Postpartum Haemorrhage 1

Running Head: POSTPARTUM HAEMORRHAGE

EPIDEMIOLOGICAL REPORT ON MATERNAL DEATHS DUE TO POSTPARTUM

HAEMORRHAGE IN PAKISTAN BETWEEN 2005 TO 2015

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Epidemiological report on maternal deaths due to postpartum haemorrhage in Pakistan between

2005 to 2015

Abstract

Haemorrhage is regarded as one of the major killers of women during the postpartum

period. In Pakistan, the condition is even worse due to lack of education and access to health

facilities. Postpartum haemorrhage can be simply defined as excessive bleeding following the

birth of a baby. It is experienced 1 to 5 percent of the population (Yousef and Haider, 2009).

Postpartum haemorrhage is comparatively more common is the caesarean as compared to the

natural delivery of the baby. In remote areas of Pakistan, as there is no access to maternal health

services, the major cause of maternal mortality indicates that postpartum haemorrhage is the

culprit. Maternal mortality is mainly defined as the death of woman during or 42 days after the

termination of pregnancy. The global ratio is provided to be 529000 deaths per anuum and the

ratio indicates maternal mortality ration of 400 maternal deaths per 100,000 (Agha and Williams,

2016). It is also reported that 90% of the total maternal deaths occur in the developing world

including Asia and Africa. The reason for this rate is the unavailability of the resources,

increased poverty level, and lack of basic facilities of life. This report aims to provide the

reported incidences of maternal deaths due to postpartum haemorrhage. It will also target the

underlying reasons responsible for the higher mortality rate. The report aims to provide the

barrier in proper health care and deal with the factors that affect the maternal health. It will target

the gradual development of symptoms associated with the condition of postpartum haemorrhage.

This report will provide the basis for further research that can contribute in improving the health

status of maternal population of Pakistan. It will also signify the current approaches that are

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being utilised in health practices. The comparison is among Pakistan, India, Africa, and Latin

America. The parameters include number of birth, cluster, 42-day maternal mortality ratio, rate

of stillbirth, and perinatal mortality rate. The parameter are selected on the basis of the indicators

that can effectively communicate the condition of the health services provided to the patient and

their impact on the overall health scenario.

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Introduction

Primary Post-partum Haemorrhage (PPH) can be defined as the loss of blood following

vaginal or caesarean delivery. The lost blood can be measured to be more than 500 to 1000mls.

According to the reports presented by the World Health Organization (WHO), 10.5 percent of

the total live births are complicated by obstetrical haemorrhage and it is regarding as one of the

leading cause of maternal deaths. PPH causes 150,000 maternal deaths on annual basis and it

estimated to form a quarter of the total maternal health. The underlying cause of PPH is uterine

atony and the failure of the capability of the uterus to contract and retract. In Pakistan, every

second women is reported to be anaemic (Agha and Williams, 2016). The condition of anaemia

is directly associated with maternal mortality as even a little loss of blood during delivery can be

fatal. The average amount of blood loss after the birth of a single baby in vaginal delivery is

about 500 ml. The average amount of blood loss for a caesarean birth is approximately 1,000 ml.

In majority of the cases, postpartum haemorrhage occurs immediately after delivery. It is also

possible that it will occur at later stage. Lack of basic medical facilities in the remote areas of

Pakistan are related with the high mortality rate due to postpartum haemorrhage. The issue of

transportation is also significant as currently there are no guidelines to transport the patient to the

medical facility.

Discussion

Postpartum haemorrhage is considered to be the major risk factor in case of maternal

mortality. Even the competent obstetricians can be regarded incompetent when dealing with the

women in life threatening situations (Yousef and Haider, 2009). The main reason of this

dilemma is the unavailability and no access to the lifesaving drugs especially in the remote areas.

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Another reason is limited or no access to the safe blood transfusion services that can save the life

of the patient. This scenario is not limited to the public hospitals rather it is common in major

cities of Pakistan. The hospitals in metro cities are best equipped but have no access to live

saving medications. In majority of the cases, the deliveries occur at home and these deliveries are

concluded under the supervision of traditional birth attendants (Pal, 2007). This trend is changing

nowadays, as women are more inclined towards the safer practices of delivery. Nowadays, most

women prefer to go to maternity homes or hospitals for the delivery due to the better equipment

and medical facilities. The case in rural areas is completely different due to lack of the basic

health facilities. Majority of the rural areas lack the emergency obstetric care facilities and they

are helpless to provide any assistance in any case of complication and emergency. Lack of

financial resources. Poverty, lack of proper education, and poor transportation can be defined as

the main hindrances in the delivery of health care services to the rural population of Pakistan.

Early marriage and lack of planning is also regarded as a major contributing factor (Naz et al,

2008). The nutritional state is less than ideal that leads to the complications including anaemia.

Pre-pregnancy anaemia is also common due to the state of malnutrition. The oppression and lack

of empowerment are the barriers that affect the decision to seek medical attention. The culture of

the society also influence the individual approach of the patient. Pregnancy is considered a

private condition and women are scolded if they complain about unusual symptoms (Agha,

2014). The issues directly affect the health status of the women and they seek medical attention

as a last resort. The lack of nutritional reserves further complicate the job of the health

professional and leaves little margin of error in case they are faced with a bleeding pregnant

woman (Pal, 2007). Obesity, previous pregnancies, and previous condition of PPH also increase

the chances of postpartum haemorrhage. The development of fibroid is also linked with

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numerous complications in pregnancy including cervical laceration and placenta accreta. The

recovery of the patient depends on the amount of blood lost and replenishing rate. In order to

decrease the maternal mortality ratio by 75%, prevention will considered being the key for

success. This task is huge as it is based on improving the standard of care and provided facilities

to the patients. It is highly unlikely that the female population will be empowered overnight and

hence the process is based on baby steps. They would not take care of the nutrition pattern, have

better access to health care option, enjoy better health, have improved transportation, have

improved social status, and have better health facilities (Naz et al,2008). The present scenario

indicates that the ambulance currently in operation are not equipped with paramedical staff or

emergency equipment. The safe blood transfusion services are still unlikely to be available at a

lower cost nationally. It is the case of life saving emergency drugs also. These medications are

hardly available and in case they are available, the families cannot afford them.

Communication in Pakistan is vastly improved due to the increase in the usage of phone

services. It is considered to be affordable by the common man in the remotest areas of Pakistan.

This factor is directly associated with the improvement in the access to health care facilities. The

use of the cellular devices is especially useful in the scenario when junior doctor are available

(Pasha et al, 2015). They can get the instruction of the dosage and correct practices via phone

and administer the medication in an effective manner. In this case, also, the availability of the

equipment is necessary and the condition cannot be tackled if this condition cannot be applied. It

should be kept in mind that even the best skilled health professionals seem incompetent while

dealing with the condition of postpartum bleeding hence preventive approaches are regarded as

one of the most effective approaches.

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The Epidemiology of Postpartum Haemorrhage

Most common symptoms of postpartum haemorrhage includes decreased blood pressure,

uncontrollable bleeding, elevated heart rate, pain and swelling in vaginal tissues and decrease in

the number of red blood cells (red blood cells count). These are the general symptoms, however

the severity and presence of the symptoms depends on the individual as the symptoms and their

intensity may vary person to person (Uddin et al, 2015). These symptoms are similar to other

medical condition and hence it is always to consult a health care professional for accurate

diagnosis of the condition.

Diagnosis

The diagnosis of the condition is based on symptoms along with the physical examination

and laboratory tests. The diagnostic tests mainly include the estimation of blood loss, clotting

factor present in the blood, red blood cell count, pulse rate, and the measurement of blood

pressure (Malik and Kayani, 2014).

Treatment

There are specific treatment plan for the cure of postpartum haemorrhage. These

treatment plans are finalized by the health care provider and are based on the medical history,

overall health status, pregnancy, and extent of the condition (Bibi et al, 2007). The treatment

plans also depend on the tolerance of the patient for specific measure, procedure, and

medications. The selection of the treatment plan also depends on the preferences of the patients,

and expected course of the condition.

Aim of the Treatment

The aim of the planned treatment is to induce uterine contraction with the help if

medication. Another option that is commonly utilised is the manual massage of the uterus to

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promote the contractions (Bhutta et al, 2004). Another treatment approach is to remove the

pieces of placenta that remain in the uterus. Examination of pelvic and uterine tissue is also

regarded as a type of treatment plan. Uterine compression suture are also used to control the

bleeding via blood vessels. Hysterectomy is regarded as the last resort as it is based on the

surgical removal of the uterus (Duhan et al, 2017). The condition of postpartum haemorrhage is

serious but it can be completely healed in case of positive response of the patient to the treatment

approach.

Comparison to other countries

The reports that provide the insight about the prevalence of the condition are mainly

based on the comparison of the cases reported in Pakistan with the reported cases of the

neighbouring countries (Agha and Tappis, 2016). This table provides the comparison of different

parameters that are involved in the maternal mortality related to postpartum haemorrhage. The

comparison is among Pakistan, India, Africa, and Latin America. The parameters include number

of birth, cluster, 42-day maternal mortality ratio, rate of stillbirth, perinatal mortality rate.

Pakista Latin Total except

Countries India Africa
n America Pakistan
Nagpur,
Kafue/Chongw Chimaltenang
Thatta, Maharasht
e, Zambia o, Guatemala
Sindh ra
Sites
Western
Belgaum, Corrientes,
Province,
Karnataka Argentina
Kenya
Births, N 48,868 119,785 63,976 39,557 223,318
Clusters, N 20 40 30 22
42-day
maternal
mortality 144
142 (122) 76 (121) 35 (90) 253 (116)
ratio, n (313)
(rate/100,0
00 LB)

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Stillbirth, n
2,760
(Rate/1,000 3,068 (25.6) 1,356 (21.2) 681 (17.2) 5,105 (22.9)
(56.5)
)
Perinatal
mortality, n 4,589
5,303 (44.3) 2,188 (34.4) 1,197 (30.4) 8,688 (39.0)
(Rate/1,000 (95.2)
)
28-d
Neonatal
2,270
mortality, n 2,755 (23.6) 1,020 (16.4) 719 (18.6) 4,494 (20.7)
(50.0)
(Rate/1,000
)

Graphical Representation

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Comparison of Pregnancy Health Care

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%
Births, N Clusters, N 42-day maternal Stillbirth, n Perinatal 28-d Neonatal
mortality ratio, n (Rate/1,000) mortality, n mortality, n
(rate/100,000 LB) (Rate/1,000) (Rate/1,000)

Pakistan India Africa Latin America

The graph indicates the parameters utilised in the comparison. It is the comparison

between Pakistan, Indian, Africa, and Latin America. This table provides the comparison of

different parameters that are involved in the maternal mortality related to postpartum

haemorrhage (Ahmad, Jafar, and Chaturvedi, 2005). The comparison is among Pakistan, India,

Africa, and Latin America. The parameters include number of birth, cluster, 42-day maternal

mortality ratio, rate of stillbirth, perinatal mortality rate. The parameter are selected on the basis

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of the indicators that can effectively communicate the condition of the health services provided

to the patient and their impact on the overall health scenario.

The table and graphs provide the complete description of the current scenario and it

compared the status of maternal health of Pakistan with other countries. Here it also important to

note that the difference is based on the total population and total number of the reported cases. It

is also important to note that the budget approved in Pakistan for the healthcare sector is

comparatively greater than the other countries (Ahmad, Jafar, and Chaturvedi, 2005). However,

the output is not that significant. The reason of this scenario is based on the improper utilisation

and spending of the budget. The lack of proper health care resources is also regarded as an

important contributing factor in the deteriorating health care condition in Pakistan.

The second table is based on the division of the selected parameters and dividing them

further to provide accurate picture. The countries selected for the comparison are same and hence

the result is almost similar to the previous graphical representation.

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Countries Pakistan India Africa Latin America

Sites Thatta, Sindh Nagpur, Maharashtra Kafue/Chongwe, Zambia Chimaltenango, Guatemala
Belgaum, Karnataka Western Province, Kenya Corrientes, Argentina
42-day maternal mortality ratio/100,000 deliveries
2010 219 (159, 302) 153 (117, 200) 143 (95, 216) 136 (75, 244)
adjusted risk
estimate
[95% CI]
2013 333 (233, 476) 98 (66, 146) 88 (56, 138) 70 (31, 154)
adjusted risk
estimate
[95% CI]
Change 54.3% increase 35.9% decrease 38.5% decrease 48.5% decrease
2010 to 2013
(%)
P-value 0.0325 0.0409 0.1825 0.1724
for 2010-
2013 trend
test
Stillbirth, rate/1,000 births
2010 55.1 (49.5, 61.3) 30.0 (27.4, 32.9) 23.7 [19.6, 28.6] 19.2 (15.9, 23.1)
adjusted risk
estimate
(95% CI)
2013 58.3 (51.0, 66.6) 23.4 (21.5, 25.3) 20.6 [16.8, 25.4] 15.4 (12.8, 18.4)
adjusted risk
estimate
(95% CI)
Change 5.8% increase 22.0% decrease 13.1% decrease 19.8% decrease
2010 to 2013
(%)
P-value 0.755 0.0003 0.7192 0.0489
for 2010-
2013 trend
test
28-d Neonatal mortality, rate/1,000 live births
2010 48.5 (42.3, 55.7) 25.5 (23.1, 28.2) 20.7 (16.7, 25.7) 19.5 (14.7, 25.9)
adjusted risk
estimate
(95% CI)
2013 46.7 (40.9, 53.4) 25.6 (23.6, 27.7) 13.9 (11.6, 16.6) 18.7 (16.1, 21.7)
adjusted risk
estimate
(95% CI)
Change 3.7% decrease 0.4% increase 32.9% decrease 4.1% decrease
2010 to 2013
(%)
P-value 0.2609 0.5975 0.0449 0.3984
for 2010-

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2013 trend
test
Perinatal mortality, rate/1,000 births
2010 91.6 (83.1, 100.8) 49.8 (45.9, 54.1) 39.7 (34.0, 46.5) 34.1 (28.9, 40.3)
adjusted risk
estimate
(95% CI)
2013 93.2 (83.8, 103.7) 43.4 (40.9, 46.0) 32.3 (27.0, 38.6) 28.0 (24.6, 31.9)
adjusted risk
estimate
(95% CI)
Change 1.7% increase 12.9% decrease 18.6% decrease 17.9% decrease
2010 to 2013
(%)
P-value 0.5501 0.0089 0.3437 0.005
for 2010-
2013 trend
test

Recommendations

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Prevention can be the most effective recommendation in this case as it can help in

decreasing the chances of postpartum haemorrhage. The report provides an insight about the

diagnosis, epidemiology, prevalence, possible treatment, and comparison of the prevalence of the

condition in other countries. It can be utilised as the basis for further researches. The treatment

approaches discussed in the research can also be utilised to improve the quality of health care

services provided to the patient. The factors associated with the conditions are also highlighted.

The mortality ratio can be decreased but the most effective approach is based on the preventive

measures.

Conclusion

Postpartum haemorrhage is considered to be the leading cause of death among pregnant

population of the country. There are various factors that are directly associated with the

progression of this condition. Poverty, lack of education, lack of transport facilities, and early

marriage are the key factors that plays a vital role in the development of complication associated

with pregnancy. Haemorrhage is regarded as one of the major killers of women during the

postpartum period. In Pakistan, the condition is even worse due to lack of education and access

to health facilities. Postpartum haemorrhage can be simply defined as excessive bleeding

following the birth of a baby. In remote areas of Pakistan, as there is no access to maternal health

services, the major cause of maternal mortality indicates that postpartum haemorrhage is the

culprit. 90% of the total maternal deaths occur in the developing world including Asia and

Africa. The reason for this rate is the unavailability of the resources, increased poverty level, and

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lack of basic facilities of life. It is concluded that the maternal mortality rate due to postpartum

haemorrhage can be decreased by provide quality health care facilities to the population.

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References

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