How postpartum haemorrhage risk is killing joy of motherhood

Childbirth is not only a painful process, it also brings out the strength of women, for it is sometimes akin to dancing with death. Unfortunately, some women don’t survive it.

As an expectant mother enters the delivery room, the biggest danger she faces is postpartum hemorrhage (PPH), which is excessive bleeding after childbirth. It is the leading cause of maternal deaths worldwide.

In October 2020, Alice Ojera’s daughter, Evelyne, 42, went into labour with her seventh child. What would have been a routine delivery turned tragic when she bled profusely. Despite being rushed to the hospital, she didn’t make it.

“On our way to Kenyatta National Hospital, she passed away,” Ojera recounts.

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In Kenya, the situation is particularly dire. The country ranks among the top five globally on maternal mortality rates. 

According to the Kenya Demographic and Health Survey 2022, the maternal mortality ratio stands at 355 deaths per 100,000 live births. This translates to approximately 5,000 to 6,000 women dying annually due to pregnancy-related complications, with PPH accounting for 40-50 per cent of these deaths.

Prof Moses Obimbo Secretary of the Kenya Obstetrics and Gynecological Society (KOGS) and Associate Professor at the University of Nairobi, puts these numbers into perspective.

“It means about 3,000 women every year in this country die of PPH. If you had put 60 buses full of 50 women each, all these buses crashing, it would be news all over the world for many years. Those is the number of women we’re losing every year.”

According to Dr Obimbo, postpartum hemorrhage is defined as blood loss of 500 ml or more within 24 hours after birth. Several factors can contribute to PPH, including, uterine atony, which is the most common cause, where the uterus fails to contract after delivery. Retained placental tissue, genital tract trauma and blood coagulation disorders are also possible contributors.

Dr Laura Oyiengo, UNICEF Health Specialist in Maternal and Newborn Health, says that while Kenya has sound policies for managing PPH, implementation remains a challenge.

“We need healthcare workers, training, equipment, medicines, and blood products. That’s where the challenge is,” she notes 

A 2022 cross-sectional study published in BMC Pregnancy and Childbirth surveyed 364 healthcare providers in Kenya. It found that while 89 per cent of respondents were aware of PPH management guidelines, only 62 per cent reported consistently following them.

The study identified key barriers including lack of essential supplies, inadequate staffing, and insufficient training. 

The University of Nairobi, in collaboration with KOGS and the Midwives Association of Kenya, has designed a four-pillar strategy to address PPH. Advocacy and community engagement, research and reskilling, health innovations, data ecosystem strengthening, and several innovative approaches are being developed to combat PPH in Kenya.

“Initiatives like walking blood banks aim to create a network of potential blood donors who can be called upon in emergencies,” says Obimbo.

He adds that Non-pneumatic Anti-Shock Garment (NASG), a pressure suit that can be wrapped around a bleeding mother to buy time for transfer to a better-equipped facility; and the use of Uterine Balloon Tamponade (UBT) -a device inserted into the womb and inflated with saline to apply pressure on bleeding vessels – are some of the emergency measures that can be applied. 

A 2019 cluster-randomised trial published in The Lancet Global Health demonstrated the effectiveness of the NASG in reducing PPH-related mortality by 54 per cent in low-resource settings.

Beyond the immediate physical danger, PPH can have profound mental health implications for survivors, families and communities.

According to Obimbo, survivors may experience Post-Traumatic Stress Disorder (PTSD), anxiety and depression, sleep disorders and fear of future pregnancies.

A 2021 systematic review in BMC Pregnancy and Childbirth found that women who experienced severe PPH had a three-fold increased risk of postpartum depression compared to those without PPH.

 For families who lose a mother to PPH, the impact is devastating. Children born to mothers who die of PPH are less likely to survive to their fifth birthday. A 2020 study in The Lancet Global Health found that maternal death increases the risk of death for children under five by up to 50 per cent

  “Husbands often struggle with depression, trying to maintain a facade of strength while grappling with loss and new responsibilities,” Dr Obimbo explains.

 One systemic issue highlighted by Obimbo is the undervaluation of maternal care in health insurance policies. “When you have an insurance cover, they tell you a medical cover is 5 million in-patients, right? But how much is granted to your maternity care as a lady? About 100K,” he points out.

 This disparity often forces women to pay out of pocket for quality maternal care or complications arising from childbirth.

 Addressing PPH requires a multi-pronged approach, Obimbo notes, adding that increased funding, training and capacity building, continuous training of healthcare workers on the latest PPH management techniques is crucial.

 Alice Ojera’s plea serves as a powerful reminder of what’s at stake.

“What I can tell people is when there is a pregnant woman under your care and they are under distress, don’t waste time. Take them to the hospital before it gets ugly.”