Influence of health system factors on Fetomaternal outcomes among pregnant women presenting with antepartum hemorrhage at Jaramogi Oginga Odinga Teaching and Referral Hospital, Kisumu-Kenya

Background: Globally, maternal mortality is decreasing, but in developing countries, especially Sub-Saharan Africa, maternal death has remained high. Antepartum haemorrhage (APH), which is the per-vaginal bleeding after 28 weeks of gestation and before delivery complicates 2-5% of pregnancies. Although timely access to quality obstetric services, availability of trained health service providers, availability of transfusion products, theatre waiting time are major determinants of both maternal and new-born outcomes after antepartum haemorrhage, the impact of the health system and health provider related factors associated with APH on the neonatal and maternal outcomes remains to be investigated.  As such, this study evaluated the influence of health system factors on maternal and neonatal outcomes among women presenting with Antepartum haemorrhage at the Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH), Kisumu County, Kenya.

Methods: The study was a prospective case-control study that recruited mothers (n=63) presenting at the maternity department with antepartum haemorrhage. The control group comprised of mothers (n=63) presenting without antepartum haemorrhage at the same maternity. The study took a period of one year.  Data was coded and analysed by SPSS program version 23.0 and STATA version 14.0.

Results: Abruptio placentae and placenta Previa were the major causes of APH recorded in 17 (27%) and 39 (61.9%) of APH patients, respectively. A large proportion of patients presenting with antepartum haemorrhage (APH) were younger, aged between 20-29 years (n=37, 58.7%), with an overall mean age of 26.22. Cases with APH had a lower mean parity (1.17), while controls had a higher mean parity (2.97 Caesarean section rate was high among pregnant women who had APH (n=42, 66.7%). (p=0.001). Out of these, 32 (52.4%) were done as emergency. Majority of the emergency caesarean sections were done within 30 minutes from the time the decision to deliver had been made (n=17, 54.8%).  Most patients who presented with APH were referred from another facility (n=42 (66.7%) in our study. Risks of perinatal and maternal mortality were higher for patients who came from outside of JOOTRH compared to patients from JOOTRH (OR=3.16, 95%CI=1.34-5.57, P< 0.0001).  High risks of perinatal mortality (19.9%) and maternal mortality (3.2%) were observed among APH patients in our study hospital compared to mothers who did not experience APH (8% and 0% respectively). Majority of new-borns of patients who had APH were admitted to NBU (n=42, 66.7%) (p=0.017) and the major reason for admission to NBU was prematurity and low Apgar score.

Conclusion of the study is that APH is a major cause of maternal and perinatal morbidity and mortality. This could be prevented by regular and focused antenatal care, early detection of risk factors and prompt referrals. Many facilities for caesarean sections, availability of blood banks and blood transfusion products, facilities with ICU and proper new-born units with adequate staffing can improve maternal and perinatal outcome of patients with APH