Beyond maternal mortality: obstetric hemorrhage in a Malawian district

OBJECTIVE: To identify substandard care factors in the management of obstetric hemorrhage at district hospital level in rural Malawi. DESIGN: Retrospective hospital-based cohort study. SETTING: Thyolo District Hospital. POPULATION: Women who delivered at this facility in 2005. METHODS: All cases of obstetric hemorrhage were included according to the following criteria: any antepartum hemorrhage, postpartum hemorrhage with more than 500 ml of blood loss within 24 hours after delivery, uterine rupture, retained placenta and peripartum blood transfusion. MAIN OUTCOME MEASURES: Incidence of antepartum and postpartum hemorrhage, related maternal and perinatal mortality and mode of delivery. RESULTS: A total of 133 hemorrhage cases occurred among 3 085 hospital deliveries (43.1 per 1 000 deliveries), six of which resulted in maternal death (case fatality rate 4.5%). Twenty of 95 postpartum hemorrhage cases (21%) were peri-cesarean hemorrhages. Sixteen cesareans delivered lifeless fetuses, where a maternal indication for operative delivery was present in only four. Monitoring of pregnant women was regularly insufficient, including monitoring of women in waiting homes, and the use of uterotonics was often inconsistent. CONCLUSIONS: Morbidity review revealed important substandard care factors, including unnecessary cesarean sections. These factors may be modified against affordable cost, which could make an important improvement in maternal outcome.