Postpartum hemorrhage affects 27 million women and causes approximately 43,000 deaths annually worldwide.
A series of articles published in The Lancet has outlined new approaches for the detection and treatment of postpartum hemorrhage (PPH). The research, led by scientists from the World Health Organization (WHO), the University of Oxford, and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research (HRP), presents a comprehensive look at the global challenge.
Global Impact and Risk Factors
The global economic burden of PPH is estimated at over US$10 billion annually. While the rate of PPH is similar in high-income and low-income countries, mortality rates can be over 200 times higher in under-resourced settings.
Women identified as being at higher risk include those with:
- Home births
- Anemia
- Pre-existing conditions
- Caesarean births (particularly emergency procedures at full dilation)
- Deliveries in understaffed facilities
Revised Detection Methods
The series recommends a new approach to diagnosing PPH. Treatment should begin when blood loss reaches 300 milliliters accompanied by abnormal vital signs, or 500 milliliters of blood loss alone—whichever occurs first.
Traditional visual estimation of blood loss is inaccurate and misses approximately half of all PPH cases. As a replacement, the authors advocate for the use of calibrated blood collection drapes to provide accurate measurement.
Treatment Protocols
The research presents a first-response treatment bundle called MOTIVE, which includes:
- Uterine massage
- Oxytocic drugs
- Tranexamic acid
- Intravenous fluids
- Examination of the bleeding source
A trial involving over 200,000 women in Nigeria, Kenya, Tanzania, and South Africa tested early detection using calibrated drapes followed by this bundle. The trial reported a reduction in progression to life-threatening hemorrhage by up to 60%. The protocol is designed so that midwives and nurses can implement it immediately without waiting for specialist review.
For cases of life-threatening hemorrhage, the series recommends the immediate attendance of an emergency team including senior obstetricians and anesthesiologists.
Implementation Challenges
The series identifies six critical delays from diagnosis to treatment that often influence survival outcomes. It notes that substandard clinical care is a root cause of PPH deaths.
While the authors state that essential knowledge and tools exist to reduce PPH-related deaths, they identify the implementation of these practices into consistent clinical care across diverse healthcare settings as a significant challenge.
Specific barriers include the requirement for refrigeration of the drug oxytocin, which is an issue in low-resource settings. The series calls on governments, health systems, professional associations, and donors to prioritize PPH and implement proven interventions at scale through policy commitments, resource allocation, and quality improvement efforts.
Economic Considerations
The report argues that the cost of preventing PPH is lower than the cost of managing its consequences. The authors advocate for investment in prevention strategies, including:
- Reducing anemia in pregnancy
- Addressing unmet contraception needs
- Avoiding unnecessary cesarean sections
- Ensuring all women receive effective uterotonic medicines after birth
Recommended Interventions
The series outlines several key recommendations for action:
- Use of calibrated drapes for accurate blood loss measurement
- Prompt initiation of the MOTIVE treatment bundle upon detection
- Simulation-based training for healthcare teams
- Reduction of anemia in pregnancy
- Addressing unmet contraception needs
- Avoiding unnecessary cesarean sections
- Ensuring universal access to effective uterotonic medicines after birth
- Investment in prevention strategies