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PREVALENCE AND OUTCOME OF POSTPARTUM HAEMORRHAGE AMONG WOMEN WHO DELIVERED IN FEDERAL TEACHING HOSPITAL ABAKALIKI FROM 2004 TO 2013

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 CHAPTER ONE

INTRODUCTION

Background to the study

Postpartum haemorrhage (PPH) is an obstetric emergency that may follow vaginal or caesarean birth. The World Health Organization (WHO, 2014) defined PPH as the loss of more than 500mls of blood after vaginal delivery. PPH could occur within few hours of delivery of the baby or within 6 weeks postpartum, with uterine atony being the major cause (Healthline, 2012).

Postpartum haemorrhage has a global prevalence rate of 6% and 10.5% in Africa with associated case fatality of 1% and estimated to contribute about 25% of global maternal death (Clinical Practice Guideline, 2010). According to

Fawole, Awolude, Adeniji & Onafowokan (2010), PPH accounts for more than 30% of all maternal deaths and this varies considerably between developed and developing countries. It is the leading cause of maternal mortality and morbidity with highest prevalence in developing countries (Allan, 2010).This implies that Africa as a continent is lagging behind in containing maternal mortality due to postpartum haemorrhage. Maternal mortality is defined  by WHO (2014) as the death of a woman while pregnant or within 42days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from incidental or accidental causes. The maternal mortality ratio (MMR) is the number of maternal deaths during a given period per 100,000 live births during the same time period (WHO, 2014).

The International Confederation of Midwives (ICM) stated that “every minute around the world, 380 women become pregnant, 110 women experience pregnancy related complications, and 1 woman dies”. This implies that 529,000 women die annually from pregnancy complication or childbirth. This is quite alarming!  Ajefunja, Adepiti & Ogunniyi (2010), stated that an overwhelming proportion of about half a million women who die as a result of complications of pregnancy and childbirth, occur in developing countries where facilities are either poorly developed, or there is lack of trained attendants at delivery. Majority of these deaths occur within 24hours of delivery and in most cases are due to PPH (Ajefunja et al., 2010). According to the United Nations Population Fund Agency (UNFPA) reports in 2010, developing nations accounted for ninety-nine percent (99%) of maternal deaths with majority of these deaths occurring in sub-Saharan Africa and Southern Asia. Nigeria was rated second highest contributor with 14% or 40,000 deaths while India was first with 19% or 56,000 deaths.

The burden of postpartum haemorrhage on developing countries cannot be overemphasized. Many women have lost their lives, some have lost their uterus and many who survived it, are faced with one health challenge or the other. Many children have also been rendered motherless and many families suffer pain. It is not out of place to say that PPH is also a social menace because marriages have been broken in some cases of uterine loss, children have been neglected or abandoned in some cases of maternal deaths and often, there is society-directed violence when many families suffer pain. Fathalla as reported in Obinna (2014) stated that women are not dying because of the disease that cannot be treated, but are dying because the society is yet to make the decision that their lives are worth saving. This implies that PPH as the highest contributor to maternal deaths could be prevented to make childbirth safer.

The intervention to prevent PPH in developing countries is no doubt pivotal in the global effort to achieve the millennium development goal (MDG5) of reducing maternal mortality ratio by three quarters by 2015 from 1990. Also foremost among the objectives of the nation’s policy on reproductive health is, to reduce maternal morbidity due to pregnancy and childbirth by 50%. The International Federation of Obstetricians and Gynaecologists (FIGO) and the International Confederation of Midwives (ICM) in collaboration with WHO, have recommended active management of the third stage of labour (AMTSL) and routine use of uterotonics for prevention of PPH (PATHS, 2014).  However the low socio-cultural and economic status of women as well as the inadequacies of our existing health systems, have contributed to the delays that lead to complications and the death of women with PPH (WHO, 2014).

Nigeria as one of the developing countries was ranked the second highest contributor to global maternal death and Ebonyi being one of the states with high maternal mortality rate of 800 per 100,000 (Ebonyi State Ministry of Health, 2010), is deemed as suffering severely the impact of this menace.

Being a gender based health problem, PPH like many other health conditions require critical attention to curb its menace on the health of the nation, and precisely that of women. From the foregoing, it is therefore expedient to investigate the prevalence and outcome of postpartum haemorrhage in Federal Teaching Hospital Abakaliki to provide a baseline data in nursing literature in this area of study in Ebonyi State.

Statement of Problem

Postpartum haemorrhage is the major cause of maternal mortality worldwide (Allan, 2010). Following the documented statistics in Nigeria, Ebonyi is one of the states with high maternal mortality rate (Pathfinder International, 2013). This was concurred in Uneke, Ndukwe, Ezeoha, & Urochukwu (2013), which reported maternal mortality rate in Ebonyi to be 602 per 100,000 live births making it to be one of the highest in Nigeria. By implication there is high prevalence of PPH in the State. This is because PPH is the highest cause of maternal mortality worldwide. The First Civilian Governor of the State, Dr. Sam O. Egwu, in his commitment to reducing maternal deaths especially due to PPH, introduced free maternal health services from pregnancy to 6 weeks postpartum. The free maternal health Services was commenced in 2001 (Ezegwui, Onoh, Ikeakor, Onyebuchi, Umeorah, Ezeonu & Ibekwe, 2013). Also in 2007, the MacArthur Foundation awarded Pathfinder International a grant of 10.7 million USD (US Dollars) to implement a project aimed at preventing and managing PPH in Nigeria and India (Pathfinder International, 2013). It was a four-year project which used community and clinical action as an approach to address postpartum haemorrhage (CCA-PPH) and Ebonyi State was one of the seven beneficiaries of this project in Nigeria while Ebonyi State University Teaching Hospital was one of the hospitals equipped and used for the project, from 2009 to 2013 (Pathfinder International, 2013). Also in her bid to check PPH, the Federal Ministry of Health (FMOH) under the midwives scheme, also trained selected health professionals from the 36 States and FCT on the use of Misoprostol to prevent PPH (FMOH, 2011).

With all these laudable programmes aimed at preventing PPH(which is the major cause of maternal deaths), having been initiated and carried out in Ebonyi State, women still have PPH. The researcher having observed many cases of PPH in Federal Teaching Hospital Abakaliki, especially among younger women, and the painful death of one of them admitted into the Intensive Care Unit (ICU), began to wonder why many women had PPH within a space of time, what were the causes of the PPH, and the outcome of the intervention?  The foregoing stimulated the desire to carry out this study. The study will attempt to provide answers to the worrisome questions, and also provide a baseline data for empirical documentation and intervention purposes.

Purpose of the Study

The purpose of the present study was to investigate the prevalence, causes, types, interventions and outcomes of cases of postpartum haemorrhage as documented in Federal Teaching Hospital Abakaliki from 2004 to 2013.

Study Objectives

The study objectives were to:

  1. determine the prevalence of PPH and the annual distribution from 2004 to 2013 as documented in Federal Teaching Hospital Abakaliki
  2. compare the prevalence of PPH before and after Pathfinder Project within the period under study
  3. identify the documented immediate and remote causes of PPH in these cases
  4. find out the type of PPH that was prevalent among these women during the period of study
  5. identify the documented intervention measures adopted in these cases
  6. find out the outcomes of intervention on PPH in these women during the study period.

Research questions

  1. What is the prevalence of PPH and the annual distribution from 2004 to 2013 as documented in Federal Teaching Hospital Abakaliki?
  2. What is the prevalence of PPH before and after Pathfinder Project within the period under study?
  3. What are the documented immediate and remote causes of PPH in these cases?
  4. What type of PPH that was prevalent among these women during the period of study?
  5. What are the documented intervention measures adopted in these cases?
  6. What are the outcomes of intervention on PPH in these women during the study period?

Hypothesis

  1. There is no significant difference in the prevalence of PPH before and after Pathfinder Project within the period under study.
  2. There is no significant association between obstetrics/ clinical factors and PPH prevalence within the period of study.
  3. There is no significant association between socio-demographic characteristics of the women and PPH prevalence within the period of study.

Significance of the Study

The findings of this study revealed the prevalence as well as the type and causes of PPH amongst mothers who had childbirth during the period under study. It also revealed the intervention measures used to address the PPH and the outcome of the intervention in these cases.

The findings revealed the annual prevalence of PPH and the impact of the 4years Pathfinder Program on the prevalence of PPH in the state so to reveal the necessary areas of attention that government, non-governmental agencies and concerned individuals will need to focus on, in provision of requisite health facilities to basically reduce PPH in pursuance of the realization of the Millennium Development Goal 5 (MDG 5). It also added to the body of existing knowledge of PPH as well as necessitated further research.

Information from this study when communicated will serve as guide for counselling, to encourage women to see the need to attend prenatal clinics and ultimately, certified health centres/hospitals for childbirth. It also highlighted the socio-demographic characteristics and obstetric factors of women that can be associated with PPH prevalence so as to proffer solution to address them.

Scope of the study

The study is confined to investigating the prevalence, causes, types, interventions and outcomes of postpartum haemorrhage amongst mothers who had PPH after caesarean birth or spontaneous vaginal delivery as recorded in Federal Teaching Hospital Abakaliki from 2004 to 2013.

Operational Definition of Terms

These terms were defined for the purpose of this study.

  • Postpartum haemorrhage (PPH): blood loss from the mother after childbirth that amounted to 500mls and above in vaginal delivery, and 1000mls and above in caesarean birth.
  • Prevalence: Percentage of the total number of women who had PPH as documented in Federal Teaching Hospital Abakaliki during the period under study (2004 to 2013).
  • Intervention: These are different types of treatment methods used to stop the bleeding and treat its effect on the women who had PPH within the period under study. It could be vaginal packing, pitocin infusion, rectal misoprostol, surgery, etc.
  • Outcome of intervention: this is the overall effect of PPH on individual mother after receiving health care in Federal Teaching Hospital Abakaliki . Outcome could be treated and discharged home, post-partum anaemia, renal complication, longer stay in the hospital, loss of uterus, death.
  • Federal Teaching Hospital Abakaliki (FETHA): this refers to the highest level of health care provider/delivery in Ebonyi state. It encompasses both defunct Ebonyi State University Teaching Hospital and Federal Medical Centre.
  • Parity: refers to the total number of previous childbirth by individual mother who had PPH within the period under study.
  • Obstetric factors: factors associated with pregnancy such as parity, gestational age, booking status, number of antenatal visits, labour duration, and mode of delivery.

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