important predictor for primary PPH was parthograph utilization, in this study; mothers with primary PPH were four times more likely to have unmonitored labor with parthograph when compared to mothers without Primary PPH. This finding is in line with prior study conducted in Parakou (21). The possible reason for the association here might be parthograph is not given enough attention by health professionals and labor might not be followed properly, and if labor is not monitored adequately it may become extended or unnecessary interventions like labor augmentation and cesarean sections may be performed(51–55). Therefore, birth attendants must strictly adhere to the parthograph and properly document for every laboring woman.

In some studies, grand multiparity has been reported as a risk factor for PPH, however, this study found no association. Similarly, Extreme lower or higher ages in pregnancy (age < 20 and > 35 years) were identified as risk factors for primary PPH in prior studies (9); advanced maternal age had an indirect role in the development of PPH for parity and gravidity were expected to occur at older ages, but in the current study no difference was observed. The disparity could be explained by the fact that most of the respondents in this study were fell between the ages of 20 &34 years and parity of 2-4.

In preceding studies illiteracy or had primary level schooling and from a rural vicinity of residence, had been stated to be a risk factor for PPH (21), however in the current study, no association was reported. The possible reason might be the continuous health education application provided by way of health extension employees in the network and household ranges might have helped to have a similar level of recognition about the issue and this, in turn, could make the difference invisible.

Abnormality in the third stage of labor, Caesarean route of delivery, lack of AMTSOL, absence of labor monitoring with parthograph, complications during pregnancy and non-utilization of ANC were found to be risk factors of primary postpartum hemorrhage. Consequently, unique emphasis must be located on a strategy towards improving antenatal care coverage, strengthening the universal use of parthograph and active management of the third stage of labor for all labors and detecting and handling complications in a timely and proper way.

AMTSL: Active Management of Third Stage of Labor; ANC: Antenatal Care; AOR: Adjusted Odds Ratio; APH: Antepartum Hemorrhage; CI: Confidence Interval; COR: Crude Odds Ratio; C/S: Cesarean Section; GA: Gestational Age; HGB: Hemoglobin; ICM: International Confederation of Midwife, MCH: Maternal Child Health; OR: Odds Ratio; PI: Principal Investigator; PIH: Pregnancy Induced Hypertension; PPC: Postpartum Care; PPH: Postpartum Hemorrhage; R: Reference; SPSS: Statistical Package for the Social Science; SVD: Spontaneous Vaginal Delivery; WHO: World Health Organization

Ethical considerations

Ethical clearance was obtained from the institutional review board (IRB) of Mekelle University (Reference number: ERC 1381/2019). An official letter obtained from the Tigray regional health bureau was submitted to each hospital and data was collected after permission was obtained from the medical director of the hospital. Additionally, the informed consent of the participant in the study was secured before conducting the interview. Participants took part voluntarily. Anonymity and confidentiality were maintained by excluding personal identifiers from the data collection tool and records were kept strictly confidential.

Consent for publication

It is not applicable to this study

Availability of data and materials

The data sets used and or analyzed during the current study are available from the corresponding author on reasonable request via email.

Computing of interests

The authors declared that there are no conflicts of interest regarding the publication of this article.

Funding

The authors’ received no specific funding for this work.

Authors’ contributions

All authors contributed to this research article from the beginning to the very end of this manuscript’s preparation. GM made a significant contribution to the conception and study design, the collection, analysis, interpretation of data, writing of the report and finally the preparation of the manuscript. LW, BG have actively participated in the acquisition, analysis, and interpretation of data, as well as writing of the manuscript. All authors read and approved the final manuscript.

Acknowledgment

The authors acknowledge Mekelle University, the data collector and study participants.

Authors’ information

^1*Department of Midwifery, College of Health Science, Mekelle University, Mekelle, Ethiopia); Email: [email protected]

²Department of Environmental Health, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia); Email:[email protected]

³Department of Integrated Emergency Surgery and Obstetrics, Amdework Primary Hospital, Waghimera Zone, Ethiopia; Email: [email protected]

⁴Department of Midwifery, College of Medicine and Health Science, Wachamo University, Wachamo, Ethiopia); Email:[email protected]

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No competing interests reported.

Risk factors of primary postpartum hemorrhage among postnatal mothers in the public hospital of southern Tigray, Ethiopia, 2019: a case-control study

Status:

Version 1

Abstract

Figures

Introduction

Methods

Study area and period

Study design

Populations

Eligibility criteria

Ascertainment of cases and controls

Sample size determination, and sampling technique

Data collection tools and procedures

Data quality control and assurance

Data Processing and analysis

Study Variables

Definitions of terms

Results

5.1. Socio-demographic characteristics of the study participants

Past Obstetrics and Gynecology history of the study participants

Current pregnancy characteristics of the study participants

Intrapartum and postpartum characteristics of the study participants

Risk factors of primary postpartum Hemorrhage

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1