A total number of 46 informants participated in individual in-depth interviews (11 women) and FGDs (7 groups involving a total of 35 participants). To ensure confidentiality of study participants, they are identified as follows: W1, 2, 3, ….. (women); HCP1, 2, 3, ….. (health care professionals), CHW1, 2, 3, ….. (community health workers), R1, 2, 3 (relatives).
Influencing factors to quality care in PPH prevention
Four interrelated themes that described the factors influencing PPH prevention care were identified: 1) Meaning factors: personal beliefs, knowledge and understanding of PPH 2) Organizational factors 3) Caring factors and family involvement and 4) Perceived risk factors and barriers to PPH prevention. These themes included several sub-themes, which will be described in the following sections.
Meaning factors: Personal Beliefs, knowledge and understanding of PPH
This theme incorporates the way in which women, their partners or close relatives, CHWs in charge of maternal health and health care providers think about PPH, and what it means in this context. It highlights a variety of beliefs, and clinical understanding relating to the nature and prevention of PPH. It also describes what beneficiaries and health care providers say about their need for information about PPH, in terms of level of knowledge from a beneficiary’s perspective and additional training needs from a healthcare provider perspective.
The health care providers working in health facilities defined PPH as blood loss more than 500 ml within the first hour after birth and the quantity of blood loss was described as visually estimated. Most CHWs described recognizing PPH in a woman when she “changes the sanitary pad two times or more within the first hour” after childbirth. But the majority of the women participants described bleeding after childbirth as “not well known” but an unusual blood loss after birth is a condition that needs to be resolved in a hospital setting.
“...I really don’t know what is it but what I know from myself, I delivered my child after a while I felt like I was sleeping in a basin of water, was full of blood all over, was feeling dizzy and told the nurse that I was uncomfortable the whole body, after that I did not know what was the next, and I woke up after being transferred in another referral hospital” ( W1).
PPH was also described by relatives as coming “unexpectedly” and it was believed that every woman is “candidate” to PPH, i.e. at risk of experiencing it: “When I try to look through it I assume that this problem happens unexpectedly and my conclusion is that every mother is a candidate, that is why all women must be prepared whether they are rich or poor” (R12).
Many health care providers mentioned that PPH has been associated with common causes like uterine tonicity, retained tissues after birth, tearing and trauma of genital organs during birth, and coagulopathy problems. It has been also echoed among many participants that the condition was also associated to some beliefs like hard manual labor performed by the woman, to poison in the village, and the beliefs may lead to delay to seek appropriate care: “Now in the village they like to say that the problem is associated to poisons and a woman may go to the traditional doctor which can be the reason to be late to reach the health facility and may lead to those problems of bleeding” (HCP22).
Participants revealed that there is a culture of “hiding” a complication that might happen during childbearing. Close relatives indicated that such hiding might be associated with lack of awareness about PPH in the community as the condition is believed to be associated to poison: “what I saw in many Rwandans is that they try to hide that they have had a complication afterbirth. I think this might be associated to lack of awareness of the causes as some might link it to poison” (R17). Participants mentioned that family members have a great influence in forcing women to follow what they believe in such as the use of traditional medicines. These beliefs might be contradictory to the woman’s own knowledge on PPH. “..for example a woman can be aware of the signs that can lead to PPH but her mother-in-law oblige her to take traditional medicines telling her that if her grandchild faces a problem because she did not take those traditional medicines she will be accountable and will explain it” (HCP29).
Participants shared their desire for information to improve their knowledge on PPH prevention. The women and their relatives revealed that CHWs in charge of maternal health in their village educate families about abnormal signs (in this case, participants talked about severe headaches, fever and bleeding) in pregnant woman and in postpartum period. It was also indicated that CHWs encourage the pregnant women to go to the health facility for antenatal consultation and for delivery. They suggested to have local leaders, like administrative leaders of the local village to be educated about PPH as they are close to the population in the village. “…...I can suggest that all leaders at the villages’ level can take this as their duty and I think this can contribute a lot to prevent some maternal health problems.” (R21).
The health care providers and CHWs expressed the need for continuous training. In this case, participants noted that health care providers and CHWs may change workplace, looking for a new job. It was mentioned that the new staff might not be aware of new updates in protocols in PPH prevention. The health care providers working in antenatal clinics stated that when they are well informed about PPH and its risk factors, they are able to teach and help women gain knowledge about the signs and symptoms of PPH and what actions to take. They remarked when a woman notices one of the symptoms she will know to immediately come to the hospital which, in turn reduces the risk of PPH. CHWs in particular said they wanted to be adequately trained on some procedures like assisting home deliveries so they are able to provide care in case a woman delivers in the community before reaching the health facility. One CHW explained: “…as a community health worker who meet women with PPH before reaching the health center, and as you know it is most of the times difficult for them to get transport, my suggestion is that they can train us on basic practices, like home deliveries, and delivery of the placenta so that the woman reaches the health center after being basically treated”.
Organizational factors influencing PPH prevention
This theme highlights some of the organizational factors that influence the prevention of PPH. In this regard, healthcare providers identified factors associated with some policies in use for PPH prevention and the majority of participants felt that adequate resources were a necessary factor, as was the influence of collaboration across the health system structure for PPH prevention.
Participants mentioned some policies around PPH prevention. Health care providers described that teaching women about PPH and prevention strategies is among their expectations.
“……. Our Ministry of Health always encourage the health providers at the hospitals and health centers to teach pregnant women to go for the pregnancy checkup and to give birth in a hospital setting and I think this contributes to the prevention of PPH…..” ( HCP13).
CHWs expressed that their role is to educate woman about risk factors and “get her to the health facility” when she is approaching the expected date of delivery so that she can been assisted by a skilled birth attendant. In case the woman gives birth at home or on the way to the health facility the policy of task shifting allows CHWs to provide Misoprostol to the woman after delivery to prevent PPH. “when a woman gives birth at home or before reaching the hospital we give her the misoprostol which reduces the hemorrhage, then we take her to the health providers who orders her to take enough rest, for us we use the advice and trainings given to help women (CHW36).
In addition to some policies, participants affirmed that limited human and material resources and the lack of continuity of care across the health system are other factors affecting the prevention of PPH. The shortage of qualified health professional in maternity was highlighted as a challenge by all participants. Participants stated that having “specialized health professionals” in health care settings would contribute to the reduction of PPH cases. Health care providers stated that having only a small number of knowledgeable staff on a shift creates problems “to follow up properly” women every fifteen minutes after birth, and they do not have time to effectively teach mothers about factors that may lead to PPH. Relatives of the women recognized that health care providers’ heavy work load may hamper recognizing a client who is bleeding after birth:
“… all levels may influence our women to bleed. The health care provider may be overwhelmed because of many patients when she is one or two on a shift, it is hard for her, for example my wife gave birth without any complication but by accident she was damaged which caused her to bleed, I could not say that it is the understandings instead it was the problem of health personnel” (R16)
Though health care providers were aware of the recommendation to administer injectable oxytocin for the management of third stage of labor to prevent PPH, they were not confident about its effectiveness because of the heat sensitivity of the medicine. The lack of refrigerators in maternity units was highlighted as their main challenge for quality prevention of PPH.
“… the injectable oxytocin we use is the one to be kept in the fridge but all maternities in the health centers or the hospital do not have a fridge to keep the oxytocin, it is kept in the general pharmacy which will prevent us to give the oxytocin on time and with appropriate temperature...” (HCP35).
Furthermore, the majority of participants mentioned the importance of information sharing for the continuity of care and a proper follow up of clients across the health system from the community to the district hospital. When there is a client in labor or with another obstetrical problem in the community, the CHWs, through a system of “rapid SMS”, use their cell phones to call health providers at the health facility to send the ambulance. Women and their relatives affirmed that this is a good collaboration between the health facility and the CHWs, although sometimes there is delay in sending the ambulance. However, women identified the need for getting accurate information about PPH during pregnancy, delivery and the postpartum period so that they can make informed decisions regarding when to seek follow up care. The health care providers mentioned that the client’s health information related to her pregnancy is not well shared from the antenatal clinic of the health center to the maternity setting where the woman gives birth, which can further impede the recognition of clients at risk of PPH.
“Most of the signs and symptoms discovered during antenatal consultation remain in the clinic, a woman does not have that information, what is only written on her file is to come early and give birth at the health center” (HCP29).
Participants mentioned that for a proper prevention of PPH the awareness should be enhanced in the health system so as to ease the identification of risk factors as early as possible by means of regular checkups of well-informed women before and after delivery.
Caring factors and family involvement
This theme reveals personal qualities, role expectations and clinical skills valued by women and their relatives, CHWs in charge of maternal health and the health care providers during their interactions contributing to PPH preventions. It also highlights some disrespectful practices that women experienced while seeking care.
Participants discussed family involvement in their decision-making to prevent PPH. The women mentioned feeling dependent upon family members for assistance. “The family help me in not doing heavy activities and not being stressed… I first inform the person I live with, here I mean my husband, then we take a decision to go to the hospital because they are the right people to help me prevent against PPH.” (W2).
The partners to women expressed the feeling of “being less helpful” to women in terms of PPH prevention due to their lack of knowledge to be able to take informed decision on the health conditions of their wives. They feel that their main role is to “get the woman to the health facility” to be assisted by qualified health professionals. However, CHWs feel that the prevention of PPH should start in the nuclear family, with parents teaching their young daughters about prevention.
“A family has to be the first one to teach their young daughters to prevent early pregnancies which may lead to PPH, and to have that discussion in their home.” (CHW43).
The women and their relatives view the role of CHWs in charge of maternal health as their “parent” as they live together in the community, closely following up pregnant women and reporting to the health facility. But they also pointed out that CHWs have insufficient knowledge about PPH and PPH prevention to be able to provide enough information to community members. “Community health workers are available but we do not discuss about that issue of bleeding. They accomplish well their tasks but I think they do not know much about PPH so that they can teach us too about it” (W10).
Regarding the care provided by health care providers, women’s relatives recognize the busy work of health professionals. They have appreciated the recommendation from the government of Rwanda to health care professionals to stop using cell phones during working hours.
“There are things that the government has changed according to the way we were used to be given medical services like that thing of stopping cell phones at hospitals changed a lot things and we are so thankful. Before when we needed assistance from them, we used to find them busy on phone.” (R20).
Women and their relatives expressed feelings of frustration and anxiety when they have to enter into relationships with angry and irritable health care providers which may be a barrier to the good communication for the prevention of PPH.
…there are some problems we face at hospitals where we find doctors or other medical professions who are always angry or with bad services and you will realize that some patients are not comfortable and are fearing to tell everything to the health care provider. There are people who can look at you and you have fear to express yourself…. (R19).
Perceived risk factors to PPH prevention
This theme elaborates on risk factors associated with PPH and participants describe them as antepartum and intrapartum risk factors. They also stated that the socioeconomic status of the family and the delays to receiving health care are factors that affect access to quality care for PPH prevention. Participants highlighted that knowledge and consideration of these risk factors can contribute greatly to timely prevention of PPH.
Health care providers mentioned that the “knowing of pregnant women with predisposing risk to PPH” would contribute to PPH prevention. As presented in the previous themes, participants feel that the lack of knowledge and insufficient information sharing across all levels of care is a barrier to the recognition of the clients at risk of PPH and hinders effective and timely PPH prevention. The risk factors are described to be non-use of family planning methods leading to frequent birthing, history of PPH, retained placenta, tearing/trauma of genital organs. In case of trauma of genital organs during birth, women and their relatives sometimes feel that birth attendant “damage the woman’s internal tissues”. Some of the risk factors are thought by women and relatives to be associated with some religions where people consider “use of family planning as sinful” and such people are the ones who give birth frequently without birth spacing. Women and their relatives commented that giving birth at home heightens the risk of complications such as retained placenta or tears of genital organs which lead to PPH.
“...my last born was born at home but the placenta remained inside and I bled and bled a lot so they took me to the health center, I recovered my consciousness when I realized that I was lying on the bed of the health center…” (W 11).
Relatives of women as well as health care providers also expressed the view that poor nutritiondiet exposes the woman to developing PPH. “what I can add is that the challenge the society meet is the poverty because if a pregnant woman does not eat a balanced diet when she is pregnant, she may have post-partum hemorrhage after giving birth”. (R13)
Participants also highlighted barriers related to delays to seeking care which prevent women from getting quality services for the prevention of PPH. The socioeconomic status of the family echoed among the majority of all categories of participants to adversely impact PPH prevention, was poverty. CHWs highlighted that poor families experience the challenge of not being able to afford to buy basic food, or to seek care at the health facility, which is believed to increase the risk for PPH.
“there is a problem of poverty like people in the first category are our big challenge because they are the ones who live with malnutrition problems and give birth frequently, they tell you their problems at a later stage when the woman cannot even sit on a motorcycle and we pay for their transport ( CHW38).
Family conflict was also expressed as a challenge associated with socioeconomic conditions. Health care providers in this study revealed that families living with conflict may be less likely to take good decisions to pay for medical insurance hence don’t access medical services on time leading to childbearing complications.
“Families can miss the insurance and you may find a husband in a family who is a drinker or cheating on his wife and when it comes to go to hospital the wife miss someone to accompany her and then she chooses to stay home instead of paying a motorcycle for transportation, a community health worker can recognize this situation late when a woman is in a bad situation, that is how poverty is still a barrier in our zone” (HCP29).
Participants stated that the shortage of staff leads to the delay to proper follow up of childbearing women especially those at risk to develop PPH. This has been expressed as “delay to attend a case” which might mean that signals of an emergency are missed as expressed by a CHW: “A health provider might be working alone in maternity and she has assisted a woman to give birth thereafter, she might be called by other women in labor to look after them, and meanwhile the lady who just gave birth is left alone, no one is there to provide follow up. In this case the woman may be at risk of bleeding, then bleed and the health care provider will delay to attend the case, no one will know…” (CHW39)
Most of the women participants expressed the delay associated to “the location of some health facilities is also mattering because we live in high hilled lands “and people resort to taking motorcycles in case the ambulance takes a long time to reach them. The delay to transfer the woman from a health center to a district hospital has been also expressed as a risk to a woman to have her health status complicated:
“… there is a problem of a delaying decision making when a woman is at the health center or hospital, they may delay to take decision to refer her at night while she has been there for a day bleeding and when she reaches the hospital they may try to intervene while it is no longer possible…” ( HCP34)
To address the factors influencing PPH as presented in this section, participants recommended placing an emphasis on prevention measures. They suggested to start prevention strategies pre-conception, and antenatally.