Impact of socio-cultural beliefs on postpartum hemorrhage recognition in Bangladesh

Globally postpartum hemorrhage (PPH) is the primary cause of maternal mortality and a significant cause of maternal morbidity for an estimated 1.6 million women annually. Maternal deaths and complications due to postpartum hemorrhage are preventable; bleeding can be medically managed. In Bangladesh, PPH accounts for one-fifth of direct obstetric deaths each year. Despite a national policy supporting use of skilled birth attendants (SBA), 90% of all Bangladeshi deliveries occur in the home and 77% are attended to by family members and by traditional birth attendants (“dais”) with no SBA in attendance. Communities' perceptions of wellness and illness influence problem identification. The purpose of this work is to explore socio-cultural beliefs that impact recognition of PPH with the goal of understanding factors which facilitate and which impede early recognition of PPH. Postpartum bleeding is considered to be a necessary stage in cleansing the body among diverse cultures. In Bangladesh traditional beliefs which frame PPH recognition include the concept of polluted or impure blood and the understanding that bleeding after pregnancy is a necessary, cleansing stage. This qualitative study analyzed secondary data from a larger quantitative and qualitative study on PPH recognition and careseeking. The qualitative phase consisted of 18 small group interviews with PPH survivors and their caregivers. Constant comparative analysis was used to perform descriptive, topic and analytic coding and to inform conceptual framework development. Key findings of this study were that heavier bleeding was attributed to impure blood and was not a cause of worry until secondary complications, such as unconsciousness, developed. Traditional practices to facilitate postpartum bleeding were employed by birth attendants. Characteristics of bleeding played a role in how bleeding was perceived, and served as both a facilitator and a barrier to early recognition of PPH. Recommendations to improve early recognition of PPH include a change in policy to resume training dais who are first level providers for women who deliver at home. A second recommendation is the development and distribution of postpartum sanitary pads to standardize measurement of postpartum bleeding. This intervention has been researched and found successful in other countries.