Reducing maternal mortality through identifying unmet need for postpartum hemorrhage stabilization in rural emergency obstetric care facilities: Development and testing of a tool in Bangladesh

doi:10.21203/rs.3.rs-3586527/v1

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Reducing maternal mortality through identifying unmet need for postpartum hemorrhage stabilization in rural emergency obstetric care facilities: Development and testing of a tool in Bangladesh

https://doi.org/10.21203/rs.3.rs-3586527/v1

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Background: Maternal mortality is stagnating globally, and postpartum hemorrhage (PPH) is the leading contributor. Time from onset of PPH to death is estimated at two hours, the fastest of all life-threatening obstetric complications. Resistance to treatment of critical obstetric emergencies in rural settings is ubiquitous and under-reported. Ensuring initial stabilization close to communities is central to improving maternal mortality rates. Systemic and unspoken refusal of care leads to hidden unmet need for treatment of PPH. Current global guidance for monitoring emergency obstetric care may be inadequate.

Aim: The aim of this research was to develop a tool that measures unmet need for PPH stabilization in local health facilities. The newly developed tool was tested in rural sub-districts in Bangladesh. The results and their implications are discussed.

Method: A proposed calculation was developed for determining the expected number of PPH cases in a given population based on its size, birth rates, community delivery rate, and estimates of PPH rates. Using the new tool, calculated estimates were applied to rural districts in Bangladesh against actual numbers of PPH cases managed in public district and sub-district hospitals. Births in private and NGO facilities were also accounted for.

Findings: Substantial discrepancies were found between expected PPH arising in rural areas and PPH treated in rural facilities in those areas. The actual number of cases treated at local rural public facilities was 16% of what was expected. This is a notable finding that is missed by using global recommendations for monitoring EmONC signal functions.

Conclusion: The proposed tool presents an opportunity for countries to examine the availability of facility response to obstetric emergencies, specifically PPH, in facilities reported to be providing basic emergency obstetric care. Establishing a simple method for the calculation of expected numbers of PPH will help countries to address hidden gaps. Further research is needed in other contexts to verify this tool and investigate if uncovering under performance of health facilities could be an opportunity for strengthening maternal and newborn health systems.

(4-6) postpartum hemorrhage

emergency obstetric care (EmONC)

signal functions

maternal mortality

maternal health

Despite decades of global focus, maternal mortality rates are stagnating [1]. Literature identifies contributors, including poor quality maternity care, non-standard health care providers, and gaps in provision of emergency obstetrics [2–4]. Postpartum hemorrhage (PPH) is the leading cause of maternal death, and the obstetric emergency requiring the most immediate treatment, with estimates of death occurring on average two hours following the onset. It is estimated that 6% of birthing women experience PPH, meaning that each year 8.4 million women are affected, resulting in 80,000 maternal deaths [5–8]. In addition to maternal deaths, PPH is associated with significant maternal morbidity including shock and severe anemia. Rates of PPH are affected by availability of preventative care immediately following the birth, and urgent and skilled treatment [9, 10].

Eighty percent of PPH related maternal deaths are avoidable as they are caused by a delay in diagnosis or management [11]. The recent World Health Organization (WHO) road map for post-partum hemorrhage (PPH) calls for more research specifically to address gaps in PPH response implementation [12]. Both between and within countries, the most marginalized women have the highest maternal mortality rates [3, 13, 14]. In low- and middle-income countries (LMICs), the poorest women often give birth in communities, outside of healthcare facilities [15]. In this context, one key to reducing maternal mortality is ensuring rural health facilities treat women who present with PPH, both when PPH arises in the facility, and when women present at the hospital with PPH—often in critical condition—after giving birth in their homes.

Though little discussed, resistance to treating PPH in rural facilities has been noted in the literature [16] Although provision of initial stabilization of PPH is within the scope of most rural health facilities, typically these facilities have less resources and expertise than tertiary facilities, and thus may feel ill equipped to treat critical patients [17–19]. Facilities designated for normal birth may feel vindicated by global and national guidelines that often mention to treat or refer [20]. In addition, some countries' rural primary health facilities may only perform outpatient care, with no triage area for emergency stabilization [21–23]. The above concerns result in unmet need for PPH treatment, even in contexts where facilities are thought to provide emergency obstetric care (EmONC) [24]. Referral without treatment is sensitive to discuss, and likely under-reported. Direct anticipatory programming to prevent the resulting maternal deaths should be considered.

In its recently published roadmap for reducing deaths from PPH, WHO calls for new indicators to monitor progress [12]. The globally used signal function framework to measure facility provision of emergency obstetric care states that servicing one case in the previous three months indicates functionality, when in fact in larger populations, one case in three months may be a red flag [25]. Literature finds that facilities’ level of utilization of obstetric and newborn emergency care is positively correlated with service availability, meaning that gaps in service utilization are more likely to reflect availability of services, than community demand [26]. In this vein, limited emergency obstetric care service availability reflects lack of provision rather than lack of need.

This study examines a tool developed to assess emergency obstetric care availability by comparing estimates of likely PPH cases within facility catchment areas in rural Bangladesh with actual cases treated. Attempts to estimate unmet need for emergency obstetric care as a method to assess health facility functioning have been carried out using the well-established metric of 15% of births to estimate the prevalence of obstetric complications [25, 26]. This research uses a similar process but narrows in on estimates of PPH as it is the leading cause of death, and because time of onset to treatment is of the essence with PPH, making treatment in rural facilities even more critical.

Setting

Bangladesh is a densely populated low-income country with a large rural population. Over 5,000 women die during pregnancy and childbirth annually [27], and PPH is the leading cause (31%) [28]. While the maternal mortality ratio (MMR) declined from 1990 to 2020 from 574 to 196 per 100,000 live births, in recent years, it has stagnated [29]. Bangladesh is divided into eight divisions with the largest urban centers, and 64 districts. Bangladesh’s public health system is made up of tertiary medical college hospitals in divisional heads, secondary district hospitals, primary health complexes, and community health centers. All are designated for basic emergency obstetric and newborn care (BEmONC) services, and some for comprehensive [30].

Overall, 34.9% of women give birth in communities, while within the poorest quintiles 57.3% do [29]. Of those that give birth at home, only 5% use skilled birth attendants. Across all births, 17.9% take place in public facilities, 45.1% in private facilities, and 1.7% in non-governmental organization (NGO) run facilities. Women living in urban areas and from higher wealth quintiles are more likely to deliver in private facilities, and rural women from lower wealth quintiles are more likely to deliver at home. Most obstetric emergencies that arise in rural areas are managed at urban tertiary health facilities following long referrals, and denial of care at lower-level facilities is a noted pattern for women with obstetric emergencies coming from rural areas [16, 31–33]. Recent maternal mortality surveys including maternal and perinatal death reviews have found that the majority of maternal deaths in Bangladesh occur in transit, which reiterates the importance of initial management of emergencies at the health facility closest to the community [34].

Bangladesh uses the District Health Information System Version 2 (DHIS2) for health information management [33]. The standard DHIS2 package does not monitor the rate of rural facilities receiving PPH cases from the community. Rather, reported PPH rates are aggregates of those managed in public health facilities. This includes those arising at the facility, and those received both from the community (i.e., home births referred to the hospital) as well as from private and NGO facilities that refer serious cases to public facilities [35]. Overall, PPH rates at both district and sub-district government health facilities are notably low given the large populations.

Intervention

Tool development

A tool to calculate unmet need for PPH treatment was developed using estimates of expected PPH cases based on district population levels and crude birth rates (CBRs). The Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) checklist for reporting global health estimates was used to structure the tool development description. Estimated cases of PPH were then compared to actual cases treated. The tool (Fig. 1) was developed following an iterative process of conceptualization, data gathering, and testing and refinement of inclusion and exclusion criteria, led by one of the authors (QM) with input from all other authors. Initially, the idea was conceived of to estimate obstetric emergency prevalence using the WHO estimate of 15% of all births. However, searching the literature revealed adequate evidence for using the estimated PPH prevalence of 6% of all births. It was determined that district-level birth rates could be estimated using 2022 population census data [36], CBR calculations from the national sample vital registration system (2021), and established global estimates of stillbirth rates [37, 38]. Various types of datasets were considered for inclusion in the tool methodology. Initially, population projections were going to be used from the 2011 Census. However, the 2022 Census was published during the tool’s development and was used instead. Consideration was also given to incorporating into the tool sub-categories by wealth quintile. However, this proved not useful, as relatively equal proportions of each wealth quintile attend public facilities, and PPH referrals are not tracked by wealth quintile. Public, private and NGO facility births, as well as home births, were estimated using the national distribution of births at these locations from the most recent national demographic and health survey (BDHS) [29]. Estimates of PPH cases by district, at each hospital type and in home births were calculated using the 6% prevalence estimate in the published literature. While various studies have found nationally estimated prevalence ranges from 3.2% in the United States to 8.24% in Ethiopia, PPH is higher in LMICs and depends on the care provided at birth [5, 10, 39–41]. One study in three hospitals in southern Ethiopia found a PPH prevalence rate of 16.6% [39]. As a result, a 6% prevalence is more likely an underestimate than an overestimate. It is also expected that PPH rates are higher during home births where birth attendants may not have expertise in stopping PPH and may use harmful interventions that can lead to PPH such as oxytocin injections in labor [42]. Due to the variation of PPH prevalence among populations giving birth in low-resource settings, uncertainty intervals were not calculated and the estimate of 6% of births was applied as the best available metric.

Actual numbers of PPH cases managed at district and sub-district public health facilities were extracted from DHIS2 reports. Districts with divisional heads and thus public medical college hospitals were not included as the focus for this assessment was rural response. To calculate unmet need, the estimated PPH numbers anticipated from community births and public facility births within a given district were compared with the actual numbers of PPH cases treated within that district’s public facilities. To be conservative, estimated PPH arising at private and NGO-run facilities were assumed to be treated at those facilities, although it is known that some will be referred to public facilities.

Certain limitations should be taken into consideration when applying this tool. The exact formula is dependent on locally available data for population, birth rates, and birth locations. In addition, although the global estimate for PPH is 6%, rates in different contexts will vary. In particular, those giving birth at home with no skilled birth attendant will have higher rates than those receiving routine prophylaxis. The actual rate of postpartum hemorrhage in the context of community births in Bangladesh is not known. Finally, as women can attend either public or private facilities and data from private facilities is not reported.

The tool was applied using population and annual birth data from all districts in Bangladesh without tertiary care-level public medical college hospitals (Table 1). Unmet need was greater than 90% in 11 districts, and 69%, 59% and 54% in the three districts with the lowest rates. Nationally, the average unmet need across all study districts was 84%.

The results from Bagerhat, a district in southwestern Bangladesh, are described here in further detail. Bagerhat has one public district hospital and nine public sub-district hospitals. The population of Bagerhat is 1,613,079 and the CBR is 19.2 [37]. The number of births for Bagerhat in 2022 was 31,606 [29]. Using the WHO 6% estimate for PPH, 1,896 PPH cases were expected in Bagerhat district in 2022. Of the PPH cases, 339 were expected in public facilities, 885 in private facilities, 32 at NGO facilities, and 662 in the community. It is expected that the public facilities would manage the PPH cases that developed within their facilities, and additionally they would receive cases of PPH arising from women giving birth in their homes, as skilled birth attendance in that setting is only 12%. This would mean the public facilities would expect 1,001 PPH cases annually which is just under 10 times the number they actually received—121. The estimate of 1,001 is conservative because, as mentioned, some PPH cases will come from private and NGO facilities that refer to public facilities [35]. Based on this conservative calculation, Bagerhat public health facilities received far under the number of PPH cases that likely occurred in the district in 2022, indicating unmet need among 88% of PPH cases.

As the BDHS reports on only the number of PPH cases at public facilities, the numbers expected in private and NGO facilities were calculated based on the 6% of births anticipated within those facilities. As noted, the DHIS2 does not disaggregate by origin of PPH. Therefore, of the 121 PPH cases reported in Bagerhat’s public facilities, it is not known whether they arose at the public facilities or whether they were referred from home births or other facilities.

This paper suggests that unmet need for PPH treatment in rural hospitals, even those designated as EmONC, is likely a significant contributor to stagnating maternal mortality. The tool and its results are presented, highlighting underperformance in public rural hospitals in Bangladesh that are designated as BEmONC sites. The results magnify gaps that are already documented—notably, only 24% of sub-district hospitals meet BEmONC criteria [43]—and provide an alternative approach to assessing facility functionality for addressing PPH. As meeting BEmONC criteria requires only one case provided with each signal function service within a 3-month period, areas with large populations may have significant unmet need even if local facilities meet BEmONC criteria. This tool brings the unmet need to light with more precision than signal function monitoring.

Gaps in rural EmONC services are widely documented [26, 44, 45]. In most cases, the problem is explained as gaps in life-saving commodities or health provider capacity [46, 47], in spite of the fact that initial stabilization as defined by global emergency obstetric and newborn care guidelines for the leading causes of maternal death are relatively simple, requiring not more than an injection, and/or a simple manual procedure that can be accomplished by basic health care providers [48].

The nuanced complexities of why women are not receiving care warrant further exploration. In all cases, simple interventions could be provided that would be life-saving. Though not yet scaled up, evidence-informed strategies for implementation of the effective practices have demonstrated positive results in low resource settings [19, 49]. Due to the simplicity and availability of what is needed to stop excess bleeding, the pervasiveness of PPH care gaps amounts to systemic care refusal. The problem with overlooking care refusal is that rather than establish accountability measures to ensure women are provided care, countries wait for a time when they have enough additional resources. Thus, if the problem is not resources, this time may never come. In Bangladesh, there is literature identifying refusal of care (i.e., referral of PPH cases without treatment to stop bleeding) in facilities with specialist doctors, and adequate supplies [31].

Though not as explicitly documented, this scenario may be indicative of the demonstrated larger problem and is likely true in other countries as well [17, 47, 50]. Research exploring this in other countries describes ineffective task sharing between doctors and midwives, and delays in family members authorizing providers to initiate emergency care measures. These issues may require sensitive conversations to get to the root of and resolve. Yet, that is what is needed to lower stagnating maternal mortality rates [51]. Qualitative interviews with doctors and hospitals managers in Bangladesh revealed that many do not feel they have the needed safety net to take care of critical patients in rural facilities given the potential for patient death. Although their health facilities have the basics needed to provide initial stabilization before referral, managers’ and providers’ concerns around their own safety if a patient dies, as well as judgements within the health system, are deterrents to care provision in rural facilities [16]. Trust among health workers increases intrinsic motivation, and influences evidence-based quality care provision [52, 53].

Therefore, while treating PPH in low-resource settings is simple, the barriers to doing so are systemic and will require focused attention to change [54, 55]. The recently updated State of The World’s Midwifery report highlights that many countries restrict midwives’ provision of emergency obstetric care. Some countries do not allow midwives to use oxytocin, thus creating a systemic barrier to rural emergency care provision in contexts without doctors [56]. In its recent roadmap to preventing PPH, WHO calls for standard indicators for assessing PPH [12]. The DHIS2, a free software used in many LMICs to support the health system, does not disaggregate for PPH arising in the facility as opposed to PPH coming from the community. This means that it is not possible to monitor if facilities are receiving critical cases from the community, or if PPH cases are a result of gaps in postpartum care. Broader gaps have also been documented in LMICs regarding DHIS2 utility for monitoring emergency obstetric care [57]. Utilizing local level estimates of expected PPH may be a more effective way of tracking unmet need for PPH treatment in rural areas.

The findings of this article are remarkable in that rural public health facilities were receiving roughly 16% of the expected number of PPH cases and this critical life-threatening concern has not to date been identified within the Bangladesh government or the development community. Other countries and contexts are encouraged to use this or similar tools to see if rural facilities are functioning to meet the needs of PPH treatment in the community.

The gap between estimated PPH and PPH cases treated is staggering. This tool will help policy makers and international agencies in LMICs to formulate new plans for timely management of PPH to reduce maternal mortality.

Ethics approval and consent to participate

Per the Bangladesh Medical Research Council’s authority, given by the National Research Strategy (Memo No: MOHFW/ Hospital -2 / Misc-16/07/06, date: 05 January, 2009), ethical approval was not required for this study as no primary collection of data was carried out and data used are publicly available (58). All methods were carried out in accordance with relevant national guidelines and regulations. Informed consent for original survey data (linked in this paper) was obtained from all subjects and/or their legal guardians.

Consent for publication

Not applicable for this secondary analysis study.

Availability of data and materials

All data analysed during this study are publicly available. Original sources are in the links below.

Bangladesh Bureau of Statistics. Population & Housing Census 2022 Preliminary Report

Produced by the Bangladesh Bureau of Statistics, Statistics and Informatics Division, Ministry of Planning, Government of The People’s Republic of Bangladesh. Complete count of total population of Bangladesh. Total Population 165,158,616. The sixth Population and Housing Census was conducted in June 2022. The sample included 81,712,824 males, 83,347,206 females, and 12,629 Hijra (third Gender). Due to an unpredicted sudden flash flood, the data collection period was extended up to June 28 in the districts of Sylhet, Sunamganj, Moulvibazar and Netrokona, following the international census protocol. The digital census was conducted using the Computer Assisted Personal Interviewing method.

Bangladesh Bureau of Statistics. Report on Sample Vital Registration System (SVRS) 2021

Produced by the Bangladesh Bureau of Statistics, Statistics and Informatics Division, Ministry of Planning, Government of The People’s Republic of Bangladesh. Nationally representative. In the SVRS 2021, data on vital events, such as, births, deaths, marriages, divorce/separation, inmigration and out-migration, contraceptive use and disability were collected in 2021 through two independent systems. Under System 1, a local female registrar collects in prescribed schedules the occurrences of vital events as and when those occur. Under System 2, supervisors collected retrospective data on birth, death, marriage, divorce and separation on quarterly basis, migration data on half yearly basis and contraceptive use, disability on a yearly basis and submitted filled-in schedules to deputy directors of district statistical offices who sent them to headquarters. All information was collected using dual recording systems, and underwent systematic and rigorous consistency checks. Documents of the two systems were matched and accepted or rejected as per the tolerance limit specified in advance. The complete enumeration found 643,621 males and 655,820 females in the sample areas resulting in a sex ratio of 98.12 males per 100 females; 27.7% of the population was under 15 years of age and 66.6% was working age. The Integrated Multi-Purpose Sample (IMPS) frame developed from the 2011 census served as the sampling frame for the collection of data in the SVRS 2021. A single stage stratified cluster sampling methodology was adopted for the sample enumeration areas. Prior to the selection, each of all the enumeration areas containing less than 40 households was merged with an adjacent enumeration area to be comparable with the remaining enumeration areas. Selection of enumeration areas within the strata was done with probability proportional to the estimated number of households from a computerized list ordered alphabetically within the 64 districts. Each of the seven administrative divisions of the country was regarded as a domain of the study. These domains were divided into three residential categories, rural, urban and city corporation, resulting in 21 domains. Recall bias could have affected responses as respondents had to provide information about vital events that ocurred in the past.

Bangladesh Demographic and Health Survey (BDHS) Preliminary Reports/Key Indicators Reports 2022

Produced by the National Institute of Population Research and Training (NIPORT), Medical Education and Family Welfare Division, and the Ministry of Health and Family Welfare. The sampling frame used for the 2022 BDHS is the Integrated Multi-Purpose Sampling Master Sample, selected from a complete list of enumeration areas covering the whole country. The survey is based on a two-stage stratified sample of households. In the first stage, 675 enumeration areas (237 in urban areas and 438 in rural areas) were selected with probability proportional to enumeration size. In the second stage of sampling, a systematic sample of an average of 45 households per enumeration area was selected to provide statistically reliable estimates of key demographic and health variables for urban and rural areas separately and for each of the eight divisions in Bangladesh. Based on this design, a total of 30,375 residential households were selected (19,710 from rural areas and 10,665 from urban areas). The household listing operation was carried out in two phases (each about 4 weeks in duration) in all selected enumeration areas from May 25 to July 27, 2022. Data collection occurred in four phases (each about 4 weeks in duration) beginning on June 27, 2022, and ending on December 12, 2022. A total of 30,330 households were selected for the sample, of which 30,149 were found to be occupied. Of the occupied households, 30,018 were successfully interviewed, yielding a response rate of 99.6%. In the interviewed households, 30,358 ever-married women age 15–49 were identified as eligible for individual interviews. Interviews were completed with 30,078 women, yielding a response rate of 99.1%. A total of 20,217 women were eligible for the full questionnaire, and 19,987 were successfully interviewed. Response rates were 98.9% for the full questionnaire and 99.5% for the short questionnaire. Potential bias in survey responses includes memory bias. Respondents of different ages had to report on information from up to 2 years in the past, which could have led to misremembrance of events.

District Health Information System 2 Bangladesh

This is the national health information system of Bangladesh. It is managed by the Management Information System office at the Director General of Health Services (DGHS), Ministry of Health & Family Welfare. It represents the entire population of Bangladesh and is made up of monthly reporting of all the health incidents from all the public health facilities under the DGHS. Data is collected from the health service point. Data are entered in an established software developed by the University of Oslo, Sweden. Though there is a well-established monitoring system, data validation is not conducted, and data entry is led by lower skilled frontline health care workers, elevating the potential for error. Public access to the DHIS2 is provided through registration with the Directorate General of Health Services by contacting [email protected].

Competing interests

The authors declare that they have no competing interests.

Funding

Not applicable

Authors' contributions

Formulation of research aims, data curation and analysis, writing and supervision were carried out by RA. QM led data curation, methodological development, and analysis. FS supported writing and editing. AW assisted with formal analysis, writing and editing.

Acknowledgements

Not applicable

Authors' information

Rondi Anderson is a midwife with a PhD in public health who is dedicated to strengthening quality, evidence-based maternal and newborn health services to the poorest women. She has worked in both clinical service delivery and reproductive health program management, serving marginalized communities in the U.S., Sierra Leone, Somalia, India, Rwanda, Bangladesh, and Syria. She worked as an international midwifery specialist with UNFPA Bangladesh from 2015–2022 and served as an emergency coordinator for sexual and reproductive health programs with UNFPA in Aleppo, Syria throughout 2023. She holds a PhD from Lancaster University and has published more than 15 articles in peer reviewed journals on midwifery related issues, she is a leading voice on the provision of quality sexual and reproductive health care in low resource health systems.

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Table 1 is available in the Supplementary Files section.

No competing interests reported.

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Reducing maternal mortality through identifying unmet need for postpartum hemorrhage stabilization in rural emergency obstetric care facilities: Development and testing of a tool in Bangladesh

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