Ante partum haemorrhage (APH) is an obstetric emergency that endangers the lives of pregnant women and complicates both labor and delivery. The risk factor for this complication include intrauterine foetal death, malpresentation, prematurity, low birth weight, congenital malformation, birth asphyxia, retained placenta, postpartum haemorrhage, anaemia and shock (1–3). APH was defined as bleeding from or through the genital tract occurring at the beginning of the 24th week of pregnancy and prior to the birth of the baby (4). It complicates 3–5% of all pregnancies and is a leading cause of perinatal and maternal mortality worldwide (4). Although maternal mortality has declined globally, by approximately 38% from 2000 to 2017, 810 women still die daily due to complications resulting from pregnancy and childbirth (5). Maternal mortality in Africa is a leading cause of death, especially in Sub-Saharan African regions, and accounted for approximately 70% of global maternal deaths in 2020; however, there was an average 3.0% decrease from 2000 to 2017 (6–8).
Tanzania is situated in the Sub-Saharan African region, and its maternal mortality rate in 2020 was 238.00 per 100,000 live births, but this figure has decreased by 9.16% since 2019 (9). However, efforts need to be made in Tanzania to reach the Sustainable Development Goals target of 140 maternal deaths per 100,000 by 2030 (10). Tanzania’s Health Management Information System reports from 2009 show that Mwanza was a leading region for maternal mortality in Tanzania and had (176) deaths, followed by Tabora (164) and Dar es Salaam (137) (10). According to the Lake Zone maternal deaths report in 2022, among the seven regions of the Lake Zone, Mwanza was still the leading region for 75% of maternal deaths, while the remaining six regions carried only 25% of maternal deaths (11). Furthermore, a 2019 report from the Mwanza Region Health Centers showed that 21.3% of women with complications related to pregnancy and delivery had APH (12). According to the register book of the Bugando Medical Centre (BMC), where obstetric emergencies were ranked from 2019–2022, APH was the 2nd most common obstetric emergency condition in 2019, 2020, 2021 and 2022, with 59 (23%), 62 (24%), 45 (26%) and 83 (21%) women, respectively, but still had a leading haemorrhagic condition. The leading obstetric emergencies were preeclampsia and eclampsia (13).
High-quality antenatal care for women depends on competent midwives to reduce the risk of APH. According to the International Confederation of Midwives, early detection and treatment or referral are essential competencies for midwives to provide high-quality antenatal care to maximize health during pregnancy (14). The same competencies are also emphasized by the Tanzania Nurses and Midwife Council (TNMC) based on the World Health Organization (WHO) (15). According to the TNMC, a graduated midwife should be able to identify deviations from normal pregnancy and initiate the referral process for conditions requiring higher levels of intervention to prevent complications (16). Midwives also required to practice treatment process confidently, when providing preventive and promotive care for a normal pregnancy. Also, to have ability to detect complications, and carrying out emergency measures, including treatment or initiation of the referral process for complicated cases (15, 17). Midwives must interpret laboratory findings, analyze and synthesize data critically to identify gaps and areas for improvement, and, subsequently, plan and implement modified care (18). Previous studies, such as Bhandari and Hunter (19, 20), have shown that a poor outcome of care (21) is among the leading factors associated with maternal mortality. Other factors include poor management of women in 17% of the women treated in hospitals in Tanzania (2), a shortage of a skilled birth attendant(22), a lack of quality skills in midwives (23), and lack of evidence-based guidelines for the management of pregnant women(21). However, morbidity and mortality rates can decrease and become more preventable. Mothers may have a great chance of survive if timely and adequate interventions are provided by a skilled birth attendant (6, 24–26).
Actions have been taken to empower pregnant women to lower their mortality rate. For instance, the Continuing Professional Development (CPD) program begins after basic training. The aim is to improve performance by continuously updating knowledge, skills and attitudes, and among the strategies used to ensure quality care is the involvement of midwives in CPD. The employer is responsible for providing, facilitating, sustaining, and supporting the provision of CPD for midwives by reviewing the practice, identifying learning needs, and planning and participating in relevant learning activities. With the continuous use of CPD, midwives retain their capacity to practice safely, effectively, competently and legally within their scope of practice. (27). The government of Tanzania and other partners, such as the Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO), also, provided technical assistance by developing the Essential Maternal and Neonatal Health Guidelines in 2016. They have also conducted training and supervision using different midwifery simulations and reduced maternal morbidity and mortality rates (27). However, among the leading obstetric emergencies facilitated during the training, APH was solely conducted theoretically; it is not known whether the midwives could obtain the required practical competences to care for women with APH. Generally, midwives were expected to have essential competencies in emergency care after completing the course.
These factors are associated with maternal mortality and indicate that pregnant women are still at risk of not receiving necessary care when experiencing APH, leading to the health and wellbeing of these women being at risk (2, 21–23). There is a need for midwives to continuously practice, simulate, prepare and use the standards during the provision of care to women with APH to prevent complications. Therefore, this study aimed to explore midwives’ clinical actions and experiences regarding the care of women with APH. The results may provide knowledge and tools to improve midwives’ education and clinical practice. In the long run, complications may be prevented, suffering may be minimized, and health and well-being may increase.