Mergy Gayatri, Dyah Krisnawati Satia Pratiwi, Nanda Agnesia Jati Pratiwi, Sutrisno
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THE RELATIONSHIP BETWEEN OBSTETRIC FACTORS
AND POSTPARTUM HAEMORRHAGE MATERNAL
DEATHS IN JEMBER DISTRICT
Mergy Gayatri
1
, Dyah Krisnawati Satia Pratiwi
2
, Nanda Agnesia Jati Pratiwi
3
, Sutrisno Sutrisno
4
, I
Wayan Agung Arsana
5
Brawijaya University, Malang, Indonesia
1234
[email protected].id
1
, [email protected]
2
, nandaagnesia@student.ub.ac.id
3
,
[email protected]
4
, [email protected]m
5
KEYWORDS
Haemoglobin Level,
Retained Placenta,
Uterine Atony, Perineal
Tear, Postpartum
Haemorrhage, Maternal
Mortality
ABSTRACT
Maternal mortality remains public health issue. One of its leading
causes is postpartum haemorrhage. The aim of this study is to test
the relationship between haemoglobin levels, perineal tear, retained
placenta, uterine atony, and maternal mortality from postpartum
haemorrhage in Jember district, Indonesia. This case-control study
comprised 43 mothers died from postpartum haemorrhage (cases),
and 43 mothers survived from postpartum haemorrhage (controls)
between from January 2017 and December 2019. Data were
obtained from maternal verbal autopsies, complemented by birth
registrations and medical records in 26 community health centres
across Jember district. The chi-square, and multivariate logistic
regression were administered to test the hypothesis. The results of
this study indicate that Haemoglobin levels (p = 0.032, OR 6.372,
95% CI 1.172 - 34.626), retained placenta (p = 0.033, OR 4.578
95% CI 1.128 – 18.587), and atonia utery (p= 0.014, OR 4.578 95%
1.364 – 16.502) had significant relationship with maternal deaths
from postpartum haemorrhage. However, perineal tear (p= 0.155,
OR 0.347 95% 0.081 – 1.490) had no significant relationship with
maternal deaths from postpartum haemorrhage. The conclusion in
this study is Identifying obstetric factors are important. Therefore,
conducting early detection screening during pregnancy is
encouraged to reduce postpartum haemorrhage maternal death.
INTRODUCTION
Maternal mortality continues to be a public health issue worldwide. In Indonesia, the
high maternal mortality rate is caused by various complications that occur during pregnancy,
childbirth and the postpartum period (WHO, 2018). The majority of maternal deaths in
Indonesia are caused by haemorrhage (1,280 cases in 2019) .
Postpartum haemorrhage is blood loss of more than 1000 ml or more accompanied by
symptoms of hypovolemia within 24 hours to 12 weeks postpartum (Watkins & Kellay,
2020). The main causes are tone, tissue, trauma and thrombin (H.Jessica L. Bienstock, 2021).
Mothers with haemoglobin levels less than normal are called anaemia (Mremi et al., 2022).
Mothers with haemoglobin levels below 11gr/dl will be at risk of death in pregnancy and
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childbirth both at present and in the future (Allen, 2000). Anaemia causes a reduced supply of
oxygen in the blood causing the uterus fails to contract (Lancaster et al., 2020). With the
failure of contractions, there is a failure to expel the placenta or it is called retained placenta
(Perlman & Carusi, 2019a). The level of anaemia in the mother affects the severity of
postpartum haemorrhage even to death (Lancaster et al., 2020). Anaemia during pregnancy
also affects uterine tone, resulting in a high risk of uterine atony, which is the biggest
contributor to postpartum haemorrhage mortality (Kebede et al., 2019). In addition, anaemia
in pregnancy also increases the risk of childbirth with measures such as forceps and vacuum
so that the risk of tearing the birth canal increases (Omotayo et al., 2021; Mahmood et al.,
2019).
East Java is the province with the second highest number of maternal deaths in
Indonesia. Jember district remains having the highest Maternal Mortality Ratio (MMR) in
East Java province for many years. In 2020, the maternal health indicators in the district are
good; the coverage of four antenatal visits, and three postnatal visits coverage were 82% and
92.3% accordingly. Moreover, the coverage of deliveries assisted by professional birth
attendants was 93.7%. However, the MMR was high (170 per 100,000 live). Postpartum
haemorrhage was reported as the main cause of maternal death in the district.
METHOD RESEARCH
This case-control study aims to identify risk factors associated with postpartum
haemorrhage maternal mortality in Jember district, Indonesia. This study analyses maternal
anaemia, retained placenta, atony uterine, and perineal tear.
Study Setting
Jember, a district in East Java, comprises 31 sub-districts, which were resided by
approximately two million populations. This district has 50 community health centres (In
Indonesian: Pusat Kesehatan Masyarakat) and 135 auxiliary health centres (In Indonesian:
Pusat Kesehatan Masyarakat Pembantu).
Data and Sample
A case-control study of mothers who had haemorrhage from January 2017 to
December 2019 was conducted in Jember district. Forty-three cases (n=43) were mothers
who died from postpartum haemorrhage, and forty-three controls (n=43) were surviving
mothers who had postpartum haemorrhage, acquired from maternal verbal autopsy forms.
Data from medical records and birth registers in 26 community health centres, where
the childbirth from the mothers who died from postpartum haemorrhage were taken to
complement the data. Cases were obtained through total sampling, while controls were taken
using purposive sampling. We excluded women with comorbidities, or other complications.
Maternal verbal autopsy reports were conducted through an audit by Maternal
Perinatal Audit team, who identify the causes of maternal and infant morbidity and mortality
to prevent future morbidity and mortality. As a result, maternal and infant mortality rates will
decrease. Maternal Verbal Autopsy (MVA), which was developed by The Ministry of Health,
is used in the audit. This MVA consists of questions and potential factors that contributed to
the maternal death.
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Postpartum haemorrhage maternal death was the outcome. The risk factors included
anaemia, retained placenta, perineal tear, and uterine atony. The measurements of the
variables are based on the Maternal verbal autopsy reports. Maternal anaemia is haemoglobin
levels <9 gr/dl (Yes/ No), while retained placenta is the failure of the placenta in
spontaneously separate during the third stage of labour (Yes/No) (Combs et al., 1991;
Dombrowski et al., 1995; Nikolajsen et al., 2013). Uterine atony is a failure of the uterus to
contract adequately following delivery (Yes/No) (Cunningham, 1997), while perineal tear is
the tear in the area between vaginal opening and anus (Yes/No) (RCOG, 2022).
Data analysis
The hypothesis were examined using bivariate and multivariate logistic regression
analysis to find out the relationship between risk factors and postpartum haemorrhage
maternal death. Data were analysed using SPSS for Windows 25.0.
RESULT AND DISCUSSION
A. RESULT
Table 1. Table of respondent characteristics and bivariate analysis
Risk factor
Cases
(N = 43)
Controls
(N = 43)
OR
(95% CI)
p-value
Contingency
Coefficient
(C)
Haemoglobin
level
0.001*
0.338
< 11g/dL
41 (95.3%)
29 (67.4%)
9.897
11g/dL
2 (4.7%)
14 (32.6%)
(2.088 – 46.910)
Uterine atony
3.795
0.004*
0.297
Yes
23 (53.5%)
10 (23.3%)
(1.502 – 9.591)
No
20 (46.5%)
33 (76.7%)
Retained placenta
3.703
0.009*
0.271
Yes
18 (41.9%)
7 (16.3%)
(1.347 – 10.179)
No
25 (58.1%)
36 (83.7%)
Perineal tear
0.191
0.004*
0.295
Yes
4 (9.3%)
15 (34.9%)
(0.057 – 0.639)
No
39 (90.7%)
28 (65.1%)
Table 1 shows the number of cases (n=43) and the control group (n=43). The majority
of mothers experienced anaemia in both the case and control groups with a total of 41
(95.3%) and 29 (67.4%) accordingly. The association is statistically significant as p = 0.001.
Therefore, the null hypothesis is rejected and thus restated as there is a significant
relationship between anaemia and postpartum haemorrhage maternal mortality.
In addition, the majority of mothers in the case group experience uterine atony (53.5%),
while in the controls, the majority of the mothers did not (76.7%). The association is
statistically significant as p = 0.004. Therefore, the null hypothesis is rejected and thus
restated as there is a significant relationship between uterine atony and postpartum
haemorrhage maternal mortality.
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The majority of mothers in both groups did not experience retained placenta, which
constituted (58.1%) and (83.7%) respectively. The association is statistically significant as p
= 0.009. Therefore, the null hypothesis is rejected and thus restated as there is a significant
relationship between retained placenta and postpartum haemorrhage maternal mortality.
Finally, the majority of mothers in both groups did not experience lacerations; cases (90.7%)
and controls (65.1%). The association is statistically significant as p = 0.004. Therefore, the
null hypothesis is rejected and thus restated as there is a significant relationship between
perineal tear and postpartum haemorrhage maternal mortality.
Table 2 . Multivariate logistic regression analysis
Risk factor
B
p- value
Odd Ratio
95% CI
Haemoglobin Level
1.852
0.032*
6.372
1.172 – 34.626
Uterine atony
1.557
0.014*
4.744
1.364 – 16.502
Retained Placenta
1.521
0.033*
4.578
1.128 – 18.587
Perineal tear
-1.057
0.155
0.347
0.081 – 1.490
Constant
-1.455
0.210
0.233
Probability
91.82%
Table 2 presents mothers with haemoglobin level < 11g/dL are at greater odds of
dying from postpartum haemorrhage than those who are not anaemia (OR 6.372, 95% CI
1.172 – 34.626). This means anaemia is associated with postpartum haemorrhage maternal
mortality, and mothers with anaemia have an increased risk of 9.897 times experiencing
death from postpartum haemorrhage compared to those who do not have anaemia.
Similarly, mothers experiencing uterine atony are at greater odds of dying from
postpartum haemorrhage than those who do not experience uterine atony (OR 4.744, 95% CI
1.364 – 16.502). This means uterine atony is associated with postpartum haemorrhage
maternal mortality, and mothers with uterine atony have an increased risk of 4.744 times
experiencing death from postpartum haemorrhage compared to those who do not have uterine
atony.
Regarding retained placenta, mothers with retained placenta are at greater odds of
dying from postpartum haemorrhage than those who do not have retained placenta (OR
4.578, 95% CI 1.128 – 18.587). This means retained placenta is associated with postpartum
haemorrhage maternal mortality, and mothers with uterine atony have an increased risk of
4.578 times experiencing death from postpartum haemorrhage compared to those who do not
have retained placenta.
Lastly, mothers with perineal tear are at greater odds of dying from postpartum
haemorrhage than those who do not have retained placenta (OR 0.347, 95% CI 0.081 –
1.490). This means perineal tear is associated with postpartum haemorrhage maternal
mortality, and mothers with perineal tear have an increased risk of 0.347 times experiencing
death from postpartum haemorrhage compared to those who do not have perineal tear.
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B. DISCUSSION
Our findings show significant relationship between haemoglobin levels and maternal
deaths from postpartum haemorrhage. Half of the population of pregnant women in the world
is anaemic (Lumbanraja et al., 2019). Delivery with anaemia (haemoglobin level <11 g/dl)
will result in disruption of uterine muscle function directly so that it cannot cause adequate
contractions. Anaemia is considered a direct cause of postpartum haemorrhage (Omotayo et
al., 2021; Mahmood et al., 2019).
(Nur et al. (2021) reported that mothers who experience anaemia will have a risk of
developing postpartum haemorrhage of 7.8 than mothers who give birth without anaemia.
Mothers with anaemia are closely associated with death (Lancaster et al., 2020). Moreover,
mothers with postpartum haemorrhage were found to have significantly lower haemoglobin
levels than mothers with postpartum haemorrhage who survived. Mothers died from
postpartum haemorrhage had an average Hb level of 6.2 g/dL, while survived mothers had an
average of 9.2 g/dL. Mothers who previously had a history of postpartum haemorrhage were
found to be anaemic in subsequent pregnancies with an average haemoglobin level of 6.2
g/dL (Lancaster et al., 2020). In a study conducted by (Smith et al., 2019) discovered that
anaemia was greater in mothers with a high risk age such as younger < 20 years and older or
40 years. With the age of the mother being included in a high risk if the mother also has
anaemia, the death from postpartum haemorrhage will be much greater depending on the
severity of anaemia (Smith et al., 2019).
Anaemia has been shown to affect myometrial contractility, which is associated with
decreased transport of haemoglobin and oxygen into the uterus, leading to cellular
dysfunction and impaired enzymes in tissues (Bazirete et al., 2020). There is a relationship
between anaemia and the risk of death from postpartum haemorrhage, namely the first is the
role of changes in the physiology of red blood cells that trigger the occurrence of postpartum
haemorrhage, in a preliminary study carried out that lower than normal red blood cells in the
blood circulation will change the frictional force, so it will reduce the interaction of platelets
with the walls of blood vessels which will lead to the ability to close vascular (Lancaster et
al., 2020). Second, there is evidence that chronic hypoxia caused by anaemia may increase
the susceptibility of the placenta and uterus to vascular damage during postpartum
haemorrhage. Third, anaemia is associated with uterine atony (Lancaster et al., 2020). The
fourth assumption that blood loss <500 mg that does not meet the criteria of postpartum
haemorrhage is often ignored by health workers and the individual himself, but blood loss
<500 will actually have a bad impact on sufferers with severe anaemia (Lancaster et al.,
2020). So it is necessary to classify the severity of anaemia for pregnant and childbirth
women (Lancaster et al., 2020). If pregnant and giving birth mothers experience anaemia, it
will cause death in pregnancy and or childbirth in the future (Allen, 2000).
The failure of the uterus to contract is called uterine atony, which ccurs because the
relaxed myometrium fails to constrict blood vessels (Khan, R. U., & El-Refaey, 2006). At
term 1/5 of the maternal cardiac output or 1000 mL/min enters the uteroplacental circulation.
Postpartum haemorrhage can cause exsanguination (blood loss both externally and internally)
in a short time (Khan & El-Refaey, 2006). The presence of uterine atony predominates with
retained placenta (Khan, R. U., & El-Refaey, 2006). The retained placenta plays a role in
inhibiting uterine contractions which is strong enough in the process of constricting the
placental blood vessels. In the case of postpartum haemorrhage with atony, it is more
associated with retained placenta so that contraction failure is more common (Khan, R. U., &
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El-Refaey, 2006). The cause is not clearly known except for the presence of uterine fibroids,
in which the source of distension cannot be removed by uterine contractions, resulting in
atony. Multiple pregnancy, polyhydramnios is also a cause of uterine distension which
correlates with postpartum haemorrhage.
Retained placenta is one of the aetiology of postpartum haemorrhage. This is a
condition in which the placenta or retained placenta is not delivered more than 30 minutes
after the birth of the baby (Perlman & Carusi, 2019a). In our study, retained placenta has a
significant relationship with the incidence of postpartum haemorrhage death. The results of
the calculation of the odds ratio (3,464) also strengthen this relationship, so it can be
interpreted that mothers who experience retained placenta have a risk of death from
postpartum haemorrhage 3,464 times greater than mothers who do not experience retained
placenta. The relationship between retained placenta was also found by several previous
studies which stated that the absence of the placenta or retained placenta for more than 30
minutes would have an impact on the incidence of postpartum haemorrhage death (Erickson
et al., 2020 ; Rottenstreich et al., 2021).
Tiruneh et al., (2022) stated that mothers with retained placenta had four times the
risk of death. This is supported by (Edwards, 2018) who argues that retention is the biggest
cause of postpartum haemorrhage which leads to death. In his research, Edward looked for
the causes and predictions of postpartum blood loss, where retained placenta contributed to
more blood loss, namely 1000 ml as much as 34%, 1500 ml as much as 47%, 2000 ml as
much as 53%. The most when compared to uterine atony and lacerations (Edwards, 2018).
Another study from (Liu et al., 2021) stated that retained placenta contributed to the
incidence of postpartum haemorrhage by 55.83%, greater than the 10% reported by WHO
(Liu et al., 2021).
(Perlman & Carusi, 2019b) stated that there are three main causes of retained
placenta, one of which is caused by the uterus failing to contract or uterine atony, causing
failure to separate and expel the placenta (Perlman & Carusi, 2019b). In the accompanying
risk factors, anaemia is correlated with the incidence of retention and postpartum
haemorrhage, namely anaemia causes the uterine muscles to not contract properly, so this
will result in uterine atony in postpartum mothers. Poor contractions or the appearance of
atony will result in the remaining placenta not being properly detached from the uterine wall
so that the risk of bleeding is greater (Lancaster et al., 2020).
A study by (Endler et al., 2016) reported that mothers with retained placenta tend to
have low levels of GPX1 protein concentration in placental tissue which leads to oxidative
stress (Endler et al., 2016). Retention of the placenta is a death factor associated with
secondary postpartum haemorrhage and is associated with anaemia, malnutrition during
pregnancy and the lack of adequate transportation facilities to health care centres, the number
of deliveries at home also contributes to the higher severity of cases (Abrar et al., 2016). The
threshold for expulsion of the placenta is only at 30 minutes and at 15 and 20 minutes the rest
are at risk for postpartum haemorrhage (Edwards, 2018), the longer the duration of the third
stage, the higher the risk of postpartum haemorrhage. Some of the placental tissue can be left
in the mother's uterus, whether consciously or not by health workers. It can appear as
abnormal bleeding days to weeks after delivery and is the biggest cause of secondary
postpartum haemorrhage (Perlman & Carusi, 2019).
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The results of our study found that perineal tear had no significant relationship with
the incidence of postpartum haemorrhage. This result is different from the findings of
previous researchers who stated that tears of the vagina, the perineum, and episiotomy were
all associated with severe postpartum haemorrhage. Of the three studied genital tract tears,
vaginal tearing >3 cm was the most common reason for severe postpartum haemorrhage with
a twofold risk of occurring in 8% of the women. Vaginal tearing is rarely measured or
discussed in the scientific literature and may therefore be underestimated in general. It is well
known that genital tract tears are associated with severe postpartum haemorrhage as it is
included as one of the four classical causes of severe postpartum haemorrhage uterine atony,
genital tract tears, retained placenta, and coagulation disorders. As genital tract tears have a
strong association with postpartum haemorrhage, timely identification and management by
the birth attendant may reduce the amount of postpartum haemorrhage. Restricted use of
episiotomy only with foetal indication is recommended, and slowing down the birth of the
infant's head by assisting the parturient in breathing the baby´s head out between contractions
or at the end of a contraction to avoid sphincter tears (Graugaard & Maimburg, 2021). The
differences of the results in this study suspected due to the lack of research samples and the
presence of other concomitant factors that require further research. Although it showed
insignificant results, the incidence of birth canal lacerations cannot be underestimated as one
of the causes of postpartum haemorrhage so it still requires proper attention and treatment to
reduce mortality and morbidity due to postpartum haemorrhage (Pourali et al., 2019).
CONCLUSION
The results of this study provide important findings that there was a significant
relationship between anaemia, retained placenta and maternal mortality from postpartum
haemorrhage. Early detection of such obstetric factors is crucial in order to prevent
postpartum haemorrhage deaths. Qualitative study exploring the risk factors for postpartum
haemorrhage deaths among healthcare providers is encouraged
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Copyright holders:
Mergy Gayatri, Dyah Krisnawati Satia Pratiwi, Nanda Agnesia Jati Pratiwi,
Sutrisno Sutrisno, I Wayan Agung Arsana (2022)
First publication right:
Devotion - Journal of Research and Community Service
This article is licensed under a Creative Commons Attribution-ShareAlike 4.0
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