A total of 15 midwives participated in the study. All the participants were registered midwives and nurses. Table 1 provides other details of demographic characteristics of the study participants. Data analysis revealed four themes: (a) Interventions for preventing PPH; (b) Approaches to managing PPH (c) Challenges of preventing and managing PPH; (d) Ways of supporting midwives to overcome the challenges of preventing and managing PPH in rural health care settings. Table 2 demonstrates how the themes were developed from sub-categories to categories and then themes.
Demographic characteristics of the study participants
Characteristics of the participants
Level of Midwifery Education
Length of Midwifery practice
Over 10 years
Current area of practice
Labour and Birth
Labour, Birth & Postnatal care
Themes, categories, and sub-categories from midwives’ experiences of reducing maternal morbidity and mortality from postpartum haemorrhage
Interventions for preventing PPH
Antenatal care interventions
Interventions for preventing PPH during labour and childbirth
Antenatal assessment, diagnosis, and treatment of anaemia
Antenatal education and health promotion
Approaches to PPH management
Challenges associated with prevention and management of PPH
Issues with access to maternity care services
The effects of inadequate resources
on prevention and management of PPH
Ways of supporting midwives to overcome the challenges of preventing and managing PPH in rural health care settings
Theme 1: Interventions For Preventing Pph
This theme deals with the strategies used by the midwives to prevent PPH and reduce potential complications associated with PPH. This theme contains two categories namely: (a) Antenatal care interventions (b) Interventions during labour and birth
Antenatal care interventions for preventing PPH
Antenatal care provided opportunities for assessing and promoting maternal well-being in general, and preventing PPH through assessment, diagnosis, and treatment of risk factors associated with the development of anaemia during pregnancy. This category contains two sub-categories: (a) antenatal assessment, diagnosis, and treatment of anaemia; (b) antenatal education and health promotion.
Antenatal assessment, diagnosis, and treatment of anaemia
Antenatal assessment and screening were among the strategies used to prevent PPH. Women were encouraged to book early to enhance early investigations and identifications of risk factors for PPH such as anaemia. Full blood counts were routinely tested to assess and monitor the levels of women’s haemoglobin as well as correcting anaemia in pregnancy.
“The rate of anaemia in Nigeria is alarming and killing many people. We do routine laboratory investigations of clients’ HB during pregnancy. Many women have low HB and low PCV because of poor diet. Women with low HB and low PCV levels are treated for anaemia with iron therapy during pregnancy”.
“I monitor the haemoglobin level of all pregnant women. This helps to prevent and correct anaemia before labour and delivery of the baby”
“Antenatally, I encourage pregnant women to book on time at gestational age of 12-16 weeks. I check the level of the women’s PCV, that is, packed cell volume. We give them advise according to the results”.
The midwives also discussed how pregnant women were prophylactically treated for malaria to reduce malaria related anaemia.
“We give preventive treatment to prevent malaria during pregnancy because malaria can lead to anaemia during pregnancy".
The midwives emphasized that since PPH is not always predictable, efforts should be made to maintain optimum haemoglobin levels during the antenatal period to enhance women’s abilities to cope with PPH if it occurs.
“It is not always easy to predict who will have PPH based on risk factors because few of the women who had PPH had no risk factor. It is better to make efforts during pregnancy to improve women’s HB level before labour so that her blood loss during childbirth will not have bad effect on their health”.
Antenatal education and health promotion.
Antenatal education provided opportunities for health education aimed at promoting women’s health and wellbeing during pregnancy. The importance of eating healthy diet was discussed during antenatal education. The benefits of birthing in the health facilities were also discussed.
“PPH is prevented by educating the mother from antenatal clinic during first, second and third trimesters on how to promote and maintain good health during pregnancy.
Health education is also provided to the women on the importance of hospital delivery”
"Antenatal health education is a very good tool. I advise women to eat balanced diet to prevent anaemia."
Some midwives were unable to provide adequate antenatal health education to some women because of poor maternal health literacy, language barrier, personal, religious, and spiritual beliefs held by the women.
“The hindrances we do have for effective prevention of PPH in the community clinic are some patients’ attitudes to accepting antenatal talk on healthy diet in pregnancy due to their religious beliefs and status which may result in poor feeding and anaemia. Some women are also reluctant to accept family planning talk antenatally. They don’t know the dangers of uterine atony due to multiparity”.
“Illiteracy of some of the women can be challenging. Some women believe that PPH is caused by an enemy or witchcraft. It is difficult to explain to such people the actual cause of PPH when they have a very strong belief that it was caused spiritually by an enemy”
“Illiteracy among some of the rural women is a hindrance to successful antenatal education and health promotion because some of them lack understanding of complications of PPH. Language barrier makes it hard for us to fully explain complications of PPH and what to do to prevent PPH antenatally”
Intervention for preventing PPH during labour and childbirth
Midwives employed a variety of measures when managing all stages of labour to minimise the risks of PPH. They also identified the importance of managing physical labour pain as well as providing emotional support to the woman. Pharmacological and non-pharmacological pain management options were used to promote women’s comfort. Efforts were made to minimize the risks of bleeding from perineal trauma by guarding the perineum during childbirth, minimising the use of episiotomy and timely suturing of the perineum. The clinical skills and experiences of the midwives contributed to effective management of the various stages of labour.
“How I manage 2nd and 3rd stages of labour in labour ward are important. Labour pain is not an easy one, so I always encourage the women not to bear down before time. I relief them from pain a bit with sacral massage, telling the woman stories, reassure her and intramuscular analgesia. I always guard the perineum during delivery to prevent tear and bleeding”.
“I eliminate or at least minimise the use of episiotomy “I suture any tear sustained or episiotomy given soon after the baby is born. This helps to reduce bleeding from any perineal tear that requires suturing. All stages of labour can be well managed with experience and these actions help to prevent PPH”.
The third stage of labour was actively managed by all participants. The importance of accurate assessment of risk factors associated with PPH, accurate estimation of blood loss and careful monitoring of the woman’s condition and side effects of medication were discussed.
“In order to prevent this deadly condition (PPH), I try to accurately assess the risk factors and blood loss. Our health care facility guidelines encourage the practice of active management of third stage of labour. This have helped to reduce the number of PPH cases in our health care facility. I administer a uterotonic drug immediately after the birth of the baby. I also use controlled cord traction when delivering the placenta. We use oxytocin as our first choice of drug but we try to be careful of oxytocin induced hypotension and tachycardia by monitoring vital signs.
“What helps me to prevent PPH is the use of misoprostol, good history taking and careful conducting of delivery”
Theme 2: Approaches To Pph Management
The midwives’ understanding of PPH as an emergency, frightening and life-threatening condition enhanced their abilities to provide prompt physical and emotional care to the women and their birth partners to reduce the risks of physical complications and emotion distress. The midwives also discussed the challenges they experienced when managing PPH. Thus, the theme contains three categories namely: (a) Physical care following PPH, (b) Emotional support; (c) Challenges in managing PPH.
The midwives identified PPH as an obstetric emergency that required prompt recognition, diagnosis, treatment to control the bleeding and prevent deterioration. The participants explained that having guidelines and policy for preventing and managing PPH in their wards/units enabled them to diagnose, treat and manage PPH in a timely and effective manner.
“We used and followed the algorithm for management of PPH. This helped us to diagnose and treat PPH without wasting time. PPH was mainly caused by atonic uterus.
Sometimes the steps in diagnosing and managing PPH happen at the same time. Having another midwife or doctor in the room to help was very useful”.
“Our guidelines start with history taking. Noting any history of previous PPH help me to prepare properly to prevent and manage PPH as required. My emergency and midwifery care involves prompt diagnosis and treatment of the problem to minimise serious sequela like shock, anaemia, and prolonged stay in the health care facility”.
“PPH can be deadly, so we treat it as an emergency and try to implement the health facility protocol in a manner similar to cardiac arrest protocol, with the same attention to detail and documentation”
The midwives’ abilities to diagnose and treat PPH effectively were also influenced by their levels of knowledge, skills, clinical experiences, and availability resources including staff.
"As a midwife, I have a lot of knowledge, clinical experience, and skills for managing PPH. “It is an emergency, both material and medical manpower must be on hand, decisions and actions must be taken adequately to save the life of the patient and prevent complications”.
“I was adequately prepared to manage PPH. I received adequate education and training on PPH management during my midwifery education program. I am a registered nurse and midwife. I have had a lot of opportunities to work with more qualified midwives and learnt from them. The knowledge and experiences I gained have helped me to effectively manage PPH as a qualified nurse and registered midwife.
The midwives spoke about PPH as a frightening condition requiring physical, emotional, and spiritual considerations and care. The importance of providing care in a competent, compassionate, and sensitive manner to reduce anxiety and psychological distress for the women was emphasized.
“Managing PPH needs everything possible to tackle the problem. It is between life and death and so we did everything to tackle it competently with knowledge and skills, and with all sensitivity to reduce the fear of the patient and save her life”
“PPH is an emergency, I try to be tactful and confident when the woman is bleeding heavily because the patient is always anxious and afraid of what might happen to her. I render care and reassurance in sensitive and skilful ways.
The midwives discussed the importance of actively communicating with the woman and her partner to enhance their active participation in their care and alleviate their anxiety. The midwives demonstrated their abilities to pay attention to them and show empathy in the given situations.
“PPH is not just about physical care. It a life-threatening and traumatic experience for women especially when bleeding is severe. I feel for the woman and her birth partner. I try to pay attention to their needs and communicate with them with compassion and sensitivity”.
“I always involve the woman in her care. I talk with her and draw her attention to what is happening before starting any intervention. I explain everything to her and make sure she understands what is happening and what we want to do to make her feel better”.
Religious and spiritual beliefs are sources of inner strength for many individuals. Severe PPH disrupts the spiritual conditions of some of the midwives and the women.
‘PPH is an obstetric emergency and time is everything, but by God’s interventions and careful detection of the cause of the bleeding, we were able to control the bleeding
“To manage PPH is not an easy task especially if the PPH is severe. It disorganises spiritual and physical conditions of the midwife and the patient”.
With God’s help and team effort we were able to control the bleeding
Theme 3: Challenges associated with prevention and management of PPH
The prevention and management of PPH posed considerable challenges to the midwives in rural clinical setting and communities. Hindrances to the provision of effective care in relation to PPH prevention and management included issues with access to maternity care services, and inadequate resources for managing PPH. Ways of overcoming challenges of preventing and managing PPH in rural health care settings were also discussed.
Issues with access to maternity care services
Problems with access to the maternity care centres resulted in delay in treatment of women who had PPH. These include difficulties with transportation, and late referral from maternity home to health care facilities.
“We have so many challenges. For example, some roads are not good, there is poor accessibility to health facility. There is poverty amongst Nigerian many women. Some of them live far away from the health facility and have no car. Public transportation system is not reliable. These problems lead to delays in getting to the health care facility and delay in treatment especially if the baby was born before arrival to the health facility”
“Late referral from maternity home is not helpful. It leads to delay in treating the woman. The day we had PPH case in our facility, actually it was referred from a nearby maternity home”.
The effects of inadequate resources on prevention and management of PPH
Inadequate resources were identified as a major barrier to the midwives’ efforts in adequate prevention and management of PPH in the rural communities. Insufficient resources such as infrastructure, labour ward equipment, laboratory facilities, medication, staff shortages were inhibitory factors for the provision of timely and adequate care to women in the rural communities.
“What inhibit my ability to effective prevention and management of PPH in health facility is that we don’t have adequate equipment and drugs. We don’t have lab for grouping and cross matching. We don’t have enough staff in the facility. Imagine in the health facility you see only one midwife doing everything alone, and you just have a maternity care attendant to help you”
“There is a lack of some equipment in the clinic, for example, equipped labour ward with theatre, in case of emergency caesarean section, and instruments for instrumental deliveries. We have few delivery kits”.
“It was not easy managing PPH in the local area where there is no adequate equipment, drugs and staff. Many midwives and other health care workers don’t want to go to rural areas to work because there is no road, no electricity, no properly equipped health care facility”.
Although the effective management of PPH were challenging, the midwives were motivated by the passion they had for their work, and determination to save women’s lives. These resulted in their job satisfaction.
“Actually, it has not been easy managing PPH, but one feels satisfied when you have achieved your aim of controlling the bleeding and saving the life of the woman”.
“Determination is the key to success. I like my job as a midwife. I feel satisfied when I can help my patients and when the bleeding is well managed”.
Theme 4: Ways of supporting midwives to overcome the challenges of preventing and managing PPH in rural health care settings
It is essential that midwives are adequately supported by their organisations and the government to overcome the challenges of inadequate resources including human resources to enhance their abilities to prevent and manage PPH effectively in rural health care settings.
“We will prefer to have a well-equipped labour room where we will have facilities that will enable us control bleeding for example, a bed where patient can be placed in a lithotomy position if necessary and placenta is expelled with its membranes completely with an angle light for easy assessment”
“Government should employ more trained midwives. We need more midwives in the labour ward. We also need enough equipment and drugs for managing PPH. More doctors should be assigned to work in the health facilities in the rural areas”
Effective management of PPH in an on-going manner requires continuous practice review, emergency drills and continuing education and training of midwives. These actions are necessary for the provision of high standard of care to women in the rural health care settings.
“Just as with other advanced life support protocols, it is important to have a periodic review of everybody’s practice. We also need practice drills. Practice review is helpful in improving practice.
“I have gone to various training such as LSS training, that is, life-saving skills; Mc pop training, that is, mandatory continuing professional development programme;
DEAQHSN – Delivering Effective and Quality Health Service in Nigeria (training); PAHCG (A Pivot to Adequate Health Care at the Grassroot), etc. These trainings occur once every three to four years”.
“I need continuous training and retraining because practices are changing as well as drugs used in management of illnesses”.
Effective management of massive PPH is dependent upon timely collaborative multidisciplinary team approach. Midwives are therefore encouraged to escalate care in a timely manner to their senior colleagues and other multidisciplinary team members such as the obstetricians and anaesthetists for women experiencing severe PPH to enhance optimum provision of care to them.
“As a midwife, I was involved with the multidisciplinary team including obstetricians and anaesthetists in looking after patients diagnosed to have intractable post-partum haemorrhage and not managed with standard medical treatment and were subsequently treated with operative interventions. The operative interventions were successful”
“Midwives should not delay in transferring care to doctors if they can’t control the bleeding. More studies are required on how to recognise and rectify any deficiencies in midwifery practice for urgent transfer of patient for surgery if indicated. If bleeding cannot be managed by midwives, they must transfer the care to doctors because surgery may be required to save the woman’s life”.