Association of primary postpartum hemorrhage with inter-pregnancy interval in urban South Ethiopia: A matched nested case-control study

Abstract

Background: Globally, postpartum hemorrhage is the leading preventable cause of maternal mortality. To decrease postpartum hemorrhage-related maternal mortalities, identifying its risk factors is crucial to suggest interventions. In this regard, little is known about the link between primary postpartum hemorrhage and inter-pregnancy interval in Ethiopia, where more than half of pregnancies occur shortly after the preceding childbirth. Therefore, we aimed to elucidate the association of primary postpartum hemorrhage with an inter-pregnancy interval in urban South Ethiopia.

Methods: A community-based matched nested case-control study was conducted among a cohort of 2548 pregnant women. All women with primary postpartum hemorrhage during the follow-up (n = 73) were taken as cases. Women who were randomly selected from those without primary postpartum hemorrhage (n = 292) were taken as controls. Cases were individually matched with controls (1:4 ratio) for age group and location. A conditional logistic regression analysis was done using R version 4.0.5 software. Statistically, a significant association was declared using 95% CI and p-value. Attributable fraction (AF) and population attributable fraction (PAF) were used to estimate the public health impacts of the inter-pregnancy interval.

Results: This study found out that more than half (66%) of primary postpartum hemorrhage was attributed to inter-pregnancy interval <24 months (AF = 66.3%, 95% CI: 37.5, 82.5%). This could be prevented if the inter-pregnancy interval was increased to 24-60 months. Likewise, nearly half (49%) of primary postpartum hemorrhage in the study population could be prevented if the inter-pregnancy interval <24 months was prevented. Additionally, primary postpartum hemorrhage was attributed to antepartum hemorrhage, prolonged labour and multiple pregnancies.

Conclusions: Primary postpartum hemorrhage was associated with inter-pregnancy interval under 24 months, highlighting the need to improve postpartum modern contraceptive utilization in the community. Counseling couples about how long to wait until subsequent pregnancy and the risk when the inter-pregnancy interval is short need to be underlined.

Fig 1. Schematic presentation of sampling procedure for the study of primary PPH in the urban South Ethiopia, July 2019-September 2020.