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Maternal death due to haemorrhage is common in developing countries. The clinical and physiological aspects of maternal bleeding are well researched and better known whereas the social, cultural and religious beliefs are not well understood. These cause delays that increase the risk of maternal death. This study sought to close that gap by using qualitative data from twelve (12) focus group discussions with women aged 19 to 49 years and six (6) key informant interviews with traditional and spiritual community birth attendants. These discussions were conducted in five (5) rural districts of Zimbabwe. A grounded-theory approach was used to analyze the data and verbatim quotes are presented with the results. The study found that, among women of child-bearing age, harmful maternal bleeding through the vagina and menstruation are regarded as synonymous. In some cases, harmful maternal bleeding is regarded as a normal and expected feminine experience, a shameful subject for discussion, the body's self-cleansing process or a necessary occurrence during maternity. In other cases, women fear to raise false alarms. These social constructions of maternal haemorrhage tend to prolong the time between the incidence of bleeding and the instance of receiving appropriate care or death. The researchers conclude that maternal death due to haemorrhage headlines a bigger story involving delays in recognizing danger and deciding to seek care. Interventions must involve women, partners and/or husbands, households and communities to address harmful social norms, beliefs and attitudes towards vaginal bleeding.
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2018; 6(6): 130-137
doi: 10.11648/j.ajhr.20180606.12
ISSN: 2330-8788 (Print); ISSN: 2330-8796 (Online)
Blood Drain: A Threat to Maternal Health in Zimbabwe
Dodzo Munyaradzi Kenneth
1, *
, Mhloyi Marvellous
, Dodzo Memory
Centre for Population Studies, University of Zimbabwe, Harare, Zimbabwe
Institute of Development Studies, National University of Science and Technology, Bulawayo, Zimbabwe
Email address:
Corresponding author
To cite this article:
Dodzo Munyaradzi Kenneth, Mhloyi Marvellous, Dodzo Memory. Blood Drain: A Threat to Maternal Health in Zimbabwe. American
Journal of Health Research. Vol. 6, No. 6, 2018, pp. 130-137. doi: 10.11648/j.ajhr.20180606.12
Received: November 10, 2018; Accepted: November 29, 2018; Published: December 21, 2018
Maternal death due to haemorrhage is common in developing countries. The clinical and physiological aspects of
maternal bleeding are well researched and better known whereas the social, cultural and religious beliefs are not well
understood. These cause delays that increase the risk of maternal death. This study sought to close that gap by using qualitative
data from twelve (12) focus group discussions with women aged 19 to 49 years and six (6) key informant interviews with
traditional and spiritual community birth attendants. These discussions were conducted in five (5) rural districts of Zimbabwe.
A grounded-theory approach was used to analyze the data and verbatim quotes are presented with the results. The study found
that, among women of child-bearing age, harmful maternal bleeding through the vagina and menstruation are regarded as
synonymous. In some cases, harmful maternal bleeding is regarded as a normal and expected feminine experience, a shameful
subject for discussion, the body’s self-cleansing process or a necessary occurrence during maternity. In other cases, women
fear to raise false alarms. These social constructions of maternal haemorrhage tend to prolong the time between the incidence
of bleeding and the instance of receiving appropriate care or death. The researchers conclude that maternal death due to
haemorrhage headlines a bigger story involving delays in recognizing danger and deciding to seek care. Interventions must
involve women, partners and/or husbands, households and communities to address harmful social norms, beliefs and attitudes
towards vaginal bleeding.
Zimbabwe, Socio-cultural, Religion, Attitudes, Beliefs, Haemorrhage, Maternal Risk
1. Introduction
Bleeding through the vaginal opening is a common
experience with most women. It occurs to different people in
different forms at various times, particularly during
pregnancy, child-birth and within forty-two days after
delivery or termination of pregnancy. Vaginal bleeding
during pregnancy and child-birth is known as obstetrical or
maternal hemorrhage [1, 2], but it can also occur inside the
abdominal cavity often with fatal consequences [2].
The physiological experience of maternal bleeding can
generate beliefs, attitudes and perceptions. The converse is
also possible, whereby beliefs, attitudes and perceptions
influence the biological process and its consequences. In
general, it has caused untold suffering, not only among
women, but also humanity at large. In this paper, the
researchers look at how attitudes, beliefs and perceptions of
vaginal bleeding shape the risk of maternal mortality in
Zimbabwe, whose maternal mortality ratio has risen to
unprecedented levels in over two decades to 650 per 100,000
live births in 2015 from 283 per 100,000 live births in the
1990s [3, 4].
Research has focused on post-partum haemorrhage (PPH),
whose definition is considered arbitrary and problematic,
although generally agreed to be blood loss of more than one
pint (500ml) after vaginal delivery or more than two pints
(1,000ml) after Caesarean delivery [1, 2, 5]. Early or
primary PPH occurs within 24 hours of delivery and
secondary PPH may occur after that [1, 2, 6]. Problems
have been noted around estimations of blood loss during
delivery [5, 7, 8]. Furthermore, the retrospective diagnosis
of blood loss is usually for research and not very useful for
preventive purposes [6]. WHO notes that severe bleeding
can cause maternal death within hours if not attended and
131 Dodzo Munyaradzi Kenneth et al.: Blood Drain: A Threat to Maternal Health in Zimbabwe
recommends timely management and treatment, including
the use of oxytocin after child-birth [9]. Unfortunately, this
approach is also reactive rather than proactive [6-8] and
excludes women, households and communities from being
part of the solution.
Clinical diagnostics for PPH includes women with
pregnancies ≥20 weeks and excludes those of lower
gestational age [1, 2, 5, 6]. Thus, bleeding earlier in the
pregnancy is less understood although it can also be fatal.
Besides, costs related to seeking medical care and duration of
hospital stay can have negative socio-economic effects [10].
Maternal haemorrhage is the single most significant cause of
maternal mortality worldwide, accounting for 25 to 30
percent of all maternal deaths [9, 11, 12]. Every day,
approximately 830 maternal deaths occur from preventable
causes, including maternal bleeding [9]. Globally, severe
haemorrhage is the most common direct cause of maternal
mortality with 8.7 million cases, 83,000 of them being
reported in 2015 [9, 13].
Although maternal haemorrhage is a global problem, there
are clear differences between developed and developing
nations. In the United States of America for example, PPH
accounts for over 11 percent of maternal deaths [10, 14]. This
is comparable to 13 percent in the United Kingdom [15]. In
Zimbabwe, the rates are slightly higher at around 17 percent
[16, 17], although accurate data are not always easy to come
by. The global maternal mortality rates have declined in the
past decade [9], but much more greatly in the developed than
developing world [9, 11, 12]. About 99 percent of all
maternal deaths due to severe bleeding are in low- and
middle-income countries, compared to only one percent in
industrialized nations [1, 9, 18]. A huge proportion of these
deaths are highly preventable through early identification of
risk factors, quick diagnosis, timely and active management
of the third stage of labour [9, 11, 12, 15, 20, 21].
The patterns of hemorrhagic maternal deaths point to
inefficient and ineffective responses in the developing world.
Higher case fatalities may also be due to fragile health
systems coupled with presence of comorbidities that reduce
women’s tolerance of blood loss [6]. The developed world
also struggles with severe PPH related to anaemia during
pregnancy [22-25], obesity [26] or use of medical drugs in
late pregnancy [27, 28]. Much more importantly, there is
limited understanding on the phenomenon of maternal
bleeding and the antecedent risk factors that lie outside of
clinical settings.
The major challenges with most studies on maternal
haemorrhage are several-fold. Firstly, they focus on PPH at
the expense of ante-partum and intra-partum haemorrhage.
Yet is known that heavy bleeding in the first trimester
heightens the risk of miscarriage and other obstetric
complications [29, 30]. Although spotting and light episodes
of bleeding are less likely to be fatal, especially if only
lasting one to two days [29-31], women are less likely to
understand these clinical delimitations. Secondly, current
research has obsessed with the biological issues without
exploring the underlying religious and cultural aspects.
Thirdly, most of the studies are fixated with bleeding after
vaginal and Caesarean deliveries [1, 2, 5-8], yet bleeding can
occur with other modes of delivery. Lastly, the studies have
been confined to health facilities and excluded women,
households and communities, where bleeding often starts.
This study examines maternal haemorrhage as a biomedical
phenomenon and as a religious and socio-cultural construct.
This study shows how attitudes, beliefs and practices around
vaginal bleeding increase maternal risk through delays in
recognizing danger and deciding to seek appropriate care
2. Methods
Qualitative data from twelve (12) focus group discussions
(FGDs) and six (6) key-informant interviews (KIIs) were
analysed. These data were collected from five (5) rural
districts of Zimbabwe, namely Makonde, Marondera, Mt.
Darwin, Nyanga and Insiza. Two FGDs were conducted in
each district except in Nyanga and Insiza, where three FGDs
were conducted. These districts were part of a broader study
on the patterns and determinants of maternal mortality in
Zimbabwe [17]. Data from these five districts were extracted
because they had most insights around maternal bleeding.
After 12 FGDs and six KIIs, the researchers reached a
saturation point, i.e. a stage where it was felt that recruiting
more participants would not add new dimensions and insights
on the subject.
2.1. Focus Group Discussions (FGDs)
The researchers conducted 12 FGDs with child-bearing
women aged 19 to 49 years. This approach was chosen for its
convenience. FGDs were facilitated by the researcher and
two research assistants using a semi-structured FGD guide.
FGDs had between eight (8) and twelve (12) participants and
were conducted at rural health centres with women seeking
either antenatal or postnatal care services. The participants
included pregnant women and those with children under two
years of age. Convenience sampling was used by making
prior arrangements with clinic staff. The researchers visited
clinics that had specific days scheduled for antenatal and
postnatal care.
Most rural clinics in Zimbabwe dedicate one day in the
week to maternal and new-born care services. These days are
generally referred to as baby-scale days (mazuva eskero
yevana) and are carefully selected to coincide with the
cultural weekly holiday (chisi) that is enforced by village
heads. On such days, women rest from their routine
agricultural activities, which affords them time to visit the
clinic. In collaboration with clinic staff, women who satisfied
the inclusion criteria were provided with information on the
study and requested to participate in a focus group
discussion, after providing verbal consent.
2.2. Key Informant Interviews (KIIs)
Six (6) KIIs were conducted with community birth
American Journal of Health Research 2018; 6(6): 130-137 132
attendants using a semi-structured KII guide, tailored along
the FGD guide. Three (3) of the key informants were
traditional birth attendants (TBAs) and three (3) were
spiritual birth attendants (SBAs). The aim for including KIIs
was not representativeness but to get perspectives associated
with maternal haemorrhage from non-clinical service providers.
Since community birth attendants (CBAs), both spiritual and
traditional, are outlawed in Zimbabwe, it was difficult to identify,
reach and interview them. Therefore, the referral technique was
used, whereby FGD participants directed the research team to
the CBAs.
2.3. Data Management and Analysis
Qualitative data from FGDs and KIIs were captured through
note-taking and audio-taping. The discussions/interviews were
conducted in Shona and Ndebele languages, depending on the
area, but were translated into English during transcription.
Emerging themes linked to vaginal bleeding or maternal
haemorrhage were identified and re-coded. The output displayed
results in the form of a stem-and-leaf diagram, where the stems
and leaves represented themes and supporting issues,
respectively. The analysis extracted ad verbatim, the most
cogent quotes made by focus group discussants that captured
more accurately the deeper and most representative sentiments
prevailing around the group. In most cases, these were captured
under the stem-category where broad themes were recorded and
subjected to further interrogation through probing. In the
narrative, the supporting facts are articulated using information
from the ‘leaf-categories’ of the qualitative analysis.
2.4. Ethical Issues
The study was approved by the Medical Research Council
of Zimbabwe (Ref: MRCZ/B/423). It respected freedom to
participate and adhered to research principles pertaining to
privacy and confidentiality. FGD and KII respondents
provided verbal consent to respond to be interviewed and
audio-taped. Verbal consent was selected, firstly because the
purpose of the study and expectations from the interviews
were also done verbally. Secondly, some respondents
requested that they did not want the interviews to appear
formal, as would happen if consent forms were written and
signed. Verbal consent was therefore audio-taped as provided
for and approved by the Medical Research Council of
Zimbabwe. It was also explained that participation was
voluntary and withdrawal could be done at any time with no
negative repercussions. Participants were also instructed not
to respond to questions that they were not comfortable with.
3. Results
The methodology resulted in an opportunistic sample that
had twelve focus group discussions (FGDs) with women of
child-bearing age and six key informant interviews (KIIs)
with female CBAs, all from the selected rural areas. The
educational levels of FGD participants ranged from primary
to secondary. The ages of the key informants ranged from 39
to 72 years, while FGD participants ranged from 19 to 49
years. Table 1 below summarizes the demographic
characteristics of the FGD participants and key informants.
Table 1. Socio-demographic Characteristics of Study Participants.
Characteristics Focus Group Discussions Key Informants
Number of Respondents 12 Groups (81 Participants) Six (3): Two (3) SBAs and Three (3) TBAs
Residence All Rural All Rural
Sex All Female All Female
Age Range: 19 – 49 years Range: 39 – 72 years
Level of Education
32 completed O-level
42 completed primary; no O-Level
7 did not complete primary
3 completed O-level
2 completed primary only
1 did not complete primary (eldest)
Marital Status
67 married/cohabiting
9 polygamous
5 not married.
1 widowed
3 married/co-habiting
2 not established but not living with husbands
The study findings are presented in the following thematic
sections where relevant citations from the raw data are
analysed for major thoughts and general sentiment. This
qualitative inquiry explored individual, household and
community perceptions and interpretation of maternal
haemorrhage. It also looked at how this increases maternal
risk through delays. The sub-topics are the researchers’
interpretation and re-presentation of dominant ideas
emerging from the results.
3.1. Women Bleed Through the Vagina by Nature, Any
Maternal haemorrhage can be associated and confused
with menstruation a natural and rhythmic occurrence.
Unexpected bleeding, which is not in sync with regular
menstrual patterns, is interpreted as irregular menses. A focus
group participant in Makonde summed up this perception in
the following remark:
‘I don’t see any reason to panic because blood is coming
out of the vagina. Any woman capable of giving birth must
have a vaginal blood flow every month’ (Focus Group
Discussion, Makonde)
The above sentiment shows that women are conditioned to
normalize vaginal blood flow. Apparently, this conditioning
is propagated by an ignorance of what is normal and
abnormal bleeding. It appears that women have an
expectation of rhythmic monthly blood flow during
menstruation. Irregular bleeding, spotting or staining can be
associated with menses rather than complications of
pregnancy. This tragedy of association leads to delays in
133 Dodzo Munyaradzi Kenneth et al.: Blood Drain: A Threat to Maternal Health in Zimbabwe
recognizing maternal danger.
3.2. It is Shameful to Discuss Genitalia
Another dimension to the problem of vaginal bleeding is
that it concerns the genitalia, which are a conservative area
for public discussion. In Shona culture, it is generally
considered shameful or improper to talk about private parts,
particularly the female genitalia or reproductive system. In
fact, there is no modest language for genitalia, apart from that
which is considered irreverent, immoral and vulgar. In some
instances, it is regarded as talking about sex in public. A
focus group discussant in Marondera succinctly expressed
this predicament when she remarked:
‘Even if you are worried about the bleeding down there
(from the vagina), who do you talk to? It’s a private matter of
the private parts’. (Focus Group Discussion, Marondera).
Apart from invoking feelings of shame among some
women, female genitalia are also revered as sacred and
hallowed. They are subliminally conceived as the source of
generations and, to avoid vulgarity and sexual explicitness,
are referred to as sikarudzi’ the procreator. The
hallowedness of female genitalia is acknowledged even
among men, amongst whom the worst form of unbearable
insult is when a mother’s genitalia is mocked subtly or
explicitly. The secrecy associated with genitalia extends to
sexually transmitted diseases, infections and other
complications. Nonetheless, in the unlikely event that genital
problems must be discussed, the audience is carefully
selected. By the time such a decision is made, serious delays
would have already set in.
3.3. A Woman’s Body Self-cleanses Through Bleeding
Vaginal bleeding is also interpreted as the process by
which the woman’s body cleanses itself, particularly during
pregnancy or soon after child-birth. It is believed that a
vaginal blood flow is a way of expelling ‘bad blood’. Bad
blood (ropa rakaipa) and misfortune (munyama) are said to
be related. It is also believed that the power of curses,
hereditary diseases and inherited disabilities is activated in
bad blood.
As such, vaginal bleeding is perceived as a means of
expelling material from spontaneous abortions, ectopic
pregnancies (that develop outside the fallopian tubes) and
molar pregnancies, whereby abnormal tissue grows inside the
uterus (chimimbamutekwe). A spiritual birth attendant in
Insiza remarked:
‘When a woman delivers a dead baby, it is an answer to
prayer because she has expelled death, which was lingering
in her body. Spontaneous abortion (kusveedza) is an
expulsion of curses and demons from the body. If not
expelled, they may claim the woman’s life’. (Personal
Interview, Insiza)
Abortion complications can directly cause maternal death
but when they are spiritualized the risk increases several-
fold. The sentiment above shows that maternal bleeding is
anticipated, indeed celebrated, even among community birth
attendants. The irony is that a danger sign is inversely
perceived as a sign of health and well-being.
In other instances, bleeding is expected among women
who experience painful menstruation (jeko) as this is also
believed to be an outlet for polluted blood. The thought of
releasing contaminated blood extends to nasal bleeds
(mututu) and other injuries where they are regarded as a
divine way of protecting a person from future misfortune or
illness. Such bleeding is expected to subside naturally, upon
which it is believed that all the bad blood has streamed out.
This is a paradox, where bleeding is construed as necessary
for health and life, whereas in most instances it signifies
physical injury and threat to life.
3.4. The Foetus Self-cleanses and Baths
Maternal bleeding can be associated with foetal
development processes. Irregularities noted with vaginal
blood flows are sometimes attributed to the interference of
the pregnancy itself. A traditional birth attendant in Mt.
Darwin remarked:
‘If you are pregnant, you should understand that some
discharges come from the baby as it relieves or baths itself
(kugeza). What must be worrying is seeing no discharge or
blood flow. Of course, it should be different from menstrual
blood’. (Personal Interview, Mt. Darwin)
It is evident from the quotation above that abnormal
vaginal blood flows or discharges are assumed to be foetal
interference or accepted as a sign of foetal growth and
development. Whereas this would normally be a danger sign
outside pregnancy, the pregnancy is assumed to have
mediatory effects on the frequency, timing, amount and
duration of bleeding.
3.5. Bleeding Is a Necessary and Inevitable Life-giving
In some contexts, maternal haemorrhage can assume
religious dimensions. Just like with culture, some religious
beliefs tend to underplay the dangers of vaginal bleeding.
Quoting scriptures, a spiritual birth attendant in Nyanga
explained that:
‘Blood is life. GOD makes it clear that the life of all living
animals, including people, is in the blood (Leviticus 17:11,
14). Again, Jesus Christ had to shed His blood to give us life
(John 10:10). Giving birth is a bloody affair, for without
blood there cannot be life’. (Personal Interview, Nyanga)
The above sentiment shows that bleeding is not only
expected during pregnancy, delivery and after child-birth but
also desired. While the spiritualization of maternal bleeding
does not trivialize associated danger, it appears to demand
martyrdom from women, who should be like Jesus Christ
who “had to shed his blood to give… life”. It also refutes
implied notions of bloodless child-birth, but calls on a
woman to bravely bear any associated pain.
3.6. Bleeding is Preparation or Healing of the Birth Canal
It is also believed that prolonged blood flow is not a
American Journal of Health Research 2018; 6(6): 130-137 134
problem. Coupled with lack of knowledge about how much
blood and for how long the bleeding should take place, post-
delivery bleeding is often ignored and sometimes trivialised.
A traditional birth attendant in Makonde remarked:
‘Delivery is tough work. When the baby comes out from
the other world, it travels a difficult road with the assistance
of ancestors. This road suffers damage and obviously takes
time to heal. So, the woman should rub herbs into her vagina
to quicken the healing process. As expected, some water,
fluids and blood will come out but the wells (matsime) soon
dry up. What nature injures, it heals!’ (Personal Interview,
It can be noted from the quote above that the key issues
include incorrect interpretation of post-partum haemorrhage.
While acknowledging that bleeding indicates physical injury,
the severity is underplayed and the injury treated as normal.
Secondly, maternal haemorrhage is expected to naturally
subside since it was caused by a natural process. Thirdly,
there is a vicious cycle of harmful responses initiated by
wrong diagnosis. These include insertion of herbs in the
vaginal opening, which can subsequently cause reproductive
tract infections and lead to serious delays in seeking
appropriate care.
4. Discussion
This paper set out to explore major attitudes, beliefs and
practices around maternal haemorrhage and how subsequent
delays contribute to maternal mortality in Zimbabwe. It is
instructive to note that haemorrhage is a major cause of
maternal death in the developing world than in developed
states [9, 11, 12, 15, 16, 18] yet research on religious and
socio-cultural factors is minimal. The different fatality rates
seem to mirror contextual perceptions, interpretations and
responses given to haemorrhagic complications, rather than
Maternal haemorrhage can occur at any point in the
pregnancy continuum, from pregnancy itself, through labour
and delivery to the puerperium. Despite extensive research
around PPH [1, 2, 5-7, 20] to date, whether patterns of
haemorrhage in early pregnancy are related to haemorrhage
in subsequent stages is not clear. Furthermore, the
relationship between incidence of haemorrhage in one
pregnancy and the next is not clear. In addition, most
research on haemorrhage has been biomedical [1, 5-7, 20]
and focused on clinical events, and less on the underlying
social, cultural and religious factors. This qualitative enquiry
shows that although maternal haemorrhage is a natural
phenomenon caused by the breaking of tissue during child-
birth, it can be interpreted differently through social and
religious lenses. Although, almost all women bleed during
maternity, the risk to maternal health hinges on how much
bleeding occurs and for how long.
Apparently, bleeding is generally associated with physical
injury, for which the remedy, as is normally believed, lies
within clinical settings. The paradox is that fatal maternal
haemorrhage does not manifest with observable physical
injury. This paper partially corrects that misconception and
invites biomedicine and social science to collaborate on
maternal haemorrhage and relevant interventions.
The study also shows that vaginal bleeding and femininity
are almost synonymous. There appears to be a subtle but
harmful belief that women normally bleed through the
vaginal opening and therefore must bleed during pregnancy.
Unfortunately, such a belief is held and propagated by
women themselves who, from sexual debut or menarche to
menopause, are so accustomed to vaginal bleeding that they
cannot easily differentiate between the normal and the
harmful. Consequently, women are likely to perceive vaginal
bleeding as a rhythmic monthly occurrence and a symbol of
their femininity. This bio-socialization tends to subdue
women’s emergency reflexes with respect to vaginal blood
Indeed, while an irregular amount, frequency, texture,
colour or duration of vaginal blood flow would be a good
indicator of danger, there is no standard difference between
what is usual and what is not and this has been an area of
conflict, controversy and confusion even in clinical
experimental settings [2, 5]. As a result, subjective
interpretations lead to delays in recognizing danger and
deciding to seek institutional health care. What is not easy to
establish now are the cognitive motions through which
individual women go at the sight of vaginal blood flow.
Further research must appeal to behaviour models to
understand how individual knowledge, attitudes, beliefs and
intentions affect perceived/actual control on subsequent
maternal behaviours.
Owing to the perceptual proximity between maternal
haemorrhage and menstruation, when either occurs without
pain, women tend to normalize and ignore it. The results
indicated that only painful menstruation (jeko) causes women
to seek urgent attention. Painless bleeding is not treated as a
sign of maternal danger, yet clinical research shows that
heavy bleeding in the first trimester is strongly associated
with miscarriage or other complications [29-31]. In contexts
where fertility is prized, it is possible that women take
prompt action for painless bleeding because they fear losing
the pregnancy more than the need to manage the bleeding
itself. The tragic reality, however, is that pain rather than
blood flow is the sign of danger.
Results show that maternal bleeding is sometimes regarded
as a cleansing process by the woman’s body or the foetus.
The challenge is that abnormal haemorrhagic manifestations,
that are plainly different from menstrual bleeding, are treated
as normal. Just as there are disagreements around definitions
and manifestations of blood loss in clinical experiments [5],
women also find it difficult to differentiate between
menstrual and pregnancy-induced bleeding, thereby
distorting threat and severity [17]. Since vaginal bleeding is
not triggered by visible physical injury or tearing of tissue, it
is not easily associated with harm. Vernacular reference to
menstruation as ‘bathing’ (kugeza) is a misleading linguistic
notation for this social construct. However, it appears that the
concept of bathing is related to self-cleansing by either the
135 Dodzo Munyaradzi Kenneth et al.: Blood Drain: A Threat to Maternal Health in Zimbabwe
foetus or the woman’s body.
The study also shows that maternal bleeding goes beyond
haematology (the branch of medicine focusing on the study
of blood). It is also a social phenomenon and a spiritual
symbolism for life. This is possibly because it is juxtaposed
with other feminine life events such as conception,
pregnancy, labour and the post-delivery period.
Inadvertently, the socio-cultural and religious conjectures
suggest that pregnancy and child-birth must be literally
bloody. Granted that most women in Zimbabwe are spiritual
or superstitious, the symbolism of blood and life, together
with its counter-symbolism to death, cannot be
overemphasized. However, the antithesis is that maternal
bleeding is the only instance where bleeding is associated
with life and vitality, when everywhere else it symbolises
danger and death.
Another notable phenomenon revealed in this study is
social expectancy, whereby women look forward to bleeding.
This anticipation is reinforced through religious beliefs,
which take bleeding as an inevitable part of the pregnancy
and delivery process. Such beliefs can underplay the impact
of bleeding and lead to delays in recognizing danger.
Nonetheless, there seems to be a latent acknowledgement of
the hazards associated with maternal bleeding, but it is
outweighed by an emphasis of the necessity of endurance or,
if need be, martyrdom.
It can be argued that maternal bleeding does not directly
kill women as implied in most biomedical investigations [1,
2, 5-8, 21]. Such deaths can be avoided using known, tested
and low-cost methods [9, 11, 12, 15, 20, 21]. On the contrary,
delays in accessing effective and adequate responses to
maternal haemorrhage are the real problem in developing
countries, which explains huge differences in case fatalities
[1, 18-20]. Yet, the major problem lies in a limited
understanding of the problem of maternal bleeding. This
failure to define the problem clearly is a major barrier to
proper responses. For too long, maternal haemorrhage has
not been linked to its socio-cultural and religious foundations
that cause delays. Subsequently, interventions have been
fixated with what clinicians can do to treat [7, 8], not what
individuals, households and communities can do to prevent
The authors acknowledge a few weaknesses intrinsic to
this study. Firstly, the convenient approach that was used to
select FGD participants from women seeking health care at
clinics might have introduced bias. It is likely that the
resulting opportunistic sample excluded participants with
unique socio-cultural and religious characteristics, who could
not seek health care from clinics. As such, the researchers are
left wondering whether the results would have been similar
had they randomly selected participants from the community.
Secondly, and most importantly, this paper leaves a huge gap
in understanding the supply side issues of blood and related
services. However, this provides an opportunity for further
inquiry into how blood products and blood transfusion
services affect maternal risk in Zimbabwe. The researchers
think that a focused study on processes, procedures and
protocols, covering procurement, processing and provision of
blood services could reveal supply-side dynamics, otherwise
not accessible through demand-oriented study like this one.
Thirdly and lastly, this study is mainly explorative and does
not link knowledge, attitudes, beliefs and practices around
maternal bleeding to the actual event of maternal death.
Perhaps more rigorous studies, with better data, can estimate
the odds of death among rural women in Zimbabwe who
bleed in the community.
5. Conclusions
This paper has revealed that maternal haemorrhage can be
a major, but highly avoidable, maternal risk in Zimbabwe as
in the rest of the developing world. Maternal bleeding
threatens the entire child-bearing continuum from the
antenatal period, through labour and delivery, to the post-
partum period, although current clinical research has focused
on the latter. A new dimension revealed is that, while
maternal bleeding is a natural biological experience, socio-
economic, cultural and religious beliefs, attitudes,
perceptions and interpretations can lead to delays, which are
sometimes fatal. It can therefore be argued that maternal
haemorrhage would not kill women just by itself, were it not
for the aggravating effects of delays caused by religious and
socio-cultural factors. Maternal survival chances in
Zimbabwe can be improved with appropriate interventions
and timely responses as in the developed countries. Fatalities
from maternal haemorrhage can be stemmed by addressing
social norms that ignore, trivialize or expect vaginal
bleeding, while simultaneously strengthening blood services.
A methodological insight ensuing from this study is that
asking the right questions greatly helps in getting proper
answers to address the highly preventable problem of
hemorrhagic maternal deaths. This may prove to be a lot
more difficult than anticipated, as it involves a socio-cultural
and religious evolution of society. Maternal health care
interventions must involve not only women, but also their
partners, husbands, households and communities. In all these
efforts, sustainable results can only be guaranteed when
coupled with strong health systems. Finally, a complete
understanding of the effects of blood and bleeding on
maternal outcomes can only be achieved with a more
rigorous analysis of reliable data that also covers the supply
and service provision aspects.
Competing Interests
The authors declare that they have no competing interests.
Authors' Contributions
Munyaradzi conceived the study, collected the data,
analysed them and wrote the manuscript. Marvellous
contributed to the conception of the study and participated in
its design and coordination and was the chief reviewer of the
manuscript. Memory participated in the data collection,
American Journal of Health Research 2018; 6(6): 130-137 136
critical review of the manuscript for coherence and assisted
with the analysis of qualitative data. All authors read and
approved the final manuscript.
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ResearchGate has not been able to resolve any citations for this publication.
Objective: To examine whether using selective serotonin reuptake inhibitors and selective serotonin-norepinephrine reuptake inhibitors in pregnancy is associated with an increased risk of postpartum hemorrhage. Methods: We conducted a population-based cohort study including 225,973 women with 322,224 pregnancies in British Columbia, Canada, between 2002 and 2011. Women were categorized according to whether they had late-pregnancy exposure (at least 15 of the last 30 days of pregnancy), midpregnancy exposure (in the last 5 months of pregnancy but not the final 30 days), or no exposure. Postpartum hemorrhage was identified using International Classification of Diseases (9th and 10th Revisions) codes in data on all hospitalizations. Results: We found an increased risk of postpartum hemorrhage associated with exposure to an serotonin-norepinephrine reuptake inhibitor in the final month of pregnancy after adjustment for potential confounders (n=1,390; adjusted odds ratio [OR] 1.76, 95% confidence interval [CI] 1.47-2.11, respectively) corresponding to 4.1 (95% CI 2.4-5.7) additional cases of postpartum hemorrhage per 100 people treated. There was no significant relationship between selective serotonin reuptake inhibitor use in the final month of pregnancy and postpartum hemorrhage (n=6,637; adjusted OR 1.09, 95% CI 0.98-1.21), except when confining the cohort to women with complete body mass index (BMI) information (n=235,031 [73%]) and controlling for BMI (adjusted OR 1.14, 95% CI 1.01-1.28) or when controlling for variables that are possibly on the causal pathway (adjusted OR 1.13, 95% CI 1.02-1.26). Midpregnancy exposure to a serotonin-norepinephrine reuptake inhibitor (n=242) or a selective serotonin reuptake inhibitor (n=1,507) was not associated with an increased postpartum hemorrhage risk. Conclusion: Serotonin-norepinephrine reuptake inhibitor exposure in late pregnancy was associated with a 1.6- to 1.9-fold increased risk of postpartum hemorrhage.
Obstetric hemorrhage remains the leading cause of maternal death in the United States, and 54% to 93% of these deaths may have been preventable. Leaders must honor the lives of women who die from obstetric hemorrhage by reviewing their deaths and sharing lessons learned. Shortening the current 3 to 7 year data gap will allow for timely initiation of quality improvement efforts. Designated leaders and researchers from the Association of Women's Health, Obstetric, and Neonatal Nurses are ideally positioned to lead these quality initiatives.
Hemorrhage remains as one of the top 3 obstetrics related causes of maternal mortality, with most deaths occurring within 24-48 hours of delivery. Although hemorrhage related maternal mortality has declined globally, it continues to be a vexing problem. More specifically, the developing world continue to shoulder a disproportionate share of hemorrhage related deaths (99%) compared with industrialized nations (1%). Given the often preventable nature of death from hemorrhage, the cornerstone of effective mortality reduction involves risk factor identification, quick diagnosis, and timely management. In this monograph we will review the epidemiology, etiology, and preventative measures related to maternal mortality from hemorrhage.
To derive nationally representative incidence rates of postpartum haemorrhage (PPH), and to investigate trends associated with method of delivery, blood transfusion and morbidly adherent placenta (accreta, percreta and increta). Population-based retrospective cohort study. Republic of Ireland. Childbirth hospitalisations during the period 1999-2009. International Classification of Diseases (ICD)-9-CM and ICD-10-AM diagnostic codes from hospital discharge records were used to identify cases of PPH. Significant temporal trends in PPH incidence were determined using Cochrane-Armitage tests for trend. Log-binomial regression was conducted to assess annual changes in the risk of PPH diagnosis, with adjustment for potential confounding factors. PPH, uterine atony, blood transfusion and morbidly adherent placenta. A total of 649,019 childbirth hospitalisations were recorded; 2.6% (n = 16,909) included a diagnosis of PPH. The overall PPH rate increased from 1.5% in 1999 to 4.1% in 2009; atonic PPH rose from 1.0% in 1999 to 3.4% in 2009. Significant increasing trends in atonic PPH rates were observed across vaginal, instrumental, and emergency and elective caesarean deliveries (P < 0.001). The rate of atonic PPH co-diagnosed with blood transfusion also significantly increased (P < 0.001). Relative to 1999, the risk of atonic PPH in 2009 was three-fold increased (adjusted RR 3.03; 95% CI 2.76-3.34). Women diagnosed with a morbidly adherent placenta had a markedly higher risk of total PPH (unadjusted RR 13.14; 95% CI 11.43-15.11). Increasing rates of atonic PPH highlight the pressing need for research and for clinical audit focusing on aetiological factors, preventative measures and quality of care, to guide current clinical practice.