The impact of human immunodeficiency virus infection on obstetric hemorrhage and blood transfusion in South Africa

Abstract

Background Globally, as in South Africa, obstetric hemorrhage (OH) remains a leading cause of maternal mortality and morbidity. Although blood transfusion is critical to OH management, the incidence and predictors of transfusion as well as their relation to HIV infection are poorly described. Study Design and Methods A cross-sectional study was conducted of all peripartum patients at four major hospitals in South Africa (April to July 2012). Comprehensive clinical data were collected on patients who sustained OH and/or were transfused. Logistic regression was used to model risk factors for OH and transfusion. Results A total of 15,725 peripartum women were evaluated, of whom 3,969 (25.2%) were HIV positive. Overall, 387 (2.5%) women sustained OH and 438 (2.8%) were transfused, including 213 (1.4%) women with both OH and transfusion. There was no significant difference in OH incidence between HIV positive (2.8%) and HIV negative (2.3%) patients (adjusted OR = 0.95, 95% CI 0.72–1.25). In contrast, the incidence of blood transfusion was significantly higher in HIV positive (3.7%) than in HIV negative (2.4%) patients (adjusted OR = 1.52, 95% CI 1.14–2.03). Other risk factors for transfusion included OH, low prenatal hemoglobin, the treating hospital, lack of prenatal care and gestational age ≤34 weeks. Conclusion In the South African obstetric setting, the incidence of peripartum blood transfusion is ten-fold higher than in the U.S. and other high-income countries while OH incidence is similar. While OH and prenatal anemia are major predictors of transfusion, HIV infection is a common and independent contributing factor.

Antenatal blood transfusion in South Africa: indications and practice in a high‐HIV‐prevalence setting

“…In our study, RBC transfusion for anemia was strongly associated with advanced gestational age. This supports findings from our prior studies of peripartum transfusion practice in South Africa, which suggested that unaddressed antenatal anemia is a significant risk factor for later maternal transfusion. Anemia renders pregnant patients less likely to tolerate the physiological blood loss that accompanies delivery.…”

“…[5][6][7] The findings suggest excess rates of transfusion, relative to those of several high-income countries, despite comparable rates of hemorrhage. 6 Reasons that have been postulated for these increased rates of transfusion include a high prevalence of antenatal anemia, rendering some patients unable to tolerate the physiological blood loss associated with delivery. High incidence of peripartum blood transfusion is not unique to South Africa; rather, it is a major challenge in sub-Saharan Africa, where there is already inability to meet regional transfusion demand.…”

“…Of note, South Africa has a high HIV prevalence, and HIV testing is performed routinely during prenatal care. We have previously reported on perinatal (i.e., within 48 hours of delivery) transfusions at these hospitals under the Recipient Epidemiology and Donor Evaluation Study‐III (REDS‐III) . South Africa is ranked by the World Bank as an upper‐middle‐income country.…”

“…Blood use offers insight into obstetric practices and outcomes, and can serve to identify deficiencies in care. Several studies have been conducted in South Africa to characterize peripartum blood use . The findings suggest excess rates of transfusion, relative to those of several high‐income countries, despite comparable rates of hemorrhage .…”

“…Several studies have been conducted in South Africa to characterize peripartum blood use . The findings suggest excess rates of transfusion, relative to those of several high‐income countries, despite comparable rates of hemorrhage . Reasons that have been postulated for these increased rates of transfusion include a high prevalence of antenatal anemia, rendering some patients unable to tolerate the physiological blood loss associated with delivery.…”