Post-Partum Hemorrhage in Sub-Saharan Africa: A Prospective, Multi-Faceted Intervention Study in Metropolitan Mozambique

Introduction: Maternal Mortality (MM) is high in Sub-Saharan Africa (SSA), estimated at ≈500-1,000 maternal deaths per 100,000 live births (vs ≈5-20 in developed countries). Postpartum hemorrhage (PPH) is a known major contributor, but data on contemporary incidence, contribution to mortality and rescue interventions, are scarce.

Aims: To study MM, PPH and the effects of a combined intervention strategy (introduction of cryoprecipitate production capacity in conjunction with an early massive transfusion and standardized PPH care protocol, single-use hemorrhage boxes, PPH education and simulations) prospectively at Maputo Central Hospital (MCH) in Mozambique.

Methods: We collected data on MM, PPH, and associated risk factors prospectively from consecutive deliveries at MCH between February 2019 and January 2021 (pre-intervention), and between October 2022 and April 2024 (post-intervention). Data included age, HIV status, parity, delivery mode, notes, vital signs, laboratory values, and fetal parameters. PPH was determined by charted diagnosis, blood loss >500 mL, the need for transfusion, and/or notes indicating significant bleeding (eg: placental abruption). Patient characteristics and pregnancy outcome data were analyzed descriptively. Group comparisons, including pre- vs post-intervention, were done using Chi-square tests for categorical variables, and T-tests or Mann-Whitney U tests for continuous variables, as appropriate. Models were fit using logistic regression, and generalized additive models were used to produce predictive curves. Adjusted odds ratios (AOR) were controlled for high-risk age intervals (<20, >35).

Results: Records of 14,996 women were available for analysis (n= 8,879 pre-intervention and 6,087 post-intervention). Demographic characteristics between the two groups were similar. Significant improvements in MM (1,104/100,000 [1.10%] vs 279/100,000 [0.28%], P<.001) and PPH (14.01% vs 4.90%, P<.001) were observed pre- vs post-intervention. Infant mortality also improved (3.44% vs 2.58%, P=.004) but was still high. Laboratory evaluations (only drawn when deemed “in distress” due to resource limitation) on admission were available for ≈13% of women (n=1,954) and revealed that anemia or thrombocytopenia were strongly associated with PPH, in the pre- as well as the post-intervention period. Despite the sharp decline in post-intervention PPH, moderate and severe anemia (hemoglobin <10 g/dL) remained a strong PPH risk factor (AOR=3.31, P<.001). The same was true for thrombocytopenia (platelets <150 x10⁹/L) (AOR=4.55, P<.001). The risk of PPH increased with increasing anemia severity and was additive in the presence of thrombocytopenia. Cryoprecipitate and Tranexamic acid were used to intervene in 39.26% (n=117) and 16.11% (n=48) of post-intervention PPH cases, respectively. Across both phases: eclampsia (AOR=3.49, P<.001), parity >4 (AOR=2.50, P<.001), pre-term delivery (AOR=2.00, P<.001), maternal age <20 (OR=1.73, P=.005), maternal age >35 (OR=1.73, P=.001), and pre-eclampsia (AOR=1.66, P<.001) were some of the predominant risk factors associated with PPH. Uterine atony, although rare (147 cases, ≈1%), invariably preceded PPH (135/147, 91.84%). Assessing residency impact, “non-local” women (living outside Maputo, ≈50%) and local women revealed improvements in MM and PPH. However, in general, non-local women tended to have more prevalent risk factors and worse outcomes than local women. In contrast, PPH incidence (≈10%), rates of anemia (≈50%), thrombocytopenia (≈20%), and distributions of hemoglobin and platelets were similar. Also, the strong association of PPH with anemia and/or thrombocytopenia was present pre- and post-intervention for both groups.

Conclusions: MM and PPH were extremely high during the pre-intervention phase and associated with correctable risk factors (including pre-natal anemia). The substantial reduction of MM and PPH following a dedicated effort to institute a multi-faceted PPH prevention and intervention program demonstrates the effectiveness of those measures as a future guide across the region. Addressing management of prenatal anemia, which facilitates PPH, may be additional steps to improve MM.