Incidence and risk factors for postpartum hemorrhage in Uganda

Globally, postpartum haemorrhage (PPH) remains a leading cause of maternal deaths. However in many low and middle income countries, there is scarcity of information on magnitude of and risk factors for PPH (blood loss of 500 ml or more). It is important to understand the relative contributions of different risk factors for PPH. We assessed the incidence of, and risk factors for postpartum hemorrhage among rural women in Uganda.

Between March 2013 and March 2014, a prospective cohort study was conducted at six health facilities in Uganda. Women were administered a questionnaire to ascertain risk factors for postpartum hemorrhage, defined as a blood loss of 500 mls or more, and assessed using a calibrated under-buttocks drape at childbirth. We constructed two separate multivariable logistic regression models for the variables associated with PPH. Model 1 included all deliveries (vaginal and cesarean sections). Model 2 analysis was restricted to vaginal deliveries. In both models, we adjusted for clustering at facility level.

Among the 1188 women, the overall incidence of postpartum hemorrhage was 9.0%, (95% confidence interval [CI]: 7.5-10.6%) and of severe postpartum hemorrhage (1000 mls or more) was 1.2%, (95% CI 0.6-2.0%). Most (1157 [97.4%]) women received a uterotonic after childbirth for postpartum hemorrhage prophylaxis. Risk factors for postpartum hemorrhage among all deliveries (model 1) were: cesarean section delivery (adjusted odds ratio [aOR] 7.54; 95% CI 4.11-13.81); multiple pregnancy (aOR 2.26; 95% CI 0.58-8.79); foetal macrosomia ≥4000 g (aOR 2.18; 95% CI 1.11-4.29); and HIV positive sero-status (aOR 1.93; 95% CI 1.06-3.50). Risk factors among vaginal deliveries only, were similar in direction and magnitude as in model 1, namely: multiple pregnancy, (aOR 7.66; 95% CI 1.81-32.34); macrosomia, (aOR 2.14; 95% CI1.02-4.47); and HIV positive sero-status (aOR 2.26; 95% CI 1.20-4.25).

The incidence of postpartum hemorrhage was high in our setting despite use of uterotonics. The risk factors identified could be addressed by extra vigilance during labour and preparedness for PPH management in all women giving birth.