Excessive blood loss of 500 ml or more within 24 hours after childbirth, referred to as postpartum hemorrhage (PPH) is a critical condition responsible for most maternal deaths globally. This significant health concern is primarily caused by four major factors, often summarized as the "Four T's": Tone, Trauma Tissue, and Thrombin.
- Tone (Uterine Atony): (70%)The most common cause. This occurs when the uterus fails to contract adequately after delivery leading to continuous bleeding.
- Trauma (Lacerations): (20%)Physical injuries to the birth canal, including tears or lacerations can result in substantial blood loss.
- Tissue (Retained Placenta)(10%)Retained placental fragments can prevent the uterus from contracting properly, causing persistent bleeding.
- Thrombin (Coagulopathy)(<1%)Blood clotting disorders or coagulopathies can impede the body's ability to form clots exacerbating bleeding
[1]In Kenya, bleeding during pregnancy (Obstetric haemorrhage) is responsible for 40% of maternal deaths. This high mortality rate underscores the urgent need for improved maternal healthcare services and interventions to address and manage these complications effectively. To achieve the Sustainable Development Goals, (SDGs) indicators on maternal health, Kenya is working towards reducing maternal deaths from 355/100,000 to less than 100 deaths/100000 live births by the year 2030, contributing to the global commitment to reduce it to less than 70 maternal deaths /100000 live births . Factors contributing to this include limited access to quality prenatal and postnatal care, poor quality of maternal health medicines, inadequate healthcare infrastructure, shortage of skilled healthcare professionals and limited translation of national guidelines to practice.
[2]Sub-Saharan African and South Asian countries account for 87 of global maternal deaths. Obstetric haemorrhage is the leading cause of maternal mortality, accounting for 27% of all maternal deaths occurring worldwide each year. Most of these deaths are due to postpartum haemorrhage (PPH). This high mortality rate is exacerbated by factors such as poverty and cultural practices that encourage home births, which often lack the necessary medical support and interventions to manage severe bleeding. Even for those who seek medical care, the quality of drugs used, such as oxytocin, can be substandard.
According to Torloni (2020), there is a widespread challenge of quality of maternal health medicines in low-resource settings. Overall, 48.9% of 1,890 samples of medicines that cause the uterus to contract (uterotonics) to prevent excessive bleeding after birth, from 19 studies failed quality tests. Failures rates were 75% for ergometrine and nearly 40% each for oxytocin and misoprostol. [3]Additionally, because blood loss is often estimated visually, 46.9% and 49% of PPH is missed (Champion’s Trial data) and (E-MOTIVE trial data) respectively. Calibrated obstetric drapes is a recently recommended innovation to address this challenge.
In Kenya, the development of Human Resources for Health remains a significant challenge. Despite efforts to improve healthcare delivery, there are persistent issues related to the training, retention and distribution of skilled healthcare professionals. These challenges contribute to gaps in service provision and can impact the quality of care particularly in rural and underserved areas.
Makueni is one of the Counties in Kenya that has previously experienced high numbers of postpartum hemorrhages and maternal deaths due to PPH. To address this challenge, , the County department of health in collaboration with Jhpiego(Accelerating Measurable Progress and Leveraging Investment for -Postpartum Haemorrhage Impact project) has introduced recently recommended PPH innovations including use of Heat-Stable Carbetocin (HSC) for PPH prevention and the first response bundle(Massage of the uterus, Oxytocics drugs, Tranexamic acid, Intravenous fluids, Examination and Escalation(MOTIVE) for PPH treatment in 36 health facilities accounting for 92% of births in the County. Heat-stable carbetocin is a long-acting derivative of oxytocin that does not require cold-chain transportation and storage, making it a practical solution for settings with limited cold chain. Additionally heat stable carbetocin gives a four times longer uterine contraction compared to oxytocin. This intervention has contributed to zero maternal deaths due to PPH in 2023 and 2024 compared to 12 maternal deaths from PPH recorded in 2022.
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