Cross-Sectional Survey to Assess Hospital System Readiness for Hemorrhage During and After Cesarean Delivery in Africa

Background: Mothers in Africa are 50 times more likely to die after cesarean delivery (CD) than in high-income countries, largely due to hemorrhage. It is unclear whether countries across Africa are adequately equipped to prevent and treat postpartum hemorrhage (PPH) during and after CD.

Methods: This was a cross-sectional survey of anesthesiologists and obstetricians across the African Perioperative Research Group (APORG). The primary objective was to determine readiness of the hospital system to implement the World Health Organization (WHO) recommendations for prevention and treatment of PPH during and after CD. The secondary objectives were to evaluate the availability of blood products, skilled human resources and establish available postoperative care after CD. Survey question format was close-ended or Likert scale, with options "always," "sometimes," or "never."

Results: Responses were analyzed from 1 respondent from each of 140 hospitals from 29 low- and middle-income countries across Africa. Most respondents completed every data field on the case report form. Regarding WHO recommendations on prevention of PPH, oxytocin and misoprostol were available in 130/139 (93.5%) and 101/138 (73.2%) hospitals, respectively. There was limited access to heat-stable carbetocin (12/138 [8.7%]) and ergometrine (35/135, [25.9%]). Controlled cord traction for removal of placenta was always performed in 133/135 (98.5%) hospitals. Delayed cord clamping when neonatal resuscitation was not indicated, was not performed universally (86/134 [64.2%]). Regarding the treatment of PPH, crystalloids were always available in 133/139 (95.7%) hospitals, and the preferred initial resuscitation fluid (125/138 [90.6%]). Uterine massage was always performed in 117/139 (84.2%) hospitals. Tranexamic acid was always available in 97/139 (69.8%) hospitals. The availability of intrauterine balloon tamponade devices was limited. Most had immediate access to theater (126/139 [90.6%]). Responses concerning organizational recommendations showed that 113/136 (83.1%) hospitals had written protocols for the treatment of PPH. Protocols for patient referral and simulation training were limited. Most hospitals had access to emergency blood (102/139 [73.4%]). There was limited access to blood component therapy, with platelets available at 32/138 (23.2%), cryoprecipitate at 21/138 (15.2%) and fibrinogen at 11/139 (7.9%) hospitals. In-person specialist cover was reduced after-hours.

Conclusions: Important WHO-recommended measures to reduce hemorrhage during and after CD, are not currently available in many hospitals across Africa. It is likely that the lack of a combination of factors leads to failure to rescue mothers in Africa from postoperative complications. These findings should facilitate codesign of quality improvement initiatives to reduce hemorrhage related to CD.