title: Factors associated with postpartum hemorrhage maternal death in referral hospitals in Senegal and Mali: a cross-sectional epidemiological survey.
abstract: BACKGROUND
  Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in Sub-Saharan-Africa (SSA). Although clinical guidelines treating PPH are available, their implementation remains a great challenge in resource poor settings. A better understanding of the factors associated with PPH maternal mortality is critical for preventing risk of hospital-based maternal death. The purpose of this study was thus to assess which factors contribute to maternal death occurring during PPH. The factors were as follows: women's characteristics, aspects of pregnancy and delivery; components of PPH management; and organizational characteristics of the referral hospitals in Senegal and Mali.
  
  
  METHODS
  A cross-sectional survey nested in a cluster randomized trial (QUARITE trial) was carried out in 46 referral hospitals during the pre-intervention period from October 2007 to September 2008 in Senegal and Mali. Individual and hospital characteristics data were collected through standardized questionnaires. A multivariable logistic mixed model was used to identify the factors that were significantly associated with PPH maternal death.
  
  
  RESULTS
  Among the 3,278 women who experienced PPH, 178 (5.4%) of them died before hospital discharge. The factors that were significantly associated with PPH maternal mortality were: age over 35 years (adjusted OR = 2.16 [1.26-3.72]), living in Mali (adjusted OR = 1.84 [1.13-3.00]), residing outside the region location of the hospital (adjusted OR = 2.43 [1.29-4.56]), pre-existing chronic disease before pregnancy (adjusted OR = 7.54 [2.54-22.44]), prepartum severe anemia (adjusted OR = 6.65 [3.77-11.74]), forceps or vacuum delivery (adjusted OR = 2.63 [1.19-5.81]), birth weight greater than 4000 grs (adjusted OR = 2.54 [1.26-5.10]), transfusion (adjusted OR = 2.17 [1.53-3.09]), transfer to another hospital (adjusted OR = 13.35 [6.20-28.76]). There was a smaller risk of PPH maternal death in hospitals with gynecologist-obstetrician (adjusted OR = 0.55 [0.35-0.89]) than those with only a general practitioner trained in emergency obstetric care (EmOC).
  
  
  CONCLUSIONS
  Our findings may have direct implications for preventing PPH maternal death in resource poor settings. In particular, we suggest anemia should be diagnosed and treated before delivery and inter-hospital transfer of women should be improved, as well as the management of blood banks for a quicker access to transfusion. Finally, an extent training of general practitioners in EmOC would contribute to the decrease of PPH maternal mortality.
authors.affiliation: Research Institute for Development, Paris Descartes University, Sorbonne Paris Cité, MERIT - UMR 216, Paris, France. julie.tort@gmail.com.|UPMC University, Paris, France. julie.tort@gmail.com.|Paris Diderot University, Paris, France. julie.tort@gmail.com.|UMR 216, Faculté de Pharmacie, Laboratoire de Parasitologie, 4 Avenue de l'Observatoire, 75270, Paris Cedex 6, France. julie.tort@gmail.com.
authors.forename: Julie
authors.initials: J
authors.lastname: Tort
authors.affiliation: Department of Obstetrics and Gynecology, Poissy Saint-Germain Hospital, Poissy, France. prozenberg@chi-poissy-st-germain.fr.|EA7285, Clinical risk and safety in women's health and perinatal health, University of Versailles Saint-Quentin (UVSQ), St Quentin en Yvelines, France. prozenberg@chi-poissy-st-germain.fr.
authors.forename: Patrick
authors.initials: P
authors.lastname: Rozenberg
authors.affiliation: URFOSAME, Referral health center of the Commune V, Bamako, Mali. mtraore133@gmail.com.
authors.forename: Mamadou
authors.initials: M
authors.lastname: Traoré
authors.affiliation: Research Centre of CHUM (CRCHUM), University of Montreal, Montreal, Canada. pierre.fournier@umontreal.ca.
authors.forename: Pierre
authors.initials: P
authors.lastname: Fournier
authors.affiliation: Research Institute for Development, Paris Descartes University, Sorbonne Paris Cité, MERIT - UMR 216, Paris, France. alexandre.dumont@ird.fr.|UPMC University, Paris, France. alexandre.dumont@ird.fr.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Dumont
mesh_terms: D000328:Adult; D000367:Age Factors; D000740:Anemia / Q000150:complications; D002908:Chronic Disease; D003430:Cross-Sectional Studies; D005260:Female; D005843:Geography; D006801:Humans; D008302:Mali / Q000453:epidemiology; D063130:Maternal Death / Q000209:etiology*; D008428:Maternal Mortality; D006473:Postpartum Hemorrhage / Q000209:etiology / Q000401:mortality*; D011247:Pregnancy; D011250:Pregnancy Complications, Hematologic / Q000209:etiology; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012307:Risk Factors; D012675:Senegal / Q000453:epidemiology; D011795:Surveys and Questionnaires; D014620:Vacuum Extraction, Obstetrical / Q000009:adverse effects; D055815:Young Adult