Excessive bleeding after childbirth: A silent killer

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OPINION

By Dr Eric Ssennuni

According to the report from WHO, a mother dies from a pregnancy and or birth-related complication every two minutes.

Maternal death, therefore, remains a global public health threat, with low-resource settings suffering the most. In Uganda, maternal death is currently estimated to be 189 per 100,000, a figure far above the Sustainable Development Goal (SDG) 3, target 3.1 of less than 70 per 100,000 by 2030.

Sadly, the majority of these mothers die from otherwise preventable causes. Like many parts of Africa, in Uganda, excessive bleeding after childbirth (also referred to as postpartum haemorrhage- PPH) remains the leading cause of maternal death, silently killing about one in three mothers during/ after childbirth. It therefore poses a significant risk to the lives of many mothers as well as national development.

The fight against Maternal Death: Uganda’s National PPH Campaign

Globally, there has been a significant decline in maternal deaths of over 40 % in the last two decades, and Uganda is one of the Sub-Saharan African countries with commendable improvement in maternal Health, with a decrease in maternal deaths from 336 per 100,000 live births (2016) to 189 per 100,000 (2022). This is attributed to several ongoing international, national and institutional initiatives, including the Uganda National Ministry of Health (MoH) Campaign against maternal deaths due PPH, which launched in August 2024 under the theme “Every Drop of Blood, Every Minute Counts”. This campaign is aimed at empowering and educating communities and frontline health providers to prevent and effectively manage excessive bleeding.

This year, the campaign is themed “Ending Maternal Death Due to Excessive Bleeding After Childbirth: A Collective Responsibility.”. Activities undertaken during this campaign include PPH awareness through social media, television, and baraza, and training of health providers on the recent evidence-based PPH prevention and management approaches. Although the awareness message used in this campaign is comprehensive, it bears little emphasis on the role of operative and anaesthesia interventions for mothers before, during and or after pregnancy and childbirth, herein referred to as surgical care, in promoting maternal health and preventing preventable death from PPH and other common conditions.

Why Surgical Care Access is Critical?

Access to surgical care is essential in preventing and managing several conditions leading to maternal death, PPH inclusive. For instance, early identification of high-risk pregnancies, such as those with babies lying abnormally in their mothers’ wombs, allows for planned caesarean deliveries, hence averting potentially life-threatening situations. Also, when bleeding becomes uncontrolled by other measures, timely surgical interventions, including removal of the mother (which is often the last option) can save mothers’ lives.  

Worthy understanding is that these procedures depend on well-equipped operating theatres, trained surgical teams, adequate anaesthesia services, and a reliable blood supply- all of which, if absent, inadequate or non-functional, compromise care and result in an unnecessary rise in maternal death.

Currently, Uganda’s surgical care system faces critical challenges, including shortages and maldistribution of skilled surgical care providers. For example, obstetricians/gynaecologists are less than 1 per 10,000 population and mainly concentrated in urban and tertiary-level health facilities. Additionally, many theatres are non-functional or ill-equipped, and this is compounded by other factors such as a shortage of blood supply and weak referral systems. Addressing these requires urgent action by all stakeholders, with the community taking the lead.

To facilitate early detection of conditions that may lead to PPH and subsequent need for surgical intervention, pregnant mothers should routinely attend antenatal visits as advised by the healthcare providers, and plan for hospital-based delivery, with support of their families and or caregivers. Community health workers (CHWs) have a fundamental role in following up pregnant mothers in their villages to ensure they receive timely and appropriate care, including surgical intervention when needed. CHWs should therefore be empowered with knowledge, skills and tools essential in the detection of danger signs in pregnancy, such as bleeding, and coordination of early transfer of mothers to health facilities through well-streamlined referral pathways.

The government, through MoH, must enhance and sustain surgical capacity, especially at health centre IV facilities and district hospitals- not only through building more theatres but also fully equipping and functionalising the existing ones.

Furthermore, the government needs to make additional investment in surgical care providers (including the non-physicians) training and their recruitment and retention with a focus on lower facilities and underserved areas.

On the other hand, health professionals ought to update their PPH prevention and management knowledge and skills through institutional or national continuous professional development programs like the MoH EMS ECHO initiative, have an interest in specialising in surgical-related disciplines, including anaesthesia, and champion surgical care available and accessibility.

Summary

Despite the decrease in maternal deaths globally, low-resource settings like Uganda continue to have many preventable deaths, PPH being the leading cause, which undermines the realisation of SDG 3 target 3.1.

Ending maternal deaths from excessive bleeding is possible, especially if all mothers in need have access to timely, safe, quality and affordable surgical care services. We must therefore enhance and sustain the surgical care capacity, particularly at health centre IV facilities and district hospitals and stay committed to advocating for better maternal health through initiatives like the PPH awareness campaign.

The writer is a Medical Doctor and Global Health (Surgery) specialist and advocate affiliated to Gulu University Sexual and Reproductive Health Resource Centre