Barriers to Timely and Safe Blood Transfusion for PPH Patients: Evidence from a Qualitative Study in Dhaka, Bangladesh

Abstract

Background and ObjectivesIn Bangladesh, postpartum hemorrhage (PPH) is the leading cause of maternal mortality accounting for 31% of all blood transfusions in the country. Although safe blood transfusion is one of the 8 signal functions of Comprehensive Emergency Obstetric Care (CEmOC) strategy, most of the designated public sector CEmOC facilities do not have on-site blood storage system. Emergent blood is mainly available from external blood banks. As a result, emergent patients are to rely on an unregulated network of brokers for blood which may raise question about blood safety. This study explored lived experiences of patients’ attendants, managers, providers, and blood brokers before and after the implementation of an on-line Blood Information and Management Application (BIMA) in regards to barriers and facilitators of blood transfusion for emergent patients.MethodsData were collected at Dhaka Medical College Hospital (DMCH), a tertiary-level teaching hospital before (January 2014) and after (March 2015) the introduction of an online BIMA system. Data collection methods included 24 key informant interviews (KIIs) and 40 in-depth interviews (IDIs). KIIs were conducted with formal health service providers, health managers and unlicensed blood brokers. IDIs were conducted with the relatives and husbands of women who suffered PPH, and needed emergency blood.ResultsPatients’ attendants were unaware of patients’ blood type and availability of blood in emergency situation. Newly introduced online BIMA system could facilitate blood transfusion process for poor patients at lower cost and during any time of day and night. However, service providers and service recipients were heavily dependent on a network of unlicensed blood brokers for required blood for emergent PPH patients. Blood collected through unlicensed blood brokers is un-screened, unregulated and probably unsafe. Blood brokers feel that they are providing a needed service, acknowledged a financial incentive and unaware about safety of blood that they supply.ConclusionsEnsuring safe and timely blood transfusion is necessary to end preventable maternal mortality. In a context where facilities have no on-site blood, and both providers and patient attendants are heavily dependent on an unregulated cadre of unlicensed blood brokers, access to timely safe blood transfusion is seriously threatened. BIMA is a promising intervention to reduce inefficiencies in obtaining blood, but steps must be taken to ensure buy-in from current purveyors of blood, and to increase the acceptance of the intervention.

The WOMAN trial: clinical and contextual factors surrounding the deaths of 483 women following post-partum haemorrhage in developing countries

“…Hence, in developing countries availability of blood for transfusion may be a factor that leads to maternal deaths. This agrees with other studies showing that poverty, lack of donors and logistic problems contribute to scarcity of safe blood in low-and middle-income countries [19][20][21][22][23][24][25]. However, our study cannot confirm that deficit of blood transfusion was a cause of death, nor that the transfusion was administered too late.…”

“…Several of the narratives highlighted the absence of blood for transfusion due to availability or cost. Poverty, lack of donors and logistic problems contribute importantly to blood shortages [19][20][21][22][23][24][25]. For women with severe anaemia, treatment of an established PPH is often too late to prevent death and effective prevention is needed.…”

Organizational models for health actions in the field of blood and blood products in Brazilian and Spanish regional contexts

“…The results of this study, summarized in Table 4, point to the importance of considering the population profile and the territorial dimension as key characteristics and, therefore, elements to understand the organizational differences that affect access to health services. The urban or rural concentration, as evidenced in the territories of Madrid and Extremadura, respectively, points out differences in blood supply, including limitations and challenges especially in rural areas, as studies show in other regions of the world, for example in the Sub-Saharan Africa [12] and in Asia, Bangladesh [13], and in maternity emergency units in rural India [14]. There is no information system made available by the 'Consejer ıa de Salud' .…”

<p>Transfusion Safety: Lessons Learned In Ibero-America And Considerations For Their Global Applicability</p>

“…44,45 Lack of government oversight, inadequate resources and fragmented national systems are some of the factors identified as responsible for poor access to safe blood, 46,47 which in turn leads to poor patient outcomes. 48,49 Recognizing regional heterogeneities, 50 identifying gaps within each country, focusing attention at the local levels, and using successful experiences as models [51][52][53][54] have been suggested as the basis for improving transfusion safety in LLMC. Table 6).…”