DOI: 10.1111/1471-0528.

12636 Original article

www.bjog.org

Postpartum haemorrhage management, risks,

and maternal outcomes: findings from the World
Health Organization Multicountry Survey on
Maternal and Newborn Health
lmezoglu,c B Winikoff,a on behalf of the WHO
WR Sheldon,a J Blum,a JP Vogel,b,c JP Souza,c AM Gu
Multicountry Survey on Maternal and Newborn Health Research Network
a
Gynuity Health Projects, New York, NY, USA b School of Population Health, Faculty of Medicine, Dentistry and Health Sciences, University
of Western Australia, Perth, WA, Australia c Department of Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank
Special Programme of Research Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva,
Switzerland
Correspondence: Dr WR Sheldon, Senior Program Associate, Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY 10010,
USA. Email [email protected]

Accepted 4 November 2013.

Objective To explore the clinical practices, risks, and maternal parity, gestational age, induction of labour, caesarean section, and
outcomes associated with postpartum haemorrhage (PPH). geographic region. Among those with PPH, 92.7% received
uterotonics for treatment, and 17.2% had an SMO. There were
Design Secondary analysis of cross-sectional data.
significant differences in the incidence of SMOs by age, parity,
Setting A total of 352 health facilities in 28 countries. gestational age, anaemia, education, receipt of uterotonics for
prophylaxis or treatment, referral from another facility, and
Sample A total of 274 985 women giving birth between 1 May
Human Development Index (HDI) group. The rates of death were
2010 and 31 December 2011.
highest in countries with low or medium HDIs.
Methods We used multivariate logistic regression to examine
Conclusions Among women with PPH, disparities in the incidence
factors associated with PPH among all births, and the Pearson
of severe maternal outcomes persist, even among facilities that
chi-square test to examine correlates of severe maternal outcomes
report capacity to provide all essential emergency obstetric
(SMOs) among women with PPH. All analyses adjust for facility-
interventions. This highlights the need for better information
and country-level clustering.
about the role of institutional capacity, including quality of care,
Main outcome measures PPH, SMOs, and clinical practices for in PPH-related morbidity and mortality.
the management of PPH.
Keywords Maternal death, maternal near miss, postpartum
Results Of all the women included in the analysis, 95.3% received haemorrhage, quality of care, uterotonics.
uterotonic prophylaxis and the reported rate of PPH was 1.2%.
Factors significantly associated with PPH diagnosis included age,

Please cite this paper as: Sheldon WR, Blum J, Vogel JP, Souza JP, G
ulmezoglu AM, Winikoff B, on behalf of the WHO Multicountry Survey on Maternal and
Newborn Health Research Network. Postpartum haemorrhage management, risks, and maternal outcomes: findings from the World Health Organization
Multicountry Survey on Maternal and Newborn Health. BJOG 2014; 121 (Suppl. 1): 513.
this can vary somewhat by geographic region and delivery
Introduction
setting.3 Severe morbidities associated with PPH include
Postpartum haemorrhage (PPH) is a major cause of mater- anaemia, disseminated intravascular coagulation, blood
nal morbidity and mortality, accounting for about transfusion, hysterectomy, and renal or liver failure.4,5
one-third of all pregnancy-related deaths in Africa and Only about one-third of PPH cases have identifiable risk
Asia.1 Primary PPH is typically defined as bleeding from factors. These are believed to include: a history of prior
the genital tract of 500 ml or more in the first 24 hours PPH;6,7 nulliparity;6,8,9 overdistended uterus (e.g. caused by
following delivery of the baby.2 The incidence of PPH in multiple gestations or a large baby);6,7,1013 placental abnor-
observational studies is believed to be around 6%, although malities, such as placenta praevia or placenta accreta;11

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 Sheldon et al.

coagulation abnormalities;7,13 anaemia;8,13 induction of for all women giving birth and all women with SMOs who
labour, augmentation of labour, or use of an epidural;6,7,912 received services at participating health facilities during the
and prolonged labour.6,7,9,10 In spite of speculation to the data collection period. The data collected included: demo-
contrary, high multiparity does not appear to be a risk graphic and reproductive characteristics for all eligible
factor.8,11,14 There are also no known risk factors to help women; information about their pregnancy and childbirth
predict which women will fail to respond to treatment with status, complications, and receipt of related interventions;
conventional uterotonics.15 and the health outcomes of the women and, if applicable,
Uterine atony, or failure of the uterus to contract after their newborn babies. Institutional data were provided by
delivery, is the most common cause of PPH.3,5,16 The pro- participating facilities through the completion of institu-
phylactic administration of a uterotonic has been shown to tional data forms that provided information about available
reduce the incidence of PPH through inducing uterine con- obstetric and newborn care services. The study protocol and
tractions.1719 Oxytocin is considered the gold standard for other details of the data collection, entry, and cleaning
prophylaxis,20 although ergometrine, methergyne, and mi- procedures for this survey have been reported elsewhere.23,25
soprostol are also frequently used. When uterine atony
occurs, the timely administration of a uterotonic drug is Statistical analysis
recommended.20,21 Uterotonic treatment can help prevent A total of 274 985 women attending 352 health facilities in
the need for more sophisticated interventions, such as the 28 countries were included in this analysis. We excluded all
administration of intravenous fluids, additional drug 2987 participants from Japan, as it was one of only two
therapy, blood transfusion, and surgical intervention. participating countries that was categorised as developed,
Although PPH occurs in all settings and all geographic and it had an atypically high incidence of PPH. We also
regions, the majority of maternal deaths as a result of PPH excluded 39 141 women who had caesarean sections before
take place in developing countries. This disparity has been labour, and 1421 others whose mode of delivery was either
attributed to differences in quality of care, including the unknown or who had induced terminations of pregnancy
availability of trained personnel attending deliveries, access or laparotomy for ectopic pregnancy.
to quality uterotonic drugs, and the timely receipt of We used frequencies to examine PPH among all births,
needed interventions when obstetric emergencies arise.22 SMOs among women with PPH, and clinical practices for
Yet disparities in severe maternal outcomes (SMOs) also the management of PPH. We used multivariate logistic
occur within higher level health facilities. In the recent regression to examine factors associated with PPH among
World Health Organization (WHO) Multicountry Survey all births and Pearsons chi-square test to examine corre-
that documented the incidence of maternal morbidity and lates of SMOs among women with PPH. We adjusted all
mortality at health facilities globally, PPH accounted for analyses using the svy procedure in STATA 11.2 to account
27% of all deliveries with an SMO.23 The aim of this analy- for clustering at the levels of the health facility (primary
sis, therefore, was to explore the clinical practices, risks, sampling unit) and country (strata). Severe maternal out-
and maternal outcomes associated with PPH. comes were defined as the occurrence of either a maternal
death or a maternal near miss within 7 days of giving birth
or having an abortion. Maternal near miss was defined as
Methods
the survival of a life-threatening condition based on stan-
Survey methodology dard markers of organ dysfunction.26 P values < 0.05 were
Data for this secondary analysis were derived from the considered significant.
WHO Multicountry Survey on Maternal and Newborn
Health. This cross-sectional survey was implemented in 359
Results
health facilities in 29 countries, and included 314 623 births.
Health facilities were considered eligible if they recorded at Figure 1 summarises the PPH-related outcomes of survey
least 1000 deliveries annually and had the capacity to pro- participants. Overall, 1.2% of all women giving birth were
vide caesarean section. Most of the facilities in this survey
had also participated in the prior WHO Global Survey on Maternal death
(n=105 )
Maternal and Perinatal Health (20042008).24 Countries, SMO
provinces (or other equivalent political divisions within (n=589) Maternal near
PPH
miss
(n=3,349)
countries), and health facilities were randomly selected All births No SMO (n=484)
(n=274,985) (n=2,760)
through a stratified, multistage cluster sampling strategy. No PPH
(n=271,636)
Data were collected on individuals and institutions
between 1 May 2010 and 31 December 2011. Information on
individuals was obtained from analysis of hospital records Figure 1. Flow chart of survey participants and PPH outcomes.

6 2014 RCOG
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 Postpartum haemorrhage management, risks, and outcomes

Table 1. Maternal, delivery, and institutional characteristics by Table 1. (Continued)

incidence of postpartum haemorrhage
PPH No PPH
PPH No PPH (n = 3349) (n = 271,636)
(n = 3349) (n = 271,636)
Geographic region
Maternal Data available 3349 268,809
Age Africa 970 (29.0) 69,240 (25.8)
Data available 3346 267,952 Asia 1571 (46.9) 137,716 (51.2)
<20 years 340 (10.2) 29,788 (11.1) Latin America and 602 (18.0) 53,822 (20.0)
2034 years 2458 (73.5) 209,265 (78.1) the Caribbean
35 years 548 (16.4) 28,899 (10.8) Middle East 206 (6.2) 8031 (3.0)
Marital status
Data available 3286 265,473 Data are n (%). Percentages have been rounded.
With partner 2975 (90.5) 237,433 (89.4)
Without partner 311 (9.5) 28,040 (10.6)
Education diagnosed with PPH. The maternal, delivery, and institu-
Data available 3349 271,636 tional characteristics of survey participants by incidence of
<5 years 670 (20.0) 53,213 (19.6)
PPH is shown in Table 1. In general, women with PPH
58 years 638 (19.1) 58,914 (21.7)
911 years 818 (24.4) 62,266 (22.9)
tended to be slightly older, of higher parity, and with preg-
>11 years 1223 (36.5) 97,243 (35.8) nancies of lower gestational age than women without PPH.
Number of previous births They were also more likely to receive labour induction and
Data available 3348 268,263 caesarean section, and to have been referred from another
0 1379 (41.2) 113,185 (42.2) health facility. There were few notable institutional differ-
1 or 2 1212 (36.2) 109,431 (40.8) ences in PPH incidence, with the exception of geographic
3+ 757 (22.6) 45,647 (17.0)
region, for which Africa and the Middle East were slightly
Gestational age at delivery
Data available 3232 265,637
over-represented, as compared with non-PPH cases,
<37 weeks 552 (17.1) 19,018 (7.2) whereas Asia, Latin America and the Caribbean were
3741 weeks 2604 (80.6) 242,369 (91.2) slightly under-represented.
>41 76 (2.4) 4250 (1.6) Table 2 presents the characteristics of study participants
Delivery according to receipt of uterotonic prophylaxis. Overall,
Onset of labour 95.3% of women received uterotonics for the prevention of
Data available 3290 270,968
PPH. There were some differences in prophylactic coverage
Spontaneous 2727 (82.9) 239,073 (88.2)
Induced 563 (17.1) 31,895 (11.8)
by age, marital status, and parity. Those who did not
Mode of delivery receive uterotonic prophylaxis tended to be younger, of
Data available 3312 268,664 higher parity, and were more likely to be single than those
Vaginal 2477 (74.8) 218,061 (81.2) who received prophylaxis. Figure 2 summarises prophylaxis
caesarean Section 835 (25.2) 50,603 (18.8) practices by type of uterotonic for women with and
Institutional without PPH. About 5% of all women did not receive
Self-reported facility location
prophylaxis; among those who did, oxytocin was the most
Data available 3135 251,338
Urban 2662 (84.9) 211,602 (84.2)
common uterotonic provided. The provision of oxytocin
Peri-urban 338 (10.8) 26,336 (10.5) alone, however, was significantly more common among
Rural 135 (4.3) 13,400 (5.3) those with no PPH (72 versus 56%), whereas those
Referred from another facility diagnosed with PPH were nearly twice as likely to have
Data available 3349 271,636 received more than one uterotonic for prophylaxis (35
Yes 248 (7.4) 1228 (0.5) versus 19%).
No 3101 (92.6) 270,408 (99.6)
Table 3 presents results from a logistic regression analy-
HDI group
Data available 3349 268,809
sis of the predictors of PPH diagnosis. Factors associated
Very high 164 (4.9) 11,124 (4.1) with increased adjusted odds of PPH diagnosis included:
High 687 (20.5) 54,811 (20.4) age 35 years (OR 1.42; 95% CI 1.261.60); nulliparity
Medium 1060 (31.7) 89,334 (33.2) (OR 1.12; 95% CI 1.011.25); parity of three or more (OR
Low 1438 (42.9) 113,540 (42.1) 1.32; 95% CI 1.091.59); gestational age at delivery of
<37 weeks or >41 weeks, as compared with 3741 weeks

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 Sheldon et al.

Table 2. Maternal, delivery, and institutional characteristics by receipt of uterotonic prophylaxis

Any uterotonic for No uterotonic for P

prophylaxis (n = 259,145) prophylaxis (n = 12,653)

Maternal
Age
Data available 258,388 12,557 0.0060
<20 years 28,217 (10.9) 1850 (14.7)
2034 years 202,115 (78.2) 9351 (74.5)
35 years 28,056 (10.9) 1356 (10.8)
Marital status
Data available 256,023 12,446 0.0213
With partner 229,762 (89.7) 10,381 (83.4)
Without partner 26,261 (10.3) 2065 (16.6)
Education
Data available 259,145 12,653 0.0828
<5 years 50,907 (19.6) 2923 (23.1)
58 years 56,093 (21.7) 3412 (27.0)
911 years 60,398 (23.3) 2647 (20.9)
>11 years 91,747 (35.4) 3671 (29.0)
Number of previous births
Data available 258,730 12,578 0.0183
0 109,665 (42.4) 4787 (38.1)
12 105,555 (40.8) 4981 (39.6)
3+ 43,510 (16.8) 2810 (22.3)
Delivery
Onset of labour
Data available 258,686 12,454 0.8094
Spontaneous 227,998 (88.1) 11,060 (88.8)
Induced 30,688 (11.9) 1394 (11.2)
Mode of delivery
Data available 259,119 12,526 0.0875
Vaginal 211,121 (81.5) 9133 (72.9)
Caesarean section 47,998 (18.5) 3393 (27.1)
Institutional
Self-reported facility location
Data available 240,366 11,132 0.9032
Urban 202,202 (84.1) 9544 (85.7)
Peri-urban 25,366 (10.6) 1026 (9.2)
Rural 12,798 (5.3) 562 (5.1)
Referred in from other facility
Data available 259,145 12,653 0.0610
Yes 1297 (0.5) 133 (1.1)
No 257,848 (99.5) 12,520 (99.0)
Human development index group
Data available 259,145 12,653 0.0631
Very high 10,945 (4.2) 329 (2.6)
High 51,569 (19.9) 3894 (30.8)
Medium 87,928 (33.9) 2445 (19.3)
Low 108,703 (42.0) 5985 (47.3)
Geographic region
Data available 259,145 12,653 0.0993
Africa 65,629 (25.3) 4306 (34.0)
Asia 134,143 (51.8) 5112 (40.4)
Latin America and the Caribbean 51,188 (19.8) 3183 (25.2)
Middle East 8185 (3.2) 52 (0.4)

Data are n (%). Percentages have been rounded. We used Pearsons chi-square test to test for differences between groups. All tests were
adjusted for clustering at the levels of the health facility and country.

8 2014 RCOG
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 Postpartum haemorrhage management, risks, and outcomes

As shown in Figure 1, 17.6% of PPH events resulted in

an SMO: 14.5% were considered near misses involving
some marker of organ dysfunction, and 3.1% resulted in
maternal death. Table 4 summarises PPH treatment prac-
tices by severity of maternal outcome. Close to 93% of all
PPH cases received uterotonics for the treatment of PPH,
32.5% received blood products, and 23.1% received thera-
peutic intravenous antibiotics. Other, less frequently
reported interventions included the removal of retained
products of conception, manual placental removal, laparot-
omy, artery ligation/embolisation, and balloon/condom
tamponade. As might be expected, the provision of most
interventions was considerably higher among women with
SMOs, about two-thirds of whom received blood products
and one-quarter of whom received massive transfusion
Figure 2. Receipt of uterotonic prophylaxis by incidence of postpartum and/or hysterectomy.
haemorrhage. *95% confidence intervals are in parentheses. Table 5 summarises the correlates of SMOs among
women with PPH. There were significant differences by
(respective ORs were 2.63; 95% CI 2.283.04 and 1.56; demographics [age, education, and Human Development
95% CI 1.022.38); induction of labour (OR 1.55; 95% CI Index (HDI) group] as well as clinical variables (parity,
1.202.00); caesarean section (OR 1.46; 95% CI 1.201.79); gestational age at delivery, anaemia, receipt of uterotonic
and residence in the Middle East as compared with Africa prophylaxis, and receipt of uterotonics for the treatment of
(OR 1.79; 95% CI 1.202.67). PPH). As might be expected, the incidence of SMOs was

Table 3. Factors associated with postpartum haemorrhage: logistic regression results

PPH diagnosed

Crude OR (95% CI) P Adjusted OR (95% CI) P

Age
<20 years 0.97 (0.821.16) 0.749 0.96 (0.811.14) 0.664
2034 years Ref. Ref.
35 years 1.61 (1.431.83) 0.000 1.42 (1.261.60) 0.000
Number of previous births
0 1.10 (0.991.22) 0.065 1.12 (1.011.25) 0.038
12 Ref. Ref.
3+ 1.50 (1.281.75) 0.000 1.32 (1.091.59) 0.005
Gestational age
<37 weeks 2.70 (2.333.13) 0.000 2.63 (2.283.04) 0.000
3741 weeks Ref. Ref.
>41 weeks 1.66 (1.082.57) 0.021 1.56 (1.022.38) 0.039
Onset of labour
Spontaneous Ref. Ref.
Induced 1.55 (1.172.05) 0.002 1.55 (1.202.00) 0.001
Caesarean section 1.45 (1.211.75) 0.000 1.46 (1.201.79) 0.000
Geographic region
Asia 0.81 (0.611.09) 0.167 0.82 (0.601.12) 0.215
Africa Ref. Ref.
Latin America 0.80 (0.591.09) 0.151 0.75 (0.541.03) 0.077
Middle East 1.83 (1.242.69) 0.002 1.79 (1.202.67) 0.005

All estimates were adjusted for clustering at the levels of the health facility and country. Variables dropped from the final models because of
non-significance included the provision of uterotonic prophylaxis, marital status, self-reported facility location, HDI groups, educational attainment,
and the interaction of age with parity.

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 Sheldon et al.

Table 4. Summary of postpartum haemorrhage treatment practices Table 5. Correlates of severe maternal outcomes among women
with PPH
All PPH cases PPH near miss PPH death
(n = 3349) (n = 484) (n = 105) PPH cases PPH cases P
with SMOs with no
(n = 589) SMOs
Uterotonics for 3102 (92.7) 432 (89.3) 92 (87.6)
(n = 2760)
treatment
Blood products 1088 (32.5) 310 (64.1) 61 (58.1)
Therapeutic 773 (23.1) 156 (32.2) 39 (37.1) Age
intravenous <20 years 42 (7.1) 298 (10.8) <0.0001
antibiotics 2034 years 393 (66.8) 2065 (74.9)
Removal of retained 519 (15.5) 100 (21.7) 11 (10.5) 35 years 153 (26.0) 395 (14.3)
products of Education in years
conception <5 years 208 (35.3) 462 (16.7) <0.0001
Manual removal of 356 (10.6) 59 (12.2) 10 (9.5) 58 years 106 (18.0) 532 (19.3)
the placenta 911 years 116 (19.7) 702 (25.4)
Massive transfusion 162 (4.9) 136 (28.1) 26 (24.8) >11 years 159 (27.0) 1064 (38.6)
Hysterectomy 160 (4.8) 138 (28.5) 22 (21.0) Number of previous births
Laparotomy 156 (4.7) 85 (17.6) 26 (24.8) 0 171 (29.0) 1208 (43.8) <0.0001
Artery ligation/ 103 (3.1) 40 (8.3) 12 (11.5) 12 204 (34.6) 1008 (36.5)
embolisation 3+ 214 (36.3) 543 (19.7)
Balloon/condom 75 (2.2) 16 (3.3) 2 (1.9) Gestational age at delivery in weeks
tamponade <37 years 130 (24.1) 422 (15.7) 0.0004
3741 years 402 (74.4) 2202 (81.8)
Data are n (%). >41 years 8 (1.5) 68 (2.5)
Anaemia 228 (38.7) 405 (14.7) <0.0001
Receipt of uterotonic 495 (86.4) 2669 (96.8) <0.0001
prophylaxis
also much higher among those referred from other facilities Receipt of uterotonics 524 (89.0) 2578 (93.5) 0.0369
(30.1 versus 2.6%). Figure 3 summarises the incidence of for treatment
SMOs among PPH cases according to HDI group. The most Referred in from 177 (30.1) 71 (2.6) <0.0001
another facility
notable disparities were in maternal deaths, which occurred
Caesarean section 202 (36.1) 633 (23.0) 0.0001
with greatest frequency in low- and medium-HDI settings. HDI group
The receipt of obstetric interventions among PPH cases Very high 14 (2.4) 150 (5.4) 0.0006
with SMOs is shown in Figure 4 according to HDI group. High 109 (18.5) 578 (20.9)
In all HDI settings, the interventions most commonly pro- Medium 128 (21.7) 932 (33.8)
vided were uterotonics for the treatment of PPH and the Low 338 (57.4) 1100 (39.9)
provision of blood products. Other interventions, such as Geographic region
Africa 193 (32.8) 777 (28.2) 0.0765
various surgical manipulations, were more commonly
Asia 286 (48.6) 1285 (46.6)
reported in very high- and high-HDI settings. Latin America and 99 (16.8) 503 (18.2)
the Caribbean
Middle East 11 (1.9) 195 (7.1)
Discussion
Data are n (%). Percentages have been rounded. We used Pearsons
Main findings
chi-square test to test for differences between groups. All tests
In this survey of women giving birth at 352 health facilities were adjusted for clustering at the levels of the health facility and
in 28 countries, the vast majority received at least one country. We also conducted analyses without including women
uterotonic for prophylaxis, and 19% received more than referred from other facilities, and there were no notable differences
one uterotonic. The provision of more than one uterotonic in any of the results presented in this table.
for prophylaxis was even higher (35%) among those diag-
nosed with PPH. The reported rate of PPH among all
women was 1.2%, and factors significantly associated with intravenous antibiotics. Overall, 17.2% of PPH cases
PPH diagnosis included age, parity, gestational age, resulted in an SMO. There were significant differences in
induction of labour, caesarean section, and geographic the incidence of SMOs by age, parity, gestational age, anae-
region. Among those diagnosed with PPH, 92.7% received mia, receipt of uterotonics for prophylaxis or treatment,
uterotonics for the treatment of PPH, one-third received referral from another facility, and HDI group. Rates of
blood products, and about one-quarter received therapeutic death were highest in low-/medium-HDI countries.

10 2014 RCOG
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 Postpartum haemorrhage management, risks, and outcomes

Interpretation
The findings indicate that the provision of uterotonics for
both prevention and treatment of PPH is widespread
among the health facilities that participated in this survey.
This suggests that there has been much progress in imple-
menting recommendations from clinical guidelines for the
prevention and management of PPH.20,27,28 The reported
rate of PPH in this survey (1.2%) was lower than expected
in light of prior research, which estimated the incidence of
PPH among women treated with uterotonic prophylaxis to
be in the range of 36%.3 We suspect that the finding
from this survey may have been influenced by the use of
visual assessment of postpartum bleeding, which is the clin-
ical norm and most likely the predominant method used
Figure 3. Incidence of severe maternal outcomes among women with
PPH, by HDI group. for PPH diagnosis among the facilities in this survey. In
contrast, measured blood loss is frequently used when
attempting to record PPH incidence in studies. Visual esti-
Strengths and limitations mation has been shown to underestimate measured blood
This analysis had some important limitations. As all partic- loss by an average of 100150 ml.2931 It is also possible
ipating facilities were required to have a high volume of that many providers in this survey only documented events
births and the ability to provide caesarean section, the find- of severe PPH (clinically defined as blood loss 1000 ml).
ings may not be generalisable to women who give birth Previous research has documented rates of PPH in the
outside of health facilities or to those who give birth in range of 13% after receipt of a prophylactic uterotonic
lower level facilities where many emergency obstetric inter- when blood loss 700 ml was used to trigger treatment.32
ventions, such as blood transfusion or surgical services, are A more recent study by Zhang and colleagues31 reported
not offered. In addition, we were unable to assess the con- severe PPH (1000 ml blood loss) among 2% of deliveries
tribution of quality of care to SMOs using the current when diagnosed by visual estimation. Despite a lower than
data. expected rate of PPH in this survey, the contribution of

Uterotonics for treatment

Blood products

Hysterectomy

Massive transfusion

Removal of placeta or placental fragments

Artery ligaon/embolizaon
Very high/high HDI group (N = 123)
Medium HDI group (N = 128)
Balloon/condom tamponade Low HDI group (N = 338)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 4. Receipt of obstetric interventions among PPH cases with SMOs, by HDI group.

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 Sheldon et al.

the 1.2% of women diagnosed with PPH to SMOs was nev- and/or necessity of the various interventions provided to
ertheless substantial.23 each woman.
Many of the correlates of PPH incidence in this survey Overall, the findings suggest that when PPH occurs,
were consistent with those from prior research. In particu- timely access to adequately equipped facilities is critical.
lar, nulliparity, induction of labour, and caesarean section Strengthening institutional capacity, including the quality
were all associated with significant increases in the odds of of PPH care, at all levels of the healthcare system will
PPH, and the odds of PPH also varied by geographic contribute to efforts to reduce maternal mortality.
region. In contrast with prior research, a parity of three or
more was also significantly associated with increased odds
Conclusion
of PPH. Interestingly, the provision of uterotonic prophy-
laxis had no significant effect on PPH risk, whereas prior The use of essential maternal interventions, including
research has found that receipt of prophylaxis reduces the uterotonics for the management of postpartum haemor-
risk of PPH by up to 60%.19,20 As already noted, however, rhage, was high in the participating facilities. Yet even
the data from this survey may not reflect the incidence of among hospitals with the capacity to provide all essential
bleeding more than 500 ml, which would make it difficult interventions, disparities in the incidence of maternal
to assess adequately the full impact of uterotonic prophy- death and other severe outcomes persist. This highlights
laxis. Furthermore, we cannot be entirely certain about the the need for better information about the role of institu-
validity of what providers reported as either prophylaxis tional capacity, including quality of care, in PPH-related
versus treatment of PPH. morbidity and mortality. A focus on quality of care and
The data showing the percentage of women for whom implementing evidence-based practice in PPH management
more than one uterotonic was given and documented as should contribute to improvements in maternal health
prophylactic may be indicative of providers using other outcomes.
signals (such as a gush of blood, decrease in blood pres-
sure, or tissue trauma) in the decision to provide addi- Disclosure of interests
tional interventions to women. It is conceivable that The authors declare that we have no conflicts of interest.
non-blood loss indicators may lead many providers to offer
women a second or additional uterotonic before diagnosing Contribution to authorship
PPH. If so, this fact could account for the large differences All authors (WRS, JB, JPV, JPS, AMG, and BW) partici-
in receipt of more than one uterotonic among the PPH pated in the conception and planning of this article, and in
and non-PPH cases documented. the interpretation of the results. WRS performed the data
The data also allude to a blurring between prevention analysis and drafted the article with JB. All authors
and treatment, suggesting that providers may not distin- reviewed the article and provided input to the final version.
guish carefully between the two uses of uterotonics as The corresponding author had access to the full data set
they seek to manage postpartum blood loss. Such a situa- and final responsibility for the decision to submit this
tion raises questions about the international recommenda- article for publication.
tions supporting different dosages of uterotonics for
prevention and treatment, if indeed there is little differ- Details of ethics approval
ence in practice between the two indications. Given that The HRP Specialist Panel on Epidemiological Research
the survey did not define PPH or require similar mea- reviewed and approved the study protocol for technical
surement indices for all deliveries, the confusion could content. This study was approved by the WHO Ethical
also result from a lack of clear instructions for providers Review Committee and the relevant ethical clearance mech-
as to which interventions should be marked as prevention anisms in all countries (protocol ID, A65661; date of
and treatment. approval, 27 October 2009).
The findings indicate that the coverage of essential
maternal interventions, including uterotonics for the Funding
management of postpartum haemorrhage and intravenous The original survey was financially supported by: the UNDP/
antibiotics for maternal infections, was high in the UNFPA/UNICEF/WHO/World Bank Special Programme of
participating facilities. In spite of the availability of these Research, Development and Training in Human Reproduc-
interventions, maternal morbidities and mortalities persist, tion (HRP); World Health Organization (WHO); United
most notably in low- and medium-HDI settings. Although States Agency for International Development (USAID); Min-
there were some differences in the interventions given istry of Health, Labour and Welfare of Japan; and Gynuity
across HDI groups, the survey design does not allow us to Health Projects. This secondary analysis was funded by a
assess the contributions of the quality, timing, availability, grant from the Bill and Melinda Gates Foundation.

12 2014 RCOG
The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.
 Postpartum haemorrhage management, risks, and outcomes

18 Tuncalp O, Hofmeyr GJ, Gu lmezoglu AM. Prostaglandins for

Acknowledgements
preventing postpartum haemorrhage. Cochrane Database Syst Rev
The authors wish to thank all members of the WHO Mul-
2012;15:8.
ticountry Survey on Maternal and Newborn Health 19 Cotter AM, Ness A, Tolosa JE. Prophylactic oxytocin for the third
Research Network, including regional and country coordi- stage of labor (review). Cochrane Database Syst Rev 2001;2001:
nators, data collection coordinators, facility coordinators, CD000201.
data collectors, and all of the staff at the participating 20 World Health Organization. WHO recommendations for the
Prevention and Treatment of Postpartum Haemorrhage. Geneva:
facilities, who made the survey possible. &
WHO, 2012. Available from: http://apps.who.int/iris/bitstream/
10665/75411/1/9789241548502_eng.pdf.
21 Mousa H, Alfirevic Z. Treatment for primary postpartum
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2014 RCOG 13
The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.