The report from the lab showed a hemoglobin of 1.5 g/dL, and a glance at her pallid conjunctiva corroborated the grim results.
Earlier that day the young woman had given birth to a healthy baby boy at a district hospital in southern Malawi, but despite the work of the clinical officers, she had continued to bleed. They carefully examined her for lacerations and oversewed large tears from the difficult labor. They massaged the uterus and administered medications to encourage it to contract. And when she continued to hemorrhage, they returned to the operating theater where they performed a hysterectomy. Each of these maneuvers failed to quell her bleeding, and in desperation they moved her to an ambulance to be rushed to the tertiary referral center several hours away.
She arrived in the early morning, and she was met by a team of clinical officer interns led by an obstetrics registrar. Labs were sent while she was examined and packed to stave off further bleeding. Though the gauze was then removed to allow for examination, the bleeding continued and she was quickly repacked. It was around that time that we met — she talking, sitting on her chitenge in a small but fresh puddle of blood that had accumulated during the examination, me holding results showing a gravely low hemoglobin level.
The operating theater was mobilized while the registrar stayed with her to place anti-shock garments and prepare to move her to the holding area. I went to “chase” blood. The term was widely used when accomplishing tasks, and every day we “chased” labs, “chased” blood, and “chased” imaging. The most fruitless of these races always seemed to be those involving blood products. After about an hour and significant negotiation with the workers in the blood bank, I was to able leave carrying two units of plasma and the last two units of compatible whole blood in the bank.
As we waited for the operating room to be available, we transfused the blood and plasma. Once in the room, examination revealed large and complex lacerations throughout the vagina that were painstakingly repaired. Coagulopathy resulted in continued oozing from the repaired surfaces, however no additional products were available from the blood bank. Once again we packed the wound until it was hemostatic, then moved her to the high dependency unit.
Both the hospital and the regional blood banks were empty of compatible whole blood and empty of plasma. This was not a new scenario: for the past few weeks we had cancelled elective cases and watched helplessly as anemic patients deteriorated without transfusion. Several days prior we had been forced to perform a cesarean section on a patient with a hemoglobin of 3.5 g/dL, her uterus and intestines nearly white, later placing her to recover in a bed next to a septic patient with hemoglobin around 2 g/dL.
The World Health Organization cites post-partum hemorrhage (PPH) as the leading cause of maternal mortality worldwide, with Africa carrying a prevalence rate of PPH at 10.5%. Despite the dramatic mortality rates, recruiting blood donors remains a challenge. For many elective cases, medical facilities require blood donation from a family member or guardian before operation in order to increase their overall supply. This is able to replenish some volume, particularly in more remote districts, however some poor regions are limited in their abilities to test these samples thoroughly for HIV and other infectious diseases. Additional blood donation is difficult to come by, as even negative donors are hesitant to undergo screening for HIV and sexually transmitted infections. A significant portion of the population is ineligible to donate, whether due to age, anemia, or infection, and concern that blood donation would permanently rob the donor of their own needed blood remains common.
In the face of these challenges, blood banks continue to work to obtain donations at schools, churches, and other public events. But the supply of blood continues, itself, to be anemic. While organizations educate regarding the importance of donation, we should also fight for more aggressive hemorrhage prevention strategies and innovation in low-resource cell-saving technology to assuage the continued need. For while we do, patients bleed.