Midwives’ experiences of reducing maternal morbidity and mortality from postpartum haemorrhage (PPH) in Eastern Nigeria

This qualitative study was carried out to explore midwives’ experiences in reducing maternal mortality and morbidity from PPH in rural Eastern Nigeria.

A purposive sample of 15 qualified and practicing midwives with experiences of preventing and managing PPH willingly participated in the study. An administrative staff member in the labour ward acted as gatekeeper to recruit the participants. The process of recruitment involved issuing an initial notice about the study and invitation to participate. An information leaflet was issued subsequently.

Data were collected by the first author (FAK) through semi-structured interviews with 15 participants from health care facilities in Arochukwu Local Government Area (LGA) of Abia State in South East Nigeria from November 2018 to February 2019. Arochukwu LGA is populated by the Ibo ethnic group. It shares boundaries with other ethnic groups such as the Ibibios in Akwa Ibom State and the Efik in Cross River State (Figs. 1 and 2) [25, 26].

The interviews took place in convenient locations chosen by the participants. An interview guide (supplementary file) was used with introductory open-ended questions such as: Please tell me about your experiences of preventing and managing PPH in your rural community. What is it like to prevent and manage PPH in your health facility? The rationale for using semi-structured interviews was to enable the participants to freely respond and discuss their experiences in their own words. These interviews also provided additional benefits of enabling the researchers to probe and clarify some points with the participants in a more flexible way. The interviews lasted between 40 and 55 min. Interviews were audio-recorded. Data were transcribed verbatim. Data saturation occurred after 15 interviews. This means that no new theme emerged. A decision was made at that point to stop collecting data. Data saturation was confirmed by both authors (FAK and JNC), who are researchers and lecturers in midwifery.

Data were analysed independently by both authors using a qualitative content analysis approach as identified by Graneheim and Lundman, to provide new insights and more understanding of the experiences of midwives and to inform practical action [27‐29]. The content analysis was guided by the research questions, and answers were provided through examining all texts of the interviews. The research question was: What is it like to prevent and manage PPH in a rural community in Nigeria? The transcripts were read and re-read by each author and those words and sentences containing evidence and information regarding the research question were classified as meaning units. This was followed by condensing and coding of the meaning units, which were further sorted into their corresponding categories. Finally, the underlying meaning of the categories was organized into different themes. The findings of both authors were discussed together to reach consensus. Four themes that reflected the aim of the study emerged from data analysis.

Data trustworthiness was achieved using Lincoln and Guba’s framework for ensuring rigor as a guide. This framework includes credibility, transferability, dependability and confirmability [30]. To achieve credibility of the study, member checking was carried out to confirm the accuracy of the themes. This means that the researchers returned to the participants individually after the interviews to confirm the accuracy of the findings. All participants confirmed that the transcripts contained accurate information. During the interviews, participants were encouraged to clearly explain the meaning of their experiences. Credibility of the study was further enhanced through reflexivity. This was achieved by the researchers’ efforts to control bias through self-awareness and by describing and interpreting their own experiences of the study as researchers [31, 32]. In relation to transferability of the study findings, the researchers have placed the study in context by providing readers with examples of other studies with similar phenomena. Dependability is about the stability of the findings over time [30]. The phenomena of interest, design and methods remained the same throughout the study to enhance dependability. Although new interviews could lead to new phenomena, use of the interview guide enabled participants to remain focused on the topic. Confirmability was achieved by ensuring credibility, transferability and dependability of the study.

The researchers kept reflective research diaries and remained engaged in critical self-awareness throughout the process to prevent bias. In addition, the research skills, their knowledge as educators in midwifery and previous roles as midwifery practitioners enabled them to be theoretically sensitive to the emerging themes. Furthermore, their professional background as midwives helped to communicate effectively with participants who were also midwives, having similar background knowledge and vocabulary.

Antenatal care provided opportunities for assessing and promoting maternal well-being in general, and preventing PPH through assessment, diagnosis and detecting risk factors associated with the development of anaemia during pregnancy. This category contains two sub-categories:

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 haemoglobin as well as correcting anaemia in pregnancy to prevent complications of severe haemorrhage. In addition, folic acid supplementation was recommended throughout pregnancy to prevent folic acid deficiency. The combined use of folic acid and iron tablets helped to prevent iron deficiency during pregnancy. Women were also informed that folic acid can also help prevent congenital anomaly such as neural tube defect, which may develop in the first trimester.

“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”

“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 the importance of prophylactic treatment of malaria.

“We give presumptive treatment to prevent malaria during pregnancy because malaria can lead to anaemia".

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 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 effects on their health”.

Antenatal visits provided opportunities for health education aimed at promoting women’s health and wellbeing during pregnancy. The importance of eating healthy diet was discussed as well as the benefits of giving birth in health facilities.

“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 birth”

"Antenatal health education is a very good tool. I advise women to eat a balanced diet to prevent anaemia."

Women were also given advice on preparation for labour and childbirth. The midwives provided women with information about active management of the third stage of labour to prevent PPH.

“To prevent PPH in my community setting we use active management of third stage of labour, especially when they have risk factors. We have proper health education during antenatal care. We prepare them for labour and birth during the antenatal clinic, health talk and training.”

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. Health care staff with bilingual abilities and other voluntary translators acted as informal interpreters because none of the health facilities had professional translators.

“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 women can be challenging. Some 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”

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 pains as well as providing emotional support. 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. In addition, qualified and experienced midwives were able to carry out manual removal of placenta using sterile gloves.

“How I manage 2^nd and 3^rd stages of labour in labour ward is 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 give 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 using uterotonic agents such as ergometrine, syntocinon and misoprostol. 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 has 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.

“What helps me to prevent PPH is the use of misoprostol, good history taking and careful conducting of delivery”

The midwives’ understanding of PPH as an emergency, frightening and life-threatening condition enhanced their abilities to provide prompt medical and emotional care to the women and their birth partners to reduce the risks of complications and emotional distress. The midwives also discussed the challenges they experienced when managing PPH. Thus, the theme contains two categories: (a) Medical care following PPH and (b) Emotional support.

Prevention and management of PPH posed considerable challenges to the midwives in rural clinical setting and communities. Hindrances to the provision of effective care of PPH included access to maternity care and inadequate resources for managing PPH. Ways of overcoming these challenges in rural health care settings were also discussed.

Problems with access to maternity care centres resulted in delay in treatment of women. These include difficulties with transport and late referral from maternity home to health care facilities.

“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”.

Inadequate resources were identified as a major barrier to the midwives’ efforts in adequate prevention and management of PPH. Insufficient resources such as infrastructure, labour ward equipment, laboratory facilities, medication, staff shortages were inhibitory factors for the provision of timely and adequate care. The government provided some medications and gloves, but medications were insufficient. Women and their relatives paid for the medications used to prevent and treat PPH.

“What inhibits 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”

“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 effective management of PPH was challenging, the midwives were motivated by the passion they had for their work, and determination to prevent maternal mortality and morbidity.

“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”.

It is essential that midwives are adequately supported by their organisations and the government to overcome the challenges of inadequate resources including human resources.

“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 patients 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 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 standards of care to women everywhere.

“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, lifesaving skills; Mc pop training, that is, mandatory continuing professional development programme; Delivering Effective and Quality Health Service training in Nigeria (DEAQHSN); A Pivot to Adequate Health Care at the Grassroot (PAHCG). These training programs occur once every three to four years”.

Effective management of massive PPH is dependent upon a 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.

“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 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 patients for surgery if indicated. If bleeding cannot be managed by midwives, they must transfer to doctors because surgery may be required to save the woman’s life”.