Adverse Perinatal and Maternal Outcomes and Associated Factors among Women with Antepartum Hemorrhage in Jimma University Medical Center, Southwest Ethiopia, 2020

Background Globally, antepartum hemorrhage is the main cause of perinatal and maternal morbidity and mortality during pregnancy and childbearing. Objective To assess adverse perinatal and maternal outcomes and associated factors among women with antepartum hemorrhage in Jimma University Medical Center, Southwest Ethiopia, 2020. Methods Prospective cross-section study was conducted, and data were collected through face to face interview among pregnant women admitted with antepartum hemorrhage. Patient condition was observed and followed up, and patient card was reviewed. Data were coded, checked, entered into EPI version 4.6, and exported to SPSS version 26.0 for analysis. Multivariate logistic regression analysis was made to determine independent factors associated with adverse outcomes. Result A total of 377 pregnant women were included, and nearly half (192 (50.9%)) of women experienced adverse maternal outcome and 113 (30%) women experienced adverse perinatal outcome. The status of vital sign, address, parity, antenatal care, duration of bleeding before arrival, gestational age, prematurity, and amount of vaginal bleeding were factors significantly associated with adverse maternal and perinatal outcome at p value <0.05. Conclusion Vital sign derangement, vaginal bleeding for ≥12 hrs, gestation age before 37 weeks, rural address, prim parity, amount of vaginal bleeding, and prematurity baby has predicted high rate of adverse perinatal and maternal outcomes. Recommendation. Jimma Hospital should give patient-centered service and strengthen counseling on danger sign of pregnancy to alert women early health care seeking and immediate resuscitation, and appropriate management should be given for women admitted with APH to minimize of adverse perinatal and maternal outcomes.


Introduction
Antepartum hemorrhage is bleeding from the genital canal of the pregnant mother after the fetus has reached the age of viability (which is after 28 completed weeks or fetal weight of 1000gm or more) and before the fetus is delivered [1]. Complications during pregnancy-related death is still high according to WHO recording 295,000, 192,000, and 14,000 maternal deaths worldwide, in Africa, and in Ethiopia in 2017, respectively [2].
Majority of women with antepartum hemorrhage deliver low birth weight babies.
is is due to preterm labor or repeated small events of hemorrhage causing prolonged placental inadequacy and fetal growth restriction [5]. Antepartum hemorrhage is the main causes of bleeding during pregnancy, maternal and perinatal morbidity and death in developing countries with low capitals and services [6]. Center for Disease Control and Prevention reports that 30% of maternal mortality was due to hemorrhage cases [7]. Antepartum hemorrhage is aggressive situation in obstetrics which complicates about 2-5% of all the pregnancies [8]. Majority of maternal and perinatal morbidity and mortality especially in developing countries with low incomes and resource like Ethiopia was due to obstetric hemorrhage. is is due to well-known preexisting anemia, problems with transportation, limited health facilities, and lack of responsiveness on part of patient and families which are mainly accountable for great morbidity and death in developing countries. Most of the maternal and perinatal deaths around the world could have been prevented by improving women's contact to good-quality reproductive health care service and effective interventions. So, the purpose of this study is to assess the adverse maternal and perinatal outcome, adverse perinatal and maternal outcomes, and factors associated among women presented with APH in Jimma University Medical Center.

Study Area and Period.
e study was conducted in Jimma University Medical Center, which is located in southwest Oromiya, Jimma town, Ethiopia, which is 357 km away from Addis Ababa.
is hospital was found in the tertiary level health system. According to 2007 population census projection, Jimma zone has 753,377 women in the child bearing age which accounts 23.1% of all women living in the zone. e labour and maternity ward of Jimma University Medical Center is staffed with 11 obstetrics and gynaecology specialists, 46 midwives, and 33 residents (12 residents of first, 11 residents of second, 6 residents of third, and 6 residents of fourth year), and the study period was conducted from July1, 2020, to June 30, 2021.

Design.
Institution-based prospective cross-sectional study design was conducted.

Source Population.
All pregnant women admitted with antepartum hemorrhage at Jimma University Medical Center, labor and maternity ward, during this study period.

Study Population.
All women presenting with vaginal bleeding after 28 weeks of gestational age, not before the delivery of the fetus in the labor and maternity ward of Jimma University Medical Center.
2.5. Measurement. Data were collected by using reviewing patient charts. Patient observation was also made during admission and face-to-face interviewing mothers using a structured and semistructured questionnaire which was used to collect data concerning patient sociodemographic data, obstetric data, causes of APH, and adverse perinatal and maternal outcome. e questionnaire was prepared in English language and then translated into local language, Afaan Oromo and Amharic, by language experts and translated back to English to sustain reliability. Finally, Afan Oromo and Amharic version was used for data collection. e questionnaire was pretested by taking 5 percent of the sample size at Bedelle Hospital, and required revision was ready depending on gaps identified. Doubled data were entered into EpiData Manager cleaned and explored for outliers, omitted values, and any discrepancies.

Data Collection.
e data were collected by three midwives from Jimma university Medical Center staffs by the predesigned questionnaire. Two Obstetrics and Gynacology residents were supervisors of the data collection process. To guarantee the quality of data, two-day training was given for data collectors on the objective and relevance of the study.

Data Analysis.
e collected data were coded and entered in to EpiData Manager 4.6 and was transferred to SPSS version 26.0 for analysis. Descriptive and binary logistic regressions analysis was done. ese explanatory variables with a p value <0.25 in crude analysis were engaged for multivariate analysis, and these variables with a p value < 0.05 in multivariate analysis was considered as a significant predictor of maternal complication among women with antepartum hemorrhage. e result of the analysis was presented in texts, tables, and graphs as indicated.

Ethical
Clerance. Ethical clearance was obtained from the Jimma University Ethical Review Board (ERB). Approval message to conduct the study was secured from Jimma University Medical Center. Oral informed consents were obtained from respondents in order to execute data collection procedures. e questionnaire was anonymous to maintain privacy and confidentiality among the participants.

Conceptual
Definitions. APH: vaginal bleeding that occurs after 28 weeks of gestational age and till the delivery of the fetus. Abraptio placenta: premature separation of normally implanted placenta. Birth weight: weight of the newborn immediately after birth and classified as NBW: 2500-3999gm; LBW: 1500-2499gm; and VLBW: 1000-1499gm. Placenta previa: implantation of the placenta in the lower uterine segment in the zone of cervical dilatation and effacement within 2 cm [9]. Lowlying placenta: When placenta lies inside 2 cm of the cervical opening but does not shield it [9]. Abrupto placenta: premature separation of placenta from normally implanted uterine wall [9].
(1) Mild or grade 1: clinically asymptomatic before delivery and typically detected by the existence of a retro-placental clotting (2) Moderate or grade 2: midway, the typical marks of abruption, but the fetus is alive  [9]. According to Royal College of Obstetrics and Gynaecology guideline, the following definitions have been used: Minor hemorrhage: blood loss less than 50 ml has been recognized Major hemorrhage: blood loss of 50-1000 ml with no signs of shock Massive hemorrhage: blood loss greater than 1000 ml with signs of shock An adverse perinatal outcome is a composite of one or more of the following: preterm birth (live birth at <37 weeks' gestation), LBW (live birth weighing <2,500 g at birth), stillbirth (fetal deaths occurring >500 g or >22 weeks gestation), early neonatal deaths (neonatal deaths 0-6 days after birth), neonatal deaths (neonatal deaths 0-28 days after birth), perinatal deaths (neonatal deaths 0-6 days plus stillbirths), low APGAR score, and admission to the neonatal intensive care unit (NICU). Diagnosis at NICU and adverse maternal outcome was defined as a composite of one or more of the following: hysterectomy, postpartum hemorrhage (estimated blood loss of >500 mls following vaginal delivery or >1000 mls following cesarean delivery within 24 hours after delivery as documented in the patient's medical registration records and observation), anemia, infection, admission to intensive care unit (ICU), death, and cause of death [10].

Results
ree-hundred seventy-seven women gave birth in Jimma University Medical Center with a response rate of 98%.

Sociodemographic Characteristics of Adverse Perinatal and Maternal
Outcomes. According to the age's distribution, the mean age of pregnant women with antepartum hemorrhage was 27.72 years with a standard deviation of ±7.96 years. Greater than half patient 202(53.6%) were from urban. Among all respondents, 362 (96%) were Oromo and 280 (74.3%) were Muslim by Ethnicity and Religion, respectively. Regarding occupational status, more than half (291 (77.2%)) were housewives. Regarding educational and marital status, 231 (61.3%) could not read and write and 376 (99.7%) were married, respectively (Table 1).

Obstetric History on Adverse Perinatal and Maternal
Outcomes. Among patients who admitted with antepartum hemorrhage, most women (255 (67.6%)) were multiparous, greater half of them has no history of abortion (283 (75.1%)) and most of the patients (217 (57.6%)) have ANC follow-up. Majority of women (218 (57.8%)) admitted with APH have came before 12 hrs duration. Most of the women (290 (76.9%)) were admitted with minor amount of vaginal bleeding ( Table 2).

Maternal Condition at Admission.
A majority of women admitted with APH fetal heart beat (FHB) and at gestational, positive 300 (80%) and term pregnancy 143 (37.9%) respectively. Regarding to initial hematocrit of patient admitted with antepartum hemorrhage majority were 294 (78%) greater than 34%. Majority of women admitted with stable vital sign 349 (92.6%) and on admission 46 (12.2%) admitted with active vaginal bleeding (Table 3).

Cause of APH among Pregnant Women.
Regarding the cause of antepartum hemorrhage admitted at Jimma University Medical Center, a majority of women admitted with placenta abruptio and placenta previa were the main reasons of APH which accounts 281 (74.5%) and 77 (20.4%) of APH patients, respectively, and the rest one is unknown (16 (4.2%) and 3 (0.8%)). From those patients with placenta previa, 76 (20.2%) were diagnosed with placenta previa totalis and the rest one had low lying (1 (0.3%)). Of the 281 patients with abruption placenta, over half (159 (56.5%)) diagnosed with moderate or grade 2-midway, the typical marks of abruption; but the fetus is alive.
Regarding the risk assessment of patients admitted with antepartum hemorrhage, patient who had multiparity and HDP had greater chance of antepartum hemorrhage (Figure 1).

Obstetrics and Gynecology International
Regarding the mode of delivery among women admitted with antepartum hemorrhage at Jimma University Medical Center, a majority of them (247 (65.5%)) gave birth SVD, and cesarean section was done in 77 (20.4%) women due to placenta previa (Table 4).

Adverse Perinatal and Maternal
Outcomes. From total patients admitted with APH at Jimma University Medical Center, 113 (30%) are prone to more than one adverse perinatal outcome and 192 (50.9%), more than one adverse maternal outcome.
From these adverse maternal outcomes, only five (2.6%) women were referred to intensive care unit (ICU), and at the intensive care unit, 3 (1.6%) women with APH passed away during the peripartum time, two (66.7%) due to eclampsia, and one (33.3%) because of anesthesia-related complication. From women admitted at the maternity and labor ward with antepartum hemorrhage, 44 (24%) developed postpartum hemorrhage.

Fetal Outcome.
A total of 393 babies were born from 377 mothers who gave birth at Jimma public Hospitals; of these, 361 (95.8%) were singleton babies; the rest 16 (4.2%) were     (Table 6). Factors associated with adverse perinatal and maternal outcome among women presented with antepartum hemorrhage in Jimma University Medical Center, 2020.
Bivariate analysis shows that variables like vital sign on admission, previous history of scar, anemia, duration of bleeding before arrival, and mode of delivery with a p value <0.25 entered multivariable logistic regression model. ose variables with p value less than 0.05 in multivariate analysis had statistically significant association with adverse perinatal and maternal outcome, and others removed from it. Duration of bleeding before arrival vital sign on admission, gestational age, residence, antenatal followup, and parity had strong association with adverse maternal outcome, and prematurity and amount of bleeding had strong association with adverse perinatal outcome. ose mothers who had bleeding ≥12 hrs before arrival to hospital are 2 times more likely prone to adverse maternal outcome than those mothers who arrive less than 12 hours of duration (AOR � 2.21, 95%CI: [1.38, 3.55]). ose mothers whose vital sign was deranged were 4 times more likely to develop adverse maternal outcomes than those mothers with stable vital sign (AOR � 4.93, 95%CI: [2.97, 8.71]). ose term gestational age mothers were 2 times more likely experience adverse maternal outcome than preterm gestational age (AOR � 2.14 95%CI: [1.43, 3.33]). Mothers from rural residence were 2 times more likely to experience adverse maternal outcomes than those from urban (AOR � 2, 95% CI: [1.22, 2.67]). ose patients who has no antenatal followup were 2 times more likely to develop adverse maternal outcomes than those who have antenatal follow-up (AOR � 2, 95%CI: [1.30, 2.99]). ose multipara mothers were 2 times more likely develop adverse maternal outcomes than primipara (AOR � 2, 95%CI: [2.33, 2.95]). ose moderate 7 times and severe 4 times the amount of vaginal

Discussion
During this study, three-hundred and seventy-seven women gave birth at Jimma University Medical Center. e incidence of antepartum hemorrhage was high 5.5%. But according to a study conducted in Indira Gandhi Medical College, the incidence of APH was found out to be 1.98%, and according to another study conducted in Iraq, the incidence of antepartum hemorrhage was 2.34%. is difference may be due to poor health education about health during antenatal follow-up [5,11].
Abruption placenta was the top cause of antepartum hemorrhage at Jimma University Medical Center which accounts 281 (74.5%) women. ese findings were similar according to a study conducted in South Africa. e primary reason of hemorrhage was abruptio placenta which accounts 37.8% [12].
is study shows that hypertensive disorder during pregnancy and multiparty are risk factors for antepartum hemorrhage. Similar study conducted in India suggesting 73% PIH is one of the key risk factors for APH [13].
From those women diagnosed with antepartum hemorrhage and gave birth in Jimma University Medical Center maternity and labor ward, 192 (50.9%) develop adverse maternal outcome. During this study period, five (2.6%) women referred to intensive care unit (ICU), and at the intensive care unit, 3 (1.6%) women with APH died during the peripartum time, 2 (66.7%) due to eclampsia, and 1 (33.3%) because of anesthesia complication. In this study, among patients admitted with antepartum hemorrhage, 3 (1.6%) patients died, and according to a study conducted in Tertiary Hospital in Ibadan, Nigeria, there were 2 maternal deaths (1%). e difference may be due to low quality of service and care given at Jimma University Medical Center [14].
From total patients admitted with APH at Jimma University Medical Center, 113 (30%) are prone to more than one adverse perinatal outcome. From those experiencing adverse perinatal outcomes in this study, 18 (54.5%) needs resuscitation and 32 (94%) referred to NICU; a majority of them were diagnosed with HMD (25 (80%)) and referred to NICU, and 13 (39.45) died. e study identified five variables which have strong positive significant associations with adverse maternal outcome. Maternal vital sign on admission, duration of vaginal bleeding before arrival, term, rural, those mothers who has no antenatal follow-up, and multiparty have strong positive association with adverse maternal outcome. ose mothers with deranged vital sign are more likely prone to adverse maternal outcomes than those with stable vital sign, and those patients admitted with moderate and severe vaginal bleeding and prematurity were strongly associated with adverse perinatal outcomes.

Conclusion and Recommendation
Antepartum hemorrhage affects all pregnancies and increases complication especially in developing countries with low incomes and services and the main causes of maternal complication and death. Duration of bleeding ≥12 hr before arrival, deranged vital sign on admission, term gestational age, patient from rural area, those who has no antenatal follow-up, and multiparty had strong association with adverse maternal outcome, and those patients admitted with moderate and severe vaginal bleeding and prematurity were strongly associated with adverse perinatal outcome. Institution should give inclusive service at labor and delivery unit with well-arranged equipment and staffs with friendly care, timely identification, preparing family for blood donation in case of blood transfusion, skilled anesthesia person, and avail all necessary human resource to effectively manage APH thereby reducing the adverse maternal and perinatal outcome.

Data Availability
Data are available on request.

Conflicts of Interest
e authors declare no conflicts of interest.