THE EFFECT OF DELAY IN THE MANAGEMENT OF POSTPARTUM BLEEDING ON THE RATE OF NEAR-MISS AND
H Risanto Siswosudarmo
Department of Obstetrics and Gynecology
Faculty of Medicine Universitas Gadjah Mada/ Sardjito Hospital
Jogjakarta
Background: Postpartum bleeding is the most common cause of maternal death in the developing countries. One of the inadequacy in the management of postpartum bleeding is delay, either early detection, referral system, or early management. As maternal mortality has declined, near-miss case is now used as indicator to assess obstetric care.
Objective: To recognize the effect of delay in the management of postpartum bleeding to the occurrence of near-miss and maternal death cases.
Design of study: Prospective cohort. The study population was patients with postpartum hemorrhage. The exposed group was those who delay and the control was those without delay. Near-miss and miss cases were results being observed.
Material and method: Thirteen hospitals (Sardjitodan 12 Affiliated Hospitals) were used. All cases with postpartum bleeding were recorded. Those with delay was assigned to the exposed group while those without delay was the control. The study was carried out from January 1st to June 30th 2009. The outcome of interest was women with near-miss and miss. Near miss was defined as those who underwent severe shock, demonstrated by systolic blood pressure 90 mmHg or less. Data were processed by means of statistical package in the computer. Chi square test, t-testand logistic regressions were used as statistical analysis.
Results: From January 1st to June 30th 2009 there were 139 cases of postpartum bleeding among 8924 deliveries, or 1.6%. There were 22 from 80 referred cases (27.5%) were delay, and 12 from 139 (8.6%) were delay in the hospital. A total 30 cases among 139 (21.6%) underwent both delay outside and inside hospital. There were 74 near-miss cases, 9 of which died. The real occurrence of near-miss is then 65 from 139 cases or 46.8% while the miss were 9 out of 139, or 6.47%. Case fatality rate was 9 from 139 or 6.47%; Maternal near-miss ratio6.22; Mortality index13.84% and Maternal mortality ratio 103/100.000 live births. Multivariate analysis showed delay in referral increased the risk of near-miss to 8.37 folds, bleeding >1500 ml 12.12 folds. Delay both referral and management in the hospital increased the risk of miss cases to 25.34 folds, hemoglobin < 6 g/dL to 31.58 folds and lack of blood to 13.39 folds.
Conclusion: Delay in the referral and delay in the hospital management increased the occurrence of near-missand miss cases significantly. Multivariate analysis showed that amount of bleeding, hemoglobin level and lack of blood availability influenced more than the delay it’s self.