{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T13:09:01Z","timestamp":1790168941030,"version":"4.1.0"},"reference-count":50,"publisher":"Public Library of Science (PLoS)","issue":"9","license":[{"start":{"date-parts":[[2025,9,3]],"date-time":"2025-09-03T00:00:00Z","timestamp":1756857600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100005416","name":"Norges Forskningsr\u00c3\u00a5d","doi-asserted-by":"publisher","award":["324933"],"award-info":[{"award-number":["324933"]}],"id":[{"id":"10.13039\/501100005416","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Postpartum haemorrhage (PPH) is a leading cause of maternal mortality, near-misses and morbidity in Uganda and globally. Kawempe National Referral Hospital (KNRH), Uganda\u2019s largest obstetric referral hospital, receives many obstetric emergencies, including PPH, from lower-level health facilities. Little is known about the outcomes and management of severe PPH at KNRH. This study aimed to map the occurrence, profile and management challenges of severe PPH at KNRH.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>A prospective hospital-based observational pilot study was conducted between 5th April and 30th May 2023 at KNRH. Sixty women with severe PPH, both in-house and referrals, were enrolled. Data collection was done by research assistants on day 0\u20133 and 42 of inclusion, capturing characteristics, management and outcomes of the participants. Descriptive statistics were used for analysis.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>Of the 60 participants, 47 were referrals. There were 3 maternal deaths, 56 maternal near-misses (hysterectomy, cardiovascular dysfunction, uterine rupture or massive blood loss, and 46 underwent critical interventions (intensive care, laparotomy or blood transfusions). All the participants with uterine ruptures and 12 out of the 13 participants with stillbirths and hysterectomies, respectively, were among referrals. Only referrals had an initial systolic blood pressure\u2009\u2264\u200960\u2009mm Hg and received\u2009\u2265\u20095 units of blood. In both groups approximately two thirds received tranexamic acid and oxytocin\/misoprostol while few of the participants (23.3%) received uterine massage. Nine women had surgical site infections (8 were referrals), and 15 had suboptimal (fair\/poor) wellbeing at 6 weeks postpartum (13 were referrals). None of the comparisons were statistically significant due to too few observations.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>Referrals were more critically ill and disproportionally affected by adverse outcomes and substandard care. While drugs and fluids were often timely administered according to national guidelines and did not differ greatly between the groups, gaps remained particularly non-pharmaceutical interventions. Bettered implementation of evidence-based PPH management and strengthening of the referral system could improve quality of care and maternal outcomes.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0331512","type":"journal-article","created":{"date-parts":[[2025,9,3]],"date-time":"2025-09-03T17:38:27Z","timestamp":1756921107000},"page":"e0331512","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":1,"title":["Severe postpartum haemorrhage at a large referral hospital in Uganda: A prospective observational pilot study"],"prefix":"10.1371","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8338-1360","authenticated-orcid":true,"given":"Mia","family":"Appelb\u00e4ck","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Clare","family":"Lubulwa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lawrence","family":"Kazibwe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Knut Haakon","family":"Stens\u00e6th","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thorkild","family":"Tyllesk\u00e4r","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Josaphat","family":"Byamugisha","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2025,9,3]]},"reference":[{"key":"pone.0331512.ref001","volume-title":"Trends in maternal mortality estimates 2000 to 2023: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA\/Population Division","author":"World Health Organization","year":"2025"},{"issue":"6","key":"pone.0331512.ref002","article-title":"Global causes of maternal death: a WHO systematic analysis","volume":"2","author":"L Say","year":"2014","journal-title":"Lancet Glob Health"},{"issue":"1","key":"pone.0331512.ref003","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1002\/ijgo.12096","article-title":"A systematic review of maternal near miss and mortality due to postpartum hemorrhage","volume":"137","author":"S Maswime","year":"2017","journal-title":"Int J Gynaecol Obstet"},{"issue":"2","key":"pone.0331512.ref004","doi-asserted-by":"crossref","first-page":"131","DOI":"10.1016\/j.ijgo.2014.08.023","article-title":"Severe maternal morbidity and near miss due to postpartum hemorrhage in a national multicenter surveillance study","volume":"128","author":"EA Rocha Filho","year":"2015","journal-title":"Int J Gynaecol Obstet"},{"key":"pone.0331512.ref005","volume-title":"Evaluating the quality of care for severe pregnancy complications: the WHO near-miss approach for maternal health","author":"World Health Organization","year":"2011"},{"key":"pone.0331512.ref006","volume-title":"Uganda Demographic and Health Survery (UDHS) 2022","author":"Uganda Bureau of Statistics","year":"2023"},{"key":"pone.0331512.ref007","volume-title":"The National Annual Maternal and Perinatal Death Surveillance Report (MPDSR) for FY 2022\/2023","author":"Ministry of Health [Uganda]","year":"2023"},{"issue":"2","key":"pone.0331512.ref008","doi-asserted-by":"crossref","first-page":"214","DOI":"10.1016\/j.ijgo.2016.05.009","article-title":"Prevalence of maternal near miss and community-based risk factors in Central Uganda","volume":"135","author":"E Nansubuga","year":"2016","journal-title":"Int J Gynaecol Obstet"},{"issue":"3","key":"pone.0331512.ref009","first-page":"144","article-title":"Maternal mortality and associated near-misses among emergency intrapartum obstetric referrals in Mulago Hospital, Kampala, Uganda","volume":"80","author":"D Kaye","year":"2003","journal-title":"East Afr Med J"},{"issue":"8","key":"pone.0331512.ref010","doi-asserted-by":"crossref","first-page":"1091","DOI":"10.1016\/0277-9536(94)90226-7","article-title":"Too far to walk: maternal mortality in context","volume":"38","author":"S Thaddeus","year":"1994","journal-title":"Soc Sci Med"},{"issue":"11","key":"pone.0331512.ref011","article-title":"High-quality health systems in the Sustainable Development Goals era: time for a revolution","volume":"6","author":"ME Kruk","year":"2018","journal-title":"Lancet Glob Health"},{"issue":"5","key":"pone.0331512.ref012","doi-asserted-by":"crossref","first-page":"496","DOI":"10.1111\/aogs.12071","article-title":"Responsiveness of emergency obstetric care systems in low- and middle-income countries: a critical review of the \u201cthird delay\u201d","volume":"92","author":"FL Cavallaro","year":"2013","journal-title":"Acta Obstet Gynecol Scand"},{"issue":"1","key":"pone.0331512.ref013","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1056\/NEJMoa2303966","article-title":"Randomized trial of early detection and treatment of postpartum hemorrhage","volume":"389","author":"I Gallos","year":"2023","journal-title":"N Engl J Med"},{"key":"pone.0331512.ref014","article-title":"Assessment of structural and process readiness for postpartum haemorrhage care in Uganda and Ghana: A mixed methods study","author":"T Tancred","year":"2024","journal-title":"BJOG"},{"key":"pone.0331512.ref015","unstructured":"World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. 2012."},{"key":"pone.0331512.ref016","volume-title":"Essential Maternal and Newborn Clinical Care Guidelines for Uganda, May 2022","author":"Ministry of Health [Uganda]","year":"2022"},{"issue":"5","key":"pone.0331512.ref017","doi-asserted-by":"crossref","first-page":"535","DOI":"10.1111\/tmi.13557","article-title":"Know-do gaps in obstetric and newborn care quality in Uganda: a cross-sectional study in rural health facilities","volume":"26","author":"S Rokicki","year":"2021","journal-title":"Trop Med Int Health"},{"key":"pone.0331512.ref018","volume-title":"Service Provision Assessment Survey 2007","author":"Ministry of Health [Uganda] and Macro International Inc","year":"2008"},{"key":"pone.0331512.ref019","unstructured":"Kawempe Regional Referral Hospital 2023. Accessed 30th October 2023. https:\/\/kawempehospital.go.ug\/overview"},{"issue":"1","key":"pone.0331512.ref020","doi-asserted-by":"crossref","first-page":"445","DOI":"10.1186\/s12884-017-1640-x","article-title":"Adaptation of the WHO maternal near miss tool for use in sub-Saharan Africa: an International Delphi study","volume":"17","author":"AK Tura","year":"2017","journal-title":"BMC Pregnancy Childbirth"},{"issue":"39","key":"pone.0331512.ref021","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1016\/S0968-8080(12)39601-8","article-title":"The role of delays in severe maternal morbidity and mortality: expanding the conceptual framework","volume":"20","author":"RC Pacagnella","year":"2012","journal-title":"Reprod Health Matters"},{"key":"pone.0331512.ref022","volume-title":"Managing prolonged and obstructed labour Midwifery education module 3","author":"World Health Organization","year":"2008"},{"key":"pone.0331512.ref023","volume-title":"Monitoring emergency obstetric care: a handbook","author":"World Health Organisation, United Nations Population Fund, Mailman School of Public Health, Averting Maternal Death and Disability & United Nations Children\u2019s Fund (UNICEF)","year":"2009"},{"key":"pone.0331512.ref024","volume-title":"Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity","author":"World Health Organization","year":"2011"},{"issue":"3","key":"pone.0331512.ref025","doi-asserted-by":"crossref","first-page":"264","DOI":"10.1016\/j.ijoa.2012.03.004","article-title":"The National Institute for Health and Clinical Excellence (NICE) guidelines for caesarean section, 2011 update: implications for the anaesthetist","volume":"21","author":"S Soltanifar","year":"2012","journal-title":"Int J Obstet Anesth"},{"key":"pone.0331512.ref026","article-title":"Initial management of postpartum hemorrhage: A cohort study in Benin and Mali","author":"J Tort","year":"2016","journal-title":"Int J Gynaecol Obstet"},{"key":"pone.0331512.ref027","volume-title":"Women\u2019s health perinatal nursing care quality measures specifications 2014","author":"Association of Women\u2019s Health OaNNA","year":"2014"},{"key":"pone.0331512.ref028","article-title":"Association between labour outcomes and level of healthcare system at which initial delivery assessment is done before referral in South Western Uganda","volume":"26","author":"M Ronald","year":"2016","journal-title":"Journal of Health, Medicine and Nursing"},{"key":"pone.0331512.ref029","doi-asserted-by":"crossref","first-page":"24","DOI":"10.1186\/s12884-016-0811-5","article-title":"Maternal near misses from two referral hospitals in Uganda: a prospective cohort study on incidence, determinants and prognostic factors","volume":"16","author":"A Nakimuli","year":"2016","journal-title":"BMC Pregnancy Childbirth"},{"issue":"3","key":"pone.0331512.ref030","doi-asserted-by":"crossref","first-page":"265","DOI":"10.4103\/aam.aam_8_22","article-title":"Audit of emergency obstetric referrals at a tertiary center in Kano","volume":"22","author":"IU Takai","year":"2023","journal-title":"Ann Afr Med"},{"issue":"1","key":"pone.0331512.ref031","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0116675","article-title":"Determinants of maternal near-miss in Morocco: too late, too far, too sloppy?","volume":"10","author":"B Assarag","year":"2015","journal-title":"PLoS One"},{"issue":"1","key":"pone.0331512.ref032","doi-asserted-by":"crossref","DOI":"10.1080\/27707571.2022.2157996","article-title":"Maternal near misses (MNM) and their determinants among women who sought obstetric care from fort portal regional referral hospital, Western Uganda","volume":"10","author":"K Omona","year":"2022","journal-title":"Cogent Public Health"},{"issue":"6","key":"pone.0331512.ref033","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2019-033771","article-title":"Delays in emergency obstetric referrals in Addis Ababa hospitals in Ethiopia: a facility-based, cross-sectional study","volume":"10","author":"EM Assefa","year":"2020","journal-title":"BMJ Open"},{"issue":"1","key":"pone.0331512.ref034","doi-asserted-by":"crossref","first-page":"292","DOI":"10.1186\/s12884-020-02996-8","article-title":"Journey of vulnerability: a mixed-methods study to understand intrapartum transfers in Tanzania and Zambia","volume":"20","author":"T Lavender","year":"2020","journal-title":"BMC Pregnancy Childbirth"},{"issue":"1","key":"pone.0331512.ref035","doi-asserted-by":"crossref","first-page":"498","DOI":"10.1186\/s12884-023-05795-z","article-title":"Experiences of referral with an obstetric emergency: voices of women admitted at Mbarara Regional Referral Hospital, South Western Uganda","volume":"23","author":"H Nabulo","year":"2023","journal-title":"BMC Pregnancy Childbirth"},{"issue":"1","key":"pone.0331512.ref036","doi-asserted-by":"crossref","first-page":"432","DOI":"10.1186\/s12884-018-2064-y","article-title":"Predictors of uterine rupture in a large sample of women in Senegal and Mali: cross-sectional analysis of QUARITE trial data","volume":"18","author":"R Delafield","year":"2018","journal-title":"BMC Pregnancy Childbirth"},{"issue":"1","key":"pone.0331512.ref037","doi-asserted-by":"crossref","first-page":"835","DOI":"10.1186\/s12884-023-06148-6","article-title":"The factors associated with stillbirths among sub-saharan African deliveries: a systematic review and meta-analysis","volume":"23","author":"GA Kasa","year":"2023","journal-title":"BMC Pregnancy Childbirth"},{"key":"pone.0331512.ref038","doi-asserted-by":"crossref","first-page":"64","DOI":"10.1111\/1471-0528.17822","article-title":"Burden and outcomes of postpartum haemorrhage in Nigerian referral-level hospitals","author":"T Adebayo","year":"2024","journal-title":"BJOG"},{"key":"pone.0331512.ref039","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1111\/1471-0528.12636","article-title":"Postpartum haemorrhage management, risks, and maternal outcomes: findings from the World Health Organization Multicountry Survey on Maternal and Newborn Health","author":"WR Sheldon","year":"2014","journal-title":"BJOG"},{"issue":"1","key":"pone.0331512.ref040","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1186\/s12884-016-1219-y","article-title":"Assessment of quality of care among in-patients with postpartum haemorrhage and severe pre-eclampsia at st. Francis hospital nsambya: a criteria-based audit","volume":"17","author":"A Lumala","year":"2017","journal-title":"BMC Pregnancy Childbirth"},{"issue":"3","key":"pone.0331512.ref041","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pgph.0001670","article-title":"Quality of care for postpartum hemorrhage: A direct observation study in referral hospitals in Kenya","volume":"3","author":"E Clarke-Deelder","year":"2023","journal-title":"PLOS Glob Public Health"},{"issue":"1","key":"pone.0331512.ref042","doi-asserted-by":"crossref","first-page":"216","DOI":"10.1186\/s12884-017-1407-4","article-title":"The third delay: understanding waiting time for obstetric referrals at a large regional hospital in Ghana","volume":"17","author":"DM Goodman","year":"2017","journal-title":"BMC Pregnancy Childbirth"},{"issue":"3","key":"pone.0331512.ref043","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2020-042909","article-title":"Why women die after reaching the hospital: a qualitative critical incident analysis of the \u201cthird delay\u201d in postconflict northern Uganda","volume":"11","author":"G Alobo","year":"2021","journal-title":"BMJ Open"},{"issue":"1","key":"pone.0331512.ref044","doi-asserted-by":"crossref","first-page":"1707403","DOI":"10.1080\/16549716.2019.1707403","article-title":"\u201cWe do what we can do to save a woman\u201d health workers\u2019 perceptions of health facility readiness for management of postpartum haemorrhage","volume":"13","author":"F Alwy Al-Beity","year":"2020","journal-title":"Glob Health Action"},{"issue":"6","key":"pone.0331512.ref045","doi-asserted-by":"crossref","first-page":"1426","DOI":"10.1007\/s00268-023-06964-z","article-title":"In-Hospital Obstetric Delays in Rural Uganda: A Cross-Sectional Analysis of a Hospital Cohort","volume":"47","author":"M Poppens","year":"2023","journal-title":"World J Surg"},{"issue":"11","key":"pone.0331512.ref046","doi-asserted-by":"crossref","first-page":"695","DOI":"10.1097\/OGX.0000000000000123","article-title":"Uterine rupture in resource-poor countries","volume":"69","author":"Y Berhe","year":"2014","journal-title":"Obstet Gynecol Surv"},{"key":"pone.0331512.ref047","article-title":"Linking families and facilities for care at birth: what works to avert intrapartum-related deaths?","volume":"107","author":"AC Lee","year":"2009","journal-title":"Int J Gynaecol Obstet"},{"issue":"5","key":"pone.0331512.ref048","doi-asserted-by":"crossref","first-page":"675","DOI":"10.1080\/01443615.2020.1820467","article-title":"Maternal near miss: reaching the last mile","volume":"41","author":"MK M","year":"2021","journal-title":"J Obstet Gynaecol"},{"key":"pone.0331512.ref049","volume-title":"Standards for improving quality of maternal and newborn care in health facilities","author":"World Health Organization","year":"2016"},{"issue":"2","key":"pone.0331512.ref050","doi-asserted-by":"crossref","first-page":"140","DOI":"10.1111\/1471-0528.17562","article-title":"Determinants of stillbirths in sub-Saharan Africa: A systematic review","volume":"131","author":"A Mukherjee","year":"2024","journal-title":"BJOG"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0331512","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,3]],"date-time":"2025-09-03T17:38:38Z","timestamp":1756921118000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0331512"}},"subtitle":[],"editor":[{"given":"Hale","family":"Teka","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2025,9,3]]},"references-count":50,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2025,9,3]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0331512","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,9,3]]}}}