CHAPTER TWO: LITERATURE REVIEW

2.0 Introduction This chapter presents a comprehensive review of relevant literature on the topic
entitled: “Assessment on the Attitude of Midwives Toward Management of Danger Associated with
Postpartum Hemorrhage Among Women in Gynecology Unit.” The review covers conceptual,
theoretical, and empirical studies, highlighting key issues, gaps, and the rationale for the study.

2.1 Conceptual Review This conceptual review is structured in line with the objectives of the study,
focusing on midwives’ attitudes, dangers associated with postpartum hemorrhage, and preventive
measures in the gynecology unit.

Concept of Postpartum Hemorrhage (PPH) Postpartum hemorrhage (PPH) is defined as blood loss of 500
ml or more following vaginal delivery or 1000 ml or more following cesarean section within the first 24
hours after birth. It is classified into primary PPH, which occurs within 24 hours, and secondary PPH,
which occurs from 24 hours to six weeks postpartum. PPH remains a leading cause of maternal mortality
globally and in Nigeria, accounting for a significant proportion of preventable maternal deaths. The
major causes of PPH are commonly described using the “four Ts”: uterine atony (tone), retained
placental tissue (tissue), genital tract trauma (trauma), and coagulation disorders (thrombin).

Concept of Attitude of Midwives Toward PPH Management (Objective One) Attitude refers to the
predisposition of midwives to respond positively or negatively toward the recognition and management
of postpartum hemorrhage. It encompasses cognitive components (knowledge and beliefs), affective
components (feelings and perceptions), and behavioral components (readiness and willingness to act).
In the gynecology unit, a midwife’s attitude influences early detection of excessive bleeding, prompt
initiation of first-line interventions, adherence to standard protocols, and timely referral. Positive
attitudes are associated with vigilance, confidence, and effective teamwork, whereas negative attitudes
may result in delays, poor decision-making, and increased maternal risk.

Concept of Dangers Associated with Postpartum Hemorrhage (Objective Two) Postpartum hemorrhage
is associated with several life-threatening dangers if not promptly managed. These include hypovolemic
shock, severe anemia, coagulopathy, acute renal failure, organ dysfunction, hysterectomy, psychological
trauma, and maternal death. The rapid progression of PPH makes early recognition and immediate
response critical. In low-resource settings such as many Nigerian health facilities, these dangers are
often worsened by delayed referral, inadequate blood transfusion services, and limited emergency
obstetric care.

Concept of Preventive Measures for PPH (Objective Three) Preventive measures for postpartum
hemorrhage focus on reducing its occurrence and severity. These include antenatal risk assessment,
skilled birth attendance, and the Active Management of the Third Stage of Labour (AMTSL), which
involves the routine use of uterotonic drugs, controlled cord traction, and uterine massage after
delivery. Other preventive strategies include continuous monitoring of vital signs, early identification of
abnormal bleeding, availability of emergency drugs and equipment, and adherence to institutional
guidelines. Midwives play a central role in implementing these preventive measures, and their attitudes
significantly influence compliance and effectiveness.

Gynecology Unit Context The gynecology unit serves as the primary setting for intrapartum and
postpartum care, where midwives are the first-line providers responsible for preventing, identifying, and
managing PPH. The unit’s functionality, availability of resources, staffing levels, and supportive
supervision directly influence midwives’ attitudes and their ability to manage postpartum hemorrhage
effectively.

2.2 Theoretical Review Health Belief Model (HBM) The Health Belief Model (HBM) provides the
theoretical framework for this study. The model explains health-related behaviors by examining
individuals’ beliefs, perceptions, and attitudes toward a health condition and its management.

Key Components of the Health Belief Model: Perceived Susceptibility – the midwife’s perception of the
likelihood that postpartum hemorrhage may occur among women under her care. Perceived Severity –
beliefs regarding the seriousness of PPH and its potential consequences, including maternal morbidity
and mortality. Perceived Benefits – beliefs about the effectiveness of preventive measures and
emergency interventions in reducing the risks associated with PPH. Perceived Barriers – perceived
obstacles to effective management, such as inadequate supplies, heavy workload, lack of training, or
institutional constraints. Cues to Action – internal or external factors that trigger prompt action,
including clinical guidelines, emergency drills, supervision, and previous experiences with PPH cases.
Self-Efficacy – the midwife’s confidence in her ability to successfully prevent and manage PPH.

Application of the Theory to the Study The Health Belief Model is applicable to this study because
midwives’ attitudes toward the management of PPH are shaped by their beliefs about the condition and
their confidence in handling it. Midwives who perceive PPH as a serious and likely complication (high
perceived susceptibility and severity) are more likely to take preventive actions and respond promptly
during emergencies. When perceived benefits of intervention outweigh perceived barriers, midwives are
more inclined to adhere to recommended guidelines. Cues to action such as training, protocols, and
supervision further reinforce positive behaviors, while self-efficacy enhances competence and timely
decision-making. Therefore, the HBM provides a suitable framework for understanding how attitudes
influence midwives’ management of dangers associated with postpartum hemorrhage.

2.3 Empirical Review The empirical review is organized in line with the specific objectives of the study,
focusing on midwives’ attitudes, dangers associated with postpartum hemorrhage, and preventive
measures in the gynecology unit.
2.3.1 Empirical Studies on Midwives’ Attitudes Toward PPH Management

Several empirical studies have shown that midwives’ attitudes significantly influence the management of
postpartum hemorrhage. Studies conducted in low- and middle-income countries indicate that
midwives who receive regular in-service training and emergency obstetric care education demonstrate
more positive attitudes, improved confidence, and better responsiveness to PPH cases (Wake & Wogie,
2020; Ramadhani et al., 2020).

Conversely, negative attitudes among midwives have been associated with inadequate training, fear of
complications, heavy workload, and lack of institutional support, which often lead to delayed
recognition and poor initial management of PPH (Mamakou et al., 2020).

2.3.2 Empirical Evidence on Dangers Associated with Postpartum Hemorrhage

Empirical evidence indicates that postpartum hemorrhage is associated with severe maternal
complications, including hypovolemic shock, severe anemia, coagulopathy, acute renal failure,
hysterectomy, and maternal death (Sharma & Dhakal, 2018; Wei et al., 2020).

Global studies further report that delayed intervention and weak referral systems significantly increase
the severity of these dangers, especially in low-resource settings (World Health Organization [WHO],
2018). Clinical evidence also shows that most PPH-related deaths are preventable with timely and
appropriate management (ACOG, 2017).

2.3.3 Empirical Studies on Preventive Measures for PPH

Studies have consistently demonstrated that adherence to preventive measures, particularly the Active
Management of the Third Stage of Labour (AMTSL), significantly reduces the incidence and severity of
postpartum hemorrhage (WHO, 2018).

Evidence from midwife-led care models suggests that skilled midwifery practice can avert a substantial
proportion of maternal deaths related to PPH (Renfrew et al., 2014). Additionally, simulation-based
training and emergency drills have been shown to improve midwives’ confidence, response time, and
decision-making during obstetric emergencies (Voillequin et al., 2022).

2.3.4 Consequences of Poor Management of PPH Delayed or poor management leads to severe
outcomes such as shock, coagulopathy, renal failure, hysterectomy, and maternal death. Empirical
studies emphasize that most PPH-related deaths are preventable with prompt recognition, effective
intervention, and timely referral.

2.3.5 The Role of Training and Simulations Simulation drills and emergency obstetric care training
significantly improve midwives’ confidence, response time, and decision-making ability. Facilities that
routinely conduct drills report improved management efficiency and reduced maternal mortality.

2.4 Synthesis and Link to Objectives

- Midwives’ attitudes influence both preventive and emergency actions.

- Facility readiness shapes midwives’ perception of barriers, affecting attitude.

- Training improves knowledge, attitude, and adherence to protocols.

- Proper management significantly reduces PPH complications.

These findings support the objectives of the study by confirming the relevance of assessing midwives’
attitudes, identifying dangers associated with PPH, and evaluating preventive measures.

2.5 Gaps in Literature

Existing literature reveals gaps such as:

1. Limited facility-level studies targeting specific gynecology units.

2. Insufficient studies linking attitude scores directly with management practices.

3. Outdated local evidence on adherence to AMTSL and preventive measures.

4. Lack of qualitative insights explaining why midwives act or respond in certain ways during
emergencies.

This study aims to address these gaps by focusing specifically on midwives in the gynecology unit and
examining their attitudes toward PPH management.

2.6 Summary

This chapter reviewed conceptual issues regarding PPH, midwives’ attitudes, and management
strategies. The Health Belief Model provided a theoretical foundation. Empirical studies demonstrated
the crucial relationship between midwives’ attitudes, training, facility readiness, and maternal
outcomes. Identified gaps justify the need for this study.

Reference
American College of Obstetricians and Gynecologists. (2017). Practice bulletin No. 183: Postpartum
hemorrhage. Obstetrics & Gynecology, 130(4), e168–e186.
[Link]

Mamakou, X., Papagiannopoulou, P., & Koulouris, G. (2020). Midwives’ roles and challenges in the
management of postpartum hemorrhage. International Journal of Caring Sciences, 13(2), 1231–1238.

Ramadhani, F., Mbekenga, C., & Christensson, K. (2020). Factors influencing midwives’ preparedness in
managing postpartum hemorrhage in low-resource settings. BMC Pregnancy and Childbirth, 20(1), 1–9.
[Link]

Renfrew, M. J., McFadden, A., Bastos, M. H., Campbell, J., Channon, A. A., Cheung, N. F., Silva, D. R. A. D.,
Downe, S., Kennedy, H. P., Malata, A., McCormick, F., Wick, L., & Declercq, E. (2014). Midwifery and
quality maternal and newborn care. The Lancet, 384(9948), 1129–1145. [Link]
6736(14)60789-3

Sharma, S., & Dhakal, I. (2018). Postpartum hemorrhage: Incidence, risk factors, and outcomes in low-
resource settings. International Journal of Gynecology & Obstetrics, 143(1), 52–57.
[Link]

Voillequin, C., Dupont, C., & Deneux-Tharaux, C. (2022). Impact of simulation-based training on
healthcare professionals’ management of postpartum hemorrhage. BMC Pregnancy and Childbirth,
22(1), 1–9. [Link]

Wake, A. D., & Wogie, A. G. (2020). Assessment of midwives’ knowledge and practice in the
management of postpartum hemorrhage. BMC Pregnancy and Childbirth, 20(1), 1–7.
[Link]

Wei, Q., Zhang, L., Xu, J., & Li, X. (2020). Incidence and maternal outcomes of postpartum hemorrhage in
hospital-based deliveries. BMC Pregnancy and Childbirth, 20(1), 1–8. [Link]
020-02954-2

World Health Organization. (2018). WHO recommendations for the prevention and treatment of
postpartum haemorrhage. World Health Organization.