This was a cross-sectional prospective, descriptive and analytical study conducted over a period of 3 years, from the 1^st of January 2019 to the 31^st of December 2021. It took place in the obstetrics and gynaecology department of Bouaké University Hospital. The city of Bouaké is located in the centre of Ivory Coast and is the second most populous city after Abidjan, with a general population estimated at 1,542,000 according to the MICS 2021 [9] . The city has a university hospital, which is a tertiary-level hospital according to the country’s health pyramid. The centre has a gynaecology department, which provides medical and surgical care for Gynaecological and Obstetric pathologies. It is a referral service, receiving patients referred from general and peripheral hospitals in the town of Bouaké, as well as from surrounding towns in the centre, north and west of the country. The maternity ward in the Gynaecology and Obstetrics department has 4 delivery cubicles, 6 post-natal beds and an operating theatre with two operating theatres. The daily team consists of a Gynaecologist Obstetrician, three medical doctors with a diploma in Gynaecology and Obstetrics, four midwives and two nurses.

The study population consisted of all parturients with 28 or more weeks of gestation, admitted to the delivery room in the department. Sampling was exhaustive. All parturients with RPH whose delivery took place at the university hospital were included in the study, regardless of their origin, and all cases of RPH were confirmed after delivery by the presence of haematomas or cupules. We did not include in the study patients admitted on suspicion of RPH but in whom the examination did not reveal any placental cup and patients who did not give their consent.

The variables studied were sociodemographic characteristics, course of pregnancy, delivery and neonatal parameters. The questionnaire was developed after reviewing different literatures. The data were entered into a computer and analysed using EPI INFO software version 7.2.2.6 with the use of Chi-squared statistical tests for numbers ≥ 5 and Fisher for numbers < 5 with α = 5%. A P-value of less than 0.05 was considered to be statistically significant. Descriptive statistics were used to describe the characteristics of the study respondents by using means and standard deviations for numerical variables, frequencies along with percentages for categorical variables and table.

During the study period, we recorded 20,959 deliveries at the Bouaké University Hospital maternity unit, including 202 cases of RPH, representing an incidence of 0.96%.

The mean age was 29.8 ± 7.2 years, with extremes of 15 and 45 years. The 21 - 35 age group accounted for 64.4% of cases. The patients were in a couple in 90.1% of cases and had domestic activity in 63.9% of cases. Large multigestations and multigestations accounted for 58.5% of cases. The average parity was 4, with extremes of 0 and 12. Multiparous and large multiparous males accounted for 41.6% of cases. Nulliparous women accounted for 21.8%. Of the 202 patients, 10 (5%) had not had a pregnancy follow-up. Of those with a pregnancy follow-up, 62.9% had undergone less than the mandatory 4 parental consultations (ANCs). Only one of the 202 patients had a history of RPH. Patients were referred from a public health facility in 87.6% of cases. The reasons for evacuation were dominated by 3^rd trimester metrorrhagia, RPH and uterine contractures in 51.5%, 18.2% and 10.4% of patients, respectively.

Gestational age was between 37 and 41 SA + 6 days in 48.1% of cases. Mono-foetal pregnancies accounted for 98.5%. Clinical signs on admission were dominated by metrorrhagia (100%), uterine contracture (98.5%), cervical cerclage (79.7%) and absent foetal heart sounds (83.1%) at the obstetrical level. General symptoms included hypertension in 84.6% of cases, proteinuria (45.5%) and shock (11.4%). RPH was classified as Sher grade III in 80% of cases, including 72.8% as grade IIIa. Grades 1 and 2 accounted for 3.5% and 17.3%, respectively. Caesarean section was the mode of delivery in 82.2% of patients. The mean time from admission to delivery was 51.3 ± 42.3 minutes, with extremes of [15 minutes - 4 hours]. On examination of the placenta, the mean cup size was 6.8 ± 2.2 cm with a range of [3 - 16 cm], and the cup size was greater than or equal to 5 in 88.1% of cases. The mean weight of the haematoma was 504.8 ± 245 g [100 - 1500 g].

During the study period, there were 26 maternal deaths, representing a case-fatality rate of 12.9%. Factors statistically associated with maternal death were multigestity (p = 0.04), multiparity (p = 0.01), Sher grade IIIb (p = 0.0001) and the occurrence of complications such as DIC (p = 0.0001), shock (p = 0.0001), renal complications (p = 0.002) and HELLP syndrome (p = 0.0001) (Table 1). Maternal morbidity related to RPH was dominated by anemia in 64.1% of cases, followed by DIC in 21.8% and postpartum infection in 5.1%.

During the study period, neonatal case fatality was 79.2%. Factors statistically associated with foetal mortality were cup size ≥ 5 cm (p = 0.0001) and haematoma weight ≥ 500 g (p = 0.0001) (Table 2). Foetal weight was between 1501 and 2500 g in 45.5% of cases. The Apgar score at the 5^th minute of life was less than 3 in 81.2% of cases. Of the live neonates, 71.4% were transferred to the neonatology unit.

During the study, we recorded 20,959 deliveries at the Bouaké University Hospital maternity ward, including 202 cases of RPH, giving an incidence of 0.96%. Our incidence is comparable to those of Budak and Igwebe, who found 0.66% and 0.8%, respectively [10] [11] . However, it is lower than those reported in Nigeria, India and Côte d’Ivoire [12] [13] [14] , which were 1.46%, 3.9% and 4.4%, respectively. This difference could be explained by the type of study, the diagnostic criteria and the study populations.

The 21 - 35 age group was the most represented (64.4%), with an average age of 29.8 years. The same trends have been reported by other authors for the mean age: 29 years for O Thiam in Senegal [3] and 29.14 for N Adewole in Nigeria [15] . Different authors [16] [17] have assessed the role of maternal age in the occurrence of PRH differently. According to the literature, the risk between maternal age and RPH was linked only by parity [17] . Patients’ professional occupations may constitute an obstacle to access to care. In our study, 63.9% of patients had no fixed income. This is twice as high as in the N adewole study in Nigeria [15] . According to Nayama [18] , low socioeconomic status is a risk factor for RPH. RPH appears to be a pregnancy pathology that spares no parity. However, multiparous women were the most common in our series (41.6%). Multiparity is a known risk factor for RPH [18] [19] . The risk of occurrence increases with the number of pregnancies and becomes considerable from the fifth parity onwards [18] [19] . Thieba [20] in Burkina Faso asserted that the increase in the prevalence of RPH in pregnant women, and in particular in primiparous and young pregnant women, was linked to insufficient or inadequate monitoring of pregnancy, rather than to the existence of hypertension or previous renal damage. In our study, nulliparous women accounted for 21.8%. This may be explained by the fact that multiparity favours the occurrence of RPH because of alterations in the uterine mucosa, and primiparity favours the occurrence of toxaemia gravidarum. In our series, more than half of the patients (62.9%) had not undergone the required number of antenatal consultations. According to the literature, the frequency of RPH tends to decrease as the number of ANCs increases, and poor antenatal surveillance is a factor predisposing patients to RPH [18] . Pregnant women were referred from a public health facility in 87.6% of cases, and the same finding was made by Ousmane thiam in Senegal [21] , which was 66%, and Godwin s in Tanzania [8] (46%). This high frequency of patients being evacuated could be explained on the one hand by the fact that our facility is the only public facility in Bouaké performing complete emergency obstetric and neonatal care.

RPH was classified as Sher III in 80.7% of cases, including 72.8% as grade IIIa. Our results are similar to those of F Abedlkader in Mauritania [17] , who found 86.5%, but higher than those of O thiam in Senegal [21] , who found 63%, and J Coleman in Ghana [22] who found 53%, which could be explained by the delay in consultation, thus worsening the maternal-fetal prognosis. Gestational age was full term in 48.1% of cases. The labor of O thiam in Senegal [21] was approximately 36 SA and F adelkader [17] at a gestational age of 34.7. However, Nayama in Niger [18] found cases of RPH between 20 and 27 weeks of gestation (2.5%). It should therefore be considered in pregnant women with risk factors when the pregnancy is at least 20 days gestation.

Maternal mortality was 12.9% in our study, which is much higher than the results of Godwin in Tanzania [8] at 3.6%, J Coleman in Ghana [22] at 2% and Doumbia in Côte d’Ivoire [14] at 2.9%. Morbidity was represented by anaemia in 64.1% of cases, which is higher than the study by O Thiam in Senegal [21] , who found 17.8%. This could be explained by the lack of blood products in our health facilities. The factors statistically associated with maternal death were multiple gestations, multiple pregnancies, Sher grade IIIb and the occurrence of complications such as DIC, shock, renal complications and HELLP syndrome.

Fetal weight was between 1501 and 2500 g in 45.5% of cases, whereas F Abdelkader in Mauritania [17] found a fetal weight of less than 1500 g in 46.39% of cases. Neonatal mortality was 79.2%, similar to the study by Doumbia [14] at 78.6% but higher than O Thiam in Senegal [21] at 60.5%, which could be explained by the severity of the clinical picture but also by the low weight of the foetuses, reflecting their fragility. Newborns presented a malformation in 1.5% of cases. Of the live newborns, 71.4% were transferred to the neonatology unit. The factors statistically associated with foetal mortality were cup size ≥ 5 cm and haematoma weight ≥ 500 g.