Risk factors for severe PPH among women delivering at Kawempe National Referral Hospital, A case control study

Abstract

Background: Severe postpartum haemorrhage is the leading cause of severe maternal morbidities and maternal deaths; accounting for 27.1% of maternal deaths worldwide, ranging from 8% in developed countries to 32% in Northern Africa. In Uganda, postpartum haemorrhage accounts for 34% of the maternal deaths. Despite being a treatable condition, the high number of maternal deaths resulting from postpartum haemorrhage has remained outstanding for the last 25 years. Risk factors like history of post partum haemorrhage (PPH), multi-parity, macrosomia, previous caesarean scar have been identified as risk factors for severe PPH. This study aimed to identify the risk factors for severe postpartum haemorrhage at Kawempe National Referral hospital.

Methods: This was an unmatched case-control study conducted at Kawempe National Referral hospital. We recruited 138 postnatal women between 4th January 2023 to 19th February 2023 who had delivered at or referred to Kawempe National referral hospital after obtaining written informed consent. A ratio of 1 case to 2 controls was used, which gave us 46 cases and 92 controls. Cases were women with severe postpartum haemorrhage within 24hrs after delivery consecutively sampled while controls were every 2 mothers delivered within 6 hours after a case who didn’t develop PPH by 24 hours. Data was collected using pretested interviewer-administered questionnaires, entered in Epidata version 7.1.2, cleaned, and exported to Stata v15 for analysis. Continuous variables were summarized using means and standard deviations if normally distributed or medians and interquartile ranges if not normally distributed. Categorical variables were summarized using frequencies and proportions. Logistic regression was used to compute risk factors for severe postpartum haemorrhage at bivariate analysis and variables with p-value <0.2 or those with biological plausibility were entered in the multivariate models. P-value of <0.05 were statistically significant.

Results: Among the 138 post-partum women, the mean age for cases was 28.5 (SD 6.2) years and 26.1 (SD 5.3) years for controls. Women with a previous scar were 2.4 times more likely to have severe PPH than those without a previous scar [aOR=2.40, 95% CI=1.47-6.48, P=0.018]. Those who had history of PPH were 3.24 times more likely to have severe PPH as compared to those without history of PPH [aOR=3.24, 95% CI=2.01-7.04, P=0.015]. Those who had induction of labour were 2.62 times more at risk of getting severe PPH than those without induction [aOR=2.62, 95% CI=1.39-5.92, P=0.024]. Those who had augmentation of labour were 2.59 times more at risk of getting severe PPH compared to those without [aOR=2.59, 95% CI=1.28-5.58, P=0.031]. Patients who were delivered by C-section were 2.75 times more at risk of getting severe PPH as compared to those delivered by SVD [aOR=2.75, 95% CI=1.62-5.23, P=0.025] and every hourly increase in the mean duration of labour increased the risk of getting severe PPH by 2.52 times [aOR=2.52, 95% CI=1.37-5.03, P=0.018]. The risk of severe PPH was 53% lower among women with tertiary education as compared to those with primary level of education [aOR=0.47, 95% CI=0.26-0.83, P=0.013].

Conclusion: Low Education level,-parity(2-4), previous scar, history of PPH, induction and augmentation of labour, duration of labour and caesarean section were risk severe PPH. Women with the above risk factors should be identified during antenatal care and vigilance taken during labour, delivery, and the immediate post-partum period for preparedness to prevent and or manage severe PPH.