Prevalence, Causes and Complications of Postpartum Haemorrhage in Mbujimayi, Democratic Republic of the Congo (DRC): a cross-sectional study

Prevalence, Causes and Complications of Postpartum Haemorrhage in Mbujimayi, Democratic Republic of the Congo (DRC): a cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prevalence, Causes and Complications of Postpartum Haemorrhage in Mbujimayi, Democratic Republic of the Congo (DRC): a cross-sectional study Constantin Mukeba Mpoyi, Louis Ntobo Mbuyamba, Fidel Lumuanga Kayindjika, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4970337/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background According to the World Health Organization (WHO), postpartum haemorrhage (PPH) is the cause of approximately 25% of all deaths of pregnant women worldwide, especially in low-income countries, ranging from 8% in developed areas to 32% in Northern Africa. PPH is defined as blood loss from the genital tract of 500 mL or more in the first 24 hours after the delivery of the baby. The objective of this study was to determine the prevalence, causes and complications related to PPH in order to improve its management and reduce the rate of maternal deaths in Mbujimayi. Methods It was retrospective cross-sectional study curried out over a period of 5 years, from July 1, 2018 to July 1, 2023 at obstetrics and gynaecology departments of Bonzola Hospital, Christ-Roi Hospital, and Polyclinique SUMEDCO, all located in Mbujimayi, province of Kasai Oriental, in DRC. Results During the study period, the prevalence of PPH was 2.77%. Patients aged between 20-29 years old were the most represented with 44.0%. The mean age of the patients was 26.97 years, the median was 26, the mode 25, min 16 years, max 45 years, SD 7.4 and 95%CI of the true mean was lying between 27.44 and 26.5. Multigravida and multipara were the most represented with respectively 48.7%. The patients with history of previous PPH was less represented with 6.2%. The primary PPH was the most represented with 91.3%. Uterine atony was finding to be the first cause of PPH with 41.3%. Anaemia was the most represented complication with 61.8%. Conclusion Postpartum haemorrhage (PPH) remains one of the leading causes of severe maternal morbidity, and the leading cause of direct maternal deaths. Healthcare providers must have the knowledge, skills, and resources to detect and manage PPH for each birth. Anyway, we recommend to Bonzola Hospital, Christ-Roi Hospital, Polyclinique SUMEDCO, and Authorities to facilitate the diagnosis tools of PPH in Mbujimayi. Prevalence Cause Complication Postpartum Haemorrhage Mbujimayi Background Postpartum haemorrhage is defined as blood loss from the genital tract of 500 mL or more in vaginal delivery, ≥ 1000 mL in caesarean section, or a substantial drop in haematocrit compared with the antepartum level within 24 hours after the delivery of the baby. It is also defined as blood loss sufficient to cause hypovolemia, a 10% decrease in haematocrit or requiring transfusion of blood products regardless of the route of delivery. Severe postpartum haemorrhage (SPPH) is defined as blood loss from the genital tract of 1000 mL or more in the first 24 hours after the delivery of the baby. ( 1 )( 2 )( 3 ) The conditions may occur in the first 24 hours after delivery (primary PPH) or between 24 hours and 6 weeks after delivery (secondary PPH) ( 4 ) The risk factors for PPH include; older age, primigravida, past history of PPH, multiple pregnancies, grand multiparity, fetal macrosomia, preterm births, labor induction, genital tract injuries, caesarean birth, intra-uterine fetal deaths, and non-use of oxytocic for PPH prophylaxis. However, many studies are based on visually estimated blood loss as a tool for the diagnosis of PPH, this method is reported to be inaccurate. The few studies that have objectively measured blood loss after childbirth are in high-income countries, whose delivery settings differ from those in low income countries. ( 4 ) An increasing trend in PPH is observed in USA, Canada, UK, and Australia. ( 5 ) The global prevalence of PPH is 6% and the highest burden is experienced in low-income countries. The magnitude of PPH in sub-Saharan Africa is high at 10.5%. ( 4 ) In Australia, PPH rates have increased by 29% from 4.9% of deliveries in 1993 to 6.3% of deliveries in 2002. ( 6 ) Its incidence is of 28.8% in Italia, ( 5 ) 30% in Brazil. The low prevalence rates were identified in Guayaquil, Ecuador, between 2017 and 2018, where 7% of the 2,352 recorded births in 2017 were affected by PPH. Similarly, in Switzerland, PPH occurred in 3.1% between January 1993 and December 2014 and 2.19% in Peru. ( 7 ) In Africa the incidence of PPH varies from a country to another country. It is of 31.5% in Tunisia, 2.23% in Morocco, 1.13% in Nigeria, 1% in Cameroon, 47.82% in Benin, 13% in Mali, ( 8 ) 16.6% in the Southern region of Ethiopia, 1.36% in Lomé (Togo), 1.6% in Libreville (Gabon), 4.67% in the Central African Republic, 9.0% in Uganda, ( 9 )( 3 )( 4 ) and 6% in DR Congo.( 7 )( 10 ) PPH is responsible for the majority of severe maternal morbidities, such as prolonged hospital admissions, need for blood transfusions and surgical procedures that can lead to loss of reproductive function. Severe complications such as haemorrhagic shock, acute respiratory distress syndrome, disseminated intravascular coagulation, acute renal failure, loss of fertility, pituitary necrosis (Sheehan syndrome), and even maternal death may be caused by delayed recognition or improper clinical procedures.( 11 ) According to the World Health Organization (WHO), postpartum haemorrhage (PPH) is the cause of approximately 25% of all deaths of pregnant women worldwide, especially in low-income countries, ranging from 8% in developed areas to 32% in Northern Africa. Most of those deaths can be avoided by prophylactic use of oxytocic agents during the third stage of delivery, rapid and appropriate management of bleeding. Nevertheless, on average, 6% of all deliveries progress to PPH, and 1.86% to severe PPH (≥ 1,000mL blood loss).( 11 ) ( 12 ) The objective of this study was to determine the prevalence, causes and complications related to PPH in order to improve its management and reduce the rate of maternal deaths in Mbujimayi. Methods Design and setting of study It was retrospective cross-sectional study curried out over a period of 5 years, from July 1, 2018 to July 1, 2023 at obstetrics and gynaecology departments of Bonzola Hospital, Christ-Roi Hospital, and Polyclinique SUMEDCO, all located in Mbujimayi, province of Kasai Oriental, in DR. Congo. There are secondary hospitals having approximately the capacity of 120, 80 and 40 beds each, for the obstetrics and gynaecology departments only. Target population All patients who consulted at obstetrics and gynaecology departments of Bonzola Hospital, Christ-Roi Hospital, and Polyclinique SUMEDCO. Study population All patients who consulted at obstetrics and gynaecology departments of Bonzola Hospital, Christ-Roi Hospital, and Polyclinique SUMEDCO during the study period and diagnosed with PPH. Selection criteria All patient who delivered at Bonzola Hospital, Christ-Roi Hospital, and Polyclinique SUMEDCO and presented with excessive PV bleeding in post-partum, diagnosed and managed for PPH during the study period were included in the study. All patient who did not attend all the investigations, referred to the above secondary facilities, transferred to tertiary facilities or for whom the medical file was incomplete was not included in the study. Sample size, data collection and analysis The sample size was estimated using Fisher’s formula. Thus, the minimum size was 95 and could be achieved in one hospital (Bonzola). In order to achieve a good representative of the samples, 2 hospitals (Christ-Roi Hospital, and Polyclinique SUMEDCO) were randomly selected for data collection, thus the sample size of this study was exhaustive. The data were collected using a pre-established form. The important data were taken from the medical files of the patients. The general variables were demographic characteristics (age, education, occupation), obstetrics and gynaecological history (gravidity, parity, abortion, antenatal care, previous history of PPH), types (primary or secondary), causes (uterine atony, cervical tears or perineal lacerations, tissue retention, coagulopathy, and endometritis), and complications of PPH. The data was encoded in Excel 2010 software and then analysed using SPSS20.exe software. We calculated the frequency, percentage, mean age, mode, median, min, max, standard deviation and 95% confidence interval of the mean. The results are presented in the form of tables. Ethical considerations Ethical clearance was granted by the Joint Research Ethics Committee of UOM, Comité de Recherche de l’ UOM (CRUOM) and Medical Directors of Bonzola Hospital, Christ-Roi Hospital, and Polyclinique SUMEDCO. Confidentiality and anonymity of the patients were maintained. Results Frequency During the study period, 875 out of 31620 patients who delivered, i.e. 2.77% were diagnosed and managed for PPH at obstetrics and gynaecology departments of Bonzola Hospital, Christ-Roi Hospital, and Polyclinique SUMEDCO. This prevalence maybe under estimated due to visual estimation of blood loss which is the most common method for PPH detection following vaginal or caesarean birth. Sociodemographic characteristics Patients aged between 20–29 years old were the most represented with 384 out of 875 patients, i.e. 44.0%. The mean age of the patients was 26.97 years, the median was 26, the mode 25, min 16 years, max 45 years, SD was 7.4 and 95%CI of the true mean was lying between 27.44 and 26.5. Many patients had secondary level of education with 505 out of 875 patients, i.e. 57.7%. The home worker patients were the most represented with 571 out of 875 patients, i.e. 65.3%. The above situation can be related to the reproductive age where sexual activity is the very high and the low socioeconomic status. Obstetrical and gynaecological history Multigravida and multipara were the most represented with respectively 426 out of 875 patients, i.e. 48.7%. Many patients followed the antenatal care with 695 out of 875, i.e. 79.4%. The patients with history of previous PPH was less represented with 54 out of 875 patients, i.e. 6.2%. This can be due to the physiological state of the uterine muscles of the multiparous. Types, causes, and complications of PPH The primary PPH was the most represented with 799 out of 875 patients, i.e. 91.3%. Uterine atony was finding to be the first cause of PPH with 361 out of 875 patients, i.e. 41.3%. Anaemia was the most represented complication of PPH with 541 out of 875 patients, i.e. 61.8%. These results are supported by many literatures where primary PPH is the most common type of PPH and uterine atony remaining the predominate cause of PPH worldwide. Table I. Distribution of patients according to their sociodemographic characteristics Variables Frequency (n = 875) % Age (years) < 20 20–29 30–39 ≥ 40 Mean age Median Mode Min Max SD 95%CI 205 384 248 38 26.97 26 25 16 years 45 years 7.14 27.44&26.5 23.4 44.0 28.3 4.3 Education Not educated Primary Secondary University 120 12 505 238 13.7 1.4 57.7 27.2 Occupation Home maker On job 571 304 65.3 34.7 Table II. Distribution of the patients according to the obstetrical and gynaecological history History Frequency (n = 875) % Gravidity Primigravida Multigravida Grand multipara 219 426 230 25.0 48.7 26.3 Parity Primipara Multipara Grand multipara 219 426 230 25.0 48.7 26.3 Abortion Yes No 224 651 25.6 74.4 Antennal care Yes No 695 180 79.4 20.6 Previous PPH Yes No 54 821 6.2 93.8 Table III. Distribution of patients according to the types, causes, and complications of PPH variables Frequency (n = 875) % Types of PPH Primary Secondary 799 76 91.3 8.7 Causes Uterine atony Cervical tears/perineal lacerations Tissue retention Endometritis 361 221 217 76 41.3 25.3 24.8 8.6 Complications Anaemia Hypovolemic shock AKI Endometritis Vaginitis Death 541 123 1 128 62 20 61.8 14.1 0.1 14.6 7.1 2.3 DISCUSSION Frequency The frequency of PPH during the period study was 2.77%. The similar results were reported in Rwanda (2.7%) by Jean Paul Semasaka Sengoma. ( 13 ) These results are superior to 1.3% in 2017, 1.26% in 2018 and 1.4% in 2019 reported by Samson Peter Mvandal et al. in Tanzania. ( 14 ) Emma Clarke-Deelder et al. reported the highest prevalence of 8.6% in Kenya. ( 15 ) Sociodemographic characteristics Patients aged between 20–29 years old were the most represented with 44.0%. The mean age of the patients was 26.97 years, the median was 26, the mode 25, min 16 years, max 45 years, SD was 7.4 and 95%CI of the true mean was lying between 27.44 and 26.5. Many patients had secondary level of education with 57.7%. The home worker patients were the most represented with 65.3%. Phat Prapawichar et al. reported the approximatively mean age of participants of 26 years old (SD, ranged 11 to 49). ( 16 ) The average age of 29 ± 10.25 years with age ranging from 15 years to 43 years was reported by Jeremie Pagnol Bille Bonga et al. ( 8 ) Regarding profession and education, Jeanne Hortence Fouedjio et al. reported that female students were the most represented in the group of cases (29.7%) while in the second group a clear predominance of the homemaker profession was noted (37.9%). Secondary level of education was the most represented in the two groups(57%). ( 15 ) Obstetrical and gynaecological history Multigravida and multipara were the most represented with respectively 48.7%. Many patients followed the antenatal care with 79.4%. The patients with history of previous PPH was less represented with 6.2%. Prapawichar P et al. reported approximately 35.3% and 64.7% of primiparous and multiparous women being the most represented and women with past history of PPH were more likely to have increased risk of having PPH by 10.97 times (95% CI 2.27,53.05) compared to those who did not. ( 16 ) Jeremie Pagnol Bille Bonga et al. reported in their study that the frequency of delivery hemorrhage decreased as the parity increased. It was higher among primiparous with 30.5%. ( 8 ) Pacifique Mwene-Batu et al. reported that almost 47.8% of patients in their study did not completed four antenatal consultations (ANC). ( 17 ) other study published by Zahouo Pascale Ghislaine KOUAMÉ et al. established that the incidence of PPH among multiparous mothers was the most represented with 22.31%. ( 18 ) Studies show that there is an association between the incidence of PPH and grand multiparty, advance maternal age and vaginal delivery. ( 19 ) Types, causes, and complications of PPH Primary PPH was the most represented with 91.3%. these results are superior to 58.0% reported by Chigozie Ozoemena Ifeadike. ( 3 ) And uterine atony was the most represented cause of PPH with 41.3%. these results are different of those reported by Chigozie Ozoemena Ifeadike where retained product of conception was the most represented with 42.9%. ( 3 ) In our study, anaemia was the most represented complication of PPH with 61.8%. These results are superior to those reported by Jeanne Hortence Fouedjio et al. where maternal complications occurred in 11.38% of cases, the majority being soft tissue lesions (4.54%), and postpartum hemorrhage (4.54%). ( 20 ) Omrana Pasha et al. reported that maternal death occurred in 38.6% due to obstetric hemorrhage. ( 21 ) The risk of complication and death due to pregnancy is prominent in young adolescents than older women: The lifetime risk of death due to pregnancy is eminent in developing countries due to the high number of pregnancies. ( 19 ) Traoré Soumana O et al. reported the highest incidence of maternal death due to PPH of 88.80%. ( 22 ) Limitations This is the first study and available data of PPH from our setting. The sample size of this study was exhaustive in order to achieve a good representative of the samples; thus, the conclusion of our study can be generalized. However, the diagnosis of PPH was based on visually estimated blood loss, a method that has considerable inaccurate and the prevalence of our study maybe under estimated due to lack of accurate diagnosis tools. Despite these limitations, the overall findings were consistent and can describe the prevalence, cause and complication of PPH in Mbujimayi. Therefore, the need for robust data to determine the prevalence and risk factors associated with PPH using a calibrated under-buttocks drape to measure blood loss that is highly correlated with the gold standard measure of photospectometry. Conclusion Postpartum haemorrhage (PPH) remains one of the leading causes of severe maternal morbidity, and the leading cause of direct maternal deaths. Healthcare providers must have the knowledge, skills, and resources to detect and manage PPH for each birth. Anyway, we recommend to Bonzola Hospital, Christ-Roi Hospital, Polyclinique SUMEDCO, and Authorities to facilitate the diagnosis tools of PPH in Mbujimayi. Declarations Availability of data and materials All data generated or analysed during the study are included in this published article. However, the datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Acknowledgements Authors are thankful to the authorities and members of Bonzola Hospital, Christ-Roi Hospital, and Polyclinique SUMEDCO for their assistance during data collection. Funding Not applicable Author information Dr Constantin Mpoyi is joint author. Authors’ contributions CMM participated in the design of the study, analysis and interpretation of the results. He wrote the main manuscript text and prepared tables. LNM participated in the design of the study. He read and corrected the main manuscript text. FLK participated in the design of the study, the data collection, analysis and interpretation of the results. JKM participated in the design of the study, the data collection, analysis and interpretation of the results. CMK participated in the design of the study. He read and corrected the main manuscript text. Ethics approval Ethical clearance was granted by the Joint Research Ethics Committee of UOM, CRUOM, and Medical Directors of Bonzola Hospital, Christ-Roi Hospital, and Polyclinique SUMEDCO. Confidentiality and anonymity of the patients were maintained. Consent for publication Not applicable Competing interests Dr Constantin Mukeba Mpoyi reports the support from the Else-Kroner-Fresenius Stiftung foundation through the BEBUC Scholarship programme. Funds received were used outside of this study. The authors therefore declare that there is no conflict of interest. Abbreviations AKI Acute Kidney Injury ANC Antenatal Care/ Consultation BEBUC Bourse d’Excellence Bringmann aux Universités Congolaises CI Confidence Interval CRUOM Comité de Recherche de l’Université Officielle de Mbujimayi DRC Democratic Republic of the Congo PPH Postpartum Haemorrhage PPPH Primary Postpartum Haemorrhage PV Per Vagina SD Standard Deviation SPPH Severe Postpartum Haemorrhage SPSS Statistical Package for the Social Sciences UK United Kingdom UOM Université Officielle de Mbujimayi USA United States of America WHO World Health Organization % Percentage References Carroli G, Cuesta C, Abalos E, Gulmezoglu AM. Epidemiology of postpartum haemorrhage: a systematic review. Best Pract Res Clin Obstet Gynaecol [Internet]. 2008;22(6):999–1012. https://www.sciencedirect.com/science/article/pii/S1521693408001004 Lockhart E. Postpartum hemorrhage: a continuing challenge. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4970337","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":346203511,"identity":"4de26e77-e7a8-48e1-9074-46bb56fc989a","order_by":0,"name":"Constantin Mukeba Mpoyi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYHADxsYHQJKHjyjFByBamg1AWthI0MLAJgEmCanmb+89/PlDzbY8fonktsqvOXYybAzMDx/dwKNF4sy5NIkDx24XS85IbLstuy0Z6DA2Y+McPFoMJHLMGA6w3U7ccAOoRXIbM1ALD5s0AS3GHw78g2gpltxWT5QWA4mDbRAtjB+3HSasReLMGTOJs31Av/Q8bJZm3Hach42ZgF/423uMP1R8u53Hz57+8OPPbdX2/OzNDx/j0wIDCQwCCQzMPCAmMxHKIVr4DzAw/iBS9SgYBaNgFIwsAADDB0vvAWbtjAAAAABJRU5ErkJggg==","orcid":"","institution":"Université Officielle de Mbujimayi (UOM)","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Constantin","middleName":"Mukeba","lastName":"Mpoyi","suffix":""},{"id":346203512,"identity":"e29d0bab-a17e-47dd-9942-7f086d820b8a","order_by":1,"name":"Louis Ntobo Mbuyamba","email":"","orcid":"","institution":"Université Officielle de Mbujimayi (UOM)","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Louis","middleName":"Ntobo","lastName":"Mbuyamba","suffix":""},{"id":346203513,"identity":"7dba7232-d6b4-47d9-b2b9-078536cd5a31","order_by":2,"name":"Fidel Lumuanga Kayindjika","email":"","orcid":"","institution":"Université Officielle de Mbujimayi (UOM)","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fidel","middleName":"Lumuanga","lastName":"Kayindjika","suffix":""},{"id":346203515,"identity":"92117d3d-8420-48a2-bd32-2168249bf2e8","order_by":3,"name":"Junior Kasongo Mukeba","email":"","orcid":"","institution":"Université Officielle de Mbujimayi (UOM)","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Junior","middleName":"Kasongo","lastName":"Mukeba","suffix":""},{"id":346203516,"identity":"297db7ef-b452-49d0-b847-7bed78ea0d44","order_by":4,"name":"Clément Mutombo Kadima","email":"","orcid":"","institution":"Université Officielle de Mbujimayi (UOM)","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Clément","middleName":"Mutombo","lastName":"Kadima","suffix":""}],"badges":[],"createdAt":"2024-08-24 18:38:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4970337/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4970337/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103483251,"identity":"2176f1ac-53bd-4ff9-9f23-bd6ccad0f32e","added_by":"auto","created_at":"2026-02-26 08:27:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":857847,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4970337/v1/479b9f62-4e05-49c3-b231-992b4df7e150.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prevalence, Causes and Complications of Postpartum Haemorrhage in Mbujimayi, Democratic Republic of the Congo (DRC): a cross-sectional study","fulltext":[{"header":"Background","content":"\u003cp\u003ePostpartum haemorrhage is defined as blood loss from the genital tract of 500 mL or more in vaginal delivery, \u0026ge; 1000 mL in caesarean section, or a substantial drop in haematocrit compared with the antepartum level within 24 hours after the delivery of the baby. It is also defined as blood loss sufficient to cause hypovolemia, a 10% decrease in haematocrit or requiring transfusion of blood products regardless of the route of delivery. Severe postpartum haemorrhage (SPPH) is defined as blood loss from the genital tract of 1000 mL or more in the first 24 hours after the delivery of the baby. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) The conditions may occur in the first 24 hours after delivery (primary PPH) or between 24 hours and 6 weeks after delivery (secondary PPH) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe risk factors for PPH include; older age, primigravida, past history of PPH, multiple pregnancies, grand multiparity, fetal macrosomia, preterm births, labor induction, genital tract injuries, caesarean birth, intra-uterine fetal deaths, and non-use of oxytocic for PPH prophylaxis. However, many studies are based on visually estimated blood loss as a tool for the diagnosis of PPH, this method is reported to be inaccurate. The few studies that have objectively measured blood loss after childbirth are in high-income countries, whose delivery settings differ from those in low income countries. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAn increasing trend in PPH is observed in USA, Canada, UK, and Australia. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) The global prevalence of PPH is 6% and the highest burden is experienced in low-income countries. The magnitude of PPH in sub-Saharan Africa is high at 10.5%. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) In Australia, PPH rates have increased by 29% from 4.9% of deliveries in 1993 to 6.3% of deliveries in 2002. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) Its incidence is of 28.8% in Italia, (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) 30% in Brazil. The low prevalence rates were identified in Guayaquil, Ecuador, between 2017 and 2018, where 7% of the 2,352 recorded births in 2017 were affected by PPH. Similarly, in Switzerland, PPH occurred in 3.1% between January 1993 and December 2014 and 2.19% in Peru. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn Africa the incidence of PPH varies from a country to another country. It is of 31.5% in Tunisia, 2.23% in Morocco, 1.13% in Nigeria, 1% in Cameroon, 47.82% in Benin, 13% in Mali, (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) 16.6% in the Southern region of Ethiopia, 1.36% in Lom\u0026eacute; (Togo), 1.6% in Libreville (Gabon), 4.67% in the Central African Republic, 9.0% in Uganda, (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) and 6% in DR Congo.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003cp\u003ePPH is responsible for the majority of severe maternal morbidities, such as prolonged hospital admissions, need for blood transfusions and surgical procedures that can lead to loss of reproductive function. Severe complications such as haemorrhagic shock, acute respiratory distress syndrome, disseminated intravascular coagulation, acute renal failure, loss of fertility, pituitary necrosis (Sheehan syndrome), and even maternal death may be caused by delayed recognition or improper clinical procedures.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAccording to the World Health Organization (WHO), postpartum haemorrhage (PPH) is the cause of approximately 25% of all deaths of pregnant women worldwide, especially in low-income countries, ranging from 8% in developed areas to 32% in Northern Africa. Most of those deaths can be avoided by prophylactic use of oxytocic agents during the third stage of delivery, rapid and appropriate management of bleeding. Nevertheless, on average, 6% of all deliveries progress to PPH, and 1.86% to severe PPH (\u0026ge;\u0026thinsp;1,000mL blood loss).(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) The objective of this study was to determine the prevalence, causes and complications related to PPH in order to improve its management and reduce the rate of maternal deaths in Mbujimayi.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign and setting of study\u003c/h2\u003e \u003cp\u003eIt was retrospective cross-sectional study curried out over a period of 5 years, from July 1, 2018 to July 1, 2023 at obstetrics and gynaecology departments of Bonzola Hospital, Christ-Roi Hospital, and Polyclinique SUMEDCO, all located in Mbujimayi, province of Kasai Oriental, in DR. Congo. There are secondary hospitals having approximately the capacity of 120, 80 and 40 beds each, for the obstetrics and gynaecology departments only.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eTarget population\u003c/h2\u003e \u003cp\u003eAll patients who consulted at obstetrics and gynaecology departments of Bonzola Hospital, Christ-Roi Hospital, and Polyclinique SUMEDCO.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eAll patients who consulted at obstetrics and gynaecology departments of Bonzola Hospital, Christ-Roi Hospital, and Polyclinique SUMEDCO during the study period and diagnosed with PPH.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSelection criteria\u003c/h2\u003e \u003cp\u003eAll patient who delivered at Bonzola Hospital, Christ-Roi Hospital, and Polyclinique SUMEDCO and presented with excessive PV bleeding in post-partum, diagnosed and managed for PPH during the study period were included in the study.\u003c/p\u003e \u003cp\u003eAll patient who did not attend all the investigations, referred to the above secondary facilities, transferred to tertiary facilities or for whom the medical file was incomplete was not included in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eSample size, data collection and analysis\u003c/h2\u003e \u003cp\u003eThe sample size was estimated using Fisher\u0026rsquo;s formula. Thus, the minimum size was 95 and could be achieved in one hospital (Bonzola). In order to achieve a good representative of the samples, 2 hospitals (Christ-Roi Hospital, and Polyclinique SUMEDCO) were randomly selected for data collection, thus the sample size of this study was exhaustive. The data were collected using a pre-established form. The important data were taken from the medical files of the patients. The general variables were demographic characteristics (age, education, occupation), obstetrics and gynaecological history (gravidity, parity, abortion, antenatal care, previous history of PPH), types (primary or secondary), causes (uterine atony, cervical tears or perineal lacerations, tissue retention, coagulopathy, and endometritis), and complications of PPH. The data was encoded in Excel 2010 software and then analysed using SPSS20.exe software. We calculated the frequency, percentage, mean age, mode, median, min, max, standard deviation and 95% confidence interval of the mean. The results are presented in the form of tables.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e Ethical clearance was granted by the Joint Research Ethics Committee of UOM, Comit\u0026eacute; de Recherche de l\u0026rsquo; UOM (CRUOM) and Medical Directors of Bonzola Hospital, Christ-Roi Hospital, and Polyclinique SUMEDCO. Confidentiality and anonymity of the patients were maintained.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eFrequency\u003c/h2\u003e \u003cp\u003eDuring the study period, 875 out of 31620 patients who delivered, i.e. 2.77% were diagnosed and managed for PPH at obstetrics and gynaecology departments of Bonzola Hospital, Christ-Roi Hospital, and Polyclinique SUMEDCO. This prevalence maybe under estimated due to visual estimation of blood loss which is the most common method for PPH detection following vaginal or caesarean birth.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic characteristics\u003c/h2\u003e \u003cp\u003ePatients aged between 20\u0026ndash;29 years old were the most represented with 384 out of 875 patients, i.e. 44.0%. The mean age of the patients was 26.97 years, the median was 26, the mode 25, min 16 years, max 45 years, SD was 7.4 and 95%CI of the true mean was lying between 27.44 and 26.5. Many patients had secondary level of education with 505 out of 875 patients, i.e. 57.7%. The home worker patients were the most represented with 571 out of 875 patients, i.e. 65.3%. The above situation can be related to the reproductive age where sexual activity is the very high and the low socioeconomic status.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eObstetrical and gynaecological history\u003c/h2\u003e \u003cp\u003eMultigravida and multipara were the most represented with respectively 426 out of 875 patients, i.e. 48.7%. Many patients followed the antenatal care with 695 out of 875, i.e. 79.4%. The patients with history of previous PPH was less represented with 54 out of 875 patients, i.e. 6.2%. This can be due to the physiological state of the uterine muscles of the multiparous.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eTypes, causes, and complications of PPH\u003c/h2\u003e \u003cp\u003eThe primary PPH was the most represented with 799 out of 875 patients, i.e. 91.3%. Uterine atony was finding to be the first cause of PPH with 361 out of 875 patients, i.e. 41.3%. Anaemia was the most represented complication of PPH with 541 out of 875 patients, i.e. 61.8%. These results are supported by many literatures where primary PPH is the most common type of PPH and uterine atony remaining the predominate cause of PPH worldwide.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable I. Distribution of patients according to their sociodemographic characteristics\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (n\u0026thinsp;=\u0026thinsp;875)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;20\u003c/p\u003e \u003cp\u003e20\u0026ndash;29\u003c/p\u003e \u003cp\u003e30\u0026ndash;39\u003c/p\u003e \u003cp\u003e\u0026ge;\u0026thinsp;40\u003c/p\u003e \u003cp\u003eMean age\u003c/p\u003e \u003cp\u003eMedian\u003c/p\u003e \u003cp\u003eMode\u003c/p\u003e \u003cp\u003eMin\u003c/p\u003e \u003cp\u003eMax\u003c/p\u003e \u003cp\u003eSD\u003c/p\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e205\u003c/p\u003e \u003cp\u003e384\u003c/p\u003e \u003cp\u003e248\u003c/p\u003e \u003cp\u003e38\u003c/p\u003e \u003cp\u003e26.97\u003c/p\u003e \u003cp\u003e26\u003c/p\u003e \u003cp\u003e25\u003c/p\u003e \u003cp\u003e16 years\u003c/p\u003e \u003cp\u003e45 years\u003c/p\u003e \u003cp\u003e7.14\u003c/p\u003e \u003cp\u003e27.44\u0026amp;26.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.4\u003c/p\u003e \u003cp\u003e44.0\u003c/p\u003e \u003cp\u003e28.3\u003c/p\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003cp\u003eNot educated\u003c/p\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003cp\u003e12\u003c/p\u003e \u003cp\u003e505\u003c/p\u003e \u003cp\u003e238\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.7\u003c/p\u003e \u003cp\u003e1.4\u003c/p\u003e \u003cp\u003e57.7\u003c/p\u003e \u003cp\u003e27.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003cp\u003eHome maker\u003c/p\u003e \u003cp\u003eOn job\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e571\u003c/p\u003e \u003cp\u003e304\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.3\u003c/p\u003e \u003cp\u003e34.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTable II. Distribution of the patients according to the obstetrical and gynaecological history\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (n\u0026thinsp;=\u0026thinsp;875)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGravidity\u003c/p\u003e \u003cp\u003ePrimigravida\u003c/p\u003e \u003cp\u003eMultigravida\u003c/p\u003e \u003cp\u003eGrand multipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e219\u003c/p\u003e \u003cp\u003e426\u003c/p\u003e \u003cp\u003e230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003cp\u003e48.7\u003c/p\u003e \u003cp\u003e26.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParity\u003c/p\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003cp\u003eMultipara\u003c/p\u003e \u003cp\u003eGrand multipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e219\u003c/p\u003e \u003cp\u003e426\u003c/p\u003e \u003cp\u003e230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003cp\u003e48.7\u003c/p\u003e \u003cp\u003e26.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbortion\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e224\u003c/p\u003e \u003cp\u003e651\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.6\u003c/p\u003e \u003cp\u003e74.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntennal care\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e695\u003c/p\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.4\u003c/p\u003e \u003cp\u003e20.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious PPH\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003cp\u003e821\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.2\u003c/p\u003e \u003cp\u003e93.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTable III. Distribution of patients according to the types, causes, and complications of PPH\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabd\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003evariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (n\u0026thinsp;=\u0026thinsp;875)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTypes of PPH\u003c/p\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e799\u003c/p\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.3\u003c/p\u003e \u003cp\u003e8.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCauses\u003c/p\u003e \u003cp\u003eUterine atony\u003c/p\u003e \u003cp\u003eCervical tears/perineal lacerations\u003c/p\u003e \u003cp\u003eTissue retention\u003c/p\u003e \u003cp\u003eEndometritis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e361\u003c/p\u003e \u003cp\u003e221\u003c/p\u003e \u003cp\u003e217\u003c/p\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.3\u003c/p\u003e \u003cp\u003e25.3\u003c/p\u003e \u003cp\u003e24.8\u003c/p\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003cp\u003eAnaemia\u003c/p\u003e \u003cp\u003eHypovolemic shock\u003c/p\u003e \u003cp\u003eAKI\u003c/p\u003e \u003cp\u003eEndometritis\u003c/p\u003e \u003cp\u003eVaginitis\u003c/p\u003e \u003cp\u003eDeath\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e541\u003c/p\u003e \u003cp\u003e123\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e128\u003c/p\u003e \u003cp\u003e62\u003c/p\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61.8\u003c/p\u003e \u003cp\u003e14.1\u003c/p\u003e \u003cp\u003e0.1\u003c/p\u003e \u003cp\u003e14.6\u003c/p\u003e \u003cp\u003e7.1\u003c/p\u003e \u003cp\u003e2.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eFrequency\u003c/h2\u003e \u003cp\u003eThe frequency of PPH during the period study was 2.77%. The similar results were reported in Rwanda (2.7%) by Jean Paul Semasaka Sengoma. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) These results are superior to 1.3% in 2017, 1.26% in 2018 and 1.4% in 2019 reported by Samson Peter Mvandal et al. in Tanzania. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) Emma Clarke-Deelder et al. reported the highest prevalence of 8.6% in Kenya. (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic characteristics\u003c/h2\u003e \u003cp\u003ePatients aged between 20\u0026ndash;29 years old were the most represented with 44.0%. The mean age of the patients was 26.97 years, the median was 26, the mode 25, min 16 years, max 45 years, SD was 7.4 and 95%CI of the true mean was lying between 27.44 and 26.5. Many patients had secondary level of education with 57.7%. The home worker patients were the most represented with 65.3%. Phat Prapawichar et al. reported the approximatively mean age of participants of 26 years old (SD, ranged 11 to 49). (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) The average age of 29\u0026thinsp;\u0026plusmn;\u0026thinsp;10.25 years with age ranging from 15 years to 43 years was reported by Jeremie Pagnol Bille Bonga et al. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) Regarding profession and education, Jeanne Hortence Fouedjio et al. reported that female students were the most represented in the group of cases (29.7%) while in the second group a clear predominance of the homemaker profession was noted (37.9%). Secondary level of education was the most represented in the two groups(57%). (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eObstetrical and gynaecological history\u003c/h2\u003e \u003cp\u003eMultigravida and multipara were the most represented with respectively 48.7%. Many patients followed the antenatal care with 79.4%. The patients with history of previous PPH was less represented with 6.2%. Prapawichar P et al. reported approximately 35.3% and 64.7% of primiparous and multiparous women being the most represented and women with past history of PPH were more likely to have increased risk of having PPH by 10.97 times (95% CI 2.27,53.05) compared to those who did not. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) Jeremie Pagnol Bille Bonga et al. reported in their study that the frequency of delivery hemorrhage decreased as the parity increased. It was higher among primiparous with 30.5%. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) Pacifique Mwene-Batu et al. reported that almost 47.8% of patients in their study did not completed four antenatal consultations (ANC). (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) other study published by Zahouo Pascale Ghislaine KOUAM\u0026Eacute; et al. established that the incidence of PPH among multiparous mothers was the most represented with 22.31%. (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) Studies show that there is an association between the incidence of PPH and grand multiparty, advance maternal age and vaginal delivery. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eTypes, causes, and complications of PPH\u003c/h2\u003e \u003cp\u003ePrimary PPH was the most represented with 91.3%. these results are superior to 58.0% reported by Chigozie Ozoemena Ifeadike. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) And uterine atony was the most represented cause of PPH with 41.3%. these results are different of those reported by Chigozie Ozoemena Ifeadike where retained product of conception was the most represented with 42.9%. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) In our study, anaemia was the most represented complication of PPH with 61.8%. These results are superior to those reported by Jeanne Hortence Fouedjio et al. where maternal complications occurred in 11.38% of cases, the majority being soft tissue lesions (4.54%), and postpartum hemorrhage (4.54%). (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) Omrana Pasha et al. reported that maternal death occurred in 38.6% due to obstetric hemorrhage. (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) The risk of complication and death due to pregnancy is prominent in young adolescents than older women: The lifetime risk of death due to pregnancy is eminent in developing countries due to the high number of pregnancies. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) Traor\u0026eacute; Soumana O et al. reported the highest incidence of maternal death due to PPH of 88.80%. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis is the first study and available data of PPH from our setting. The sample size of this study was exhaustive in order to achieve a good representative of the samples; thus, the conclusion of our study can be generalized. However, the diagnosis of PPH was based on visually estimated blood loss, a method that has considerable inaccurate and the prevalence of our study maybe under estimated due to lack of accurate diagnosis tools. Despite these limitations, the overall findings were consistent and can describe the prevalence, cause and complication of PPH in Mbujimayi. Therefore, the need for robust data to determine the prevalence and risk factors associated with PPH using a calibrated under-buttocks drape to measure blood loss that is highly correlated with the gold standard measure of photospectometry.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePostpartum haemorrhage (PPH) remains one of the leading causes of severe maternal morbidity, and the leading cause of direct maternal deaths. Healthcare providers must have the knowledge, skills, and resources to detect and manage PPH for each birth. Anyway, we recommend to Bonzola Hospital, Christ-Roi Hospital, Polyclinique SUMEDCO, and Authorities to facilitate the diagnosis tools of PPH in Mbujimayi.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during the study are included in this published article. However, the datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Acknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors are thankful to the authorities and members of Bonzola Hospital, Christ-Roi Hospital, and Polyclinique SUMEDCO for their assistance during data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr Constantin Mpoyi is joint author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCMM participated in the design of the study, analysis and interpretation of the results.\u003c/p\u003e\n\u003cp\u003eHe wrote the main manuscript text and prepared tables.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLNM participated in the design of the study. He read and corrected the main manuscript text.\u003c/p\u003e\n\u003cp\u003eFLK participated in the design of the study, the data collection, analysis and interpretation of the results.\u003c/p\u003e\n\u003cp\u003eJKM participated in the design of the study, the data collection, analysis and interpretation of the results.\u003c/p\u003e\n\u003cp\u003eCMK participated in the design of the study. He read and corrected the main manuscript text.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was granted by the Joint Research Ethics Committee of UOM, CRUOM, and Medical Directors of Bonzola Hospital, Christ-Roi Hospital, and Polyclinique SUMEDCO. Confidentiality and anonymity of the patients were maintained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr Constantin Mukeba Mpoyi reports the support from the Else-Kroner-Fresenius Stiftung foundation through the BEBUC Scholarship programme. Funds received were used outside of this study. The authors therefore declare that there is no conflict of interest.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.32155477031802%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAKI\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.67844522968198%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAcute Kidney Injury\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.32155477031802%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eANC\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.67844522968198%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAntenatal Care/ Consultation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.32155477031802%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eBEBUC\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.67844522968198%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eBourse d\u0026rsquo;Excellence Bringmann aux Universit\u0026eacute;s Congolaises\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.32155477031802%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCI\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.67844522968198%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eConfidence Interval\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.32155477031802%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCRUOM\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.67844522968198%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eComit\u0026eacute; de Recherche de l\u0026rsquo;Universit\u0026eacute; Officielle de Mbujimayi\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.32155477031802%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eDRC\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.67844522968198%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eDemocratic Republic of the Congo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.32155477031802%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePPH\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.67844522968198%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePostpartum Haemorrhage\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.32155477031802%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePPPH\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.67844522968198%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePrimary Postpartum Haemorrhage\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.32155477031802%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePV\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.67844522968198%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePer Vagina\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.32155477031802%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.67844522968198%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eStandard Deviation\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.32155477031802%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSPPH\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.67844522968198%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSevere Postpartum Haemorrhage\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.32155477031802%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSPSS\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.67844522968198%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eStatistical Package for the Social Sciences\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.32155477031802%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eUK\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.67844522968198%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eUnited Kingdom\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.32155477031802%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eUOM\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.67844522968198%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eUniversit\u0026eacute; Officielle de Mbujimayi\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.32155477031802%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eUSA\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.67844522968198%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eUnited States of America\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.32155477031802%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eWHO\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.67844522968198%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eWorld Health Organization\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.32155477031802%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.67844522968198%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePercentage\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCarroli G, Cuesta C, Abalos E, Gulmezoglu AM. 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Etiology of Obstetric Hemorrhages Associated with Maternal Deaths in a Suburban Commune of Bamako. (Mali). 2021;10(4):216\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Prevalence, Cause, Complication, Postpartum Haemorrhage, Mbujimayi","lastPublishedDoi":"10.21203/rs.3.rs-4970337/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4970337/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the World Health Organization (WHO), postpartum haemorrhage (PPH) is the cause of approximately 25% of all deaths of pregnant women worldwide, especially in low-income countries, ranging from 8% in developed areas to 32% in Northern Africa. PPH is defined as blood loss from the genital tract of 500 mL or more in the first 24 hours after the delivery of the baby.\u003c/p\u003e\n\u003cp\u003eThe objective of this study was to determine the prevalence, causes and complications related to PPH in order to improve its management and reduce the rate of maternal deaths in Mbujimayi.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt was retrospective cross-sectional study curried out over a period of 5 years, from July 1, 2018 to July 1, 2023 at obstetrics and gynaecology departments of Bonzola Hospital, Christ-Roi Hospital, and Polyclinique SUMEDCO, all located in Mbujimayi, province of Kasai Oriental, in DRC.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the study period, the prevalence of PPH was 2.77%. Patients aged between 20-29 years old were the most represented with 44.0%. The mean age of the patients was 26.97 years, the median was 26, the mode 25, min 16 years, max 45 years, SD 7.4 and 95%CI of the true mean was lying between 27.44 and 26.5. Multigravida and multipara were the most represented with respectively 48.7%. The patients with history of previous PPH was less represented with 6.2%. The primary PPH was the most represented with 91.3%. Uterine atony was finding to be the first cause of PPH with 41.3%. Anaemia was the most represented complication with 61.8%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostpartum haemorrhage (PPH) remains one of the leading causes of severe maternal morbidity, and the leading cause of direct maternal deaths. Healthcare providers must have the knowledge, skills, and resources to detect and manage PPH for each birth. Anyway, we recommend to Bonzola Hospital, Christ-Roi Hospital, Polyclinique SUMEDCO, and Authorities to facilitate the diagnosis tools of PPH in Mbujimayi.\u003c/p\u003e","manuscriptTitle":"Prevalence, Causes and Complications of Postpartum Haemorrhage in Mbujimayi, Democratic Republic of the Congo (DRC): a cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-16 17:40:59","doi":"10.21203/rs.3.rs-4970337/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8fd41baa-898a-4c92-b602-9b48e9a2c851","owner":[],"postedDate":"September 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-26T08:25:13+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-16 17:40:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4970337","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4970337","identity":"rs-4970337","version":["v1"]},"buildId":"rHA-KDH7Qsr4HCuvH75dn","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}