Postpartum hemorrhage in Sub-Saharan Africa-a prospective study in metropolitan Mozambique.

BACKGROUND: Estimates indicate approximately ≈500 to 1000 maternal deaths per 100,000 live births in Sub-Saharan Africa (SSA) (vs ≈5-20 in developed countries). Postpartum hemorrhage (PPH) seems a major contributor to maternal mortality (MM), but there are no comprehensive data for the region. OBJECTIVES: Analyze MM, PPH, and associated risk factors. METHODS: We collected prospective data on MM, PPH, and associated risk factors in metropolitan Mozambique. We recorded consecutive deliveries at the Maputo Central Hospital between February 2019 and January 2021. Data included age, HIV status, parity, delivery mode, notes, vital signs, laboratory values, and fetal parameters. PPH was determined by charted diagnosis, blood loss of >500 mL, transfusion, and/or notes indicating significant bleeding. RESULTS: Of 8799 deliveries, ≈40% occurred in women residing outside Maputo City ("nonlocal"), with similar demographic characteristics between local and nonlocal women. However, compared with local women, nonlocal women had worse outcomes, including higher rates of MM (1.52% vs 0.78%; P =.0012) and PPH (16.51% vs 12.39%; P <.0001), whereby PPH was strongly associated with MM (adjusted odds ratio = 5.56; P <.0001). Almost all women with uterine atony (≈1%) experienced PPH. For women receiving laboratory tests on admission (drawn only if in distress; local, n = 561; nonlocal, n = 514), both cohorts revealed similar distributions of hemoglobin levels and platelet counts. Prepartum anemia (≈57%) and thrombocytopenia (≈21%) were prominent risk factors for PPH; risk increased with increasing severity and was additive in the presence of both. CONCLUSIONS: PPH is a serious problem in Maputo province, a metropolitan area of SSA, portending high MM. Identification of correctable risk factors, including anemia, should catalyze the development of region-specific prevention protocols.

Maternal death and postpartum hemorrhage in sub-Saharan Africa - A pilot study in metropolitan Mozambique.

BACKGROUND: Maternal mortality in sub-Saharan Africa is approximately 500 to 1000 per 100 000 births (vs. approximately 5-20 in developed countries). Postpartum hemorrhage (PPH) is deemed responsible for 30% to 50% of the deaths. OBJECTIVE: To study PPH, risk factors, and mortality in metropolitan Mozambique to inform future studies and intervention strategies. MATERIALS/METHODS: Retrospective cross-sectional data extraction from all charts available to us (n = 495) recording deliveries between January and June 2018 at Maputo Central Hospital. Data included age, maternal survival, HIV status, parity, delivery mode, complications, vital signs, laboratory values, and maternal/fetal data. PPH was determined by charted diagnosis, interventions for hemorrhaging, placental abruption, transfusion, or blood loss. Autopsy reports from all deceased patients (n = 35) were examined. RESULTS: Median age was 29 years with 17% HIV prevalence. Risk factors for PPH (frequency, 12%) included parity (adjusted odds ratios (AORs) for 3+ versus nulliparity, 7.20 (95% confidence interval [CI], 2.46-21.10), gestation length (AOR, 0.86; CI, 0.81-0.92 per week), and body temperature (AOR, 1.10; CI, 1.04-1.16 per 0.1°C). Maternal mortality was strongly associated with PPH (AOR, 5.22; 95% CI, 2.26-12.08) and HIV (AOR, 11.66; 95% CI, 4.72-28.78). Laboratory values (n = 241) were available from mothers experiencing complications (approximately 50%). Anemia (prevalence 54%) was a strong predictor of PPH with an inverse relationship between hemoglobin levels on admission (AOR, 0.62; 95% CI, 0.50-0.77 per g/dL higher hemoglobin) and the probability of later suffering from PPH. Mothers who died following PPH had lower median hemoglobin (6.2 g/dL) than mothers who survived (9.2 g/dL). Protocols to estimate peripartum blood loss were not used; antifibrinolytics and/or cryoprecipitate were unavailable. CONCLUSION: Postpartum hemorrhage is a serious problem even in metropolitan areas of sub-Saharan Africa, and anemia influenced bleeding and death substantially. To address this problem, it is critical to raise awareness and region-specific prevention and intervention protocols.