Background
Methods
Study design and setting
Research design
Setting
Study participants
Data collection procedures
Data collection for maternal factors
Procedure
Data collection for health service factors
Data analysis
Results
Women’s characteristics
Patients (%) (n = 1613) | None PPH (n = 1613) | PPH (n = 220) | P -Value | ||||
---|---|---|---|---|---|---|---|
n | % | n | % | ||||
Age | 0.631 | ||||||
< 20 years | 376 (20.5) | 336 | 89.4 | 40 | 10.6 | ||
20–34 years | 1241 (67.7) | 1089 | 87.8 | 152 | 12.2 | ||
≥ 35 years | 216 (11.8) | 188 | 87.0 | 28 | 13.0 | ||
(Minimum = 11 yr., Maximum = 49 yr., mean = 26 yr., SD ± 6.68) | |||||||
Gestational age | 0.69 | ||||||
< 38 wks | 395 (21.5) | 358 | 83.2 | 37 | 16.8 | ||
38–42 wks | 1438 (78.5) | 1255 | 77.8 | 183 | 22.2 | ||
Parity | .897 | ||||||
Primiparous | 651 (35.5) | 527 | 87.9 | 79 | 12.1 | ||
Multiparous | 1182 (64.5) | 1041 | 88.1 | 141 | 11.9 | ||
Complication during pregnancy | |||||||
Anemia | < 0.001 | ||||||
No | 1688 (92.1) | 1499 | 92.9 | 114 | 7.1 | ||
Yes | 145 (7.9) | 189 | 85.9 | 31 | 14.1 | ||
Twin | .255 | ||||||
No | 1830 (99.8) | 1611 | 88 | 219 | 12 | ||
Yes | 3 (0.2) | 2 | 66.7 | 1 | 33.3 | ||
GDM | .096 | ||||||
No | 1803 (98.4) | 1590 | 88.2 | 213 | 11.8 | ||
Yes | 30 (1.6) | 23 | 76.7 | 7 | 23.3 | ||
Past history of PPH | .003 | ||||||
No | 1824 (99.5) | 1608 | 88.2 | 174 | 11.8 | ||
Yes | 9 (0.5) | 5 | 55.6 | 46 | 44.4 | ||
Complication during labor | |||||||
-Retained placenta | < 0.001 | ||||||
No | 1781 (97.2) | 1607 | 90.2 | 174 | 9.8 | ||
Yes | 52 (2.8) | 6 | 11.5 | 46 | 88.5 | ||
-Poor ut.contractions | < 0.001 | ||||||
No | 1725 (94.1) | 1606 | 93.1 | 119 | 6.9 | ||
Yes | 108 (5.9) | 7 | 6.5 | 101 | 93.5 | ||
Method of delivery | .337 | ||||||
Normal birth | 1763 (96.2) | 1555 | 88.2 | 208 | 11.8 | ||
F/E | 9 (0.5) | 8 | 88.9 | 1 | 11.1 | ||
V/E | 61 (3.3) | 50 | 82 | 11 | 18 | ||
Birth assistant | 0.45 | ||||||
Obstetricians | 202 (11.1) | 174 | 86.1 | 28 | 13.9 | ||
Nurse midwives | 1617 (88.7) | 1426 | 88.2 | 191 | 11.8 | ||
Medical students | 5 (0.3) | 4 | 80 | 1 | 20 | ||
Nursing students | 4 (0.2) | 4 | 100 | 0 | 0 | ||
Episiotomy | .308 | ||||||
Yes | 1478 (80.6) | 1295 | 87.6 | 183 | 12.4 | ||
No | 355 (19.4) | 318 | 89.6 | 37 | 10.4 | ||
Perineum lacerations | < 0.001 | ||||||
Intact Perineum | 377 (20.6) | 356 | 94.4 | 21 | 5.6 | ||
First Degree | 332 (18.1) | 282 | 84.9 | 50 | 15.1 | ||
Second Degree | 1096 (59.8) | 958 | 87.4 | 138 | 12.6 | ||
Third and Fourth | 28 (1.5) | 17 | 60.7 | 11 | 39.3 | ||
Using uterotonic drugs | .39 | ||||||
Yes | 1756 (95.8) | 15 | 6.8 | 205 | 93.2 | ||
No | 77 (4.2) | 62 | 3.8 | 1551 | 96.2 | ||
Duration of labor | |||||||
1st stage of labor | .305 | ||||||
< 10 h. | 1344 (73.3) | 1189 | 88.5 | 155 | 11.5 | ||
> 10 h. | 489 (26.7) | 424 | 86.7 | 65 | 13.3 | ||
2nd stage of labor | < 0.001 | ||||||
< 1 h. | 1774 (96.8) | 1573 | 88.7 | 201 | 11.3 | ||
> 1 h. | 59 (3.2) | 40 | 67.8 | 19 | 32.2 | ||
3rd stage of labor | < 0.001 | ||||||
< 20 min | 1760 (96.0) | 1575 | 89.5 | 185 | 10.5 | ||
> 20 min | 73 (4.0) | 38 | 52.1 | 35 | 47.9 | ||
Baby birth weight | < 0.001 | ||||||
< 2500 g | 109 (5.9) | 100 | 91.7 | 9 | 8.3 | ||
2500–3500 g | 1487 (81.1) | 1327 | 89.2 | 160 | 10.8 | ||
> 3500 g | 237 (12.9) | 186 | 78.5 | 51 | 21.5 |
Characteristics of health service
Hospital characteristics
Characteristic | Type of hospital | Total (n = 14) | |||||
---|---|---|---|---|---|---|---|
Region (n = 1) | General (n = 4) | District (n = 9) | |||||
Services provided (EmOC signal functions) | |||||||
1. Parental oxytocics | 1 | 4 | 9 | 14 | |||
2. Parental antibiotics | 1 | 4 | 9 | 14 | |||
3. Parental anticonvulsants | 1 | 4 | 9 | 14 | |||
4. Assisted vaginal delivery | 1 | 4 | 9 | 14 | |||
5. Removal of retained products | 1 | 4 | 5 | 10 | |||
6. Manual removal of placenta | 1 | 4 | 8 | 13 | |||
7. Blood transfusion provided | 1 | 4 | 9 | 14 | |||
8.Caesarean section | 1 | 4 | 3 | 8 |
Factors associated with PPH
n (%) | None PPH (n = 1613) | PPH (n = 220) | P-Value | Crude OR (95% CI) | |||
---|---|---|---|---|---|---|---|
n | % | n | % | ||||
Anemia | |||||||
No | 1688 (92.1) | 1499 | 92.9 | 114 | 7.1 | Ref. | |
Yes | 145 (7.9) | 189 | 85.9 | 31 | 14.1 | 0.001 | 2.16 (1.37, 3.40) |
Past history of PPH | |||||||
No | 1824 (99.5) | 1608 | 88.2 | 216 | 11.8 | Ref. | |
Yes | 9 (0.5%) | 5 | 55.6 | 4 | 44.4 | 0.01 | 5.65 (1.42, 22.47) |
Perineum lacerations | |||||||
Intact | 377 (20.6) | 356 | 94.4 | 21 | 5.6 | Ref. | |
First Degree | 332 (18.1) | 282 | 84.9 | 50 | 15.1 | 1.98 (0.97, 4.05) | |
Second Degree | 1096 (59.8) | 958 | 87.4 | 138 | 12.6 | 1.86 (1.01, 3.45) | |
Third and Fourth degree | 28 (1.5) | 17 | 60.7 | 11 | 39.3 | < 0.001 | 9.75 (3.25, 29.24) |
-Retained placenta** | |||||||
No | 1781 (97.2) | 1607 | 90.2 | 174 | 9.8 | Ref. | |
Yes | 52 (2.8) | 6 | 11.5 | 46 | 88.5 | < 0.001 | 52.25 (19.03,143.46) |
-Poor ut.contractions** | |||||||
No | 1725 (94.1) | 1606 | 93.1 | 119 | 6.9 | Ref. | |
Yes | 108 (5.9) | 7 | 6.5 | 101 | 93.5 | < 0.001 | 172.69 (76.89,387.85) |
Baby birth weight | |||||||
< 2500 g | 109 (5.9) | 100 | 91.7 | 9 | 8.3 | 0.87 (0.42, 1.78) | |
2500-3500 g | 1487 (81.1) | 1327 | 89.2 | 160 | 10.8 | Ref. | |
> 3500 g | 237 (12.9) | 186 | 78.5 | 51 | 21.5 | < 0.001 | 3.05 (1.44, 6.44) |
Duration of labor | |||||||
1st stage of labor | |||||||
< 10 h. | 1344 (73.3) | 1189 | 88.5 | 155 | 11.5 | Ref. | |
> 10 h. | 489 (26.7) | 424 | 86.7 | 65 | 13.3 | 0.305 | 1.09 (0.79, 1.51) |
2nd stage of labor | |||||||
< 1 h. | 1774 (96.8) | 1573 | 88.7 | 201 | 11.3 | Ref. | |
> 1 h. | 59 (3.2) | 40 | 67.8 | 19 | 32.2 | < 0.001* | 3.56 (1.98, 6.41) |
3rd stage of labor | |||||||
< 20 min | 1760 (96.0) | 1575 | 89.5 | 185 | 10.5 | Ref. | |
> 20 min | 73 (4.0) | 38 | 52.1 | 35 | 47.9 | < 0.001* | 7.69 (4.72, 12.54) |
n (%) | None PPH (n = 1613) | PPH (n = 220) | P-value | Crude OR (95% CI) | |||
---|---|---|---|---|---|---|---|
n | % | n | % | ||||
Hospital levels | |||||||
Region | 276 (15.1) | 259 | 93.8 | 17 | 6.2 | Ref. | |
General | 861 (47.0) | 733 | 85.1 | 128 | 14.9 | 2.00 (1.57,4.49) | |
District | 696 (38.0) | 621 | 89.2 | 75 | 10.8 | < 0.001* | 1.84 (1.07,3.18) |
Having obstetrician | |||||||
No | 303 (16.5) | 259 | 85.5 | 44 | 14.5 | 0.140 | 1.31 (0.92,1.87) |
Yes | 1530 (83.5) | 1354 | 88.5 | 176 | 11.5 | Ref. | |
Having the standard of nurse midwife to patient. Ratio | |||||||
No | 1613 (88) | 157 | 82.6 | 33 | 17.4 | 0.016 | 1.83 (1.22,2.74) |
Yes | 220 (12) | 1456 | 88.6 | 187 | 11.4 | Ref. | |
Having nurse midwife working experience of 6–10 years | |||||||
No | 1613 (88) | 733 | 91.3 | 70 | 8.7 | < 0.001 | 1.83 (1.31,3.38) |
Yes | 220 (12) | 880 | 85.4 | 150 | 14.6 | Ref. | |
Workload | |||||||
< 25 days | 220 (12) | 247 | 87 | 37 | 13 | Ref. | |
> 25 days | 1613 (88) | 1366 | 88.2 | 183 | 11.8 | 0.009 | 2.01 (1.19,3.38) |
No. of Nurse midwives in day shift | |||||||
< 2 persons | 1613 (88) | 416 | 87.4 | 60 | 12.6 | 0.638 | 1.08 (0.79,1.48) |
> 2 persons | 220 (12) | 1197 | 88.2 | 160 | 11.8 | Ref. | |
No. of Nurse midwives in evening shift | |||||||
< 2 persons | 1613 (88) | 822 | 85.2 | 143 | 14.8 | < 0.001* | 1.79 (1.33,2.40) |
> 2 persons | 220 (12) | 791 | 91.1 | 77 | 8.9 | Ref. | |
No. of Nurse midwives in night shift | |||||||
< 2 persons | 1613 (88) | 822 | 85.2 | 143 | 14.8 | < 0.001* | 1.79 (1.33,2.40) |
> 2 persons | 220 (12) | 791 | 91.1 | 77 | 8.9 | Ref. | |
Adequate equipment and supply for EmOC | |||||||
No | 1344 (73.3%) | 1192 | 88.7 | 152 | 11.3 | 0.004 | 3.70 (1.54,8.93) |
Yes | 489 (26.68%) | 421 | 86.1 | 68 | 13.9 | Ref. |
The predictive factors associated with PPH
Factors | OR | 95% CI | P-value | |
---|---|---|---|---|
*Anemia (REF = No) | ||||
Yes | 1.29 | 0.64 | −2.58 | 0.481 |
Past history of PPH (REF = No) | ||||
Yes | 10.97 | 2.27 | −53.05 | 0.003 |
*Perineum lacerations (REF = Intact perineum) | ||||
First degree | 6.07 | 2.60 | −14.15 | 0.000 |
Second degree | 5.65 | 2.63 | −12.11 | 0.000 |
Third and fourth degree | 29.59 | 8.65 | − 101.20 | 0.000 |
*Retained placenta (REF = No) | ||||
Yes | 71.47 | 27.37 | − 186.65 | 0.000 |
*Poor uterine contractions (REF=No) | ||||
Yes | 260.11 | 111.15 | −608.70 | 0.000 |
Baby birth weight (REF = 2500–3500 g) | ||||
< 2500 g) | 0.79 | 0.30 | −2.73 | 0.635ns |
> 3500 g | 1.98 | 1.19 | −3.30 | 0.008 |
Hospital levels (REF = Regional hospital) | ||||
District hospital | 14.06 | 3.95 | −50.04 | 0.000 |
General hospital | 7.27 | 2.27 | −23.27 | 0.001 |
Adequate nurse midwife to patient ratio (REF = Yes) | ||||
No | 2.30 | 1.08 | −4.92 | 0.031 |
Having nurse midwife working experience of 6 to 10 years (REF=Yes) | ||||
No | 2.35 | 1.41 | −3.92 | 0.001 |
Adequate equipment and supply for EmOC (REF = Yes) | ||||
No | 6.47 | 1.93 | −21.63 | 0.002 |
Constant | 0.00 | 0.00 | −0.00 | 0.000 |
-log likelihood | − 369.65 | |||
AIC | 769.31 | |||
BIC | 852.01 |