Described the problems of post-partum haemorrhage in Nigeria. Also gives a direction for the way forward

1. The scourge of post
partum haemorrhage
in NIGERIA
BY
DR DUUM NWACHUKWU
MBBS, FWACS,FMCOG, DMAS

2. INTRODUCTION
• Postpartum haemorrhage (PPH) is a major risk for mothers &
newborns in Nigeria. Limited access to quality healthcare services and
inadequate prenatal care contributes to the high incidence of this life-
threatening condition.
• Postpartum haemorrhage is excessive bleeding following the birth of
a baby and is a leading cause of maternal morbidity and mortality in
Nigeria.

3. DEFINATION
• It is one of the leading causes of maternal mortality worldwide,
including in Nigeria.
• Postpartum haemorrhage is defined as blood loss of more
than 500 mL following a vaginal delivery or more than 1000 mL
following cesarean delivery. A loss of these amounts within 24
hours of delivery is termed early or primary PPH, whereas such
losses are termed late or secondary PPH if they occur 24
hours after delivery.
•

4. PROBLEMS WITH THIS DEFINITION
• The definition of PPH is somewhat arbitrary and
problematic. Estimates of blood loss at delivery are
subjective and generally inaccurate. Studies have
suggested that caregivers consistently underestimate
actual blood loss. Another proposal suggests using a
10% fall in hematocrit value to define PPH, but this
change is dependent on the timing of the test

5. PROBLEMS WITH THIS DEFINITION(cont)
• Another consideration is the differing capacities of individual patients
to cope with blood loss. A healthy woman has a 30-50% increase in
blood volume in a normal singleton pregnancy and is much more
tolerant of blood loss than a woman who has preexisting anaemia, an
underlying cardiac condition, or a volume-contracted condition
secondary to dehydration or preeclampsia.
• For these reasons, PPH should be diagnosed with any amount of
blood loss that threatens the hemodynamic stability of the woman.

6. STATISTICS
• A study published in the Nigerian Journal of Clinical Practice in 2018 examined the
incidence and risk factors of PPH among women who delivered at a tertiary hospital in
North-Western Nigeria. The study reported an overall incidence rate of 6.9% for PPH
among the participants. It also identified risk factors such as prolonged labour,
instrumental delivery, and multiple pregnancies that increased the likelihood of
experiencing PPH.
Another study published in BMC Pregnancy and Childbirth in 2019 investigated the
prevalence and associated factors of PPH among women who gave birth at a secondary
healthcare facility in Southwestern Nigeria. The study found that out of 1,200 participants,
7.3% experienced PPH. Factors such as primiparity (being a first-time mother), prolonged
labour, and episiotomy were significantly associated with an increased risk of PPH.
Furthermore, a systematic review and meta-analysis published in BMC Pregnancy and
Childbirth in 2020 aimed to estimate the prevalence of PPH in Nigeria based on available
studies. The review included 25 studies conducted between 2000 and 2019,
encompassing both facility-based and community-based settings. The findings revealed a
pooled prevalence of PPH of 6.9% among women in Nigeria.

7. The Devastating Impacts of Postpartum
Hemorrhage
• Mother: PPH can lead to maternal mortality, disability, depression,
and an inability to breastfeed or care for her infant.
• Economics Impact: PPH can lead to increased healthcare costs,
decreased productivity and increased poverty in affected families.

8. The Road to Saving Lives
• Skilled care during childbirth:
45%
• Nigeria has one of the highest maternal
mortality rates in the world, but with
crucial investments in healthcare
infrastructure and additional medical
resources, this problem can be
prevented, and lives can be saved.

9. PPH Risk Factors
Antepartum
• Pre-eclampsia
• Multiparity
• Multiple gestations
• Previous postpartum
haemorrhage
• Previous caesarean section
Intrapartum
• Prolonged third stage (>30 mins)
• Arrest of descent
• Episiotomy
• Lacerations: cervical, vaginal, perineal
• Assisted delivery: forceps, vacuum
• Augmented labour

10. Active management of third stage of labour
(AMTSL)
(AMTSL) is the key to reducing the risk of the complications
• As soon as the baby is delivered, put it on the mother’s abdomen in skin-to-skin contact
with her. Cover them with a blanket.
• Clamp the baby’s umbilical cord at two sites and cut it in between.
• Check the uterus for the presence of a second baby.
• In less than one minute, administer a uterotonic drug (a hormone-like chemical that
makes the uterus contract more powerfully).
• Apply controlled cord traction.
• After delivery of the placenta, immediately start massaging the uterus.
• Examine the placenta to make sure it is complete and none of it has been retained in the
uterus.
• Examine the woman’s vagina, perineum and external genitalia for lacerations and active
bleeding.

11. Causes of PPH:
The Four “Ts”
• Tone (70%)
• Trauma (20%)
• Tissue (10%)
• Thrombin (1%)

12. Prevention and Treatment of Postpartum
Hemorrhage
• Preparation: Prepare for childbirth with comprehensive
prenatal care and delivery with skilled birth attendants.
• Early detection: Using evidence-based protocols to identify
women at risk can help manage delivery and prevent
complications.
• Active management: This involves the use of prophylaxis
drugs, uterotonics, and other such measures to manage
delivery by a skilled healthcare provider
• Rescue interventions: Welcome, facility-based routine care
and emergency protocols are effective interventions for PPH
prevention and treatment.

13. PPH:
Resuscitative Measures
• Call for help
• Airways, Breathing, Circulation
• Two large-bore IVs
• Oxygen
• Stat labs: type & cross, hb, coags
• Consider transfusion

14. Treatment Approach for PPH
• Catheterise bladder
• Uterine massage
• Oxytocics: OXYTOCIN, ERGOT, MISOPROSTOL, CARBITOCIN
• Inspect for lacerations
• Surgical intervention

15. Access to Quality Healthcare Services
1 Infrastructure &
Transportation 🚧
The government and private
sector must invest in building
and maintaining healthcare
infrastructure and
transportation systems to
facilitate access to quality
healthcare services.
2 Underserved Areas 📍
The lack of skilled birth
attendants and emergency
obstetric care facilities in
remote areas has worsened
the problem of postpartum
hemorrhage in Nigeria.
3 Training & Capacity
Building 🏋️♀️
Continuous training and
capacity building initiatives for
healthcare providers can
improve knowledge and skills
needed to tackle postpartum
hemorrhage effectively.

16. Comprehensive Prenatal Care Matters
Importance of Regular Check-
ups
Regular check-ups during pregnancy can
help detect potential complications and
reduce the risk of postpartum
hemorrhage.
Nutrition & Proper Care
Women need proper nutrition and
prenatal care to stay healthy during
pregnancy and prevent complications like
postpartum hemorrhage.
Antenatal Education Programs
Antenatal education programs can raise
awareness about the risks and warning
signs of postpartum hemorrhage and
empower women and their families to
seek medical attention when needed.

17. Collaboration is Key
1
Government Intervention
️
The government must create
policies that prioritize maternal
healthcare, including funding for
healthcare infrastructure,
training programs, and maternal
health education initiatives.
2
Community Engagement
🌟
Healthcare professionals,
community leaders, and
traditional birth attendants must
cooperate to ensure that
pregnant women have access to
quality healthcare and that
cultural beliefs do not hamper
medical intervention.
3
Training & Capacity
Building 📚
Training programs for traditional
birth attendants can equip them
with the skills to recognize and
manage postpartum
hemorrhage. Healthcare
professionals also need
continuous training to update
their knowledge and skills.

18. The Importance of Prompt Medical Attention
Rising to the Challenge 💪
Women and families must
recognize the warning signs of
postpartum hemorrhage, such
as excessive bleeding, and seek
immediate medical attention.
Overcoming Cultural
Barriers 🌍
Cultural beliefs and practices
that hinder prompt medical
intervention must be addressed
through culturally sensitive
education and outreach
programs.
Advancing Technology &
Innovation 🌐
Advances in technology and
innovation must be leveraged to
improve the diagnosis,
prevention, and treatment of
postpartum hemorrhage.

19. Improving Maternal Health Outcomes
A Shared Responsibility
Improving maternal health outcomes in
Nigeria requires collaborative efforts
between the government, healthcare
professionals, community leaders, and
traditional birth attendants.
Access to Family Planning
Services
Improving access to family planning
services can reduce the incidence of
postpartum hemorrhage by spacing
pregnancies and allowing women to plan
their families.
Early Pregnancy Testing & Care
Early and effective pregnancy testing and
care can reduce the risk of complications
during childbirth and postpartum
hemorrhage.

20. Making Progress Together
1 Data Collection &
Reporting 📝
The collection and
analysis of data on
maternal health outcomes
can help to understand
and address the drivers of
postpartum hemorrhage in
Nigeria.
2 Advocacy &
Awareness 📣
Advocacy and awareness
campaigns are crucial to
mobilizing resources and
public support to address
the problem of postpartum
hemorrhage in Nigeria.
3 Research & Innovation 🔬
Research and innovation can lead to new interventions and
approaches that can improve maternal health outcomes and
prevent postpartum hemorrhage.

21. Empowering Women & Families
1 Maternal Health Education 🎓
Providing education and information to women
and families about maternal health and
postpartum hemorrhage can empower them to
make informed decisions and take action when
needed.
2
Maternal Healthcare Services 🚺
Ensuring access to quality maternal healthcare
services, including skilled birth attendants,
emergency obstetric care, and postpartum
follow-up care, can improve maternal health
outcomes in Nigeria.
3 Community Support ️
Community support can be mobilized to help
pregnant women access healthcare services
and promote positive maternal health
behaviors, leading to better outcomes for
mothers and newborns.

22. Investment in Maternal Health
Governments & Organizations ️
Governments, organizations, and other
stakeholders must invest in maternal
healthcare to achieve better health
outcomes in Nigeria.
Family Support ️
Family support is crucial to ensuring that
pregnant women have access to the care
and resources they need to prevent and
manage postpartum hemorrhage.
Advances in Healthcare
Technology 🚀
Advances in healthcare technology, such
as telemedicine and remote monitoring,
can improve access to quality maternal
healthcare services, particularly in remote
areas.

23. The Way Forward
1 Collaboration &
Partnership ️
Collaborative partnerships
between the government,
healthcare professionals,
traditional birth attendants,
community leaders, and
organizations can help to prevent
postpartum hemorrhage and
improve maternal health
outcomes in Nigeria.
2 Empowerment &
Education 📚
Empowering women and families
through education and
awareness can enable them to
seek prompt medical attention
and prevent postpartum
hemorrhage.
3 Investment & Innovation
🔎
Investments in infrastructure,
training, and innovation can help
to overcome barriers and
improve maternal health
outcomes in Nigeria.

24. CONCLUSION
• EDUCATION
• AND
• EMPOWERMENT
• OF
• WOMEN AND COMMUNITY

25. .
thanks for
listening

26. BIBLIOGRAPHY
• Shittu O.S, Otubu JAM, postpartum Haemorrhage in Agboola A (ED).
Textbook of obstetrics and gynaecology for medical students 2nd edition.
Heinemann Educational books (Nig) Plc 2006: 481-488.
• Koh E, Devendra K, Tan L K. B-Lynch suture for the treatment of uterine
atony. Singapore Med J 2009; 50(7): 693-697.
• Anderson JM, Etches Duncan. Prevention a n d ma n a g eme n t o f P o st p
a rt um Haemorrhage. Am Fam Physician 2007; 75: 875-882.
• WHO. Guidelines for the Prevention of Postpartum Haemorrhage. Geneva:
World Health Organization. 2007.
• Ajenifuja KO, Adepiti CA, Ogunniyi SO. Postpartum Haemorrhage in a
Teaching Hospital: a 5-year experience. Afr Health Sci; 2010 10: 71-74.

27. • Oladapo OT, Fawole B, Blum J, Abalos E. Advance distribution of misoprostol for
preventing and treating excessive blood loss after birth. Cochrane Database of
Systematic Reviews. February 15, 2012.
• National Population Commission (NPC) [Nigeria] and ICF. Nigeria Demographic
and Health Survey 2018 Key Indicators Report. NPC and ICF; 2019.
• Meh C, Thind A, Ryan B, Terry A. Levels and determinants of maternal mortality
in northern and southern Nigeria. BMC Pregnancy Childbirth. 2019; 19: 1- 13.
• Bohren MA, Lorencatto F, Coomarasamy A, et al. Formative research to design
an implementation strategy for a postpartum haemorrhage initial response
treatment bundle (E-MOTIVE): study protocol. Reprod Health. 2021; 18: 149.
• United Nations, Department of Economic and Social Affairs, Population Division.
World Population Prospects 2019: Data Booket. ST/ESA/SER. A/424. UN; 2019.
• Makinde OA, Sule A, Ayankogbe O, Boone D. Distribution of health facilities in
Nigeria: implications and options for universal health coverage. Int J Health Plann
Manage. 2018; 33: e1179- e1192.

28. • Mutihir JT, Utoo BT. Postpartum maternal morbidity in Jos, North-Central Nigeria. Niger J Clin
Pract. 2011; 14: 38- 42.
• Onyema OA, Cornelius AC, Uchenna ET, Duke OA. Primary postpartum haemorrhage in a Federal
Medical Centre, Owerri, Nigeria: a six-year review. Niger J Med. 2015; 24: 242- 245.
• Galadanci H, Künzel W, Zinser R, Shittu O, Adams S, Gruhl M. Experiences of 6 years quality
assurance in obstetrics in Nigeria - a critical review of results and obstacles. J Perinat Med. 2016;
44: 301- 308.
• Muhammad R, Isah A, Agida T, Akaba G. A prospective study to compare the effectiveness of
adjunctive rectal misoprostol or oxytocin titration in the prevention of primary post-partum
haemorrhage in at-risk patients. Afr Health Sci. 2019; 19: 1517- 1524.
• Da’u A, Kumurya AS, Bello MM, Galadanchi H, Getso KI. Availability of emergency obstetric care
(EMOC) in Kano Metropolis, Nigeria. Int J Adv Case Rep. 2016; 3: 345- 353.
• Suarez S, Conde-Agudelo A, Borovac-Pinheiro A, et al. Uterine balloon tamponade for the
treatment of postpartum haemorrhage: a systematic review and meta-analysis. Am J Obstet
Gynecol. 2020; 222: 293.e1- 293.e52.