Reducing maternal mortality through identifying unmet need for postpartum hemorrhage stabilization in rural emergency obstetric care facilities: Development and testing of a tool in Bangladesh

Abstract

Abstract Background: Maternal mortality is stagnating globally, and postpartum hemorrhage (PPH) is the leading contributor. Time from onset of PPH to death is estimated at two hours, the fastest of all life-threatening obstetric complications. Resistance to treatment of critical obstetric emergencies in rural settings is ubiquitous and under-reported. Ensuring initial stabilization close to communities is central to improving maternal mortality rates. Systemic and unspoken refusal of care leads to hidden unmet need for treatment of PPH. Current global guidance for monitoring emergency obstetric care may be inadequate. Aim: The aim of this research was to develop a tool that measures unmet need for PPH stabilization in local health facilities. The newly developed tool was tested in rural sub-districts in Bangladesh. The results and their implications are discussed. Method: A proposed calculation was developed for determining the expected number of PPH cases in a given population based on its size, birth rates, community delivery rate, and estimates of PPH rates. Using the new tool, calculated estimates were applied to rural districts in Bangladesh against actual numbers of PPH cases managed in public district and sub-district hospitals. Births in private and NGO facilities were also accounted for. Findings: Substantial discrepancies were found between expected PPH arising in rural areas and PPH treated in rural facilities in those areas. The actual number of cases treated at local rural public facilities was 16% of what was expected. This is a notable finding that is missed by using global recommendations for monitoring EmONC signal functions. Conclusion: The proposed tool presents an opportunity for countries to examine the availability of facility response to obstetric emergencies, specifically PPH, in facilities reported to be providing basic emergency obstetric care. Establishing a simple method for the calculation of expected numbers of PPH will help countries to address hidden gaps. Further research is needed in other contexts to verify this tool and investigate if uncovering under performance of health facilities could be an opportunity for strengthening maternal and newborn health systems.