WORLD over, an estimated 800 women die daily due to pregnancy related causes. The majority of these deaths occur in developing countries; the majority of which occur in Sub-Saharan Africa. Zimbabwean has one of the highest mortality rates of around 463 per 100 000; this is an estimate from yesteryears and the current standing may be worse off.
By Dr Grant Murewanehma
The three direct leading causes of maternal death are infection (sepsis), hypertensive disorders and bleeding before, during or after childbirth, otherwise known as obstetric haemorrhage. Obstetric haemorrhage is divided into antepartum haemorrhage, which implies bleeding in pregnancy before childbirth, and postpartum haemorrhage, which implies bleeding that occurs after delivery, from just after to 42 days post delivery. There are several other causes of pregnancy-related death, the frequency of which varies according to countries/regions.
In the pregnant woman, the blood flow to her uterus increases dramatically to adjust to the needs the growing baby, and can be as much as 0.8-1.2 litres around the time when the pregnancy is due. The total blood volume in a person averages around 5.5 litres, with an increase in pregnancy.
Literally that means the total blood volume of a pregnant woman can be lost in about 5 minutes if the uterus starts to bleed. It is not surprising therefore that bleeding from the uterus is a leading cause of pregnancy-related death. Swift measures are generally taken upon delivery to make sure the uterus contracts and arrests bleeding. This includes administration of medicines which cause it to contract. This has significantly reduced pregnancy-related deaths due to bleeding over the years.
A woman can bleed for many reasons after delivery; the leading reason is failure to contract sufficiently by the uterus. The other reasons could be undelivered placentas or remnants thereof, injuries to the genital tract, and bleeding problems in the patient. Uterine rupture in a patient with a previous operation, bleeding problems precipitated by hypertensive disorders, a placenta that is positioned way too low in the uterus, or premature separation of the placenta from the uterine wall before childbirth are the other causes of pregnancy-related bleeding.
Rapid identification of bleeding and the source of the bleeding is critical for saving the patient’s life. Every passing minute without identification or proper management in the bleeding patient becomes a recipe for disaster.
As explained above one can literally lose all their blood volume in a few minutes. This can lead to brain injury due to shortage of oxygen which is crucial for brain function, shutdown of the kidneys and other essential organs, and consumption of components of the blood that allow the blood to clot and stop the bleeding.
After diagnosis and identification of cause of bleeding, measures to stop the bleeding will include administration of drugs such as oxytocin, misoprostol, ergometrine and others which contract the uterus, repairing of any tears, removing any placental remnants, or operating the woman to repair uterine rupture, compress the uterus, block blood supply to the uterus, or even remove the uterus, depending on the cause. However, the urgent availability of blood products is essential to save these patients. One can do all these nice interventions, but without replacing the lost blood the patient will experience the complications explained above and lose their life.
Blood is generally from donors, but it requires expensive reagents to separate into various fractions, store them appropriately and type it to match patients’ blood groups. Thus, even though blood is donated for free, the cost of processing it makes it an expensive product. Donors and governments need to heavily subsidise this product if the people who really need it are to benefit. The USD price of a single unit of packed red blood cells is usually pegged between USD$100-120.
The new prices of blood products in the local currency are currently pegged at around 12000 RTGS (whatever currency that is), for a single unit of packed red blood cells. This cost is astronomical for the majority of Zimbabwe, who current live in extreme poverty, way before the poverty datum line.
According to the National Blood Services of Zimbabwe (NBSZ), supply chains of reagents processing were heavily affected by the restrictive lockdowns, and the unpredictable foreign currency shortages cannot make the situation any better. The donors may also have been affected by travel restrictions.
Though we can predict a few of the women who are at risk of bleeding in during pregnancy or childbirth and prepare accordingly, its entirely an unforeseen event for the vast majority. For this reason, emergency, subsidised stores of blood products must always be set aside for woman. In the dramatic event of postpartum haemorrhage there is no time to look for funds or source blood from elsewhere, thus hospitals including provincial and district hospitals must have local blood banks. Its not surprising therefore that we have more women dying from bleeding these days before and during childbirth.
Hospitals, governments and other relevant stakeholders must ensure continued availability of blood products and manpower to process these blood products at all times. Nurses are also very critical for monitoring the blood transfusions in the ward, to pick up any undesirable reactions that may occur in good time. Currently the nurses are on a crippling industrial action. There is lack of urgency in dealing with their genuine grievances, and yet people are giving birth. This means that the delivery process itself is also going on unmonitored, with nobody to pick danger signs in good time.
Given all these factors, we may lose more women to obstetric haemorrhage in the current era than before. Urgent attention to these critical issues is important if we are to avoid further loss of life from bleeding in pregnancy.
(About the author: Dr Grant Murewanhema is a public health specialist with a special interest in Maternal Health. All the opinions expressed herein are independent)