Why African women die more from birth-related bleeding

 

By: Dr. Azuka Ezeike, MBBS, FWACS (Obstetrics and Gynaecology), MSc (Public Health), Freelance Medical Writer. Editorial and Medical review by the DLHA Team.

Eleven women sitting on the floor with smiles on their faces There is a girl beside the mother and a boy standing behind them, Click on image to enlarge. Credit.

 

Highlights

• Annually, about 14 million women experience postpartum haemorrhage, with low and middle-income countries contributing to 80% of PPH-related deaths.

• Uterine atony (failure of the womb to contract after birth) is the main cause of PPH, often made worse by multiple births, prolonged labour, and poor third-stage labour management.

• Cultural misconceptions, food taboos, early marriage, and traditional birth practices contribute to delays in seeking and receiving healthcare.

• Poverty, inadequate health insurance, and high medical costs delay access to and receipt of proper maternal care.

• Weak health infrastructure, blood shortages, lack of necessary medications, and a shortage of trained health personnel hinder effective PPH management.

• Coordinated efforts by the key stakeholders are needed to create an enabling environment for optimal maternal care in Africa.

 

Introduction

 

Globally, about 14 million women experience birth-related bleeding (postpartum haemorrhage) (PPH) every year and low and middle-income (LMIC) countries contribute to approximately 80% of PPH deaths. [1, 2]  

 

Postpartum haemorrhage is excessive bleeding after delivery.  The most practical definition of postpartum haemorrhage is blood loss of more than 500 ml following vaginal delivery or more than 1000 ml following caesarean delivery. It usually occurs within 24 hours of delivery (primary postpartum haemorrhage) although on occasions beyond that and up to six weeks (secondary postpartum haemorrhage) Other authorities extend the duration of secondary postpartum haemorrhage to 12 weeks after birth.  It is an emergency that can have catastrophic outcomes.

 

Uterine atony, or the absence of uterine contraction following delivery, is typically the primary cause of PPH. In addition, blood clotting issues, delivery tract tears, and retained placenta can all cause it. African women are prone to having uterine atony due to too many births as a result of low contraception use, higher rate of multiple births, prolonged labour, home births and poor management of the third stage of labour.

 

The disproportionate rate of maternal deaths from PPH in developing countries is due to factors that cause delays in seeking and receiving care. These result from problems at the level of the individual, community, the social environment, the health system and the government.

  

Factors Enabling  Birth-Related Bleeding in Africa

 

The high rate of PPH in Africa has been enabled by so many factors. These factors are broadly classified into;

• Social and cultural 
• Economic 
• Healthcare infrastructure challenges

 

The political and legal climate in the continent directly or indirectly influences these factors.

 

Cultural and Social Barriers

 

The African continent is deeply entrenched in culture. The cultural and social interaction have been instrumental in improving the lives of the natives in many ways. However, several cultural and social barriers enhance Type 1 (delay in deciding to seek healthcare) and Type 2 (delay in reaching the place of care) delays.

 

Some of these factors are:

• The cultural misconception which regards bleeding after delivery as a ‘healthy clean out of the women’. This negative mindset leads to delays in presentation at the health facility.  [3] In some of the localities, women are given some concoction or even alcohol to encourage ‘womb wash out’.  The use of alcohol could also trigger bleeding because it causes the relaxation of the muscles of the womb. 

• Some cultures encourage food taboos in pregnancy. This could result in anaemia (low blood percentage) and the presence of anaemia increases the risk of bleeding after birth. Bleeding in the presence of anaemia also increases the risk of maternal death. [4, 5] 

• A woman with repeated pregnancy problems could be labelled as being under a curse and may even be branded a ‘witch’. The fear of being  stigmatised could lead to the concealment of  pregnancy complications and delay in presentation at the hospital
• African society is patriarchal and this inhibits women from making their own decisions without their husband's or other family members' consent. Some cultures also justify wife-beating.  These factors place the woman in a disadvantaged position that may preclude proper care during pregnancy. 

• The cultural preference for traditional birth practices instead of orthodox care also increases the risk of bleeding after birth. This is because traditional birth attendants do not have the required skills to prevent and manage complications.

• There is a cultural preference for home birth in some localities. This is because some women believe it gives them more privacy and allows them to take a birthing position of their choice.[6] Home births in the African region are usually by relatives who are unskilled in the act of delivery. The societal aversion to delivery by caesarean section is also one of the enabling factors for home births.

• Cultural, social and religious norms influence health-seeking behaviour. It is common in Africa to believe that sicknesses are of spiritual origin. This leads to delays in presentation at the hospital.

• Harmful cultural practices like Female Genital Mutilation cause the scarring of the birth canal. This increases the risk of developing lacerations (tears) during delivery.
• Early marriage and childbearing increase the risk of birth complications. It also exposes women to long periods of reproductive activity. This leads to too many births and this is a risk factor for bleeding after birth.

• Most women in Africa are not as educated as their male counterparts. This remarkably affects their decision-making power and financial capacity, thus limiting access to quality health care. [7]

• The cultural and sometimes religious aversion to birth control methods leads to too frequent and too many births. This is a risk factor for excessive bleeding after birth.

• The social problem of poor road networks and lack of an efficient transport system results in delays in transferring patients from the home to the health facilities. As a result, some of these mothers never make it to the hospital alive. 

 

Economic Factors

 

Economic factors can lead to the three types of delays (Type 1, Type 2 and Type 3). Some of the economic factors that influence the outcome of PPH in Africa include;

• African women face significant levels of poverty due to a lack of education and stable jobs. Most women's poor financial situation affects their choices and access to reproductive health services. [7]

• Health insurance coverage in Africa is inadequate, resulting in increasing out-of-pocket healthcare costs.  The inability to raise sufficient funds to get care may cause a delay in the choice to seek care (Type 1 delay). It can cause transportation delays to health care services (Type 2 delay). Furthermore, it causes delays in receiving care at a health facility due to the inability to pay for services.

• Most African countries have insufficient budgetary allocations for health, which raises the cost of services at healthcare institutions. As a result, women and their families experience delays in receiving care.

• The high cost of drugs and various medical consumables makes it difficult to access and receive care in the majority of rural African healthcare institutions.

 

Healthcare Infrastructure Challenges

 

The health system in Africa is weak and fraught with many challenges. This provides the enabling ground for Type 3 delay (delay in receiving treatment at the health facility) and contributes to the burden of PPH. [8]

These challenges include; 

• The rural areas of Africa have significant health infrastructure issues. It is either the absence of health facilities or the poor functioning of those that do exist. This inhibits pregnant women's access to healthcare. As a result, most rural women do not receive any sort of antenatal care, increasing their risk of death due to postnatal bleeding. [7]

• Most African countries are experiencing severe blood shortages for transfusions. This is due to an insufficient number of voluntary blood donors and unreliable blood transfusion services.  The inability to source blood for a bleeding patient may result in death. [9]

• Proper management of postpartum haemorrhage requires the use of some medication (oxytotic drugs) that makes the womb contract. Some of these drugs need to be stored in the refrigerator to maintain their potency. The poor storage infrastructure, poor funding and a lack of electricity lead to an inconsistent supply of these medications. [10]

• There is a gross health manpower shortage in most regions of Africa as Africa has the lowest health worker-to-population ratio. [11] This has been made worse by the migration of health workers to other climes. Within countries, there is often an unequal distribution of health personnel between urban and rural areas.

• Late detection of PPH happens even within hospitals and causes delays in the initiation of treatment. This is due to a lack of equipment to objectively measure blood loss.
• There is poor management of PPH due to a paucity of well-trained health workers, especially in rural communities in Africa.

• Poor documentation of processes and incomplete health records is a common occurrence in most health facilities in Africa. This is due to a lack of robust health information management systems like the Electronic Medical Records System. This results in delays in commencing treatment in health facilities.

• There is non-adherence to evidence-based guidelines in many facilities. This arises from the problem of poor dissemination of these guidelines to the grassroots. Some of the facilities also lack the capacity to implement the guidelines.

 

Conclusion

 

Maternal deaths caused by birth-related bleeding are largely preventable, yet they remain a significant issue in Africa. Sociocultural and economic factors impose substantial constraints on African women, and the weak health system exacerbates the problem. Key stakeholders, including community leaders, healthcare sector players, and the government, must create an environment that supports optimal maternal care in the African region.

 

References

1. World Health Organization. (WHO). WHO recommendations on the assessment of postpartum blood loss and use of a treatment bundle for postpartum haemorrhage [Internet. 2023 Dec 21]. [Cited 2024 Jun 21]. Available from here.

2. World Health Organization (WHO). A roadmap to combat postpartum haemorrhage between 2023 and 2030 [Internet. 2023 Oct. 11]. [Cited 2024 Jun 21]. Available from here.  

3. Marabele PM, Maputle MS, Ramathuba DU, Netshikweta L. Cultural factors contributing to maternal mortality rate in rural villages of Limpopo province, South Africa. Int J Womens Health [Internet]. 2020 Aug 27; 12:691–9. [Cited 2024 Jun 22]. doi: 10.2147/IJWH.S231514. Available from here.

 4. Negesa BB, Jara BD, Gelchu AS, Abebe SS, Dinku JH, Sirage N, et al. Factors associated with postpartum hemorrhage in selected Southern Oromia hospitals, Ethiopia, 2021: an unmatched case-control study. Front Glob Womens Health [Internet]. 2024; 5:1332719. [Cited 2024 Jun 28]. doi: 10.3389/fgwh.2024.1332719. Available from here.

5. Muoghalu CO. Socio-economic and cultural factors in maternal mortality in Nigeria. Gender and Behaviour [Internet]. 2010; 8(2):3226–39. [Cited 2024 Jun 28]. doi: 10.4314/gab.v8i2.69728. Available from here.

6. Adatara P, Strumpher J, Ricks E, Mwini-Nyaledzigbor PP. Cultural beliefs and practices of women influencing home births in rural Northern Ghana. Int J Womens Health [Internet]. 2019 Jun 4; 11:353–61. [Cited 2024 Jun 28]. doi: 10.2147/IJWH.S190402. Available from here.

 7. Ariyo O, Ozodiegwu ID, Doctor HV. The influence of the social and cultural environment on maternal mortality in Nigeria: Evidence from the 2013 demographic and health survey. PLoS One [Internet]. 2017 Dec 29; 12(12):e0190285. [Cited 2024 Jun 28]. doi: 10.1371/journal.pone.0190285. Available from here.

8. Lancaster L, Barnes RFW, Correia M, Luis E, Boaventura I, Silva P, et al. Maternal death and postpartum hemorrhage in sub?Saharan Africa – A pilot study in metropolitan Mozambique. Res Pract Thromb Haemost [Internet]. 2020 Mar 9 ;4(3):402–12. [Cited 2024 Jun 21]. doi: 10.1002/rth2.12311. Available from here.

9. Aneke JC, Okocha CE. Blood transfusion safety; current status and challenges in Nigeria. Asian J Transfus Sci. 2017; 11(1):1–5. [Cited 2024 Jun 28]. doi: 10.4103/0973-6247.200781. Available from here.

10. Yenet A, Nibret G, Tegegne BA. Challenges to the Availability and Affordability of Essential Medicines in African Countries: A Scoping Review. Clinicoecon Outcomes Res. 2023; 15:443-458. [Cited 2024 Jun 28[. doi: 10.2147/CEOR.S413546.  Available from here. 

11. Mbadiwe EO, Abdulkarim M, Dounebaine B, Ngange NM, Egwu KC. Addressing the health workforce gap to achieve the Universal Health Coverage and “The Africa we want”. PAMJ - One Health [Internet]. 2024; 13:9. [Cited 2024 Jun 28]. doi: 10.11604/pamj-oh.2024.13.8.43024. Available from here.

 

 

Related:

CARBETOCIN: An Essential Drug for Preventing Postpartum Haemorrhage

Social Factors Shaping African Women’s Health

6 Conditions that Put Pregnant African Women at Risk of Death

12 Top African Women's Health Issues and How to Take Action

 

 

Published: June 29, 2024

Updated: July 7, 2024

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