Prevalence, Causes and associated factors for Postpartum haemorrhage (PPH) at St. Joseph referral hospital Peramiho-Songea, Tanzania; A hospital-based retrospective cross-sectional study.


 Background

The prevalence of postpartum haemorrhage (PPH) is increasing globally that is from 6.5% in 2000 to 11% in 2016. But there are regional variations where there is decrease of PPH in some parts of Asia and increase in Africa and developed countries.
Objectives

The main objective of this study was to assess the prevalence, causes and associated factors for postpartum haemorrhage at St. Joseph referral hospital in Peramiho- Songea from November 2017 to December 2019.
Method

 The retrospective cross-sectional hospital-based study was used and data was obtained from maternity hospital registry book/data base of St. Joseph mission hospital in Peramiho Songea, from November 2017 to November 2019. Descriptive data was analysed by tables and graphs.
Results

The prevalence of PPH in Peramiho referral hospital was 1.3% in 2017, 1.26% in 2018 and 1.4% in 2019. The overage prevalence for the three years is 1.3%. However, 73.3% of total prevalence is from home deliveries in rural areas. The main cause of PPH in the hospital was uterus atony (42%), retained placenta (15.5%), 3rd and 4th grade tears (11.2%), uterine rupture (8.1%) and coagulopathy (5.6%). The main attributing factors were age > 35years (34%), other antenatal pregnancy complication (27%), previous PPH (18.6%), Antenatal anaemia (16%), placenta previa, Eclampsia, preeclampsia (12%) each.
Conclusion

The prevalence of PPH from this study is slightly high with the main cause being uterine atony and affected mainly those undergone SVD where about two quarter were home deliveries. However further research studies are needed to investigate the main reason for higher home deliveries in Peramiho residence and nearby area.


INTRODUCTION.
Annually, about 41 million cases of PPH are reported globally, among these case 127,000 died due to PPH. [1,2,3] Globally, the prevalence of PPH is increasing though there is inter-regional and intra-regional variation [4] . A study showed global increase of PPH by 4.71% in 2012 [4] . The highest prevalence of PPH revealed in Africa (25.7%) followed by Latin America and Asia (18%), North America and Europe (13%) and Oceania (7.2%) [4] .
Study done in Netherlands shows that the prevalence was 4.1% (2000) [5] which raised to 6.4% in 2013 [6] . In Ethiopia 2015 it was 16.6% [7] compared to Japan 2015 which was 13% [8] . The situation of PPH in Tanzania seems to be the second most cause of high maternal mortality. [ 9] The prevalence of PPH has been raising between 10% 2013 to-32% 2014 [6] .Studies done in three regions including Mbeya, Dar es Salam and Shinyanga showed gradual increase in incidence, that is 11.9%, 14.9% and 50% respectively. [10,11] Postpartum Haemorrhage accounts for the majority of the maternal deaths occurring annually. [12] The burden of PPH has been shown to increase in current years [9] . In Senegal PPH raised between l0% in 2007 to 23% in 2008 [4] while in Quarite PPH was 5.4% in 2015 [13] . In Tanzania

Data Processing and analysis
Data was entered in the computer program statistical packages for social science data analysis (SPSS version 20). Descriptive statistical measure ranging from tables to charts was used to present the data obtained from this study. Chi square (X 2 ) test was used to show the association between variables, a significance level of 5% (p< 0.05) were used to compare and conclude for statistical significance of the association. The statistics was compared between the three years that is January 2017 -December 2019.

Social demographic characteristics of study population
This study involved 161 PPH cases delivered at St. Joseph Mission Referral hospital in Peramiho at Songea from January 2017 to December 2019.
The age of the participants recruited in this study ranged from 15 to 45 years with the mean age of 29.12 years and median of 29 years. One quarter were the peasants and half of them had only primary education and 9.3% had higher education while 5.6% had no formal education. Three quarter of the participants live in rural areas while only less than one quarter live in urban. (Table 1) [14] this results is about tenfold less than that found in Mbeya referral hospital in 2010 [9] . Two quarter of the PPH cases were from rural areas and delivery took place at home. However the main cause of PPH found in the study was uterine atony(42%) and placental abnormalities which seems to be the main causes the same as the result found in different studies in both developing and developed countries [18,8,19] .
The main associated risk factor found in this study were similar to the results found in many literature studies which risk factors were previous PPH, multiple pregnancy, anemia, preeclampsia and eclampsia [18,10] . Furthermore, the study results indicate that the management of third stage of labor was not a really problem because 73.3% of those suffered PPH had attained safe third stage delivery within less than 30 minutes. As compared to the study done in 2010, the prevalence of PPH was higher in C/S but it found that SVD has as twice increased risk as C/section [20] . Social demographic factor found to be the main risk as well as large number of sufferers were from rural and had delivered at home (73.3%), this indicate the that the services in rural are either still poor, not adequate or not accessible. [9] The other reason may be that the rural people lack good and adequate education and knowledge of reproductive health like delivering at health center, attending antenatal clinics and other.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. ORCID https://orcid.org/0000-0002-4996-6266