Postpartum hemorrhage

The risk of maternal death from childbirth represents one of the greatest inequities in global health. Women in developing countries are more than 40 times more likely than women in developed countries to die in childbirth (1 in 61 women in developing countries versus 1 in 2,800 women in developed countries).¹ This rate is significantly higher than the ten-fold difference in risk for infant mortality between developed and developing countries, which is 5 per 1,000 live births versus 61 per 1,000 live births respectively.² Even within developing countries there is a striking differential risk of maternal death for women who have access to basic essential obstetrical care compared to those who do not. Within a country, as poverty increases so does the proportion of women dying of maternal causes.³

Obstetric hemorrhage is the world’s leading cause of maternal mortality, causing 24% of, or an estimated 127,000, maternal deaths annually. Postpartum hemorrhage (PPH) is the most common type of obstetric hemorrhage and accounts for the majority of the 14 million cases of obstetric hemorrhage that occur each year.⁴

In the developed world, PPH is a largely preventable and manageable condition. In developing countries, however, mortality from PPH remains high despite international efforts. While data are limited, studies have shown that PPH causes up to 60 percent of all maternal deaths in developing countries. For example, PPH accounts for 59 percent of maternal deaths in Burkina Faso, 53 percent in the Philippines, and 43 percent in Indonesia.⁵ PPH also causes considerable suffering for women and their families and creates major demands on health systems.⁴

Causes and risk factors

PPH is defined as excessive vaginal bleeding (blood loss greater than 500 ml) within 24 hours after delivery. There is no better or more definitive definition for PPH. McCormick et al. state that, “A more accurate definition of PPH is any blood loss that causes a physiological change (e.g., low blood pressure) that threatens the woman’s life.”⁶ Unfortunately, waiting until there is a physical change would mean death for most women in developing-country settings, as immediate back up or emergency obstetric care is not available.

PPH is caused by a variety of conditions. Immediate PPH—heavy bleeding directly following childbirth or within the first 24 hours—is the most common type and can be caused by uterine atony (failure of the uterus to contract properly after delivery); retained placenta; inverted or ruptured uterus; or cervical, vaginal, or perineal lacerations. Uterine atony is the leading cause of immediate PPH.⁷

The main risk factors for PPH due to uterine atony are high parity, a large fetus, multiple fetuses, or hydramnios. Another risk factor is if a woman has previously suffered from PPH.⁸ However, the majority of women who suffer from PPH present no risk factors. Retained fragments of placental membranes, infection, and trophoblastic tumors can all produce delayed or “secondary” PPH, defined as hemorrhage after the first 24 hours but less than 6 weeks postpartum.^5,7

Prevention

The primary intervention shown to reduce the incidence of PPH is active management of the third stage of labor (AMTSL).⁹ Other preventive measures include reducing the incidence of prolonged labor (through the use of the partograph and timely intervention, when needed), minimizing the trauma associated with instrumental delivery, and possibly detecting and treating anemia during pregnancy. The need for prevention was highlighted in July 2005 by Evelyn Zimba, a Malawian midwife, who described the difficulties and frequent inability to obtain the needed blood for a transfusion. Either there is no ability to screen available blood or a donor is not available.

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¹ WHO. Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. WHO/RHR/00.7. Geneva: WHO; 2000.

² Cunningham F, MacDonald P, Gant N, Leveno K, Gilstrap L. Williams Obstetrics. Nineteenth Edition. Norwalk, Connecticut: Appleton & Lange; 1993.

³ Rogers J, Wood J, McCandlish R, Ayers, S, Truesday A, Elbourne D. Active versus expectant management of third stage of labour: the Hinchingbrooke randomized controlled trial. Lancet. 1998; 351: 693–699.

⁴ World Health Organization (WHO) Department of Reproductive Health and Research. Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF, and UNFPA. Geneva: WHO; 2004. Available at: www.childinfo.org/maternal_mortality_in_2000.pdf.

⁵ Child mortality page. UNICEF Monitoring the Situation of Children and Women. Available at: www.childinfo.org/areas/childmortality/infantdata.php. Accessed July 11, 2004.

⁶ Graham W, Fitzmaurice A, Bell J, Cairns J. The familial technique for linking maternal death with poverty. The Lancet.2004;363:23–27.

⁷ WHO. Mother-Baby Package: Implementing Safe Motherhood in Countries. WHO/FHE/MSM/94.11. Geneva: WHO; 1994.

⁸ AbouZahr C. Antepartum and postpartum heaemorrhage. In: Murray CJL, Lopez AD, eds. Health Dimensions of Sex and Reproduction. Boston: Harvard University Press; 1998:165–190.

⁹ McCormick ML, Sanghvi HCG, Kinzie B, McIntosh N. Averting maternal death and disability: Preventing postpartum hemorrhage in low-resource settings. International Journal of Gynecology and Obstetrics. 2002;77:267–275.