Haemorrhage in pregnancy : information given to women in Chiradzulu ( Malawi )

Advising women on haemorrhage in pregnancy could be viewed as an integral aspect of maternal health care in Malawi. The WHO (1999) confirmed that haemorrhage in pregnancy was not only a direct reason for maternal mortality but also a major cause of maternal death. The question on the nature of information that midwives and traditional birth attendants (referred to as TBA's) in the Chiradzulu district in Malawi gave with regard to haemorrhage in pregnancy, therefore arose. Research available focused on the women's knowledge about the complications of pregnancy but not on the nature of information women received from midwives and TBA's. This study explored and described the nature of information that was given to rural women in the Chiradzulu district by the midwives and TBA's regarding haemorrhage in pregnancy. The findings revealed that although both the midwives and TBA's included important information about haemorrhage in pregnancy, there were deficiencies in some critical areas. Examples of these deficiencies were the definition of haemorrhage in pregnancy; the predisposing factors for antepartum and postpartum haemorrhage and deficiencies in the nature of information on the management and referral of haemorrhaging patients.


Introduction and background to the problem
Malawi is a small, landlocked developing country south of the equator in sub-Saharan Africa.It has a population of approximately 10 million people (The World Fact Book, 2006).Health care in nationalised and maternal health care services are provided at three levels: primary, secondary and tertiary.The main providers of health care at all three levels are m idw ives and trad itio n al birth atten d a n ts (referred to as TB A 's). Registered midwives were trained at university level whilst TBA's received b asic n o n -p ro fessio n al train in g to provide services in rural areas where women doesn't have access to modem m atern al health services.O nly an estimated 55% of births in Malawi took place in healthy facilities (N ational Statistics Office, 1994;National statistics Office and ORC Macro, 2001).Midwives are re g istered to p ractice w ith in communities and TBA's need licensing to enable legitim ate practice that is governed by the Nurses and Midwives A ct in M alaw i. M aternal health inform ation is an essential aspect of maternal health care, and particularly in fo rm atio n on co m p licatio n s o f pregnancy, including haem orrhage.In fo rm atio n on haem orrhage in pregnancy is essential as women should be made aware that haemorrhage is a major cause of maternal morbidity and mortality, in order for them to appreciate the need to seek early emergency care for haem orrhage and thereby reduce maternal morbidity and mortality.
H aem orrh ag e is a sig n ifican t complication of pregnancy and is one of the major causes of maternal morbidity and m ortality both in developed and developing countries (M alaw i Safe Motherhood Programme (MSMP), 2000;Basin, 1996;Castro, Campero, Hernandez & Langer, 2000;C hichakli, A trash, Mackay, Musan & Berg, 1999;Chiwuzi, Okolocha, Okojie, Ande & Onoguwe, 1997& W orld H ealth O rganization (WHO), 1998).In Malawi, the maternal mortality ratio is currently estimated at 1120 per 100, 000 live births (National Statistics Office and ORC Macro, 2001).Haemorrhage alone contributed to 24% of these deaths annually (MSMP, 2000).Local studies demonstrated that women in M alaw i did not reco g n ise haemorrhage.In addition, they have limited knowledge of the complications that may occur during pregnancy that could precipitate haemorrhage or results . in reduced ability to tolerate haemorrhage.Furthermore, most research has focused on kno w led ge w om en have about complications of pregnancy and not on the nature of information women received from m idw ives and TBA's.H ealth information pertaining in particular to haemorrhage in pregnancy has a role in p reventing m aternal m orbidity and m ortality.The research question therefore is: What is the nature of the information given to rural women in Chiradzulu (Malawi) by the midwives and TB A 's re g ard in g haem orrhage in pregnancy?

Purpose and objectives of the study
The purpose of the study was to explore, describe and com pare the nature of inform ation that was given to rural women in Chiradzulu (Malawi) by the m idw ives and TB A 's re g ard in g haemorrhage in pregnancy.The results provided the fram ew ork to develop guidelines for giving this information to the women in the district both by the midwives and the TBA's.The purpose of the study was achieved through the following objectives: • To explore and describe demographic data of the participants that had bearing on the study.This demographic data included age; professional qualifications; position; years of working experience and years of working in the current maternity facility; as well as the number of working hours per week.

•
To explore, describe and compare the nature of information that is given to the rural women by the midwives and TBA's regarding haemorrhage in pregnancy.

•
To describe and compare the recommended practices that are included in the information given to the rural women by the midwives and TBA's regarding haemorrhage in pregnancy.

• Midwife
A midwife is a health practitioner who has successfully completed a prescribed course in midwifery and has acquired the necessary midwifery skills that enables her to give care according to the scope o f practice.She is able to provide n ecessary su p erv isio n , life saving obstetric care and information to women in p regnancy and the delivery (Kapyepye, 2002:9).

• Traditional birth attendant (TBA)
The traditional birth attendant is a health w orker who has undergone form al training in selected midwifery skills.She provides the backbone of m aternity services at the periphery, including life saving o b ste tric care to low risk, maternity clients.She integrates health inform ation into her care practice to enhance the women's awareness of major o b ste tric problem s, including haemorrhage in pregnancy (Kapyepye, 2002:9)

Ethical considerations
Prior to the data gathering, the researcher obtained ethical approval to conduct the study from the Committee for Research on Human Subjects (Medical) and from the Faculty of Health Sciences' Post graduate Research Com mittee at the U n iv ersity o f the W itw atersran d (Clearance Certificate M01-10-08).The N atio n al H ealth S cience R esearch Committee in the Ministry of Health and P opulation (M alaw i) approved and granted permission to carry out the study in Malawi.Informed written consent was obtained from all participants.Autonomy was ensured by voluntary participation and that participants were assured that they could withdraw from the study at any time without penalty.In addition, participants were assured of anonymity, confidentiality and non-benevolence.

Results
The resu lts w ere p resen ted in accordance with the objectives.Section A co n sisted o f six q u estio n s and addressed the first objective of the study pertaining to the demographic data of the participants.Questions pertained to age, professional qualifications, position, period of working experience, period of working in the current maternity facility and number of working hours per week.
The majority of the midwives (75%, n=30) were between the ages of 30 -49 years.
The majority of the TBA's (57.7%, n=30) were aged between 50 and 69.At least 13.5% (n=7) of the TBA's were olderthan 70 years, whereas none of the midwives were older that 70 years.Ninety three percent (93% ) o f the m idwives had enrolment certificates (n=37), 5% had a diploma (n=2) and 2.5% had a degree (n=l).All the TBA's had aTBA certificate.The majority of midwives (55%, n=22) had working experience of more than one year but less than 10 years.A quarter (25%, n = 1 0 ) of midwives had 11 to 2 0 years' experience.Approxim ately the same number (than the midwives) of TBA's (58%, n=30) had experience of more than one year but less than 1 0 years and 15% (n=8 ) had 11 to 2 1 years' experience.Ninety percent (90%) of the midwives and 79% of the TBA's worked more than the officially stipulated 40 hours per week.
S ectio n B ad dressed the second objective of the study, which was to compare the nature of the information that was given to rural women by midwives and the TBA's regarding haemorrhage in pregnancy.2).
Section C addressed the third objective of the study, which was to describe and com pare the recom m ended practices regarding haemorrhage in pregnancy that were included in the information given to the rural women by the midwifes and TBA's.Table 1 provided an overview of the reco m m ended p ra ctices for prevention of bleeding in pregnancy.It was of concern that significantly fewer TBA's than midwives would consider advising women to attend routine antenatal clinic visits as a m eans of p reventing haem orrhage (59.6% vs. 92.5%;p=<0.001).
There were no significant differences between advice given by midwives and TBA's to w om en reg ard in g the prevention of a postpartum haemorrhage.The routinely advised practice, by both midwives and TBA's, for the prevention of a postpartum haem orrhage was to en co u rag e breastfeed in g (92.5% vs. 90.4%;p=1.00).Very few midwives (12.5%) and TBA's (1.9%) considered advice on the importance of em ptying the blad d er to prevent haemorrhage.None of the m idwives or TBA's would recommend the use of traditional herbs for the p rev en tio n o f a h aem orrhage.
In fo rm atio n on recom m ended prev en tio n of a postpartum haemorrhage provided by both m idw ives and TBA's included reporting bleeding (87.5% vs. 84.6%;p=0.77) and infections (80% vs. 78.9%;p=l .00) to a health facility.Significantly few er TBA's than m idw ives would recommend exercises for the contraction of the uterus (9.6% vs. 72.5%;p=<0.001).Midwives (100%) and TBA's (96.2%) would advise women to report to the hospital immediately if they presented w ith a p o stp artu m haem orrhage.Midwives were significantly more likely to assess the patient first for blood loss and then to call an ambulance (59.4% vs. 0%; p=0.005) than the TBA's.In addition, midwives were more likely to consider resuscitating a patient whilst awaiting the arrival of an ambulance (40.6% vs. 0%; p=0.005) than the TBA's.
Both midwives (85%) and TBA's (84.6%) reported that patients' lack of awareness was a contributing factor towards women delaying to seek medical attention in the event of a haemorrhage.Midwives felt that their patients were powerless in decision making (25% vs. 1.9%; p=<0.001) and had a long way to walk to a clinic (45% vs. 11.5%;p=<0.001).These factors of decision making and the distance to walk were significantly more important in the case of midwives' patients than in the case of patients of TBA's.Both Significantly more midwives than TBA's felt that they needed more staff at the health care facilities (15% vs. 0%; p=0.005) and felt that they needed more reading m aterial (72.5% vs. 32.7%;p=<0 .00 1 ), in order to better manage haemorrhage in pregnancy.However, significantly more TBA's than midwives felt that they needed to formulate support groups within the community (76.9% vs. 50%; p=0.009) to manage haemorrhage in pregnancy more effectively.

Demographic data
The first objective of the study was to explore and describe the demographic data of the participants (Section A of questionnaire).From the demographic data it is evident that both the midwives and TBA's who provided maternal health care were older women.Based on an African cultural perspective it could have been that the patients trusted these practitioners to give advice because of their maturity (Chalmers, 1990& Gennaro, Kamwendo, Mbweza & Kershbaumer, 1998).T heir m atu rity was fu rth e r supported by the fact that the midwives and the TBA's had m any years of ex p erien ce.E xperience p ro v id es practitioners with knowledge for the understanding of issues; to becom e experts and to m aster a num ber of routines that they can perform easily (Woolfolk, 1993).
A concern identified from the results is definitely the fact that the midwives and TBA's worked very long hours.The standard working week in Malawi is 40 hours and most midwives and TBA's worked more than a standard 40-hour week.In Malawi, as in the rest of the world, practitioners are working longer hours due to staff shortages (Mahoko, 1991).The working hours of midwives and TBA's needs revision in order to provide safe and effective ante-and postnatal services.

Nature of information
T his section addresses the second objective of the study, i.e. to explore, describe and compare the nature of the information given to rural women by m idw ives and TB A 's reg ard in g haemorrhage in pregnancy (Section B of the q u estio n n aire).The findings suggested that although the midwives and TB A 's included the n ecessary information, there were deficiencies in critical areas.M idwives and TBA's should be encouraged to discuss between them the factors that could make information provision more effective and to aim for the same goal of providing a good quality health care service to all patients.It was of concern that few TBA's provided postpartum care, as it was during this period that postpartum haem orrhage occurred.According to Gennaro et al. (1998:192), postpartum haem orrhage is the leading cause of maternal mortality in Malawi.The WHO (1998) recommended that all pregnant wom en should have access to basic m aternity care during pregnancy and delivery, including antenatal care, a clean and safe delivery and postnatal care.In addition, fewer than half of the midwives and TBA's discussed complications of p reg n an cy and d an g er signs o f pregnancy with their patients.N on inclusion of these two vital topics would m ean that wom en w ere denied the opportunity to have information in the areas that may have lead to recognising the severity of the problems and to seek care timeously (Pender, 1982), resulting in maternal mortality (Walraven, Telfer & Ronsmans, 2002).Policies and guidelines fo r in fo rm atio n , ed u catio n and counselling should have emphasised the in clu sio n o f the d an g er signs and complications of pregnancy.Teaching material should also have been made available for health care providers to refer to.
The midwives and TBA's respectively,

Curationis May 2006
explained haemorrhage in pregnancy inconsistently from each other.For ex am p le, m id w iv es provided less information on care of the neonate but more inform ation on specific issues pertaining to delivery than did the TB A's.Furthermore, significantly more TBA's didn't view a blood loss of more than 300ml as abnormal.Chichakli et al. (1999:721) indicated that most pregnancyrelated deaths due to haemorrhage could have been p revented through early diagnosis and effective and immediate management.In addition, Castro et al.
(2 0 0 2 ) revealed that maternal deaths resulted from the lack of realising the needs for immediate treatment.
Both groups did not see new mothers as a specific group that required information on h aem o rrh ag e. B eger and C ook (1998:163) argued that the special learning needs of new mothers should be taken into consideration.With regard to new m others, it was recom m ended that m u ltig rav id ae w om en assist in the provision of information on haemorrhage in pregnancy to primigravidae, as they could benefit from the experience of the multigravidae.
Both midwives and TBA's explained antepartum and intrapartum haemorrhage as a type of haemorrhage to their patients.However, it was evident that TBA's did not view postpartum haemorrhage as important or dangerous, as only 13.5% included the information in their advice.This was dangerous because secondary po stp artu m h aem orrhage is ju st as im p o rtan t as p rim ary postpartum haemorrhage, especially in rural areas where patients are far away from the health facilities (Essex, 1981;Bennett & Brown, 1999).TBA's required refresher courses on the prevention and diagnosis of a secondary postpartum haemorrhage, and it should also be emphasised in their curriculum.
Significantly fewer TBA's than midwives included important information on the predisposing factors for antepartum haemorrhage such as previous history of bleeding during pregnancy, anaemia, high blood pressure and uterine fibroids (Cronje & Grobler, 2003).Anaemia was an important factor because it resulted in the patient being less able to tolerate a postpartum haemorrhage, which is thus more likely to result in maternal death (W alraven et al., 2000).In addition, significantly fewer TBA's than midwives included the follow ing im portant information on the predisposing factors for postpartum haemorrhage: full bladder, previous history of bleeding, multiple pregnancy, polyhydramnios, prolonged labour, decreased clotting factors and poor antenatal clinic attendance.All these factors were documented predisposing factors contributing towards postpartum haemorrhage (Cronje & Grobler, 2003).The information on the predisposing causes o f postpartum haem orrhage should have included the follow ing critical information: emptying of the bladder, treatment of anaemia, excluding any h isto ry o f previous bleeding, p rev en tin g pro lo n g ed labour, and preventing mismanagement of the third stage o f labour.T here m ight be significantly reduced maternal morbidity and mortality for patients who received antenatal care (Bemis, Dumont, Bouillon, Gueye, D om pnier & Bouvier-Colle, 2000:70;Browne & Dixon, 1978).

Recommended practices
The last objective of the study was to describe and com pare recommended practices that should be included in the information given to the rural women by the m idw ives and TBA's regarding haemorrhage in pregnancy (Section C of the questionnaire).In general, most common practices for the prevention of antepartum haemorrhage were included in the information given to women.It was however of concern that TBA's did not view attending the antenatal clinic as important for the prevention of bleeding during pregnancy.In addition, both midwives and TBA's did not consider an empty bladder to be necessary for the contraction of the uterus, and thus for prevention of a postpartum haemorrhage.A full bladder prevented efficient uterine contraction and also alluded to poor management of the labouring patient (Sellers, 1993).
Although traditional herbs were routinely used in Malawi, TBA's and midwives did not recommend it's use for the prevention of a haemorrhage in pregnancy.Both midwives and TBA's recommended to p atien ts that they should report a postpartum haemorrhage at their nearest health facility and that the stage at which a woman seek medical attention for a haemorrhage, determined the outcome of the situation.This is supported by Bennett & Brown (1999:71) and Sellers, (1993) w hich stated that delays in instituting treatm ent could make the problem more complicated or worse and may result in a maternal mortality.The research findings indicated that not all TBA's realised the need to explain to women that they should seek medical attention, when noticing bleeding during pregnancy or when noticing heavy blood loss after delivery.Thus, delays in referral for medical treatment were more apparent in the case of TBA's.Midwives were significantly more likely to assess the patient first for blood loss, and then call an ambulance, and would resuscitate the patient whilst awaiting the ambulance.A dvisably all m aternal health care providers should be conversant with the practice of referral that is followed in their facility so that they could explain it to their patients.
Further delays in obtaining medical treatment were caused by midwives and TBA's who did not explain the referral system to the patient, which resulted in the p atien t not un d erstan d in g the importance of complying with the referral.Undue delays or refusal might have been caused and eventually the condition may worsen and even result in the loss of life (Bennett & Brown, 1999:72).Other factors that contributed to the delay in seeking care were lack of patient awareness of the danger of haemorrhage in pregnancy, powerlessness in decision-making and the long distance to the clinic.M idw ives and TBA's recom m ended strateg ie s for the im provem ent of in fo rm atio n p ro v isio n to patients regarding haemorrhage in pregnancy.The majority of the midwives viewed provision of a variety of educational materials to the community and health w orkers as im portant, w hereas the m ajority of the TBA's viewed to the c reatio n o f support groups in the community as important.The midwives also felt that increased staff levels would assist in the provision of information on haem orrhage in pregnancy.Further recommendations for the provision of in fo rm atio n on haem o rrh ag e in pregnancy by midwives and TBA's were provided.

Recommendations for midwifery practice, education and research
F u rth er recom m endatio n s for the provision of information on haemorrhage in pregnancy by midwives and TBA's were formulated as follows:.

•
To initiate joint meetings between midwives and TB A 's, in order to discuss and share experiences that can improve the provision of health information to the women.

Conclusion
The overall view gained from the findings of the study was that both the midwives and TBA's did include basic information about haemorrhage in pregnancy but there were deficiencies in some critical areas.In addition, TBA's gave significant less information than midwives on some aspects for example antepartum and postpartum care and practices that could help prevent haemorrhage in pregnancy (p -value < 0.05).

Limitations
The sampling method that was used to select the participants who complied with the inclusion criteria prevented a wider representation of maternal health care providers in the district.This caused a decreased generalisability of the study results.In addition, the questionnaire was formulated in such a way that the participants had to respond to some questions from recall; hence the data were based on the participants' ability to recall what they knew.Lastly, data collection was done during the rainy season and this made it impossible to reach the most remote areas of the district, where the dirt roads were inaccessible.

recommended Figure 1 Types of care offered at the facilities
•Nature of information Provision of information is a planned Frequencies, means and percentages were calculated and presented in bar graphs, pie charts and tables.Fischer's E xact Tests at the 0.05 level o f sig n ifican ce w ere used to m ake com p ariso n s about the type o f information and recommendations given by midwives and TBA's.Validity was ensured by subjecting the researcher-administered questionnaire to content, construct and face validity.

Types of vaginal bleeding included in the information
of TBA's provided postpartum care.Refer to Figure 1 for the types of care offered at the facilities.The information provided to women onFigure 2