Health Systems Determinants of Occurrence of Postpartum Hemorrhage Among Women of Reproductive Age 15-49 Years - Kenya

Postpartum hemorrhage constitutes 73% of all the obstetric hemorrhage globally. Thirty-four percent of maternal deaths occurring in Kenya are due to postpartum hemorrhage. In Homa Bay County, postpartum hemorrhage is the leading cause of maternal mortality contributing 38% of all maternal deaths despite several strategies by the ministry of health to reduce occurrence. Previous studies attribute this to poor provision and utilization of essential health services. The possible contextual contribution of health systems determinants of occurrence of postpartum hemorrhage has not been explored in the County. The objective of this study was to establish the health systems determinants of occurrence of postpartum hemorrhage among women of reproductive age 15-49 years in Homa Bay County. The specific objectives were: to identify the quality of health service delivery determinants, and: to describe the human resource for health determinants. This was a cross-sectional study design in which qualitative and quantitative methods were used. The quality health service delivery determinants found statistically significant was level of attention with Pearson chi-square = 5.2872 (P-value = 0.021), while the human resource for health determinants were: change of work stations with Pearson chi-square 6.929 (P-value = 0.008), and increased number of health workers with Pearson chi2(1) = 4.1205 (P-value = 0.042) and skills. The findings have significant importance in constructing and reviewing programs for women of reproductive age focusing on quality service delivery on level of attention, human resource for health change of station, increased number, and skills.


Problem Introduction
Postpartum hemorrhage is a worldwide problem (Maswime & Buchmann, 2017). Postpartum hemorrhage (PPH) is the number one direct cause of maternal mortality and morbidity (WHO, 2014). Globally, 13 million postnatal women experience postpartum hemorrhage, 1.56 million who survive develop severe anemia and 500,000 (34%) (WHO & UNICEF, 2012). In Chinese provinces, postpartum hemorrhage accounts for nearly 50% of all maternal deaths (Kwast, 1991). Postpartum hemorrhage is one of the most serious challenges faced by the international community and that inequality still exists within and between countries in relation to progress in reducing postpartum hemorrhage maternal mortalities and morbidities (Weidert et al., 2013). Low-income countries contribute 99% of all the maternal deaths caused by postpartum hemorrhage (Mousa et al., 2014). Eighty-eight percent of maternal deaths due to postpartum hemorrhage occur within 4 hours of delivery (Kane, 1992). Co-morbidities of postpartum hemorrhage include hypertension pregnancy disorders, unsafe abortions, septic infections, obstructed labor, cervical cancer, breast cancer, diabetes, AIDS, road carnage, anemia, and other causes. In Kenya, postpartum hemorrhage accounts for 34% of all maternal deaths (CGHBC report, 2017).
Maternal deaths are noted to occur more in the rural areas, in poor households or to mothers with no basic awareness of postpartum hemorrhage (WHO, 2015). Many efforts are targeting reducing maternal mortality in Kenya with the main focus on postpartum hemorrhage as the main direct cause of morbidity and mortality among expectant mothers.
In Homa Bay County, postpartum hemorrhage is the leading cause of maternal mortality. Maternal mortality in Homa Bay County is twice the national rate: 583/100,000 versus 362/100,000 live births (KDHS, 2015). Postpartum hemorrhage contributes 38% of all the maternal deaths in Homa Bay County (CGHB Report, 2018) which a 10% increase from 2015. The effect of postpartum hemorrhage in Homa Bay County is high (Felarmine et al., 2016). HIV/AIDS causes immunodeficiency hence severe underlying infections, which exacerbates postpartum hemorrhage. Homa Bay County is also within the malaria-endemic region (58,820 per 100,000 population), which causes a lot of anemia (PIMA, 2017). High poverty level in this county also worsens the situation. According to Economic Survey 2014, Homa Bay County poverty rate was 48.4 percent against the national 36.1 percent (KNBS, 2016).
The main causes of postpartum hemorrhage have been linked to the three delays. First delay is caused by low status, lack of awareness of obstetric complications, nearest healthcare facility is more than 1 km away, uneventful previous home delivery, the family has insufficient money, poor experience of previous health care received at a healthcare facility, perceived poor quality of care at a healthcare facility, avoiding admission and long stay at a healthcare facility (Beck & Grande, 2010). The second delay is caused by inaccessibility of health facility for more than one hour due to long travel time from home to a health facility, cost of transportation, poor road condition or terrain, and visited a traditional healer or traditional birth attendant first. The third delay is caused by long waiting time before treatment is received; more than 30 min from the time of arrival to time of being assessed or receiving treatment, shortage of equipment and supplies, wrong assessment of risk, wrong diagnosis, wrong treatment, shortage of healthcare providers, lack of competence or skills among the available healthcare providers, healthcare provider unavailable, inadequate referral system, ambulances not available, no fuel, breakdown and use of public transport, and lack of treatment guidelines e.g., Pre-eclampsia, postpartum hemorrhage, manual removal of placenta.
Other causes of postpartum hemorrhage include lack of proper equipment, distance, bad roads, indecision, professional negligence, lack of blood and blood products, age, parity, literacy, poverty, abortion, history of stillbirths, anemia and infections (Opon, 2017).

Importance of the Problem
Maternal Postpartum hemorrhage is the leading direct cause of maternal mortality in Homa-Bay County, contributing 38% of all maternal deaths (CGH, 2018). Maternal mortality in Homa Bay County due postpartum hemorrhage moved from 34% to 38% from 2015 to 2017 (DHIS, 2017). In Homa Bay County, maternal mortality is about double the national rate of 583/100,000 compared to 362/100,000 National live births (Agina et al., 2016). Postpartum hemorrhage remains the leading cause of maternal morbidity and mortality despite interventions such as; training of health care workers on basic obstetric care and comprehensive obstetric care, rolling out of universal health coverage, free maternal care, increased health financing through NHIF (Gok, 2011). Integration of health services for the postnatal mothers at community and the health facility levels is also an intervention that is intensified (CHS, 2011). Another intervention that is identified is increasing the number of human resources for health, buying necessary equipment, capacity building and training staff on management postpartum hemorrhage (HSSP, 2017/2022).

Relevant Scholarship
Postpartum hemorrhage is quite an invisible killer and huge menace for the lives of women and families in Homa Bay County common anemia cases, serious underlying conditions and poverty rate (50.6%) due to high prevalence of malaria (27%) and HIV/AIDS (18.6%) (CGHB, 2020). It is a big worry to the health systems and the community as the maternal morbidity and mortality due to postpartum hemorrhage remain high. This study therefore envisions to establish the influences of health system management and give appropriate recommendations informing corrective measures to curb postpartum hemorrhage.

1)
There are no quality health service delivery determinants of occurrence of postpartum hemorrhage among women of reproductive age15−49 years in Homa-Bay County?
2) There are no human resource for health determinants of occurrence of postpartum hemorrhage among women of reproductive age 15−49 years in Homa-Bay County?
International Journal of Social Science Research ISSN 2327-5510 2021

Method
It is composed of the following sub sections.

Identification of Sub Sections
This chapter consists of a study area, research design, study population, target population, sample size, sampling procedure, data collection procedure, data collection instruments, data management and analysis, and ethical consideration.

Participants Characteristics
The study population comprised women of reproductive age 15−49 years in Homa Bay County. The total study population for this study was 46,473 who were women of reproductive age 15−49 years in Homa Bay County. The study target population were the 400 women who delivered at the 12 level 4 public hospitals in Homa Bay County during the months of December, 2019 and January 2020.

Sampling Procedure
The sample size of 400 postnatal women was proportionately allocated per level 4 public hospital in Homa Bay County. Table 1 indicates the way sample respondents were distributed throughout the Homa Bay County. The respondents were identified for a response using random sampling method where postnatal women were considered on first come, first enrolled basis. Only postnatal women who did not consent were skipped for the next postnatal woman. Every consented postnatal woman filled the postnatal woman questionnaire. The other questionnaire was filled by maternity In-Charge, and Matron. Key Informant Interviews (KII) were also conducted involving the 12 Sub County Medical Officers of Health and, the one County Gynecologist for qualitative data.

Sample Size, Power and Precision
The sample size for this study was calculated based on the formula adopted from Cochran's formula (1977) which allows calculation of an ideal sample size for a desired level of precision, confidence level, and estimated proportion of the attribute present in the population. It is considered for large and small populations. The formula is: According to (UNFPA, 2014), 10% of n was added for non-response. 10% of 363 equals 37. The final sample size, taking into account the non-response is 400 postnatal women.
Other participants were the 12 Nursing Officers in-charges, 12 Maternity Officers, 8 Sub County Medical Officers of Health, and One gynecologist.

Measures and Covariates
There were four data collection questionnaires employed: the structured closed-ended questionnaires: Postnatal woman questionnaire, Maternity In-Charge questionnaire, and Matron's questionnaire for collection of quantitative data, and the semi-structured Key Informants Interview questionnaire for collection of qualitative data. Other instruments used were phone recorder, lap top, note book, and a pen.
There were three structured closed-ended questionnaires: Postnatal woman questionnaire, Maternity In-Charge questionnaire, and Matron's questionnaire.
The postnatal woman questionnaire was divided into three main sections as follows: section one targeted the socio-demographic characteristics, section two looked at the health systems. Maternity In-Charge questionnaire looked at the administration of the labor and postnatal ISSN 2327-5510 2021 Wards administration while Matron's questionnaire was concerned with the availability of essential elements for quality obstetrics and gynecological healthcare. Key Informant Interview questionnaire also looked at the socio-demographic determinants, personal health determinants, and health systems determinants of postpartum hemorrhage. The structured questionnaires were administered by the research assistant while Key Informant Interview was carried out by myself. Each of the 12 level 4 public hospitals had one Research Assistant who administered the questionnaire to the postnatal women assigned to each of the hospitals as they were admitted at the postnatal Ward. The process of administration started with the checking of the records at the facility's postnatal Ward register to understand the condition of delivery in reference to occurrence of postpartum hemorrhage. The Research Assistant then follows-up the woman at the postnatal Ward, introduce self, and the purpose of the data collection, seek consent of the woman to administer the tool, and if granted consent, the respondent signs and research assistant moves on and administer the tool. The questionnaires that were correctly completed were analyzed.

International Journal of Social Science Research
This was composed of the Key Informant Interview (KII) questionnaire. The interview guide was used to collect data from healthcare providers through face-to-face interviews. The method was used to explore the health systems determinants of occurrence of postpartum hemorrhage. They were then invited in turns into a prepared interview room set with all the data collection instruments. The Researcher introduced himself, and the purpose for the interview and sought consent of the respondents. All of them consented and each was taken through the questionnaire at own separate time. The Gynecologist was however interviewed virtually since he was on leave in Nairobi at the time of data collection. The Researcher conducted the interview and recorded the proceedings as Research Assistant took notes.

Research Design
The study applied descriptive cross-sectional study design. Qualitative and quantitative methods were used for data collection and analysis. The descriptive study provided information concerning health systems determinants of occurrence of postpartum hemorrhage; quality health service delivery determinants, and human resource for health determinants of occurrence of postpartum hemorrhage among women of reproductive age.

Experimental Manipulations or Interventions
There were two sets of data collected: Quantitative and qualitative data sets. After the recruitment of Research Assistant, the researcher convened a one-day training meeting for the 12 Research Assistants at the Homa Bay County Health Management Team (CHMT) Boardroom on 2nd of December, 2019 from 10.00 am to 3.00 pm. The purpose of this meeting was to install the Comcare application into the phones of the Research Assistants. The second deliverable for meeting was to orientate the Research Assistant on the three questionnaires that they were to administer by going through all the questions. Lastly, each of the 12 Research Assistants was assigned specific level 4 public hospital to collect data from depending on the preference of the Research Assistant. The Research Assistants reported to the various respective health facilities on 3rd December, 2019, paying courtesy call at the Hospital Medical Superintendents, before proceeding to the postnatal Ward where again they reported to the Ward In-Charge for permission to conduct the data collection and access to the records of the women delivering at the health facilities.
The first respondent was the first woman who arrived immediately in the postnatal ward immediately the Research Assistant arrived at the postnatal ward. The Research Assistant did the exercise every day until the last respondent as per the proportion assigned the health facility. The Research Assistants were able to interview 400 postnatal women by 28th December, 2019. During the data collection period, the Researcher, convened virtual meeting with the Research Assistants for updates and review of the progress and resolution of any matters arising from the field.
In between the days, the Research Assistants interviewed the facility Matron's and the Maternity In-charge.

Results
This chapter deals with data analysis of the of the frequency and percentage distribution of the respondents and study results which were to establish the influences of health system management on occurrence of postpartum hemorrhage among women of reproductive age in Homa Bay County, Kenya. The analysis was done based on the research objectives which were to identify the quality health service delivery determinants of occurrence of postpartum hemorrhage among women of reproductive age; and to describe the human resource for health determinants of occurrence of postpartum hemorrhage among women of reproductive age. Quantitative data was collected using structured questionnaire administered on the postnatal women, and maternity in-charges, while qualitative data was collected using key informant interview of the Sub County Medical Officers of Health and the County Gynecologist as key informants and finally, the facility assessment checklist was done. Determinants are quality health service delivery, and human resource for health.

Recruitment
Data collection was done at the level four hospitals. The twelve Research Assistants who were required to have smart phone compatible with Comcare application, at least Diploma in Health-related course, and be ready to be engaged full time during the month of December, 2019. The Researcher oriented the Research Assistants, and installed them the Comcare application, and assigned the Research Assistants the hospitals to collect the data. Every day, the researcher held meeting with the Research Assistants for updates and progress assessment. After the structured questionnaires were done, the Researcher conducted Key Informant Interview which took place during the month of January, 2020. One research Assistant helped with notetaking during the Key Informant Interview.

Statistics and Data analysis
Quantitative data were collected, stored in password-protected laptops, processed through data editing and coding. Qualitative data was collected through recording and notetaking. This was stored in a password protected laptop as audio recording. The notes taken were also filed. After that, the audio recording was replayed and discussion captured according to the International Journal of Social Science Research ISSN 2327-5510 2021 objectives. Thematic approach was employed in analysis of the qualitative data.

Ancillary Analyses
This was conducted in order to test whether the questionnaire was valid. It was carried out at Kisumu County Hospital which is a level 4 public hospital. The pilot study achieved 4 respondents from the facility each filling one questionnaire. The researcher analyzed the data and determined whether the research tools used would lead to the achievement of the research objectives. The pre-test findings were used to modify the content, question structure, and sequencing of the questionnaire for example, it was realized that Key Informant Interview questionnaire needed restructuring for the interviewees to give appropriate response. On postnatal woman questionnaire, it was also realized that there was different interpretation on the question on "when was your last birth" where some understood it to mean, the current birth. The pre-test findings however were not included in the statistics of the main study.

Baseline Data (Frequency and Percentage Distribution of the Respondents)
This section looks at the distribution of respondents per facility, age distribution, education level, marital status, place of residence, type of house, house ownership and monthly income, employment status, partner occupation.

Statistics and Data Analysis
The four hundred respondents were all female and were distributed in the percentage proportion of the monthly skilled deliveries. Homa Bay County level 4 had the majority of respondents 106(26.5%) followed by Rachuonyo South level 4 hospitals with 72 (18%). Kisegi level 4 hospital, and Nyang'iela level 4 hospital were the least with 6 (1.4%) and 10 (2.5%) respectively.  ISSN 2327-5510 2021 The respondents were grouped into years with an interval of 5 according to the common WHO grouping in monitoring and evaluation of health systems on health outcomes. Majority of the respondents 197 (46.4%) were between ages 15−24 years. Those participants who were above 35 years old were a paltry 35 (8.3%). The age 40−44 years were the least 6 (1.5%). The respondents who were between ages 15−19 years were 79 (18.6%). This is an indication of high teenage pregnancy in the County. The study found out that college and university school leavers were only 51 (12.7%). This implies that most of the women in Homa Bay County drop out of school before attaining tertiary education. There were 89 (22.2%) respondents who had no spouses. These were either single, widowed, or separated. Majority 311 (77.8%) of the respondents had spouses.  ISSN 2327-5510 2021 The study showed that 308 (76.9%) respondents live in the rural. This implies that most the population in Homa Bay County are living in the rural areas. There were 287 (71.8%) of the respondents who lived in a semi-permanent house. Only 113 (28.2%) respondents lived in a permanent house. This implied that majority of the respondents had low economic status. The research shows that majority 268 (67.1%) of the respondents owned houses. However, 20 (5%) were either in the parents' house or relatives' house.   The study revealed that most of the partners of the respondents 172 (43.1%) were self-employed. Those working as casuals were 91 (22.9%) while unemployed partners were 69 (17.3%). This confirms the high rate of unemployment as seen earlier in the table of employment status of the respondents.

Adverse Events: Health Systems Factors Influencing Occurrence of Postpartum Hemorrhage
According to the study, the women who were satisfied that personnel number and infrastructure level at the facility influenced occurrence of postpartum hemorrhage were 268 (63.2%) and 347 (81.9%) respectively. However, only 267 (63%) were satisfied that cost of services at the very facilities influenced postpartum hemorrhage while 287 (67.7%) were ISSN 2327-5510 2021 satisfied that accessibility of the services was influencing postpartum hemorrhage. Those who were not satisfied with supervision by senior health officers as influencing occurrence of postpartum hemorrhage were 33 (7.7%) of the participants but 176 (41.5%) indicated that assessment frequency of service delivery in such facilities was most frequently (>80%) an influencer of occurrence of postpartum hemorrhage. This section looked at the level of attention, change of work stations, and increased number of health workers. Skills is also looked into under KII.

Influence of Level of Attention on Occurrence of Postpartum Hemorrhage
In terms of quality of health care services, level of attention given to the postnatal woman was statistically significant with Pearson Chi-square 5.28 (P-value = 0.021). Satisfaction with personnel number was statistically insignificant. Other aspects of quality such as communication, attitude, efficiency, quality of treatment, and duration of time taken were found to be statistically insignificant. In this regard, it is important for health care workers to give quality time for an eye-to-eye contact with the patients while attending to them. This means that the issue of discharging the queues should be resolved.

Influence of Change of Work Station on Occurrence of Postpartum Hemorrhage
Change of work station by human resource for health was found to be of great statistical significance in influencing occurrence of postpartum hemorrhage with Pearson chi-square 6.929 (p value = 0.008). This implies that frequent transfers should be avoided because every time the health worker is finding a bearing if the transfers are too frequent.  ISSN 2327-5510 2021 Hemorrhage Increasing number of health care workers was also found to be statistically significant with Pearson Chi-square 4.12 (P-Value = 0.042). As required by WHO, the leadership and governance of our health systems should optimize the number of health care workers. the study found out that the lower the satisfaction with personnel number, the more likely occurrence of postpartum hemorrhage. Personnel number dissatisfaction had 5.5 times likelihood of experiencing postpartum hemorrhage. Interestingly, indecision on satisfaction with number of personnel had a bearing on occurrence of postpartum hemorrhage contributing 50% reduction of occurrence of postpartum hemorrhage among unsatisfied postnatal women.

Skills of human resource for health was however statistically insignificant with Pearson
Chi-square (P-Value = 0.364) however this factor was identified under the KIIs, participant KII01 observed, "Availability of Trained Personnel who can help in managing cases……is crucial and within the County, it will take us back to the availability of skills". Skills of human resource for health in preventing the occurrence of postpartum hemorrhage among women of reproductive age in different facilities are captured in the following excerpts from KIIs: "In my facility, there is an improvement. Initially, we lacked skilled staffs but now we have 2 doctors." Participant KII01 said that "3rd delay involves finding someone with incompetency in diagnosis".

And,
KII04 "If you lack skilled personnel then PPH will be likely to occur. This results to bad outcomes in our facilities as compared to the well-stocked facilities. Instrument availability comes in handy". ISSN 2327-5510 2021 KII06 also indicated that "Limited Skills of the health care provider can lead to PPH. Late referrals of mothers to facilities is also a major contributing factor".

International Journal of Social Science Research
There are some health care providers who also had a diverse opinion on the human resource skills on preventing the occurrence of postpartum hemorrhage among women of reproductive age in different facilities. An example is a medical doctor who said, "The strength is still weak and we really need to do a lot".
Other aspects of quality such as communication, attitude, efficiency, quality of treatment, and duration of time taken were found to be statistically insignificant.
However, 66.7% of those who experience postpartum hemorrhage were satisfied that personnel number influenced to a high extent the occurrence of postpartum hemorrhage compared to only 37.2% unsatisfied with personnel number who did not experience postpartum hemorrhage. Those who experienced postpartum hemorrhage believed that special skills influence only to a small extent the occurrence of postpartum hemorrhage were 52.4%. Influence of job satisfaction, 66.7% of those who experience postpartum hemorrhage said that it moderately influences occurrence postpartum hemorrhage. Leadership factors such as accessibility to services, infrastructure, assistance frequency, satisfaction with supervision, and frequency of assessment were all found to be statistically insignificant. However, from key informant interview, accessibility of services, assistance frequency, and frequency of assessment were important factors. Participant KII02 observed that, "Postpartum hemorrhage occurs due to late recognition and diagnosis of risk factors".
The interviewee continued, "TBA's equally determine this occurrence due to the time taken before response that results to multiple complications" And the other, "2nd delays arise in delays in attending to her by the healthcare worker due to limited staffs" KII01.

Discussion
According to this study, effectiveness of quality health service delivery had relation to experiencing postpartum hemorrhage by Remya (2010). There was a significant improvement in the health status of mothers with postpartum hemorrhage. Similarly, Quality management of postpartum hemorrhage is attainable only with highly skilled health personnel (Kosińska et al., 2016).
The findings of this study reveal that changing work stations very frequently has got great statistically significant influence on occurrence of postpartum hemorrhage. Increasing the number of human resource for health was equally of statistical significance. This finding is indeed in support of the recommendations of the World Health Organization that sets an optimum number of health care workers in every cadre for quality service delivery. This ISSN 2327-5510 2021 assertion is also confirmed in this study where those dissatisfied with the number of health personnel are 5.5 times more likely to experience occurrence of postpartum hemorrhage. In terms of quality of health care services, level of attention given to the postnatal woman was statistically significant with Pearson Chi-square 5.28 (P-value = 0.021).

Recommendations
This chapter gives recommendations according to the findings of this research. It also proposes the new research model for desirable outcomes.
According to the study result, availability and accessibility of medicines and technologies was statistically significant, therefore the stakeholders are encouraged to make arrangements to provide adequate medicines and technologies. The study recommendation is that the stakeholders should improve systems to improve accessibility of health care facilities Work load should be optimum.
Collectively, accessibility of quality service delivery, supervision by human resource for health, adequate and availability of medical and technologies, efficient nursing services, and rational work load at work place collectively influence occurrence of postpartum hemorrhage. accessibility of health care facility is key in preventing occurrence of postpartum hemorrhage. Level of attention was found important factor. This means that improving one factor and leaving the other will not reduce occurrence of postpartum hemorrhage. It is therefore important to stakeholders to have improvement of health system management comprising of these factors.
Changing work station should be regulated and not done frequently. This study recommends that the posting orders should be within three years and five years. Increasing health workers was also found to be a statistically significant and therefore there should be optimum number of health care workers. As reported in the key informant interview, skills in human resource is essential for prevention of occurrence of postpartum hemorrhage. This study therefore recommends that capacity building of health personnel should be prioritized. ISSN 2327-5510 2021

Acknowledgment
My gratitude goes to Dr. Charles Angira as the head supervisor for providing leadership that made the whole team work together harmoniously. He gave me all his time and he was always ready for consultation however late. Thank you. I thank Dr Jane Owenga for her unequivocal support and push to see me move forward. She ensured that I progress by holding up my hands when I was almost losing faith in myself and continued to encourage me not to relent. Dr Japheth Ogenda, was insightful and resolved to see this work thoroughly done by coaching me even in his own house and always challenged my feelings and stood firm to ensure I remained focused, and true to the work even in tough situations. I thank my supervisors for spending long hours reading and correcting my work back and forth without giving up on me. I thank Dr George Ayodo too for nurturing me through the concept that gave birth to this study. I also thank my research assistants who collected the data. I owe them this work because without them this research would not be at this stage. My colleague students critiqued my work and their suggestions shaped this work. Finally, I sincerely thank the Almighty God for giving me life, the energy, and resources to undertake this course. 356−365. https://doi.org /10.1109/TMM.2003.822796 Asamoah, B. O., Moussa, K. M., Stafström, M., & Musinguzi, G. (2011. Distribution of causes of maternal mortality among different socio-demographic groups in Ghana: A descriptive study. BMC Public Health, 11(1), 159. https://doi.org/10.1186/1471-2458 Bale, J. R., Stoll, B. J., & Lucas, A. O. (2003). Reducing maternal mortality and morbidity. BANK, W. (2006). Oral misoprostol in preventing postpartum haemorrhage in resource-poor communities: a randomised controlled trial. The Lancet, 368 (9543)  discussion is voluntary ad any response given to the question will be treated with confidentiality. Thank you for taking the time to participate in this study.
By signing this form, I understand the conditions and willingly participate in the research as indicated above.  11. The following statements are descriptive of leadership and governance in health facilities during the time of your delivery. Using 5 = Very satisfied, 4 = Satisfied, 3 = Undecided, 2 = Unsatisfied, 1 = Very unsatisfied). Please indicate by ticking (√) in the applicable box the extent to which you are satisfied that leadership and governance in this facility have impacted the following entities to reduce the occurrence of postpartum hemorrhage in this facility. The way health care workers communicate with their clients The perception of the wrong attitude of the health care workers towards their clients The efficiency of health care workers providing services The level of attention given to the clients by health care workers Treatment given without any instruction Lack of room/time to for postnatal mothers to ask questions Jumping of queues by known or well-to-do patients postnatal mothers Time/Duration taken before attendance to postnatal mothers Special skills and experience Privacy for postnatal mothers Special practices Change of working stations Increased number of healthcare workers Job dissatisfaction by health workers International Journal of Social Science Research ISSN 2327-5510 2021