The Experiences of Handling Postpartum Hemorrhage According To Various Perspectives: A Scoping Review

One leading cause of maternal mortality and morbidity is postpartum hemorrhage (PPH). When postpartum hemorrhage is not appropriately treated, shock and loss of consciousness can occur due to a large amount of blood coming out. It causes impaired blood circulation throughout the body and can cause severe hypovolemia. If this happens, it could result in the mother not being saved. Reducing deaths from postpartum hemorrhage is a challenge that must be undertaken by mothers, families or partners, service providers, and health workers. Research Objectives: to review research results from the experience of postpartum hemorrhage management according to various perspectives. The scope of this review uses the PRISMA ScR framework with article searches using four databases, namely Pubmed, ScienceDirect, Wiley, and EBSCO. The data obtained was carried out Critical Appraisal Using The Joanna Briggs Institute (JBI). Based on the search for articles from the 3,032 that had been selected, eight articles met the inclusion criteria. This review found three main themes: knowledge of postpartum haemorrhage (PPH) and prevention and treatment of PPH. Early detection of at-risk women, regular ANC, empowering women and villagers, the importance of seeing a midwife at least once while pregnant, carrying out treatment, and referrals are important so that postpartum hemorrhage is handled immediately


INTRODUCTION
Postpartum hemorrhage (PPH) is a significant maternal health problem and causes death. As many as 140,000 women die every year, or every 4 minutes, there is one death due to postpartum hemorrhage. In the world. (Wormer et al., 2022). Globally about 1-6% PPH epidemiology of all deliveries. The leading cause of maternal death is postpartum hemorrhage, which occurs 94% of the time during childbirth and is most common in low-and middleincome countries. The cause of PPH is 10-20% due to lacerations or incisions, 80-90% originating from the uterus, and <1% due to coagulopathy disorders (James et al., 2022). According to WHO 2015, there are 14 million (11.4%) mothers in the world who suffer from PPH, while in developing countries, every year, it reaches 60% in 100 thousand maternal deaths; due to poor management of the third stage of labor, mothers lose a lot of blood. In 2020 in Indonesia, there were 1,330 cases of maternal death caused by bleeding (Profil-Kesehatan-Indonesia-Tahun-2020, n.d.).
Pregnant women who experience complications in pregnancy will be more at risk of PPH. PPH occurs suddenly; in less than 1 hour, a mother will experience death. Three delays caused this condition of death: late in making decisions, late arrival at the referral site, and late receiving appropriate care at a health facility (Kemenkes RI, 2011).
Prevention efforts that can be done are active management of the third stage in every delivery are routinely carrying out antenatal care so that health workers can detect abnormalities early or consider risk factors during pregnancy. Preparing for appropriate delivery if the mother has a history of delivery with previous postpartum hemorrhage and has a rare blood type or bleeding disorder. Pregnant women must avoid risk factors that can trigger bleeding, such as anemia, preeclampsia, obsession, and high cholesterol levels (Vander Meulen et al., 2019).
The researcher's scoping review question is, "How does the experience of dealing with postpartum hemorrhage according to various perspectives?" based on the SPIDER framework mentioned above. Sample (S) is mothers with a history of postpartum hemorrhage, or ealth workers, traditional birth attendants, who had handled postpartum. Phenomenon of interest (P) is postpartum hemorrhage. Design is descriptive phenomenology. Evaluation is experiences. Research type is qualitative.

METHODS
The researcher used the PRISMA-ScR checklist protocol, with framework SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type). Sample: Mothers who have a history of postpartum hemorrhage, health workers/health workers and traditional birth attendants who have handled postpartum hemorrhage. Phenomenon of Interest: Post partum bleeding, Design uses descriptive, Phenomenology, Evaluation: experience and Research type: qualitative.
In selecting relevant articles, the researcher determined the inclusion and exclusion criteria. Inclusion criteria is original research article, published in 2012 -2023, English research articles, full-text articles, documents/reports from WHO/other official organizations, research articles using qualitative research methods and relevant articles regarding experiences with postpartum hemorrhage. Exclusion criteria is opinion papers, article that discusses postpartum hemorrhage with congenital blood disorders. The search strategy aims to find published studies by clinical trials, peer review, and gray literature. The reference management software used was Zotero, for selecting articles that allows to check for duplicates, choose titles and abstracts, and read the full text. The flowchart Preferred Reporting Items for Systematic Reviews and Metaanalyses (PRISMA) describes the findings of the number of articles and the filter process (Tricco et al., 2018) as Figure 1.
After filtering the data, Critical Appraisal was carried out to assess the quality of the article both from a methodological point of view and the extent to which the research discussed possible biases in design. Implementation and analysis used the Joana Briggs Checklist. 8 articles were carried out by Critical Appraisal using a qualitative research design. The following are the results of the Critical Appraisal conducted by researchers:  Qualitative with a phenomenological approach 1. This research was conducted between April and June 2012. 2. Respondents were taken purposively 3. Six women who gave birth at home in the previous year 4. Nine midwives. 5. In-depth interviews do data collection Postpartum bleeding is a natural cleansing process that, if interrupted or inhibited, causes the mother's health may suffer. Respondents used a variety of indicators to identify PPH, including blood flow velocity, the volume of blood (equivalent to two fists), fainting, feeling dehydrated, fainting, or loss of consciousness soon after birth. Respondents appear to recognize PPHat-risk women (those with multiple pregnancies, high parity, or protracted labor) correctly, but many do not understand all the causes. Respondents treated PPH with cold beverages, uterine massage, and traditional medicine. Participants reported several modifiable problems when managing primary postpartum hemorrhage, and due to limited resources, they were all connected to delays in receiving appropriate and high-quality care. 5 sub-themes were identified: 'workforce,' 'communication problems among healthcare providers,"systemic problems,' 'education, training, and resource issues,' and 'lack of identification and referral.
Is there congruity between the research methodology and the research question or objectives?
Is there congruity between the research methodology and the methods used to collect data?
Is there congruity between the research methodology and the representation and analysis of data?
Is there congruity between the research methodology and the interpretation of results?
Is there a statement locating the researcher culturally or theoretically?
Is the influence of the researcher on the research, and vice-versa, addressed?
Are participants, and their voices, adequately represented?
Is the research ethical according to current criteria or, for recent studies, and is there evidence of ethical approval by an appropriate body?
Do the conclusions drawn in the research report flow from the analysis or interpretation of the data?

Selection of Sources of Evidence
Zotero was used to conduct a screening based on the results of keyword searches conducted in four databases through the SPIDER framework. A Prisma Flow Chart was used to describe the stages of article screening. Eight articles were obtained that were considered to meet the inclusion criteria and were appropriate assessments by conducting a Critical Appraisal using The Joanna Briggs Institute (JBI) (Peters et al., 2015).
Of the eight articles obtained, all used a qualitative research design, JBI critical appraisal tools were used to assess the quality of studies, and all studies deserved inclusion.

Characteristics Of Sources Of Evidence
Various characteristics of the eight articles have been selected, including characteristics based on continent, Country, design and research methods, and article grade.

a. Characteristics of Articles Based on Continent
Articles obtained from the selection results based on continents include 4 articles from the African continent, 3 from the European continent and 1 from the American continent.

Critical Appraisal Within Sources of Evidence
This review's scoping included eight articles that used qualitative studies. The critical appraisal results for eight articles were obtained, with the answer "YES" to all Joanna Briggs Critical Appraisal Tools (JBI) question items answered perfectly. Additionally, this article has the benefit of having its data sources, including samples, data collection techniques, sampling techniques, and instruments, so that the error rate can be kept to a minimum (Peters et al., 2015).

Result of Individual Sources of Evidence
The following are a few of the themes that emerged from the researcher's Scoping Review:

Synthesis of Evidence
Several articles were obtained based on the review results of 8 articles following the scoping review's purpose that discussed the theme of knowledge about PPH, prevention of PPH, and handling of PPH.
a. Knowledge of PPH Article [1] is the first article that defines PPH. In article 1, it is explained that vaginal bleeding is a common occurrence after giving birth. Even cleaners consider it normal, and every woman hopes for blood loss. Excessive vaginal bleeding after delivery, Respondents frequently discuss measuring the rate or speed of blood flow, whether they should often change their pads, or the expulsion of blood clots (Ononge et al., 2016a). Article [2] defines postpartum hemorrhage as more than 500 ml of blood lost in the first hour following delivery., which fits the WHO-recommended definition. (Bazirete et al., 2020).In article (4), PPH is defined as when a woman loses 1000 ml or if she jerks, Her legs are covered in blood, and the towels and pads get wet (Briley et al., 2021). Article (8) defines PPH as a blood loss of 500 cc (Kimberly et al., 2012).

1) Early detection of women at risk
In article (1), Despite being aware of several risk factors, respondents reported difficulty identifying which women are more likely to experience PPH. They associated a lot of bleeding with giving birth to more than five children; Retained placenta, pre-delivery bleeding, protracted labor, multiple pregnancies, and pregnancy anemia were additional risk factors mentioned. Retained placenta, pre-delivery bleeding, prolonged labor, multiple pregnancies, and pregnancy anemia were other risk factors mentioned (Ononge et al., 2016a).
(2) explained that the risk factors are listed as not using a method of family planning that prevents frequent pregnancies, a history of PPH, a retained placenta, and tearing or trauma to the genital organs. The woman's family members and medical professionals agreed that poverty and malnutrition put women at risk for PPH because a pregnant woman who eats poorly or does not eat a balanced diet may have postpartum haemorrhage. (Bazirete et al., 2020).
Article (5) explains that women with complicated deliveries are at risk for PPH (Dunning et al., 2016).

2) Antenatal Care
Article (4) states the significance of antenatal care management for high-risk pregnant women; appropriate and effective interventions can be carried out before the due date to minimize complications in childbirth (Briley et al., 2021). In article (8), Antenatal care provides an opportunity to assess and promote the general well-being of the mother. Assessment, diagnosis, and identification of risk factors linked to the emergence of anemia during pregnancy can help prevent PPH (Kalu & Chukwurah, 2022).

3) Women Empowerment
Article (2) explains that one way to empower women is to educate women and their families to increase their knowledge (Bazirete et al., 2020) 4) Educate the Villagers Article (7) explains Midwives say Before problems arise, villagers must understand the importance of seeing a midwife at least once during their pregnancy and before delivery. (Bazirete et al., 2020).

1) Action and Treatment
Article (1) describes how to treat PPH and traditional birth attendants stop excessive bleeding with cold water or soda. (Ononge et al., 2016). Article (2) explains that when treating bleeding, massage the uterus, and if the bleeding persists, call the health promoter to place an infusion. When faced with labor complications, midwives have been instructed in other training programs to transfer patients with bleeding to the hospital. (Bazirete et al., 2020). Article (3) explains various strategies for handling PPH; one of them is "family facilitators," where family members or husbands live with their partners during the management of postpartum hemorrhage (Snowdon et al., 2012). Article (8) explains the treatment of bleeding using active management of stage III and oxytocin injection (Kalu & Chukwurah, 2022).

2) Referrals
Article (2) explains that midwives trust local health services to handle postpartum hemorrhage and say they will move mothers who experience bleeding to the hospital. (Bazirete et al., 2020). Article (6) describes the necessity of referring high-risk women from primary care facilities to tertiary referral hospitals, which can only happen with appropriate screening (Bewket et al., 2022). In article (7), Midwives said they trusted local healthcare providers and would transfer bleeding mothers to local hospitals. Their role was to convince mothers to go to the hospital in an emergency. (Kimberly et al., 2012). In article (8), Access issues to maternity care centers cause women's treatment to be delayed. It includes transportation issues and late maternity home referrals to medical facilities. (Kalu & Chukwurah, 2022).

Summary of Evidence
Based on the eight selected articles, it was discovered that the articles were relevant to the scoping review's purpose, namely, discussing knowledge about PPH and prevention of PPH.
a. Knowledge of PPH

1) PPH Definition
In this discussion, several articles discuss the definition of PPH. Articles that discuss the definition of PPH include A1, A2. Postpartum haemorrhage includes all bleeding that occurs after the baby's birth, before, during, and after the expulsion of the placenta. Postpartum hemorrhage is the loss of more than 500 ml of blood in the first 24 hours after giving birth (Oxorn & Forte, 2010). Meanwhile, according to Dina Dewi et al. (2022) Postpartum hemorrhage is defined as bleeding of over 500 cc after vaginal delivery and over 1,000 ml for abdominal delivery.
Rural women view postpartum hemorrhage as a natural and cleansing process that, if stopped or inhibited, will harm the mother's health. Bleeding after delivery is normal; Every woman should anticipate bleeding. They think postpartum bleeding stops naturally and should not be prevented. Menstruation and postpartum bleeding are both regarded as natural cleansing processes. Some people believe that the blood pooled in a woman's body throughout her pregnancy should be allowed to drain away after she gives birth. By stopping the bleeding, some of the "bad" or "dirty" blood will remain in the uterus (womb) of the woman.), and most of it results in complications. It is widely held that allowing the blood to flow freely will assist in restoring a woman's health and hygiene. (Ononge et al., 2016a).
People can recognize postpartum hemorrhage or heavy bleeding using straightforward techniques like visual inspection, pails, clothes, and pads. Respondents also showed knowledge of the physiological indicators of severe bleeding and shock, such as the woman's body turning blue, persistent bleeding, rapid flow, or spurting (Snowdon et al., 2012).
Respondents have several ways to define excessive vaginal bleeding after delivery; Respondents frequently discuss assessing the rate or velocity of blood flow, frequent pad changes, and the expulsion of blood clots. However, inexperienced first-time mothers may be unable to rely on this technique. A 20-year-old woman acknowledged her inability to determine whether her bleeding was excessive and stated that she would not know unless someone else informed her that she was losing a significant amount of blood. (Ononge et al., 2016) Traditional birth attendants say a woman loses more blood than usual based on their extensive experience assisting women during childbirth. Loss of blood, "the equivalent of two fists," is a method traditional healers use to define PPH. However, Traditional birth attendants have also reported more accurate measurements of blood loss equal to 500 ml of blood by measuring blood in plastic mugs after the baby and placenta have been delivered. The amount of blood in the plastic cup indicates that the woman suffers from PPH. In addition, Without an objective method, traditional birth attendants rely on symptoms such as dizziness, sweating, thirst, or fainting, which are essential signs of hypovolemia. However, this symptom appears only as a late symptom of PPH and is not limited to excessive bleeding (Ononge et al., 2016a) PPH is typically diagnosed based on visual estimation of blood loss in the first hour after delivery, which is greater than 500 ml., which fits the WHO recommended definition. (Bazirete et al., 2020) Patients identified a lack of communication between clients and their partners before, during, and after PPH events as the most significant barrier to high-quality PPH care, as reported by Woiski et al. In addition, healthcare providers cited an absence of clear guidelines, a lack of knowledge, and poor team communication as impediments. Therefore, to improve the quality of care provided to women for the prevention of PPH, an in-depth analysis from various perspectives that identifies the factors that influence the delivery of quality PPH care will provide the information necessary to implement strategies to improve care. (Bazirete et al., 2020) b. PPH Prevention 1) Early detection of at-risk women Participants described various antepartum and intrapartum risk factors as PPH risk factors. Healthcare providers mention that "knowing pregnant women with a predisposition to PPH" will prevent PPH. The absence of a family planning method, a history of PPH, a retained placenta, and damage to the genital organs are listed as risk factors. The woman's family members and medical professionals agreed that poverty and malnutrition put women at risk for PPH because if a pregnant woman doesn't eat a balanced diet while she is pregnant, she might have postpartum hemorrhage when she gives birth. (Bazirete et al., 2020) Even though they knew the risk factors, respondents expressed difficulty predicting which women were more likely to experience PPH. They claimed that having more than five children made the uterus "tired," which they claimed was the cause of the excessive bleeding. Other risk factors include placenta retention, bleeding prior to delivery, prolonged labor, multiple pregnancies, and anemia during pregnancy. Additionally, they claimed that birth canal injuries in pregnant women made them more likely to experience their first bleeding. Traditional birth attendants say they send high-risk pregnant women to the hospital if they have any of the above problems. It is interesting that none of the respondents cited excessive bleeding as being caused by the uterus failing to contract (uterine atony) after delivery. Modern contraception has been linked to an increased risk of excessive blood loss. Respondents believed contraceptive methods that cause amenorrhea (the cessation of menstruation) could cause excessive bleeding after delivery, possibly due to the accumulation of blood before pregnancy. Some argue that because other contraceptive methods prolong menstrual bleeding in non-pregnant women, women who use contraception before giving birth are more likely to develop PPH. (Ononge et al., 2016a) 2) Antenatal Care Antenatal care allows for the assessment, diagnosis, and detection of risk factors associated with the development of anaemia during pregnancy, as well as the promotion of general maternal well-being and the prevention of PPH. Pregnant women are encouraged to perform an initial examination and determine PPH risk factors, such as anemia. Complete blood count tests are performed to evaluate and track hemoglobin levels and correct pregnancy anemia to prevent major bleeding complications. To prevent folic acid deficiency, supplementing with folic acid is also advised during pregnancy. Taking folic acid and iron supplements together prevents iron deficiency during pregnancy. It is also explained to women that taking folic acid during the first trimester of pregnancy can prevent certain congenital disabilities, such as those that affect the neural tube. Midwives stressed that PPH is not always predictable and that women should try to keep their haemoglobin levels at their best during the antenatal period to handle PPH better if it happens. Prenatal visits offer health education opportunities to support pregnant women's health and wellbeing. The significance of a healthy diet and the advantages of giving birth in a medical facility was discussed. Women are also advised on preparing for labour and delivery. To actively manage the third stage of labor and prevent PPH, midwives educate mothers (Kalu & Chukwurah, 2022).

3) Women Empowerment
Midwives empower women by educating them and their families to increase their knowledge about PPH prevention. Midwives provide education about abnormal signs such as fever, headache and bleeding during pregnancy and the puerperium, urging expectant mothers to use healthcare facilities for antenatal consultations and to give birth (Bazirete et al., 2020)

4) Educate the Villagers
Midwives reported that they required assistance in educating villagers, particularly men, about the importance of PPH prevention. The midwife emphasized to the villagers the significance of seeing a doctor or a midwife at least once during their pregnancies and before giving birth to prevent complications. Due to their close ties to the community, they recommended that local authorities, such as the head of the village administration, receive PPH training. As a result of the high turnover rate in the healthcare industry, healthcare providers and CHWs have expressed a desire for ongoing training on PPH. They stated that new employees may be unaware of the most recent PPH prevention protocols. Healthcare professionals in antenatal clinics claim that when they are knowledgeable about PPH and its risk factors, they can better instruct and assist mothers in learning about the symptoms and signs of PPH and the appropriate steps to take. The CHW expressed a desire for adequate training in procedures such as assisting with home births to provide care if a woman gives birth in the community before reaching a health facility (Bazirete et al., 2020).
The Ministry of Health promotes the presence of companion midwives as one of its mechanisms, intending to have one volunteer health worker (AMW) in each village. Most AMWs are local women who have completed secondary school on their own time and for free, and the Ministry of Health selected and trained them to provide antenatal care, routine deliveries, and postnatal care. AMW's main responsibility is to provide preventive care, which includes educating mothers about healthy pregnancy and pregnancy and encouraging births with trained birth attendants (Kyu Kyu Tan, 2017).
Educating the villagers is hoped that all residents or local officials, such as village heads, staff, volunteer workers and midwife assistants, will identify pregnant women at risk of postpartum haemorrhage. So it is easier to make referrals to more adequate services to prevent postpartum bleeding.
c. Handling PPH 1) Action and Treatment Several countries still use traditional methods for PPH treatment and prevention. In Bangladesh India, Prevention depends on placating the supernatural or spiritual forces that are blamed. " If a pregnant woman violates the rules and is outside in the morning, evening, or during the day, evil spirits attack her, resulting in heavy bleeding." PPH prevention in Madagascar, Africa, also entails mechanical methods that acknowledge the necessity of compression. After birthing the placenta, the woman's abdomen is massaged, the abdomen is tied with cloth, and it is recommended to sleep on her stomach until the bleeding stops (Soo Down, 2019).
Many traditional birth attendants claimed to have stopped excessive bleeding with cold water or soda. They think it treats and prevents PPH. They assert that this procedure has been used for a while and has proven effective. Also, drinking warm water is believed to stop bleeding because it increases blood flow and vaginal bleeding. Traditional birth attendants in Madagascar use herbs and teas with uterotonic properties to treat postpartum haemorrhage.
Most traditional birth attendants (TBA) have reported that they no longer use traditional medicine to either stop or reduce excessive bleeding in their patients. They stated that mothers who give birth at home and experience excessive bleeding after birth are referred to health facilities. Curiously, the three TBA had ergometrine medication in their house, which they could give to the woman once she had given birth. (Ononge et al., 2016a) PPH is considered an obstetric emergency by midwives and requires immediate recognition, diagnosis, and treatment to stop the bleeding and prevent the condition from worsening. Participants said PPH guidelines and policies help them diagnose and treat PPH quickly and effectively. To reduce the risk of PPH, midwives take various precautions when managing all phases of labor. By protecting the perineum during labor, using fewer episiotomies, and promptly suturing the perineum, efforts were made to lower the risk of bleeding from perineal trauma. The midwife's clinical expertise and years of experience are important factors in the successful management of the various stages of labor. Additionally, skilled midwives can manually remove the placenta while wearing sterile gloves (Kalu & Chukwurah, 2022b) Medical professionals administer oxytocin injections to manage the third stage of labor and prevent PPH actively. However, its efficacy is questionable since most healthcare facilities lack refrigeration storage in the delivery unit for oxytocin requiring transport and storage between 2 °C and 8 °C, regardless of labeling. Oxytocin, a vital medication for preventing PPH, was shown by Smith et al. to require proper storage and a consistent drug supply. It suggests improved service/clinical provider coordination as well as improved medication and maternal health supply chain management. Regular training is advised by Bartlett et al. to encourage active management of the third stage of labor and optimize the timing of uterotonics (Kalu & Chukwurah, 2022b) Midwives find cases of postpartum hemorrhage; what they do is massage the uterus, if the bleeding persists, call the health promoter to install an infusion. When faced with labor issues, midwives have been instructed in other training programs to transfer bleeding patients to hospitals, but it is unknown whether this practice is used.
As the woman approaches her anticipated due date, Community Health Officers (CHW) claim their responsibility is to inform her of risk factors and "take her to a health facility" to receive care from a qualified midwife. CHW stated that their primary goal is to prevent PPH when mothers give birth at home or in the community. If the mother is giving birth at home or en route to a health facility, the duty shifting policy permits CHWs to administer Misoprostol to prevent PPH. ".. when a woman gives birth at home or before getting to the hospital, we give her Misoprostol, which stops bleeding, and then we take her to the doctor, who tells her to get enough rest. We are used to advising women, and the training we receive helps them (Bazirete et al., 2020) Active management of the third stage, including administering uterotonic drugs following delivery, regulating umbilical cord traction, and uterine massage are the most effective intervention for preventing postpartum hemorrhage. The current best practice for preventing postpartum hemorrhage is actively managing the third stage with oxytocin injection as the uterotonic of choice. However, in remote areas, there are resource constraints and skilled providers for cold storage and administering injections, thereby hindering the distribution and use of oxytocin. Misoprostol is a uterotonic medication that can be taken orally and is often recommended in places with limited access to oxytocin. Misoprostol has been used and proven effective when administered orally by public health professionals to prevent postpartum hemorrhage in several countries because it does not need to be kept in cold storage. (Kyu Kyu, 2017).

2) Referrals
In handling postpartum haemorrhage, midwives trust local health services and will transfer mothers who experience bleeding to the hospital. The problem that midwives often face when making referrals is transportation. In some countries, the transportation is complicated; for example, in Guatemala, they have to make referrals by using a canoe to the hospital. Another consideration in making referrals is the cost factor, where renting a canoe costs a lot (Kimberly et al., 2012b). The socioeconomic status of the family has a negative impact on PPH prevention, especially poverty, that low-income families experience challenges because they cannot afford to go to health facilities, in which case the risk of PPH would be higher (Bazirete et al., 2020) Midwives face significant obstacles concerning PPH prevention and treatment in rural and community clinical settings. Access to maternity care and a lack of resources to manage PPH hinder providing effective PPH care. Access issues to maternity care facilities cause women's treatment to be delayed. It includes problems with transportation and sending patients from the maternity home to medical facilities too late) (Kalu & Chukwurah, 2022) Volunteer health workers (AMW) said postpartum hemorrhage was unexpected and scary. They were most worried about serious fear and death because of insufficient resources. The only action AMWs are trained and can provide timely referrals to the nearest hospital. Limited care at second-level health centers in rural areas where facilities for managing postpartum haemorrhage are lacking. Therefore, it would seem that the only option for further treatment of postpartum hemorrhage is to have the patient transferred to a tertiary care hospital. (Kyu Kyu et al, 2017).
Referral of obstetric patients from traditional birth attendants seems to cause concern among all mothers. Many examples of patients being transferred to health facilities with considerable delays are given. Traditional birth attendants are reluctant to make timely referrals and lack basic skills in the dukun (Jongchum Jan Beltman, 2013).
In making referrals, many problems often occur, including not being on time. Referrals are made by midwives, traditional healers, and patients. Inadequate patient selfreferral promptly or a delay in seeking care (first phase delay) is also an important reason for increased morbidity and mortality rates. Apart from not being on time, the problem that often arises is the attitude of the service provider. Arrogant attitude by healthcare providers toward patients is common. Due to the inefficient use of ambulances, slow assessment of emergency cases by doctors, and slow emergency procedure preparation by hospital staff, the transportation system is not operating as intended. The ongoing scarcity of human resources plays a significant role in the management of postpartum hemorrhage (Jongchum Jan Beltman, 2013).
It is crucial to share information throughout the health system, from community to district hospitals, to ensure continuity of care and appropriate follow-up for women. When there are women in labor or with other obstetric problems in the community, Even though there are occasional delays in the delivery of the ambulances, female helpers (CHW) use their cell phones to contact the medical staff at the health facilities to send ambulance using the "Quick SMS" system. Women need accurate PPH information during pregnancy, labor, and the puerperium to decide when to seek follow-up care. (Bazirete et al., 2020).

LIMITATION OF THE STUDY
The limitation in compiling this scoping review is that the number of articles reviewed is limited to qualitative research exploring the experiences of mothers, traditional birth attendants and health workers in treating postpartum haemorrhage.

CONCLUSIONS AND SUGGESTIONS
Postpartum hemorrhage is characterized by more than 500 cc of bleeding following vaginal delivery and more than 1,000 ml following abdominal delivery. Prevention is carried out by early detection of women at risk, including women who have experienced bleeding before, twin pregnancies, high parity, and anemia. Regular ANC should be performed to monitor general maternal health, promote it, and prevent PPH through evaluation, diagnosis, and identification of risk factors. Empowering women and midwives advised villagers to see a midwife at least once during pregnancy and before delivery to avoid complications. Action, treatment, and referrals are essential to handle postpartum haemorrhage immediately. In making referrals, there are obstacles, including transportation, costs and delays in making decisions.
Midwives in carrying out midwifery services, if they find a mother with a high risk of PPH, refer her to the nearest hospital. Take action, treatment, and immediate referral if you find a case of postpartum haemorrhage.

Funding Statement
Other organizations did not fund this review and manuscript preparation.

Conflict of Interest Statement
Authors declare that there are no conflict of interest in this research.