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 Heath Workers), R1, 2, 3 (relatives).
Characteristics of participants in the individual in-depth interviews
Of the 11 women interviewed, six were aged between 20-34 years, and five were aged between 35-43 years. The majority of the women (n=7) were in the range between parity 1-4 while four were parity 5 or above. Eight women lived in an area where they experienced difficulties to access the nearest health facility and six recalled having received Oxytocin after delivery (the other five did not know).
Characteristics of participants in the FGDs
The minimum number of participants in an FGD was four and the maximum six. Of the 14 participants in the health care provider FGDs, nine were male and five were female; 10 were nurses, 3 were midwives and 1 was a medical doctor. They had between 2 and 35 years of experience working in reproductive health care. Of the 10 participants in the relatives FGDs, eight were husbands and two were relatives. Eleven CHW’s in charge of maternal health participated in the two FGDs. All CHWs who participated in this study were female, reflecting the reality in Rwanda that CHWs responsible for maternal health care in community settings are all female.
Factors influencing the quality of PPH prevention
Four interrelated themes that described the factors influencing PPH prevention care were identified: 1) The meaning of PPH: personal beliefs, knowledge and understanding 2) Organizational factors 3) Caring 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.
The meaning of PPH: personal beliefs, knowledge and understanding
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 the variety of beliefs, and clinical understanding related to the nature and prevention of PPH. It also describes need for more information about PPH, in terms of the limited 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 being 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. When asked about PPH one woman commented,
“...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”. One participant explained that every woman is “candidate” to PPH and need to be prepared: “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. Many participants felt the condition was associated with some cultural beliefs ,such as, hard manual labor performed by the woman, poison in the village, and traditional medicine, which may delay women seeking 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 cultural practice 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. One participant mentioned cultural beliefs about care during childbirth 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 women and their families about abnormal signs (in this case, participants talked about severe headaches, fever and bleeding) during pregnancy and in postpartum period. Participants stated CHWs encourage pregnant women in their villages to go to the health facility for antenatal consultation and delivery. They suggested to have local leaders, for example 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 on PPH.as many change their workplace. They mentioned the new staff might not be aware of updated 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 effectively 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 to receive treatment as needed. 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 PPH prevention. Healthcare providers identified factors associated with some existing PPH prevention policies in Rwanda. The majority of participants felt that adequate resources were a necessary factor in prevention, as well as collaboration across the health system structure.
Health care providers stated that teaching women about PPH and prevention strategies is a required and expected part of maternal health care.
“……. 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 to receive care from a skilled birth attendant. CHWs mentioned their role functions in the event a woman gives birth at home or in the community to prevent PPH. If 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 regarding role functions and maternal care, participants expressed that limited human and material resources and the lack of continuity of care across the health system impacted PPH prevention. The shortage of qualified health professional in maternity care 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 mentioned 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, many stated they were not confident about its effectiveness because of the heat sensitivity of the medicine. The lack of refrigerators in maternity units to store oxytocin was also 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 women across the health system from the community to the district hospital. When there is a woman 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 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 health care providers during their interactions to prevent PPH. It also highlights some disrespectful practices that women experienced while seeking health care.
Participants discussed family involvement in their decision-making to prevent PPH. The women mentioned feeling dependent upon family members for assistance during pregnancy and childbirth. “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. They explained their lack of knowledge about PPH affected their ability to make informed decision on the health conditions of their wives. They described that their main role as to “get the woman to the health facility” to be assessed and treated by qualified health professionals. However, CHWs argued that prevention of PPH should start in the nuclear family, with parents teaching their young daughters about how to prevent. “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 in their community as their “parent”, who will closely follow up pregnant women and report to the health facility as needed. They also pointed out that CHWs have insufficient knowledge about PPH and preventive strategies 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. Beside the busy work, relatives of women described an issue of lack of focus by health care providers while providing services. They reported that some of them used to be busy on their cell phones making personal calls which prevented them from providing quick and timely healthcare to women. Relatedly, they expressed their appreciation about the government's policy which was put in place in response to this problem. For these relatives, the government's response is viewed as one of the ways to improve recognition of women at risk of PPH.
“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 encountered angry and irritable health care providers when receiving care. They described poor patient-health provider relationships can pose a communication barrier for the prevention of PPH. As one relative stated
…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 describes various risk factors associated with PPH which participants describe as antepartum and intrapartum. They also stated that the socioeconomic status of the family and delays to receiving health care are factors affecting 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 expressed 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 were described as non-use of family planning methods leading to frequent birthing, history of PPH, retained placenta, and tearing/trauma of genital organs. In case of trauma of genital organs during birth, women and their relatives mentioned that birth attendants “damage the woman’s internal tissues”. Some risk factors were thought by women and relatives to be associated with religious beliefs where some people consider “use of family planning as sinful” and as a result 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 resulting in 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 poverty and poor nutrition 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 receiving quality services for the prevention of PPH. The socioeconomic status of the family was mentioned by the majority of all participants to adversely impact PPH prevention, particularly, 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 their 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 revealed that families living with conflict may be less likely to make good decisions regarding health and pay for medical insurance, hence they don’t access medical services on time contributing 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 qualified staff leads to the delay to proper follow up of childbearing women especially those at risk to develop PPH. This has been expressed as a “delay to attend a case” which might mean that signs 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)
Geography and location of health facilities were mentioned by participants as a challenges to PPH prevention. Many of the women commented on 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, participants recommended placing an emphasis on prevention strategies pre-conception and antenatally.