RESEARCH ARTICLE Open Access

Influencing factors for prevention ofpostpartum hemorrhage and earlydetection of childbearing women at risk inNorthern Province of Rwanda: beneficiaryand health worker perspectivesOliva Bazirete1* , Manassé Nzayirambaho1, Aline Umubyeyi1, Marie Chantal Uwimana1 and Marilyn Evans2

Abstract

Background: Reduction of maternal mortality and morbidity is a major global health priority. However, muchremains unknown regarding factors associated with postpartum hemorrhage (PPH) among childbearing women inthe Rwandan context. The aim of this study is to explore the influencing factors for prevention of PPH and earlydetection of childbearing women at risk as perceived by beneficiaries and health workers in the Northern Provinceof Rwanda.

Methods: A qualitative descriptive exploratory study was drawn from a larger sequential exploratory-mixedmethods study. Semi‐structured interviews were conducted with 11 women who experienced PPH within the 6months prior to interview. In addition, focus group discussions were conducted with: women’s partners or closerelatives (2 focus groups), community health workers (CHWs) in charge of maternal health (2 focus groups) andhealth care providers (3 focus groups). A socio ecological model was used to develop interview guides describingfactors related to early detection and prevention of PPH in consideration of individual attributes, interpersonal,family and peer influences, intermediary determinants of health and structural determinants. The research protocolwas approved by the University of Rwanda, College of Medicine and Health Sciences Institutional Ethics ReviewBoard.

Results: We generated four interrelated themes: (1) Meaning of PPH: beliefs, knowledge and understanding of PPH:(2) Organizational factors; (3) Caring and family involvement and (4) Perceived risk factors and barriers to PPHprevention. The findings from this study indicate that PPH was poorly understood by women and their partners.Family members and CHWs feel that their role for the prevention of PPH is to get the woman to the health facilityon time. The main factors associated with PPH as described by participants were multiparty and retained placenta.Low socioeconomic status and delays to access health care were identified as the main barriers for the preventionof PPH.(Continued on next page)

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* Correspondence: baziretoliva@gmail.com1College of Medicine and Health Sciences, University of Rwanda, 3286 Kigali,RwandaFull list of author information is available at the end of the article

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Conclusions: Addressing the identified factors could enhance early prevention of PPH among childbearing women.Placing emphasis on developing strategies for early detection of women at higher risk of developing PPH, continuousprofessional development of health care providers, developing educational materials for CHWs and family memberscould improve the prevention of PPH. Involvement of all levels of the health system was recommended for a proactiveprevention of PPH. Further quantitative research, using case control design is warranted to develop a screening tool forearly detection of PPH risk factors for a proactive prevention.

Keywords: Postpartum hemorrhage, Early detection, Prevention, Influencing factors, Beneficiaries, Health workers

BackgroundMaternal mortality remains a major challenge to thehealth system worldwide. The World Health Organiza-tion(WHO) [1] reports that every year, nearly 295 000women die due to complications induced by the preg-nancy and most of them are preventable or treatable.Maternal mortality from low and lower middle-incomecountries accounts for 94% [1]. Say et al. [2], highlightthat more than 25% of these deaths result from postpar-tum bleeding, with almost 20% of all maternal deathsdue to postpartum hemorrhage (PPH). In Rwanda, 70%of maternal deaths result from direct causes and post-partum bleeding is the leading direct cause of maternaldeath with 22.7% of all documented cases [3].Primary PPH is commonly defined as a blood loss of

500 ml or more within 24 hours after birth [4, 5].Though there have been concerted initiatives to addressmaternal mortality due to PPH, the issue remains a glo-bal burden [6]. The recent data from WHO [1], suggestthat less than 50% of all births in several low incomeand lower-middle-income countries are assisted by atrained midwife, doctor or nurse while in most high-income and upper-middle-income countries, reportsdemonstrate that more than 90% of all births benefitfrom the presence of a skilled birth attendant. Factorsrelated to provision of substandard care were identifiedfor 61.1% of the maternal death cases in a study on ma-ternal death audit in Rwanda [3].As reported by evidence, effective implementation of

guidelines based on evidence is deemed to prevent ma-jority of PPH-related morbidity and mortality. WHO [7]provides recommendations for skilled health care pro-viders and other stakeholders on the effective use ofuterotonics for PPH prevention among women givingbirth in hospital or community settings from high-income, middle-income or low-income countries. How-ever, Raghavan et al. [8] affirm that routine uterotonicprophylaxis, such as, the use of Oxytocin as a goldstandard uterotonic medication for PPH prevention, isnot 100% effective in PPH prevention. Therefore, WHO[7] is urging different partners to review their respectivenational health policies and protocols on PPH preven-tion to reflect quality of care for women which involves

timely and appropriate care to achieve desired outcomesconsistent with professional knowledge and consideringthe preferences and aspirations of individual childbear-ing women and their families [9]. In addition, Prata et al.[10] highlight the need for every country to develop itsown policies and programs specific to local context andincorporating a variety of approaches to prevent and ad-dress PPH challenges.Different ways to prevent PPH fall under the widely

used Essential Public Health Operations (EPHO) that dif-ferent countries with the leadership of WHO can adaptand work on together, to assess and plan for sustainablepublic health services and capacities [11]. The EPHO-five,focuses on prevention of disease through actions takenacross the three levels of disease prevention: primary, sec-ondary and tertiary levels. Almost all the actions fromthese levels of prevention, are within the roles and respon-sibilities of health care providers in primary care, hospitalsand community services environments [11]. All the ac-tions done to prevent risks before to onset of a disease(PPH in the case of the present paper), are proactive andconstitute primary prevention. A recent qualitative sys-tematic review conducted by Finlayson et al. [6] appraisedevidence about the views and experiences of women andhealthcare providers on interventions taken to preventPPH at different prevention levels. The review generatedconsiderable emphasis on contextual factors that contrib-ute to successful implementation of strategies for PPHprevention, especially factors associated with sufficient re-sources and effective implementation by competent, suit-ably trained providers [6].There is cause to consider that the investigation of fac-

tors influencing early detection of women at risk at alllevels of PPH prevention from different perspectives iscrucial to enhance quality of care during childbear-ing period. Striking factors at different levels of servicedelivery have been found to be critical in shaping partici-pants’ experience for the implementation of obstetrichemorrhage initiative in Florida [12]. Furthermore, thestudy of Semasaka et al. [13] on self-reportedpregnancy-related health problems and self-rated healthstatus in postpartum Rwandan women observed poorsexual and reproductive health care and recommended

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that particular attention be given to determinants ofpoor quality care and to early prevention of related com-plications. Poverty, distance to facilities, lack of informa-tion, inadequate and poor quality services, and culturalbeliefs and practices are reported by WHO [1] as differ-ent categories of main factors that prevent women fromgetting access to care during pregnancy and childbirth.Lack of information among clients and their partners

before, during and after the PPH event was the mainobstacle reported by Woiski et al. [14] for high qualityPPH-care identified by patients, while health care pro-viders expressed lack of clarity of the guidelines, lack ofknowledge and poor communication within teams ashindering factors. Therefore to improve quality of careprovided to women for prevention of PPH, an in-depthanalysis from different perspectives ,identifying influen-cing factors for delivery of quality PPH-care will providenecessary information for implementing a strategy toimprove care [15]. Currently, little is known in Rwandaabout key factors that could influence early detection ofwomen at risk of PPH from the perspectives of patientsand family members, the community and health careprofessionals. This study aims to explore influencing fac-tors for prevention of PPH and early detection of at risk

childbearing women as perceived by beneficiaries andhealth workers in the Northern Province of Rwanda.

MethodsDesignAs part of a larger exploratory sequential mixed-methodsstudy, we undertook phase one of the study with a qualita-tive descriptive design to develop a rich description of thephenomenon under study [16, 17]. This design was usedto uncover daily participants’ experiences by remainingclose to described or observed events [18]. To explore in-fluencing factors for delivering PPH proactive preventivecare from different perspectives, a social determinants ap-proach to maternal deaths [19] and Social EcologicalModel (SEM) [20] were used.

SettingThe healthcare system in Rwanda reaches from the com-munity to the national referral hospitals [21]. As illus-trated by the Fig. 1, there are three levels of thehealthcare system in Rwanda: (1) community health cen-ters and health posts which constitute the primary levelof healthcare, (2) district hospitals operating at the sec-ondary level of healthcare, and (3) provincial referral

Fig. 1 Health care system in Rwanda. MOH*: Ministry of Health

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hospitals, national referral hospitals and UniversityTeaching Hospitals, serving as the tertiary and highestlevel of healthcare [21, 22].Recently, Rwandan Ministry of Health established a

new level of health facility which is in between districthospital and health center, to relieve the challenge of de-lays in referral of obstetric cases and overcrowding atdistrict hospitals. These facilities are called medicalizedhealth centers [23].The present study was conducted at primary and sec-

ondary levels of the health system in Rwanda. We reachedout to the community by involving community membersand community health workers (CHWs) in charge of ma-ternal health. This study was conducted in three health fa-cilities of the Northern Province of Rwanda. We includedone health center, one medicalized health center and onedistrict hospital. The selection criteria we used to choosefacilities to be visited included their level of performancein maternal and newborn health, location (urban versusrural), and geographical accessibility of the health facilitiesto clients. The study sites were selected by the principalinvestigator and validated by the research committee. Theselected district hospital serves a population of 444 387 inits catchment area, which also includes 24 health centers[24]. The Northern Province of Rwanda was purposivelychosen for being in a rural area where some health centersare hard to access, and for its low uptake of antenatal andpostnatal services among childbearing women [24].

Participants and recruitmentFifteen women were purposively selected for having ex-perienced PPH within the six months immediately priorto data collection, being willing to participate, and be-ing over 18 years old. The research team, in collabor-ation with the head of maternity at the facility,identified PPH cases from the birth register. For womenwho were discharged from the health facilities, theCHWs in charge of maternal health assisted to connectthe research team with them for recruitment from thevillages. Women who were still in hospital were given averbal invitation by the researcher to participate.Women and their partners or close relatives whoagreed to participate were given an appointment by theresearcher for an interview at the nearest health facility.The inclusion criteria for relatives included being herhusband or a close relative who was with her whenPPH occurred. The final sample size of eleven womenwas reached when it was determined no new themeswere emerging from the interviews and it was judgedthat sufficient data had been collected to address thestudy’s purpose [16]. Ten close relatives to the womenfrom two health facilities responded to our invitationand were willing to participate (eight husbands and twoclose female relatives).

CHWs in charge of maternal health living in the samevillage as the woman who experienced PPH were also in-vited to participate in this study since they are in controlfor not only maternal health but also for neonatal healthin their respective villages. CHWs register women of re-productive age, encourage them to use maternal careservices, go along with clients in labor from villages tothe nearest health facility to be assisted by skilled birthattendants during labor and delivery [25]. The CHWswho participated in the present study were identifiedthrough the CHW coordinator who is a full time em-ployee at the health facility. The researcher made aphone call to fourteen CHWs who were eligible, invitingthem to participate in the study. Eleven female CHWsfrom the two health facilities responded to the invitationand were sent a text message specifying the venue andtime for the focus group interview.A total of twenty-five health care providers working in

maternity units of selected health facilities were also in-vited to participate, of whom fourteen (10 nurses, 3 mid-wives, 1 medical doctor) were eligible to participate in afocus group discussion (FGD). Correspondence to po-tential participants was in Kinyarwanda language. Partic-ipants were recruited using email or telephone messages.Inclusion criteria included: being a full-time and healthcare provider with at least one year’s experience ofworking in maternity, and ability to speak and read in ei-ther English or Kinyarwanda.In this study women and their relatives are considered

as beneficiaries while health care professionals andCHWs in charge of maternal health are all considered ashealth workers. The research team consisted of memberswith expertise in qualitative research methodology, ma-ternal health and health care. Apart from one researchteam member, all were female.

Data collectionThe research team developed semi-structured interviewguides in both English and Kinyarwanda, including onefor each category of in-depth interviews (IDIs) andFocus Group Discussions (FGDs). The interview guideswere translated back and forth by an independent pro-fessional translator, to confirm that the meaning andcontent of the questions of the original copy had notchanged during the translation process. Verification ofthe translated instrument was also done by the researchteam to ensure its validity. The interview guide ques-tions focused on five interrelated levels of SEM to facili-tate identification and description of potential PPHinfluencing factors: individual, interpersonal, community,organizational, and policy/enabling environment [20].Demographic data of participants was obtained using ademographic form during individual interviews. All par-ticipants chose to be interviewed in Kinyarwanda. The

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principal investigator conducted IDIs and FGDs. As theresearcher is a Rwandan national, there were no lan-guage or cultural barriers with participants.Pretesting of the interview guides was conducted to

improve validity in data collection procedures and inter-pretation of findings [26]. The pretest was done withparticipants not included in this study but sharing sameinclusion criteria. This process assisted to determine therelevancy and appropriateness of the questions beingasked, to assess wording and identify any difficulties.The pretest results indicated that conducting IDIs whilea woman was still hospitalized, was not conducive for afree and open discussion. In fact, women were reluctantto talk about issues pertaining to their relationships withhealth care providers. Therefore, for the women whowere still hospitalized at the health facilities included inthis study, IDIs were scheduled on the day of theirdischarge.Prior to voluntarily participating in the study, partici-

pants were informed about the purpose of the study andprovided with a letter of information and consent formfor their signature. Anonymity and confidentiality wereobserved throughout the conduct of the study. Afterobtaining participants’ informed consent, all interviewswere digitally audio-recorded with participants’ permis-sion and transcribed verbatim by the researcher. Datacollection took place over a period of three months fromDecember 2018 to February 2019 in meeting rooms ofthe three selected health facilities.First, the researcher conducted one-to-one in-depth

interviews with eleven women who had experiencedPPH. Then, FGDs took place with the three groups ofparticipants: (1) two FGDs with the partners and closerelatives of the women, (2) two FGDs with CHWs and(3) three FGDs with health care providers. The durationof IDIs ranged between 45 and 60 minutes, while theFGDs lasted 45 to 90 minutes. To produce an in-depthunderstanding of early detection of women at risk ofPPH and its prevention in relation to different contexts,field notes were taken by the researcher during and afterdata collection to capture all respondents’ nonverbalcommunications and other important information fromthe researcher observations.The combination of IDIs and FGDs was used to seek

data completeness [27] in this study. Each method (IDIsand FGDs) revealed different information about

prevention of PPH and contributed to a more comprehen-sive understanding. Integration of data involved movingback and forth between the data sets to discover data con-vergence and complementarity.After the number of IDIs and FGDs described above

were completed, the participants’ responses had becomerepetitive, therefore it was determined that data satur-ation had been reached and recruitment ceased. TheTable 1 illustrates number of participants in individualinterviews and in focus groups discussions.

Data analysisData analysis was concurrently undertaken with datacollection and was initiated after the completion of thefirst interview. NVivo Pro Version 12 was used to helporganize the data for further analysis. To analyze find-ings from the present study, we used the six steps of in-ductive thematic analysis [28, 29]. As described byBraun and Clarke [28] we focused on interpreting andexplaining what the study participants shared. Through-out this process the researcher considers whether theidentified themes work in the context of the entire dataset and refines the developed themes to ensure they arecoherent and distinct from each other [30]. The tran-scripts were read while listening to the audio recordingsto ensure accuracy and completeness.First, we read and re read the transcripts to become fa-

miliar with what was stated and to be immersed in thedata, noting initial analytic observations. Second, we en-gaged in open line by line coding and assigned prelimin-ary codes to the data in order to describe the contentwith interesting features across the entire data set. Acoding guide was developed, consisting of all the codesor labels from the transcripts. Third, we proceeded togroup familiar codes into preliminary themes whichdepicted the same ideas or concepts. The themes werediscussed and agreed by the research team membersthrough consensus. Ongoing analysis helped to refinethe specifics of the themes then clear definitions andnames for each theme were created. Finally we produceda report [29] on influencing factors for PPH preventioncare from different perspectives. The research teamworked in close collaboration throughout the data ana-lysis process to discuss the codes and preliminarythemes, and come to a consensus of the final emergent

Table 1 Methods of data collection and participants in the qualitative study

Data collection methods Participants Number of IDIs/ FGDs Number of Participants

IDIs Women 11 11

FGDs Health care providers 3 14

Husbands/close relatives 2 10

Community health workers 2 11

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themes. Verbatim quotes were selected from the tran-scripts to illustrate main themes.

Data qualityTo ensure rigor [31] of the present qualitative study,trustworthiness was established by observing the criteriasuggested by Lincoln and Guba [32]: credibility, transfer-ability, dependability and confirmability.To prepare for data collection, the interview guides

were developed by the principal investigator after a lit-erature search and critical discussion with the researchcommittee members. The interview guide was initiallypilot tested with three participants who are not includedin the present study. For the credibility of data, we usedinvestigator triangulation. For data quality checkup andconsistency, reliability [33] was observed. Two tran-scripts from IDIs and one transcript from a FGDs wererandomly selected by the principal investigator andshared with research team members to ensure that find-ings are based on participants’ responses rather than onresearcher’s own preconceptions. The resulting com-ments were discussed and final decisions on codes andthemes were made by group consensus. We also in-volved an independent researcher, with a master’s degreein public health to analyze a set of data while the princi-pal investigator who conducted the interviews verifiedthe consistency and fit of analyzed data with the originaltranscripts and audio records. Credibility of data wasalso ensured by data triangulation by using differentmethods and varying sources to collect data to develop acomprehensive understanding of factors affecting PPHprevention. IDIs and FGDs were conducted with differ-ent groups of people believed to have information aboutthe topic under study. Data were gathered from threehealth facilities from the Northern Province of Rwandaoffering different levels of health services to ensuregreater representation of participants from various con-texts and experiences. One medical doctor in charge ofmaternity unit was recruited to ensure that a wide rangeof insights were gained about the phenomenon.During data collection and analysis, to account for

personal bias and maintain objectivity, the researcherused journal writing to highlight the researcher’s reflec-tions on the research in progress. A verbal check wasalso made by the researcher during and at the end ofeach interview, asking the participant to confirmwhether the researcher’s understanding of the providedinformation aligned with what the participant had meantto say. After data analysis, three participants (one fromIDIs and two from FGDs) were contacted with a phonecall to obtain feedback on the generated themes andcategories.To ensure dependability, an audit trail was maintained

to record the details of data collection, data analysis and

the decisions made throughout the research process thatled to the findings.This study was presented and assessed by the Institu-

tion Review Board at the College of Medicine andHealth Sciences, University of Rwanda, and approval(No 313/CMHS IRB/2018) to carry out the study wasgranted in accordance with the applicable rules concern-ing the review of research ethics committee and in-formed consent.

ResultsA total number of 46 informants participated in individualin-depth interviews (11 women) and FGDs (7 groups in-volving a total of 35 participants). To ensure confidential-ity of study participants, they are identified as follows: W1,2, 3, ….. (women); HCP1, 2, 3, ….. (health care profes-sionals), CHW1, 2, 3, ….. (Community Heath Workers),R1, 2, 3... (relatives).

Characteristics of participants in the individual in-depthinterviewsOf the 11 women interviewed, six were aged between 20and 34 years, and five were aged between 35 and 43years. The majority of the women (n = 7) were in therange between parity 1–4 while four were parity 5 orabove. Eight women lived in an area where they experi-enced difficulties to access the nearest health facility andsix recalled having received Oxytocin after delivery (theother five did not know).

Characteristics of participants in the FGDsThe minimum number of participants in an FGD wasfour and the maximum six. Of the 14 participants in thehealth care provider FGDs, nine were male and five werefemale; 10 were nurses, 3 were midwives and 1 was amedical doctor. They had between 2 and 35 years of ex-perience working in reproductive health care. Of the 10participants in the relatives FGDs, eight were husbandsand two were relatives. Eleven CHW’s in charge of ma-ternal health participated in the two FGDs. All CHWswho participated in this study were female, reflecting thereality in Rwanda that CHWs responsible for maternalhealth care in community settings are all female.

Factors influencing the quality of PPH preventionFour interrelated themes that described the factors influ-encing PPH prevention care were identified: (1) Themeaning of PPH: personal beliefs, knowledge and under-standing (2) Organizational factors (3) Caring and familyinvolvement and (4) Perceived risk factors and barriersto PPH prevention. These themes included several sub-themes, which will be described in the followingsections.

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The meaning of PPH: personal beliefs, knowledge andunderstandingThis theme incorporates the way in which women, theirpartners or close relatives, CHWs in charge of maternalhealth, and health care providers think about PPH, andwhat it means in this context. It highlights the variety ofbeliefs, and clinical understanding related to the natureand prevention of PPH. It also describes need for moreinformation about PPH, in terms of limited knowledgefrom a beneficiary’s perspective and additional trainingneeds from a healthcare provider perspective.The health care providers working in health facilities

defined PPH as blood loss more than 500 ml within thefirst hour after birth and the quantity of blood loss wasdescribed as being visually estimated. Most CHWs de-scribed recognizing PPH in a woman when she “changesthe sanitary pad two times or more within the first hour”after childbirth. But the majority of the women partici-pants described bleeding after childbirth as “not wellknown” but an unusual blood loss after birth is a condi-tion that needs to be resolved in a hospital setting.When asked about PPH one woman commented,

“...I really don’t know what is it but what I knowfrom myself, I delivered my child after a while I feltlike I was sleeping in a basin of water, was full ofblood all over, was feeling dizzy and told the nursethat I was uncomfortable the whole body, after thatI did not know what was the next, and I woke upafter being transferred in another referral hospital”(W1).

PPH was also described by relatives as coming “unex-pectedly”. One participant explained that every woman is“candidate” to PPH and need to be prepared: “When Itry to look through it I assume that this problem happensunexpectedly and my conclusion is that every mother is acandidate, that is why all women must be preparedwhether they are rich or poor”(R12).Many health care providers mentioned that PPH has

been associated with common causes like uterine ton-icity, retained tissues after birth, tearing and trauma ofgenital organs during birth, and coagulopathy problems.Many participants felt the condition was associated withsome cultural beliefs ,such as, hard manual labor per-formed by the woman, poison in the village, and trad-itional medicine, which may delay women seekingappropriate care: “Now in the village they like to say thatthe problem is associated to poisons and a woman maygo to the traditional doctor which can be the reason to belate to reach the health facility and may lead to thoseproblems of bleeding”(HCP22).Participants revealed that there is a cultural practice

of “hiding” a complication that might happen during

childbearing. Close relatives indicated that such hidingmight be associated with lack of awareness aboutPPH in the community as the condition is believed tobe associated to poison: “what I saw in many Rwan-dans is that they try to hide that they have had acomplication afterbirth. I think this might be associ-ated to lack of awareness of the causes as some mightlink it to poison”(R17). Participants mentioned thatfamily members have a great influence in forcingwomen to follow what they believe in, such as theuse of traditional medicines. One participant men-tioned cultural beliefs about care during childbirthmight be contradictory to the woman’s own know-ledge on PPH. “..for example a woman can be awareof the signs that can lead to PPH but her mother-in-law oblige her to take traditional medicines telling herthat if her grandchild faces a problem because she didnot take those traditional medicines she will be ac-countable and will explain it”(HCP29).Participants shared their desire for information to im-

prove their knowledge on PPH prevention. The womenand their relatives revealed that CHWs in charge of ma-ternal health in their village educate women and theirfamilies about abnormal signs (in this case, participantstalked about severe headaches, fever and bleeding) dur-ing pregnancy and in postpartum period. Participantsstated that CHWs encourage pregnant women in theirvillages to go to the health facility for antenatal consult-ation and delivery. They suggested to have local leaders,for example administrative leaders of the local village,educated about PPH as they are close to the populationin the village. “…...I can suggest that all leaders at thevillages’ level can take this as their duty and I think thiscan contribute a lot to prevention of some maternalhealth problems.” (R21).The health care providers and CHWs expressed the

need for continuous training on PPH as many ofthem change the workplace. They mentioned thatnew staff might not be aware of updated protocols inPPH prevention. The health care providers working inantenatal clinics stated that when they are well in-formed about PPH and its risk factors, they are ableto effectively teach and help women gain knowledgeabout the signs and symptoms of PPH and what ac-tions to take. CHWs in particular said that theywanted to be adequately trained on some procedureslike assisting home deliveries so they are able to pro-vide care in case a woman delivers in the communitybefore reaching the health facility. One CHW ex-plained: “…as a community health worker who meetwomen with PPH before reaching the health center,and as you know it is most of the times difficult forthem to get transport, my suggestion is that they cantrain us on basic practices, like home deliveries, and

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delivery of the placenta so that the woman reachesthe health center after being basically treated”.

Organizational factors influencing PPH preventionThis theme highlights some of the organizational factorsthat influence PPH prevention. Healthcare providersidentified factors associated with some existing PPH pre-vention policies in Rwanda. The majority of participantsfelt that adequate resources were a necessary factor inprevention, as well as collaboration across the health sys-tem structure.Health care providers stated that teaching women

about PPH and prevention strategies is a required andexpected part of maternal health care.

“……. Our Ministry of Health always encourage thehealth providers at the hospitals and health centers toteach pregnant women to go for the pregnancy checkupand to give birth in a hospital setting and I think thiscontributes to the prevention of PPH…..”( HCP13).

CHWs expressed that their role is to educate womanabout risk factors and “get her to the health facility”when she is approaching the expected date of delivery toreceive care from a skilled birth attendant. CHWs men-tioned their main functions in the event a woman givesbirth at home or in the community to prevent PPH. Ifthe woman gives birth at home or on the way to thehealth facility, the policy of task shifting allows CHWs toprovide Misoprostol to the woman after delivery to pre-vent PPH. “..when a woman gives birth at home or beforereaching the hospital we give her the misoprostol whichreduces the hemorrhage, then we take her to the healthproviders who orders her to take enough rest. For us weuse to provide advices to the women and the trainingsthat we received help them (CHW36).In addition to policies regarding maternal care, par-

ticipants expressed that limited human and materialresources and lack of continuity of care across thehealth system impact PPH prevention. The shortageof qualified health professional in maternity care washighlighted as a challenge by all participants. Partici-pants stated that having “specialized health profes-sionals” in health care settings would contribute tothe reduction of PPH cases. Health care providers re-vealed that having only a small number ofknowledgeable staff on a shift creates problems “tofollow up properly” women every fifteen minutes afterbirth, and they do not have time to effectively teachmothers about factors that may lead to PPH. Relativesof the women mentioned that health care providers’heavy work load may hamper recognizing a clientwho is bleeding after birth:

“… all levels may influence our women to bleed.The health care provider may be overwhelmed be-cause of many patients when she is one or two ona shift, it is hard for her/him to manage. For ex-ample my wife gave birth without any complica-tion but by accident she was damaged whichcaused her to bleed, I could not say that it is themisunderstandings instead it was the problem ofhealth personnel” (R16).

Though health care providers were aware of the rec-ommendation to administer injectable oxytocin for themanagement of third stage of labor to prevent PPH,many stated they were not confident about its effective-ness because of the heat sensitivity of the medicine. Thelack of refrigerators in maternity units to store oxytocinwas also highlighted as their main challenge for qualityprevention of PPH.

“…the injectable oxytocin we use is the one to bekept in the fridge but all maternities in the healthcenters or the hospital do not have a fridge to keepthe oxytocin, it is kept in the general pharmacywhich will prevent us to give the oxytocin on timeand with appropriate temperature...”(HCP35).

Furthermore, the majority of participants mentionedthe importance of information sharing for the con-tinuity of care and a proper follow up of womenacross the health system from the community to thedistrict hospital. When there is a woman in labor orwith another obstetrical problem in the community,the CHWs, through a system of “rapid SMS”, usetheir cell phones to call health providers at the healthfacility to send the ambulance. Women and their rela-tives affirmed that this is a good collaboration be-tween the health facility and the CHWs, althoughsometimes there is delay in sending the ambulance.However, women identified the need for getting ac-curate information about PPH during pregnancy, de-livery and the postpartum period so that they canmake informed decisions regarding when to seek fol-low up care. The health care providers mentionedthat the client’s health information related to herpregnancy is not well shared from the antenatal clinicof the health center to the maternity setting wherethe woman gives birth, which can further impede therecognition of clients at risk of PPH.

“Most of the signs and symptoms discovered duringantenatal consultation remain in the clinic, awoman does not have that information, what is onlywritten on her file is to come early and give birth atthe health center”(HCP29).

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Participants mentioned that for a proper prevention ofPPH the awareness should be enhanced in the healthsystem so as to ease the identification of risk factors asearly as possible by means of regular checkup of well-informed women before and after delivery.

Caring and family involvementThis theme reveals personal qualities, role expectationsand clinical skills valued by women and their relatives,CHWs in charge of maternal health and health care pro-viders during their interactions to prevent PPH. It alsohighlights some disrespectful practices that women ex-perienced while seeking health care.Participants discussed family involvement in their

decision-making to prevent PPH. The women men-tioned feeling dependent upon family members for as-sistance during pregnancy and childbirth. “The familyhelp me in not doing heavy activities and not beingstressed… I first inform the person I live with, here Imean my husband, then we take a decision to go to thehospital because they are the right people to help me pre-vent against PPH.”(W2).The partners to women expressed the feeling of “being

less helpful” to women in terms of PPH prevention. Theyexplained their lack of knowledge about PPH which af-fects their ability to make informed decision on thehealth conditions of their wives. They described theirmain role as to “get the woman to the health facility” tobe assessed and treated by qualified health professionals.However, CHWs argued that prevention of PPH shouldstart in the nuclear family, with parents teaching theiryoung daughters about how to prevent. “A family has tobe the first one to teach their young daughters to preventearly pregnancies which may lead to PPH, and to havethat discussion in their home.”(CHW43).The women and their relatives view the role of CHWs

in charge of maternal health in their community as their“parent”, who will closely follow up pregnant womenand report to the health facility as needed. They alsopointed out that CHWs have insufficient knowledgeabout PPH and preventive strategies to provide enoughinformation to community members. “Communityhealth workers are available but we do not discuss aboutthat issue of bleeding. They accomplish well their tasksbut I think they do not know much about PPH so thatthey can teach us too about it”(W10).Regarding the care provided by health care providers,

women’s relatives recognize the busy work of health pro-fessionals. Beside the busy work, relatives of women de-scribed an issue of lack of focus by health care providerswhile providing services. They reported that some ofthem used to be busy on their cell phones making per-sonal calls which prevented them from providing quickand timely healthcare services to women. Relatedly, they

expressed their appreciation about the government’s pol-icy which was put in place in response to this problem.For these relatives, the government’s response is viewedas one of the ways to improve recognition of women atrisk of PPH.

“There are things that the government has changedaccording to the way we were used to be given med-ical services like that thing of stopping cell phones athospitals changed a lot things and we are so thank-ful. Before when we needed assistance from them, weused to find them busy on phone.”(R20).

Women and their relatives expressed feelings of frus-tration and anxiety when they encounter angry and irrit-able health care providers while receiving care. Theydescribed poor patient-health provider relationships canpose a communication barrier for the prevention ofPPH. As one relative stated:

…there are some problems we face at hospitals wherewe find doctors or other medical professions who arealways angry or with bad services and you willrealize that some patients are not comfortable andare fearing to tell everything to the health care pro-vider. There are people who can look at you and youhave fear to express yourself….(R19).

Perceived risk factors to PPH preventionThis theme describes various risk factors associated withPPH which participants describe as antepartum andintrapartum risk factors. They also stated that the socio-economic status of the family and delays to receivinghealth care are factors affecting access to quality care forPPH prevention. Participants highlighted that knowledgeand consideration of these risk factors can contributegreatly to timely prevention of PPH.Health care providers mentioned that the “knowing of

pregnant women with predisposing risk to PPH” wouldcontribute to PPH prevention. As presented in the previ-ous themes, participants expressed that the lack ofknowledge and insufficient information sharing acrossall levels of care is a barrier to the recognition of the cli-ents at risk of PPH and hinders effective and timely PPHprevention. The risk factors were described as non-useof family planning methods leading to frequent birthing,history of PPH, retained placenta, and tearing/trauma ofgenital organs. In case of trauma or lacerations of genitalorgans during birth, women and their relatives men-tioned that birth attendants “damage the woman’s in-ternal tissues”. Some risk factors were thought bywomen and relatives to be associated with religious be-liefs where some people consider “use of family planningas sinful” and as a result give birth frequently without

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birth spacing. Women and their relatives commentedthat giving birth at home heightens the risk of complica-tions such as retained placenta or tears of genital organsresulting in PPH.

“...my last born was born at home but the placentaremained inside and I bled and bled a lot so theytook me to the health center. I recovered my con-sciousness when I realized that I was lying on thebed of the health center…”(W 11).

Relatives of women as well as health care providersalso expressed the view that poverty and poor nutritionexposes the woman to developing PPH. “What I canadd is that the challenge the society meet is the povertybecause if a pregnant woman does not eat a balanceddiet when she is pregnant, she may have post-partumhemorrhage after giving birth”. (R13)Participants also highlighted barriers related to delays

to seeking care which prevent women from receivingquality services for the prevention of PPH. The socioeco-nomic status of the family was mentioned by the major-ity of all participants to adversely impact PPHprevention, particularly, poverty. CHWs highlighted thatpoor families experience the challenge of not being ableto afford to buy basic food or to seek care at the healthfacility, which is believed to increase their risk for PPH.

“There is a problem of poverty like people in the firstcategory are our big challenge because they are theones who live with malnutrition problems and givebirth frequently, they tell you their problems at alater stage when the woman cannot even sit on amotorcycle and we pay for their transport (CHW38).

Family conflict was also expressed as a challenge associ-ated with socioeconomic conditions. Health care providersrevealed that families living with conflict may be less likelyto make good decisions regarding health and pay for med-ical insurance, hence they don’t access medical services ontime contributing to childbearing complications.

“Families can miss the insurance and you may finda husband in a family who is a drunker or cheatingon his wife. When it comes to go to hospital the wifemiss someone to accompany her and then shechooses to stay home instead of paying a motorcyclefor transportation, a community health worker canrecognize this situation late when a woman is in abad situation, that is how poverty is still a barrier inour zone” (HCP29).

Participants stated that the shortage of qualified staffleads to the delay of proper follow up of childbearing

women especially those at risk to develop PPH. This hasbeen expressed as a “delay to attend a case” which mightmean that signs of an emergency are missed asexpressed by a CHW: “A health provider might be work-ing alone in maternity and she has assisted a woman togive birth thereafter, she might be called by other womenin labor to look after them, and meanwhile the lady whojust gave birth is left alone, no one is there to provide fol-low up. In this case the woman may be at risk of bleed-ing, then bleed and the health care provider will delay toattend the case, no one will know…”(CHW39).Geography and location of health facilities were men-

tioned by participants as a challenges to PPH prevention.Many of the women commented on the delay associatedto “the location of some health facilities is also matteringbecause we live in high hilled lands “and people resort totaking motorcycles in case the ambulance takes a longtime to reach them. The delay to transfer the womanfrom a health center to a district hospital has been alsoexpressed as a risk to a woman to have her health statuscomplicated:

“… there is a problem of a delaying decision makingwhen a woman is at the health center or hospital,they may delay to take decision to refer her at nightwhile she has been there for a day bleeding andwhen she reaches the hospital they may try to inter-vene while it is no longer possible…” (HCP34).

To address the factors influencing PPH, participantsrecommended placing an emphasis on prevention strat-egies pre-conception and antenatally.

DiscussionThis study explored influencing factors for prevention ofPPH and early detection of childbearing women at riskas perceived by beneficiaries (childbearing women andtheir close relatives) and health workers (CHWs incharge of maternal health and health care providers) inthe Northern Province of Rwanda.

Beneficiary perspectivesThe results from the present study suggest that benefi-ciaries consider PPH as unusual blood loss followed byalteration of general health condition of the client. Par-ticipants believe that every pregnant woman has the po-tential to experience PPH as it happens “unexpectedly”.Among the causes of PPH commonly known as the ‘4Ts’mnemonic: tone, tissue, trauma, and thrombin [5, 34],beneficiaries noted that PPH is associated with traumaof genital organs that might be caused by inadequatelabor and delivery care or lack of birth spacing. Benefi-ciaries mentioned lack of balanced diet and poverty askey antenatal risk factors. Similarly Halle-Ekane et al.

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[35] report that poverty, lifestyle and malnutrition aresome broad issues which adversely influence the out-come of a patient with PPH. It has been reported thatthe knowledge of contextual-level risk factors would in-form public health interventions for PPH control [36].Our results showed indication that participants had

some knowledge about the consequences of excessiveblood loss at childbirth. This finding concurs with Fin-layson et al. [6], who conducted a qualitative systematicreview appraising available evidence about the views andexperiences of women and healthcare providers on inter-ventions to prevent PPH. They found that women weregenerally aware of the consequences of a severe PPH,but in some situations relied on traditional healers tomanage potential childbirth complications. Although ourfindings demonstrate that participants were generallyaware of the grave consequences of PPH, some benefi-ciaries believed that PPH might be associated with poi-son, and in addition some family members (e.g.mothers-in-law) are discouraging women from accessingcare at a health facility by recommending traditionalmedicine instead. Cultural norms around childbearingand supernatural beliefs about PPH remain a challengein some low- and-middle income countries to addressPPH prevention [37]. In addition Semasaka et al. [13] re-port high prevalence of poor sexual and reproductivehealth among Rwandan women in the early postpartumperiod. Education programs designed to increase aware-ness of the causes of PPH and the potential dangers mayimprove understanding in these contexts [6, 38].Apart from the understanding about PPH causes and

consequences, other factors that matter to beneficiariesin connection with prevention of PPH include avoidanceof “heavy activities”, and the prevention of psychologicaldistress associated with unsupportive partners. The emo-tional impact of PPH is sometimes not given much con-sideration in the literature but research suggests that, forsome women, the repercussions can be severe and asso-ciated with long-term mental health problems includingposttraumatic stress disorder [39]. Beneficiaries reporteda barrier of living with low socioeconomic conditionswhich sometimes lead to delay in accessing health facil-ities. Previous research suggests that funding agenciescan help underwrite initiatives aimed at reducing PPHthrough the use of cost-effective, resource appropriateinterventions to facilitate all communities especiallyfrom low- and-middle income countries, to access qual-ity services in a timely manner [7, 10, 37].With regards to the prevention of PPH, our results re-

veal that CHWs had limited knowledge. This is in agree-ment with findings from a recent systematic review [40]highlighting the risk associated with inconsistent com-munity knowledge regarding dosage and timings of mi-soprostol use for PPH prevention, and inconsistency of

CHWs’ knowledge to differentiate between PPH causedby atony or due to other causes such as uterine rupture,vaginal lacerations and placental abnormalities. Educa-tional sessions for all people involved in the preventionof PPH has been proposed as a way to contribute toearly detection of PPH risk factors.Our findings demonstrate that poor interaction be-

tween beneficiaries and health care providers, which canlead the women to be reluctant to express freely theirhealth needs during childbearing period. Beneficiariesexpressed feelings of frustration and anxiety when theyhave to enter into relationships with angry and irritablehealth care providers which may create a barrier to thegood communication needed for the prevention of PPH.The heavy workload of health care providers was ac-knowledged by beneficiaries as contributing to poorcommunication. Our findings concur with Bohren et al.[41] confirming that overcrowded and understaffed ma-ternity wards fostered a high-stress work environment.Improving quality of maternity care at health facilitiesand community settings, including women’s experiencesof care, has been highlighted in recent studies [42, 43] asa key component of strategies to further reduce maternalmortality and morbidity related to PPH. It has been alsonoted that women must be given a platform to voicetheir experiences of care [41]. Particular attention can begiven to patients and family seeking information aboutPPH and hence be a partner in their own care. Enhan-cing patient centred care and partnership is in accordwith van der Pol et al. [44] stressing that maternity ser-vices users’ views and preferences should be taken intoaccount in the provision of healthcare.Our findings demonstrate that women and their rela-

tives have trust in CHWs. The beneficiaries view the roleof CHWs in charge of maternal health as being their“parents” in the community. This might be associated toclose follow up and care by CHWs in charge of maternalhealth of women of reproductive age in the community.The trust in CHW’s has been also felt by midwives in aqualitative study conducted in Myanmar, as one of thesupportive reasons for successful shifting basic tasks toauxiliary midwives like administration of oral misopros-tol [4].

Health worker perspectivesOur findings suggest that health care providers gener-ally recognize PPH based on a visual estimation ofblood loss among women after birth which is definedas blood loss of more than 500 ml within the firsthour after birth which is in accordance with the rec-ommended definition of the WHO [5, 7] and imple-mented by Rwanda Ministry of Health [45]. TheRoyal College of Obstetricians and Gynecologists(RCOG) in the UK recently created an amendment to

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this common definition of PPH. Considering that theformal measurement of postnatal blood loss suggeststhat this volume of blood loss is very common, oc-curring in up to 50% of deliveries, the RCOG ap-proved that the postpartum blood loss of 500 ml isused as a point of ‘alert’, whereas treatment is onlygiven once the women has lost 1000 ml of blood [34].For CHWs in charge of maternal health included inthis study, they recognize a woman with PPH whenshe changes the sanitary pad two or more timeswithin the first hour following birth. Our study pro-vides support to the guidelines developed by RwandaMinistry of Health indicating that CHWs are requiredto provide close follow up of pregnant women in thecommunity during the antenatal and postpartum pe-riods [46]. In a situation where there are still debateson the importance of estimation or measurement ofblood loss, which require particular attention for thispractice, the consideration of women at risk of devel-oping PPH may improve outcomes by early identifica-tion and timely action to mitigate risks.Regarding PPH prevention at the community level,

CHWs in this study reported adherence to the taskshifting policy with administration of Misoprostol incase of a home delivery. The use of Misoprostol byCHWs in community settings has been discussed in lit-erature [6, 7]. The shortage of well-trained healthworkers is global but intensified in low- and middle-income countries whereby the WHO recommendsshifting basic tasks from higher- to lower-trainedcadres, such as Community Health Workers or auxil-iary midwives [47]. This policy is in agreement with ahost of literature [6, 7] demonstrating the effectivenessof the use of Misoprostol in reducing PPH in a varietyof community-based settings. However, careful atten-tion must be paid in the use of Misoprostol in homebirths, especially in Rwandan settings. CHWs in chargeof maternal health and some partners to the pregnantwoman reported that their role is specifically to get thewoman to the hospital for delivery which is similar tothe findings of a study conducted in Mozambique [48].This is in line with the guideline of Rwanda Ministry ofHealth stating that CHWs in charge of maternal healthduring their home visits, are to assist the mother withbirth preparedness ,to identify danger signs and makeappropriate referral [25, 46, 49]. When delivery happensat home or in transit to the health facility, CHWs areauthorized to administer Misoprostol for PPH preven-tion, then to continue to accompany the woman to thenearest health facility for further assessment and followup. This is contrary to some other settings of low- and-middle income countries where home deliveries arehappening in the community with assistance of trad-itional birth attendants or auxiliary midwives [50–53].

From an organizational perspective our findings indi-cate that healthcare providers practice active manage-ment of the third stage of labor with injectable Oxytocinto prevent PPH, but its effectiveness is questionable asmost health facilities lack refrigerator storage in the ma-ternity units to keep oxytocin which requires transportand storage at 2 °C–8 °C regardless of the label [7].Smith et al. [54] point out that oxytocin as an essentialmedicine for preventing PPH, requires proper storagewith regular supply of the medicine. This suggests aneed for better supply chain management of maternalhealth medicines and supplies, as well as greater coord-ination between clinical/service provision [7, 54]. Bartlettet al. [55] recommend regular training to improve activemanagement of the third stage of labor optimizing thetiming of uterotonic administration.

Strengths and limitations to the studyA strength of our study is its approach of triangulation[56] used to obtain credible information on influencingfactors to the provision of quality care for PPH preven-tion. We used different methods and different sources tocollect data to develop a comprehensive understandingof the phenomenon under study from health facilities ofdifferent levels of the health system of Rwanda. Anotherstrength is use of the multidisciplinary approach, includ-ing all health professionals involved in PPH preventioncare (medical doctors, nurses and midwives), CHWs incharge of maternal health, and beneficiaries, womenwho experienced PPH and their close relatives includingtheir partners. We organized one to one interviews withwomen and FGDs with other participants to identify in-fluencing factors for early detection of women with PPHand its prevention from both beneficiary and healthworker perspectives. This aligns with Kumar [57] recom-mendation to address the needs at individual, commu-nity and political levels to promote maternal health andto reduce the burden of maternal morbidity and mortal-ity due to PPH. Our findings support the using of socialdeterminants approach [19]to PPH prevention.Some study limitations bear mentioning. The factors

influencing the prevention of PPH and early detection ofwomen at risk described by participants in the presentstudy are limited to personal views and have been ana-lyzed qualitatively. Therefore, a further case controlstudy using quantitative methods is warranted to analyzepredictors for PPH among childbearing women inRwanda. The general applicability of our findings maybe questionable as the selected health facilities werefrom a rural area and thus may not be applicable to thehealth facilities from urban areas. Nevertheless, our re-sults apply to international guidelines for PPH preven-tion [5, 7] because the guidelines were referred todevelop our interview guides.

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ConclusionsIn conclusion, influencing factors for for prevention ofPPH and early detection of women at risk were de-scribed, from both beneficiary and health worker per-spectives. For beneficiaries, factors hampering PPHprevention were described to be primarily poor under-standing and knowledge of PPH, while from the healthworker perspective there was a focus on organizationalfactors associated with shortage of staff, poor team com-munication and collaboration and lack of refrigerationstorage in maternity settings to keep injectable oxytocinnearby delivery rooms. Innovative solution to have amedication of the same quality as oxytocin but withoutthe constraints related to heat sensitivity during thetransportation and storage would be considered for PPHprevention. Development of strategies for early detectionof women at risk of PPH, regular trainings of health careproviders, developing educational material for CHWsand family members could improve the prevention ofPPH. Further quantitative research, using case controldesign is warranted to develop a screening tool for earlydetection of PPH risk factors for a proactive prevention.

AbbreviationsPPH: Postpartum hemorrhage; CHW: Community health worker; W: Woman;R: Relative; HCP: Health care provider; IDIs: Individual in-depth interviews;FGDs: Focus group discussions

AcknowledgementsWe acknowledge the University of Rwanda and Western University throughTraining Support Access Model Project for supporting this research. Wewould like to thank the administration of Byumba district hospital and incharge of Rutare and Rwesero Health centers for granting us with thepermission to conduct this study. We also acknowledge health careproviders, Community health workers, Women and their close relatives fortheir participation in this study. Our sincere gratitude goes to Dr. AndreaNove, technical director at Novametrics in UK for her professional guidanceand English editing of the present paper.

Authors’ contributionsOB, MN,AU,ME designed research protocol. OB and MCU revised theresearch protocol. OB, MCU, contributed to data collection; OB, MN, MEcontributed to data analysis, OB, MCU, AU. Participated in the drafting andediting of the manuscript. All authors reviewed, edited, contributed andapproved the final version of the manuscript.

FundingResearch for the Training, Support and Access Model for Maternal, Newbornand Child Health in Rwanda Project has been undertaken with financialsupport to the University of Western Ontario from the Government ofCanada provided through Global Affairs Canada. The research team actedindependently from the funders who had no role in the data collection,analysis, interpretation of data, writing of the report, or in the decision tosubmit the article for publication.

Availability of data and materialsThe datasets used and analyzed during the current study are available fromthe corresponding author on reasonable request.

Ethics approval and consent to participateThe present study was approved by Institution Review Board at the Collegeof Medicine and Health Sciences, University of Rwanda (approval No 313/CMHS IRB/2018). All participants provided written informed consent prior toenrollment.

Consent for publicationNot applicable.

Competing interestsThe authors declare that they have no competing interests.

Author details1College of Medicine and Health Sciences, University of Rwanda, 3286 Kigali,Rwanda. 2University of Western Ontario, Arthur Labatt Family School ofNursing, 1151 Richmond St, London, ON N6A 3K7, Canada.

Received: 20 May 2020 Accepted: 30 October 2020

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