[Show abstract][Hide abstract] ABSTRACT: To identify factors contributing to the high incidence of facility-based obstetric hemorrhage in Thyolo District, Malawi, according to local health workers.
Three focus group discussions among 29 health workers, including nurse-midwives and non-physician clinicians ('medical assistants' and 'clinical officers').
Factors contributing to facility-based obstetric hemorrhage mentioned by participants were categorized into four major areas: (1) limited availability of basic supplies, (2) lack of human resources, (3) inadequate clinical skills of available health workers and (4) substandard referrals by traditional birth attendants and lack of timely self-referrals of patients.
Health workers in this district mentioned important community, system and provider related factors that need to be addressed in order to reduce the impact of obstetric hemorrhage.
[Show abstract][Hide abstract] ABSTRACT: To identify substandard care factors in the management of obstetric hemorrhage at district hospital level in rural Malawi.
Retrospective hospital-based cohort study.
Thyolo District Hospital.
Women who delivered at this facility in 2005.
All cases of obstetric hemorrhage were included according to the following criteria: any antepartum hemorrhage, postpartum hemorrhage with more than 500 ml of blood loss within 24 hours after delivery, uterine rupture, retained placenta and peripartum blood transfusion.
Incidence of antepartum and postpartum hemorrhage, related maternal and perinatal mortality and mode of delivery.
A total of 133 hemorrhage cases occurred among 3 085 hospital deliveries (43.1 per 1 000 deliveries), six of which resulted in maternal death (case fatality rate 4.5%). Twenty of 95 postpartum hemorrhage cases (21%) were peri-cesarean hemorrhages. Sixteen cesareans delivered lifeless fetuses, where a maternal indication for operative delivery was present in only four. Monitoring of pregnant women was regularly insufficient, including monitoring of women in waiting homes, and the use of uterotonics was often inconsistent.
Morbidity review revealed important substandard care factors, including unnecessary cesarean sections. These factors may be modified against affordable cost, which could make an important improvement in maternal outcome.