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Gynecology & Obstetrics
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Risk Factors for Immediate Postpartum Hemorrhages in the Maternity of the University Teaching Hospital of Parakou

Awade Afoukou Achille Obossou1*, Salifou K1, Bib Hounkpatin2, Ir Sidi1, Af Hounkponou2, Oa Houngbo1, Vodouhe M1, Rx Perrin2, Tshabu Aguemon C2

1Mother and Child Department, Faculty of Medicine, University of Parakou, Republic of Benin

2Faculty of Health Sciences, University of Abomey-Calavi, Republic of Benin

*Corresponding Author:
Awade Afoukou Achille Obossou
Obstetrician-Gynecologist, Faculty of Medicine
University of Parakou, Republic of Benin
Tel: (229)95853279/97067852
E-mail: [email protected]

Received date: March 13, 2015; Accepted date:March 24, 2015; Published date:March 26, 2015

Citation: Obossou AAA, Salifou K, Hounkpatin B, Sidi I, Hounkponou A, et al. (2015) Risk Factors for Immediate Postpartum Hemorrhages in the Maternity of the University Teaching Hospital of Parakou. Gynecol Obstet (Sunnyvale) 5:284. doi:10.4172/2161-0932.1000284

Copyright: © 2015 Obossou AAA, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.



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Abstract

Objective: Study the risk factors for immediate postpartum hemorrhage (IPPH) in the maternity of the University Teaching Hospital of Parakou (UTH/P). Method: We carried out a descriptive and analytical case-control study between May 1 and August 31, 2014. The study population consisted of 63 IPPH cases versus 126 controls matched according to age, parity, number of fetuses and number of uterine scars. Results: IPPH incidence was 9.8% (IC 95% 7.5-12.1). The socio-demographic profile was characterized by young women; most of them were married and affiliated with Islamic religion. They had average socioeconomic status and the most represented were traders. The risk factors statistically significant for the occurrence of the immediate post-partum hemorrhage were: Fulani ethnicity, rural place of residence, illiteracy, female circumcision, induced abortions or miscarriages, previous IPPH, lack of antenatal care, anemia during pregnancy, child delivery at home or on the way, lack of labor monitoring by partograph, labor duration exceeding 12 hours, lack of Active Management of the Third Stage of Labor (AMTSL) and lack of postpartum monitoring. Conclusion: The consideration of these risk factors associated with the occurrence of the immediate post-partum haemorrhage (IPPH) in a contest of improving care for pregnant and parturient must help to reduce the occurrence of this pathology.

Keywords

Risk factors; Immediate postpartum hemorrhage; Maternal death

Introduction

Maternal mortality remains a major concern of public health in Africa [1]. Everyday, at global level, 1500 women die from complications related to their pregnancies or to their child deliveries and most of those deaths occur in developing countries [2]. Hemorrhages are the leading direct cause of maternal deaths, with a 25% rate. Among them, immediate postpartum hemorrhages (IPPHs) are a substantial part. IPPHs represented 23.6% of all the causes of maternal deaths in West Africa in 2001 [3]. In Benin, many studies confirm the same trend [4,5]. For the World Health Organization (WHO), most of those deaths may be avoided when women have access to reproductive health services, appropriate equipment and supplies and to skill health personnel [6].

Therefore, there are modifiable risk factors, which are both maternal and environmental, as regards its prevention. The prophylaxis of that obstetrical nosology is thus crucial. It depends first and foremost on the identification of risk factors and the development of appropriate and specific strategies allowing prevention, diagnosis and management of immediate postpartum hemorrhages. That is the reason why we have set ourselves the objective of identifying the risk factors for IPPHs in the African context.

Patients and Methods

It was a case-control descriptive and analytical study based on prospective data collection. It had covered a four-month period running from May 1 to August 31, 2014 and was conducted in the UTH/P Gynecology and obstetrics Unit and some peripheral maternities of the town of Parakou.

The said study included female patients represented by cases (UTH/P postpartum or delivered women or women referred from a peripheral maternity) with an IPPH during the study period.

Controls were represented by female patients who had normal childbirth during the same period. Therefore, we had excluded delayed postpartum hemorrhages and patients who incidentally dropped out of the survey.

We considered as IPPH, any abnormal bleeding from the genital tract, occurred within the 24 hours following childbirth with or without impact on the mother’s overall health status. Bleeding is said to be abnormal if:

Its quantity >500 ml by vaginal route and 1000 ml by cesarean section; with or without an impact on the mother’s general health status and characterized by:

• Simple maternal intolerance

• 4 g/dl drop in the hemoglobin level

• Hypovolemic shock (consecutive acute anemia)

• Kidney failure reversible in early stage

• Disseminated intravascular coagulation [1].

We proceeded to an exhaustive recruitment of all cases of IPPH occurred during the study period.

We identified all cases of IPPH occurred after a childbirth at the THU/P and those referred to the THU/P. As regards referred cases, we moved to origin centers to count controls. These are the woman who has recently given birth (normal delivery) just before the case and the one just after the case. For each case, we matched two controls. Matching criteria were represented by the same age group (≤ 19 years, 20 to 24 years, 25 to 29 years, 30 to 34 years, 35 to 39 years and ≥ 40 years); the same category of parity (primiparous, with few childbirths (2,3 childbirths), multiparous (4, 5 childbirths), grand multiparous ≥ 6 childbirths), the identical number of cesarean scars and the type of pregnancy (singleton or multiple). The dependent variable was represented by any female patient with an IPPH. The independent variables were related to:

• Sociodemographic characteristics: ethnic group, occupation, civil status, educational level and place of residence.

• Gynecological and obstetrical history: circumcision, number of pregnancies, parity, number and type of abortions and IPPH history.

• Characteristics of current pregnancy: antenatal care, gestational age, pathologies and complications occurred on pregnancy, Fundal height and anemia.

• Delivery process: type of delivery, medicated therapy during labor, duration of labor, labor curve layout, nature of delivery and monitoring after childbirth.

• Newborn characteristics: his status (living, fresh stillborn, macerated stillborn) and his weight.

The collected data were recorded and processed by means ofthe Statistical Package for Social Sciences (SPSS) software, 20.0 version. Proportions and percentages were compared through Pearson Chisquaretest (or Fisher exact test, as the case may be). For those comparisons, p<0.05 was considered as statistically significant.

Results

Our research work focused on 189 female patients, including 63 IPPH cases versus 126 controls.

Frequency of immediate postpartum hemorrhages associated with deliveries

Our study registered 63 IPPH cases, including 22 cases occurred in the maternity of the University Teaching Hospital of Parakou (UTH/P). Over a total of 645 child deliveries. Thus, IPPHs complicated on average 9.8% of childbirths [IC 95% 7.5-12.1]. Frequency of IPPHs in the UTH/P maternity is estimated at 3.4% [IC 95% 2.4-4.8].

Risk factors for IPPH occurrence before delivery labor

Risk factors associated with sociodemographic characteristics: Table 1 explores the risk factors of female patients who were victims of IPPH from May to August 2014 according to sociodemographic characteristics (Table 1). We can see that Fulani ethnicity, residence in rural areas and illiteracy were risk factors for the occurrence of IPPH.

Sociodemographic characteristics Modalities Cases Controls OR1 95% IC p
n % n  %
Ethnicity Bariba 12 19 24 19 1   0.0029
Mina 1 1.6 6 4.8 0.33 0.04-3.04
Fulani 16 25.4 6 4.8 5.33 1.72-16.46
Lokpa 9 14.3 11 8.7 1.63 0.70-3.75
Dendi 5 7.9 23 18.3 0.44 0.22-0.84
Nago 5 7.9 18 14.3 0.55 0.21-1.42
Fon 9 14.3 20 15.9 0.9 0.32-2.55
Ditamari 4 6.3 9 7.1 0.88 0.23-3.44
Others 2 3.2 9 7.1 0.44 0.08-2.35
Civil status Married 49 77.8 79 62.7 1   0.097
Concubine 8 12.7 31 24.6 0.41 0.16-1.00
Single 6 9.5 16 12.7 0.12 0.04-0.32
Place of residence Urban 36 57.1 108 85.7 1   0
  Rural 27 42.9 18 14.3 4.5 2.22-9.06
Occupation Peasant 4 6.3 6 4.8 1   0.664
  Housewives 17 27 27 21.4 0.9 0.22-3.60
  Pupil/Student 6 9.5 13 10.3 0.69 0.14-3.39
  Resellers 19 30.2 43 34.1 0.66 0.17-2.61
  Artisan 9 14.3 28 22.2 0.48 0.11-2.08
  Civil servant 4 6.3 5 4 1.2 0.20-7.01
  Others 4 6.3 4 3.2 1.5 0.23-9.74
Educationallevel Highereducation 3 4.8 4 3.2 1   0.001
  Secondaryschool II2 4 6.3 13 10.3 0.41 0.06-2.48
  Secondaryschool I3 8 12.7 34 27 0.31 0.06-1.60
  Primaryschool 14 22.2 46 36.5 0.4 0.08-2.00
  Non scolarisées 34 54 29 23 1.56 0.31-7.54

Table 1: Risk factors of female patients who were victims of IPPH from May to August 2014 in the UTH/P according to sociodemographic characteristics.

Risk factors associated with gynecological and obstetrical history:

Table 2 explores the risk factors of female patients who were victims of IPPH from May to August 2014 in the UTH/P according to their gynecological and obstetrical history (Table 2). In our survey, induced abortions and IPPH history are risk factors for IPPH occurrence. Circumcised women were 8.9 times more at risk for an IPPH than those uncircumcised.

Obstetrical history Modalities Cases Controls OR 95% IC p
n %  n %
Number of delivery Paucigravidae 22 34.9 51 40.5 1   0.824
  Primigravida 22 34.9 36 28.6 1.41 0.68-2.9
Multigravida 10 15.9 20 15.9 1.15 0.46-2.8
Grand multigravida 9 14.3 19 15.1 1.09 0.43-2.78
Abortions No 49 77.8 81 64.3 1   0.049
Yes 14 22.2 45 35.7 0.5 0.25-1.00
Type ofabortions Spontaneous 8 12.7 41 32.5 1   0
  Induced 6 9.5 3 2.38 10.25 2.07-49.7
Spontaneous and induced 0 0 1 0.8 0 -
Circumcision No 46 73 121 96 1   0
Yes 17 27 5 4 8.9  3.11-25.5
IPPH No 55 87.3 122 96.8 1   0.001
Yes 8 12.7 4 3.17 4.44 1.28-15.37

Table 2: Risk factors of patients who were victims of IPPH from May to August 2014 in the UTH/P according to obstetrical history

Risk factors associated with current pregnancy characteristics:The risk factors of the female patients who were IPPH victims from May to August 2014 according to current pregnancy characteristics are described in Table 3. In our research work, the lack of antenatal care and anemia during the pregnancy were risk factors for IPPH occurrence.

Characteristics of current pregnancy Modalities Cases Controls OR 95% IC p
n % n %
Antenatal care Yes 53 84.1 123 97.6 1   0
No 10 15,.9 3 2.38 2.32 0.61-8.77  
Gestational age group 37-40 SA 02 Jrs 21 67.7 51 61.4 1   0.895
28-37 SA 8 25.8 21 30.1 0.9 0.34-2.35  
≥ 40 SA 03 Jrs 22 6.5 7 8.4 7.63 3.13-18.64  
Category of Fundal height (cm) Between 30 and 34 39 67.2 79 62.7 1   0.808
Lower than 30 9 15.5 24 19 0.75 0.31-0.86  
Higher than 34 10 17.2 23 18.3 0.88 0.38-2.02  
Anemia Non 53 84.1 120 95.2 1   0.01
Yes 10 15.9 6 4.8 3.7 1.28-10.70  

Table 3: Risk factors of patients who were victims of IPPH from May to August 2014 in the UTH/P according tocurrent pregnancy characteristics

Risk factors for IPPH occurrence during delivery labor

Risk factors associated with the delivery labor process: Table 4 explores the risk factors for female patients who were IPPH victims from May to August 2014 in the UTH/P according to the delivery labor process (Table 4). The risk factors for occurrence of IPPHs associated with labor process were childbirth at home or on the way to hospital, lack of labor monitoring with labor curve, length of labor less than 6 hours or higher than 12 hours, a delivery technique other than AMTSL, lack of monitoring of immediate postpartum, type of drugs used during labor (tobacco, hexabromobiphenyl (HBB) and magnesium sulphate).

Delivery labor process Modalities Cases Controls OR 95%IC P
n  % n  %
Place of delivery UTH/P 22 34.9 68 54 1   0
At home 11 17.5 0 0 - -
On the way 3 4.8 0 0 - -
CSP 10 15.9 20 15.9 0.15 0.06-0.36
CSPP 17 27 38 30.2 1.38 0.65-2.90
Monitoring by labor curve No 35 55.6 27 21.4 1   0
Yes 28 44.4 99 78.6 0.21 0.1-0.4
Duration of labor (hours) Between 6 and 12 12 19 80 63.5 1   0
Lower than 6 6 9.5 8 6.3 5 1.5-16.9
Higher than 12 18 28.6 9 7.1 13.3 4.89-36.15
Non precise 27 42.9 29 23 - -
Nature of delivery Natural 35 57.4 102 81 1   0
AMTSL 14 23 4 3.2 10.2 3.07-33.05
Artificial 7 11.5 17 13.5 1,2 0.45-3.13
Directed 4 6.6 1 0.8 11,6 1.26-106.8
DMI 1 1.6 2 1.6 1.45 0.13-16.4
Monitoring inimmediatepostpartum No 25 39.7 3 2.4 1   0
Yes 38 60.3 123 97.6 0.03 0.008-0.10  
Medicated therapy during labor
Oxytocin No 34 50.8 64 54 1   0.681
Yes 29 49 .2 62 46 0.88 0.48-1.46
Antispasmodic No 57 80.2 101 90.5 1   0.071
Yes 6 19.8 27 9.5 0.39 0.15-0.99
Analgesic
(Trabar, HBB)
No 56 97.6 123 88.9 1   0.032
Yes 7 2.4 3 11.1 5.12 1.28-20.35
Prostaglandins non 62 100 126 98.4 1   0.333
Oui 1 0 0 1,6 0 -

Table 4: Distribution of risk factors of female patients who were victims of IPPH from May to August 2014 in the UTH/P according to delivery labor process

Risk factors associated with the newborn characteristics: Table 5 describes the distribution of risk factors of female patients who were IPPH victims from May to August 2014 in the UTH/P according to newborn characteristics (Table 5). No characteristic of the newborn was found as risk factor for IPPH occurrence.

Newborn characteristics Modalities Cases Controls  OR 95% IC p
n % n %
Newborn Status At birth Alive 56 88.9 113 89.7 1   0.867
Stillbirth 7 11.1 13 10.3 1.08 0.4-2.85
Newbornweight (gr) [3000-3500] 21 34.4 43 34.1 1   0.661
<3000 g=1 33 54.1 69 54.8 0.98 0.53-1.90
[3500-4000] 6 9.8 14 11.1 0.88 0.64-1.21
≥4000 g 1 1.6 0 0 - -
Presentation of the foetus Cephalic 57 95 118 96.7 1   0.57
Breech 3 5 4 3.3 1.55 0.34-6.92

Table 5: Distribution of risk factors of female patients who were victims of IPPH from May to August 2014 in the UTH/P according to newborn characteristics

Discussion

IPPH incidence associated with deliveries

In our study, IPPH incidence is comparable to the results described by Stanford [7] in Tanzania in 2008 and Ngbale et al. [8] in Central Africa in 2012, who had noted respective frequencies estimated at 11.9% and 10.8%. The incidence of IPPHs (leading cause of maternal death) reflects the level of development of a country’s health system. In this regard, Magann et al. [9] and Woiski et al. [10] reported respectively a 5.15% incidence in Australia and 5% in the Netherlands. We also think that our rate may be associated with a surge in the number of private health facilities where child deliveries are sometimes performed by low-skilled personnel, but also with the stubbornness of some women to give birth at home.

Risk factors for IPPH occurrence associated with sociodemographic characteristics and history

In our study, one quarter of the female patients who were victims of IPPH were members of Fulani ethnic group. In the northern region, the Fulani live a precarious life and have an extremely low school enrollment rate. As a result, their development is hindered by a degree of exclusion [11]. Most Fulani women live in rural areas. They exert the following professions: sellers, peasants or housewives. They have a low socioeconomic status, they do not attend ANCs, they are often anemic and most of them give birth at home. So, they have several risk factors and are therefore more exposed to IPPH.

According to study setting, other authors established a relationship between ethnicity and IPPH occurrence. Olowokere et al. [12] had mentioned a 89.7% ratio of women from Yoruba ethnic group who were victims of IPPH. In Norway, Al-Zirqi et al. [13] also reported that ethnicity was a risk factor for IPPH.

More than one out of two women was literate. In this regard, As a result, we noted that illiteracy was a risk factor for IPPH occurrence. It is a category of women who do not understand the importance of ANCs, who are unaware of the severity of the different pathologies associated with pregnancy and child delivery. And hence, they under rate the need for them to give birth in the presence of skilled personnel. Moreover, they are often victims of early and forced marriage.

The ratio of circumcised women was statistically significant. In our series, circumcision was a risk factor for IPPH. Regard less of the type of circumcision, those acquired scars are an area of weakness and thus contribute, at the time of delivery, lacerations and even perineal tears which cause IPPH. In their study, McSwiney and Saunders [14] also found that circumcision was a risk factor for IPPH occurrence. Akan et al. [15] in turn, insisted on the fact that female genital mutilations have many consequences, including postpartum hemorrhage.

In our study, induced abortions are a risk factor for IPPH occurrence. Intrauterine maneuvers, particularly curettage history, may alter the endometrium and cause placental pathologies (placenta accreta, placenta previa); this is a source of hemorrhage. In our series, the women who have an IPPH history are 4 times more likely to have again an IPPH. Our remark had been confirmed by several studies: Olowokere et al. [12] in Nigeria, Driessen et al. [16] in France and Al- Kadri et al. [17] in Saudi Arabia.

Risk factors for occurrence of IPPHs associated with current pregnancy characteristics

Our results enabled us to conclude that the lack of antenatal care or poor quality care is a risk factor for IPPH. In Benin, Fourn et al. [18] stated that prenatal care appear as an effective action of protection against pregnancy and delivery complications. Hence the importance of antenatal care (ANC) for an early screening with possible correction of risk factors in IPPH prevention. According to Wandabwa et al. [19], the lack of antenatal care gets multiplied by five the risk for IPPH occurrence.

In our survey, one out of six female patients was anemic during pregnancy. The impact that a hemorrhage volume can have on the general health condition of a woman sometimes depends on previous hemoglobin level of the latter. Anemic women are most exposed (OR=3.7) to the risk of having an IPPH. In Nigeria, Olowokere et al. [12] also identified anemia in 12.5% of the cases as a risk factor for IPPH.

Risk factors for occurrence of IPPHs associated with delivery process and newborns

In our study, the lack of labor monitoring by partograph is a risk factor for IPPH occurrence. Partograph is the reference instrument in matters of delivery labor monitoring. It helps detect pathologies abnormalities in labor progression and take action on time. During our survey, we were given the opportunity to note that some private as well as public health centers do not use partograph. In their results, Yisma et al. [20] lamented that partograph was actually used in only 57.3% of the cases by obstetrical care providers in the public health institutions. Wandabwa et al. [19] had reported that about 9 female patients out of 10 IPPH victims had not benefitted from a monitoring during their delivery labor with partograph. As a result, the use of partograph in delivery labor monitoring plays an essential role in IPPH prevention.

In our study, we noted that the longer labor is, the higher IPPH risk is (OR=13.3). Actually, a long labor exhausts the endometrium; this will cause a uterine inertia which, in turn, will generate IPPH for two reasons. On the one hand, uterine atony itself causes hemorrhage, and on the other hand uterine atony may lead to a retained placenta which also causes hemorrhage. In addition, the time of delivery phase has a substantial impact on IPPH occurrence. Magann et al. [21] came to the conclusion that there is a correlation between maternal age above 35 years, duration of second stage of labor, extension of third stage of labor and IPPH occurrence.

The lack of immediate postpartum monitoring was a risk factor for IPPH in our study. Among our patients, 42.8% of the mothers who were victims of IPPH gave birth in (private or public) peripheral health centers. In those premises, thoroughness does not often apply as a compulsory rule for the personnel. Objectively, no monitoring sheetis drafted and immediate postpartum monitoring as well as gestures therein included are deficient. Thus, the lack of monitoring of immediate postpartum is a risk factor for IPPH. Winters et al. [22] identified variations in the monitoring and management of immediate postpartum in maternities of different countries in Europe. This leads us to say that there are still health institutions where postpartum monitoring is low with all its consequences.

We had not identified birth weight as a risk factor where as many authors found it: Sosa et al. [23] in Uruguay, Prata et al. [24] in Egypt. According to those researchers, macrosomia (>4000 g) is a major risk factor for the occurrence of IPPH. By contrast, a low birth weight under 2500 g would, conversely, be a protective factor.

Conclusion

The control of risk factors for occurrence of post partum hemorrhage is crucial in the development of prevention policies for of this pathology purveyor of morbidity and high mortality.

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