Influencing factors for prevention of postpartum hemorrhage and early detection of childbearing women at risk in Northern Province of Rwanda: beneficiary and health worker perspectives

Abstract

Background Reduction of maternal mortality and morbidity is a major global health priority. However, much remains unknown regarding factors associated with postpartum hemorrhage (PPH) among childbearing women in the Rwandan context. The aim of this study is to explore the influencing factors for prevention of PPH and early detection of childbearing women at risk as perceived by beneficiaries and health workers in the Northern Province of Rwanda. Methods A qualitative descriptive exploratory study was drawn from a larger sequential exploratory-mixed methods study. Semi‐structured interviews were conducted with 11 women who experienced PPH within the 6 months prior to interview. In addition, focus group discussions were conducted with: women’s partners or close relatives (2 focus groups), community health workers (CHWs) in charge of maternal health (2 focus groups) and health care providers (3 focus groups). A socio ecological model was used to develop interview guides describing factors related to early detection and prevention of PPH in consideration of individual attributes, interpersonal, family and peer influences, intermediary determinants of health and structural determinants. The research protocol was approved by the University of Rwanda, College of Medicine and Health Sciences Institutional Ethics Review Board. Results We generated four interrelated themes: (1) Meaning of PPH: beliefs, knowledge and understanding of PPH: (2) Organizational factors; (3) Caring and family involvement and (4) Perceived risk factors and barriers to PPH prevention. The findings from this study indicate that PPH was poorly understood by women and their partners. Family members and CHWs feel that their role for the prevention of PPH is to get the woman to the health facility on time. The main factors associated with PPH as described by participants were multiparty and retained placenta. Low socioeconomic status and delays to access health care were identified as the main barriers for the prevention of PPH. Conclusions Addressing the identified factors could enhance early prevention of PPH among childbearing women. Placing emphasis on developing strategies for early detection of women at higher risk of developing PPH, continuous professional development of health care providers, developing educational materials for CHWs and family members could improve the prevention of PPH. Involvement of all levels of the health system was recommended for a proactive prevention of PPH. Further quantitative research, using case control design is warranted to develop a screening tool for early detection of PPH risk factors for a proactive prevention.

Who is at risk? The development of a tool to predict and prevent postpartum hemorrhage

“…After consultation of the literature on PPH risk factors, the conclusion from the second round was to keep all items from the first round as the team was of the view that all items could be PPH risk factors from antenatal, intrapartum and postpartum periods. The RATP was then shaped with 46 items in three content domains (sections) on the tool: Section A, Social demographic characteristics of the woman (Items 1-10); Section B, Newborn and mother anthropometry and hemoglobin measurements (Items [11][12][13][14]; Section C, Pregnancy, obstetric, intrapartum and immediate postpartum factors (Items 15-46). The items are listed in Table 3.…”

“…In this study, we developed a content validated risk assessment tool for the prediction and prevention of PPH among childbearing women (RATP). To design the RATP, the items were generated from previous phases of this study which are published elsewhere: a scoping review [12] to describe the research output on factors affecting the prevention of PPH in low and middle income countries and a qualitative descriptive study [13] to explore the influencing factors for early detection and prevention of PPH as perceived by beneficiaries and health workers in the Northern Province of Rwanda. Our process to generate items is in agreement with Zamanzadeh et al [28] in a study focusing on the process used to assess content validity.…”

“…Fourteen participants out of fifteen agreed (agree and strongly agree) that using the tool would be an added value for PPH prevention. The majority of participants (13) agreed that the tool measured the continuity of care for PPH prevention. Then participants suggested that the tool needs to be available in three languages including French, English and Kinyarwanda to reduce language barriers as it was developed only in English.…”

“…The content domain or construct is identified by literature review, content analysis, and/or by conducting interviews with the respondents or focused groups. [31] For the present study, a scoping review and qualitative descriptive study [12,13] were conducted to determine the content domain. This first step helped the researcher to identify an agreed definition of the domain of study and generate items at a preliminary stage.…”

“…Numerous factors contributing to high PPH morbidity and mortality rates have been identified both in developed and developing countries. In our previous two studies, [12,13] we conducted a scoping review and a qualitative descriptive study to identify salient factors associated with PPH, which concluded that it is important to set up strategies and approaches for early recognition of women at higher risk of developing PPH. Prata, Bell and Weidert [14] argue that structural barriers are further complicated by difficulties in predicting who will develop PPH.…”