Maternal mortality in sub-saharan Africa: the contribution of ineffective blood transfusion services

DOI: /j x Review article Maternal mortality in sub-saharan Africa: the contribution of ineffective blood transfusion services I Bates, a GK
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DOI: /j x Review article Maternal mortality in sub-saharan Africa: the contribution of ineffective blood transfusion services I Bates, a GK Chapotera, a S McKew, b N van den Broek a a Liverpool School of Tropical Medicine, Liverpool, UK b Department of Haematology, Royal Liverpool University Hospital, Liverpool, UK Correspondence: Dr I Bates, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK. Accepted 25 June In sub-saharan Africa, where blood supply is critically inadequate, severe haemorrhage is a leading cause of maternal deaths. The aim of this review was to estimate the impact of lack of blood on maternal deaths and identify reasons and potential solutions. Databases and websites from 1970 to 2007 were searched for information concerning maternal deaths and near misses due to haemorrhage in sub-saharan Africa. Original studies that provided qualitative or quantitative information about blood transfusion services in relation to obstetric deaths or near misses were included. Data about maternal haemorrhage deaths associated with lack of blood for transfusion and reasons for blood shortages were extracted from the full text of articles by two independent reviewers using predesigned, piloted forms. Twenty of 37 selected studies described a direct association between maternal deaths and lack of blood transfusions. Five of 37 provided quantitative information which showed that overall 26% (16 72%) of maternal haemorrhage deaths were due to lack of blood. Reasons included nonaffordability of blood, lack of blood donors, unwillingness of relatives to donate and inadequate supplies and transport. Lack of blood for emergency transfusions is a major, but poorly quantified and under-researched cause of maternal deaths in sub-saharan Africa. Potential solutions include more blood donations, better financing mechanisms and more efficient management systems. Complementary approaches to prevent severe anaemia and treat hypovolaemia are important to reduce use of transfusions. Keywords Africa, anaemia, haemorrhage, maternal mortality, transfusion. Please cite this paper as: Bates I, Chapotera G, McKew S, van den Broek N. Maternal mortality in sub-saharan Africa: the contribution of ineffective blood transfusion services. BJOG 2008;115: Background Each year more than women worldwide die from complications of pregnancy and childbirth. The maternal mortality ratio (MMR) per live births is estimated to be 920 in Africa, 330 in Asia and 10 in Europe. 1 Up to 80% of these maternal deaths are directly due to five complications: haemorrhage, sepsis, eclampsia, rupture of uterus (obstructed labour) and complications of abortion. Although reliable information about the individual medical causes of maternal mortality is scarce, especially in sub-saharan Africa, 2 haemorrhage during labour, delivery and postpartum accounts for one-third of all obstetric deaths in the world and is the leading cause of maternal deaths in Africa (34%) and Asia (31%). 2 Half of the maternal deaths from severe bleeding in the world occur in sub-saharan Africa 3 and about 65% of these deaths occur in the postpartum period. The package of interventions recommended for prevention and treatment of postpartum haemorrhage, includes oxytocic drugs, blood transfusion, manual removal of placenta, uterine compression sutures and, if required, hysterectomy. 4,5 Efforts to reduce maternal deaths from haemorrhage at basic level have focused on ensuring skilled birth attendance and the availability of emergency (or essential) obstetric care. Although the ability to perform caesarean sections and to provide blood transfusions are key components of comprehensive emergency obstetric care, 6 improving the effectiveness of blood transfusion services has been relatively neglected. 3 A major reason why so many women die from haemorrhage is because once bleeding starts death can occur in around 2 hours compared with 10 hours for eclampsia and 72 hours for obstructed labour. 7 Rapid access to adequate and safe supplies of blood for transfusion is therefore absolutely critical to prevent deaths due to obstetric haemorrhage. The total shortfall in blood supply for developing countries is estimated to be 40 million units/year. 8 Only 39% of the world s blood supply is donated in developing countries although they have 82% of the global population. 9 Sub-Saharan Africa has the ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 1331 Bates et al. lowest quantity of blood donated for transfusion per person in the world; it is not known how many maternal deaths in Africa could be prevented by better blood supplies. In many developing countries, and especially in sub- Saharan Africa, transfusion services are provided by individual hospitals. Women admitted with haemorrhage have to find a replacement donor from among their family members and may resort to using a paid donor. The hospital screens potential donors for infections and checks blood groups and compatibility of donors and recipients. This replacement system results in significant delays in obtaining suitable blood for transfusion and puts additional burden on families at a time of emotional and financial stress. Overall, 80% of blood for transfusion in sub-saharan Africa comes from replacement donors. 10 Centralised, national systems that collect blood only from voluntary non-remunerated blood donors from lowrisk populations are the recommended model for transfusion services 11 but they are complex to organise and more expensive than hospital-based systems. Centralised services have therefore only been implemented in a few African countries and, with a few exceptions, their sustainability is dependent on external funding. Despite the recent global emphasis on investment in better maternal health and the universal recognition that haemorrhage is a major cause of death, very little is known about the impact of ineffective transfusion services on maternal mortality. We therefore conducted a review of the literature to estimate the proportion of maternal deaths that could be attributed to failures in the provision of timely blood transfusions. We sought to document factors that contributed to unavailability of blood transfusions and to prioritise actions for maternity and transfusion services. Methodology We searched databases and websites from 1970 to 2006 but were unable to find any studies in which the role of blood transfusions in deaths and near misses due to obstetric haemorrhage in Africa was the main focus. We therefore redesigned our search strategy to identify articles that focused on deaths and near misses due to maternal haemorrhage and then extracted relevant information about transfusion services from the text. We searched MEDLINE and African Index Medicus electronic databases, and maternal health and blood transfusion websites of the World Health Organization (global and Africa Regional Office) using various combinations of the words and phrases: maternal, mortality, morbidity, obstetric, near miss(es), haemorrhage/hemorrhage, transfusion(s), developing countries and Africa. As information about the availability of blood was not included in abstracts, the full text of all studies that provided details about haemorrhage and maternal morbidity and/or mortality was retrieved. Relevant articles from the reference lists of these studies and articles obtained through personal communication were also retrieved. Only original studies that provided either qualitative or quantitative information about blood transfusion services in relation to obstetric deaths or near misses were included in this review. Two authors (G.K.C., S.McK.) independently assessed studies for inclusion using a form which was designed to meet the objectives of this review and which had been piloted on five studies before use. Both authors extracted information from the studies using the predesigned form. In the case of disagreement, a third author (I.B.) acted as moderator. Data collected included information on the year, type and location of the study, total number of deliveries and live births, maternal mortality and near-miss rates and the proportion of women with life-threatening haemorrhage. Specific reasons for problems with blood transfusions, and, if available, the number of deaths and near misses directly attributable to lack of timely blood transfusions, were extracted from the papers. Definitions We used the definitions given below for interpretation of data. 3 Maternal death The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes (ICD-9 and ICD-10). 12 Maternal mortality ratio The number of maternal deaths during a given time period per live births during the same time period. Near-miss (severe acute) maternal morbidity An acute illness in a pregnant woman or a woman who has had her pregnancy terminated within the previous 6 weeks in whom immediate survival is threatened if immediate treatment is not administered and/or in whom survival is by chance or because of the hospital care they receive. This is usually determined by the presence of any one marker (clinical or management-based within the study). 13,14 Obstetric haemorrhage Obstetric haemorrhage includes antepartum haemorrhage (placenta praevia, placental abruption) and postpartum haemorrhage from any cause known or unknown. Postpartum haemorrhage is defined as the loss of more than 500 ml of blood from the genital tract after delivery of the baby ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology Lack of blood and maternal mortality in Africa Data synthesis Information about mortality, near misses and live births and the proportion of deaths and near misses due to haemorrhage were extracted directly or calculated from data provided in the papers. Comments and numerical data about the contribution of lack of timely blood transfusions to maternal mortality and near misses were extracted from papers, predominantly from the results and discussion sections. Quantitative information was tabulated and an estimate of the proportion of deaths and near misses that could have been prevented if blood had been available was calculated. Authors comments about the challenges of providing blood transfusions for pregnant women and specific factors that contributed to the failure of blood supply were also noted. Results We identified 37 studies from 15 countries in sub-saharan Africa that focused on, and provided quantitative information about, the contribution of haemorrhage to maternal mortality or near misses (Tables 1 and 2). From these studies, the range of MMR was per live births (Table 1). About 17.3% (mean; range %) of these deaths were due to haemorrhage. Only five studies, all from South Africa, contained information about haemorrhage as a cause of near miss obstetric emergencies (Table 2). The mean near-miss incidence rates were 6.0 per 1000 deliveries (range ) and severe haemorrhage accounted for 1.2 near misses per 1000 deliveries ( ). Overall, 19.4% Table 1. The contribution of haemorrhage to maternal mortality in Africa Country Location Year of study Live births* (total) Maternal deaths (total) MMR Total deaths due to haemorrhage % deaths due to haemorrhage Ethiopia Addis Ababa Frost 15 Gambia Banjul ** Hoestermann et al. 16 Ghana Berekum Geelhoed et al. 17 Ghana Ejisu Martey et al. 18 Kenya Nairobi Ngoka and Bansal 19 Kenya Nakuru Juma and Odiyo 20 Malawi Central ** Bullough 21 Mali Bamako ** Etard et al. 22 Niger Ilesa Ogunniyi and faleyimu 23 Nigeria Anambra Chukudebelu and Ozumba 24 Nigeria Enugu NA 26.0 Chukudebelu and Ozumba 25 Nigeria Enugu ** NA 12.9 Osefo 26 Nigeria Ilorin NA 35.6 Adetoro and Okwerekwu 27 Nigeria Ilorin ** Adetoro 28 Nigeria Jos ** NA 28.1 Ujah et al. 29 Senegal Bandafassi Kodio et al. 30 Senegal Mlomp Kodio et al. 30 Senegal Niakhar Kodio et al. 30 South Africa Pretoria Cochet et al. 31 South Africa Pretoria ** Mantel et al. 13 Sudan Medan city Dafallah et al. 32 Tanzania Bagamoyo MacLeod and Rhode 33 Tanzania Kilimanjaro ** Armon 34 Tanzania Mbulu, Hanang Olsen et al. 35 Tanzania Northwestern Walraven et al. 36 Tanzania Southern ** Urrio 37 Tanzania Southern ** Price 38 Uganda Kampala ** Kampikaho and Irwig 39 Zambia Kabwe Kilpatrick et al. 40 Zimbabwe Harare Crowther 41 Zimbabwe Harare Fawcus et al. 42 Zimbabwe Matabeleland Rutgers 43 Total , Mean MMR, maternal mortality ratio per live births (or deliveries); NA, not available. *Live births were calculated from MMR and total maternal deaths if actual figures were not provided by the authors. **Total deliveries were used for the denominator if live birth rates were not provided by the authors. ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 1333 Bates et al. Table 2. The contribution of haemorrhage to near-miss cases in sub-saharan Africa Country Year of study Total deliveries/ live births Total near misses Near-miss incidence per 1000 deliveries Total (%) near misses due to haemorrhage Near-miss incidence due to haemorrhage per 1000 deliveries South Africa (31.0) 0.4 Sebitloane and Moodley 44 South Africa (25.9) 2.8 Mantel et al. 13 South Africa (5.6) 0.7 Vandecruys et al. 45 South Africa (4.1) 0.4 Vandecruys et al. 45 South Africa (40.1) 2.8 Cochet et al. 31 Total (19.4) 1.2 (mean; range ) of near-miss morbidity was due to haemorrhage. In 21 of these 37 studies, the authors mentioned a direct association between maternal deaths and/or near misses and lack of timely blood transfusions (Table 3). Twenty of the studies were retrospective audits based in communities (n = 2) or health facilities (n = 17) or both (n = 1). Only five of 37 studies provided quantitative information about the number of haemorrhage deaths that were directly attributable to lack of blood transfusion. These studies from Gambia (n = 2), Malawi, Nigeria and Tanzania, indicated that 184 of 713 (mean 26%, range 16 71%) haemorrhage deaths were due to lack of an effective emergency supply of blood. Only six of 37 studies mentioned specific reasons why lack of blood or delays in transfusion had arisen. These reasons were inability of the women to pay for blood in advance, 27,28,46,48 lack of blood donors, 7,49 unwillingness of relatives to donate blood 27,28,38 and lack of supplies, blood bank, storage facilities and transport. 27,28 Discussion Rapid and equitable access to skilled birth attendance and basic and comprehensive emergency obstetric care, including blood transfusions, is a key principle underlying strategies to reduce maternal mortality and to achieve the Millennium Development Goal (MDG) 5 which was agreed in ,50 A recent review of maternal mortality concluded that Africa is very unlikely to achieve this MDG and that overall results for women have fallen badly short of what should have been achieved. 51 Lack of blood transfusions: reasons and contribution to maternal deaths Our study confirms recent reviews, which demonstrated that haemorrhage is a common cause of maternal deaths in Africa, 2 and from the very limited published data, it seems that haemorrhage is also an important cause of near misses. Although there has been no study from sub-saharan Africa designed specifically to document the impact that lack of blood for transfusion has on obstetric mortality and near misses, over half of the studies that focused on severe obstetric haemorrhage mentioned that lack of blood for transfusion was a contributory factor. The small number of studies that provided quantitative information indicated that at least onequarter of all maternal deaths in sub-saharan Africa due to haemorrhage could be prevented by rapid access to blood transfusions. The reasons for lack of availability of transfusions included poverty, lack of donors and logistic failures. Mechanisms for avoiding blood transfusions Although this paper argues for more effective blood transfusion capability in sub-saharan Africa, we recognise that there are other ways of preventing or managing severe haemorrhage. Active management of the third stage of labour reduces the incidence of postpartum haemorrhage. Early recognition of obstetric haemorrhage as a danger sign and timely initial management with intravenous fluids is critical. Subsequent effective management with oxytocics, misoprostol and prostaglandins should reduce the need for blood transfusions. Where necessary, surgical interventions such as manual placenta removal, uterine tamponade and compression suture are valuable alternatives to the traditional options of pelvic devascularization and hysterectomy for managing severe bleeding. Lack of intravenous access and unavailability or inappropriate use of volume expanders, also contribute to the high mortality rates. Anaemia in pregnancy is very common in sub-saharan Africa. The risks from severe haemorrhage, and consequently the need for blood transfusions, would be reduced if anaemia detection and management early in pregnancy or preconception could be improved. Limitations of the study The contribution of ineffective transfusion services to maternal mortality has not been a specific focus of research and so information has not been included systematically in publications. Almost all the studies in our review were retrospective audits of maternal deaths, and so the quality of information about availability of blood transfusions is uncertain. We had to extract information about failings in the blood transfusion 1334 ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology Lack of blood and maternal mortality in Africa Table 3. Studies that identified a direct link between inadequate blood transfusion services and maternal morbidity and mortality in sub-saharan Africa Study site Data collection period Haemorrhage deaths (/total study deaths) as a direct result of inadequate transfusion services Type of study Link between transfusion failure and obstetric haemorrhage morbidity and mortality Studies that provided quantitative information Gambia /18 (22%) Hospital-based retrospective mortality study 32% of deaths were associated with delays due to unavailability/faultiness of drugs, equipment or blood transfusion Gambia /18 (28%) Community-based retrospective mortality study Deaths occurred in women inpatients while waiting for a blood transfusion; lack of blood.turned out to be fatal for them Hoestermann et al. 16 Walraven et al. 7 Unavailability of blood at referral level partly due to a lack of donors A clear need for improved blood transfusion services identified Malawi /28 (71%) Hospital-based retrospective mortality study Blood shortage was a vital factor in deaths Bullough 21 Nigeria /624 (24%) Hospital-based retrospective mortality study All deaths from maternal haemorrhage Adetoro 28 Tanzania /25 (16%) Health facility-based retrospective mortality study Total deaths directly attributable to failure of transfusion services/total deaths due to haemorrhage 184/713 (26%) were due to lack of prompt, adequate blood transfusion 41% of women died within 24 hours of admission in a teaching hospital, which had limited stocks of blood and where relatives had to donate or pay for blood for emergency transfusion Problems identified were lack of adequate quantity of blood for transfusion, inefficient blood bank facilities and poor response of husbands or relations to donate blood willingly Four deaths due to haemorrhage were because no blood was available, relatives were not available or they refused to give blood 17/89 all maternal deaths were avoidable ; lack of blood was the second most common cause of avoidab
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