Postpartum hemorrhage: A preventable cause of maternal death
April 14, 2025
Postpartum hemorrhage is characterized by blood loss over 500mL after vaginal delivery or 500mL to 1,000mL after cesarean section, categorized into primary (within 24 hours) and secondary (from 24 hours to 12 weeks) hemorrhage.
Postpartum hemorrhage (PPH) remains a critical issue in maternal health, recognized as a preventable cause of maternal death. As Professor Datuk Dr Harlina Halizah Hj Siraj, an Obstetrician & Gynecologist at Universiti Kebangsaan Malaysia (UKM), emphasizes, “When a mother passes away, the entire family is profoundly affected. While the father may eventually find another partner, the child will never have another mother. This stark reality underscores the urgency of addressing PPH, which has historical significance; for instance, the Taj Mahal was built by Shah Jahan to honor Mumtaz Mahal, who died from PPH after delivering her 14th child in 1631.
Defining postpartum hemorrhage PPH is defined as blood loss exceeding 500mL following a vaginal delivery and between 500mL to 1,000mL after a cesarean section. Dr Harlina clarifies that “this measurement is subjective and is divided into primary and secondary. Primary (early) happens within 24 hours of delivery, while secondary (late) occurs from 24 hours to 12 weeks post-delivery.” Even if a mother appears stable within the first 24 hours, there remains a risk of later PPH that could be life-threatening. The importance of PPH awareness PPH is one of the most common obstetrical emergencies and a leading cause of maternal morbidity, ranking among the top three causes of direct maternal death in both developing and developed countries. It is also the primary reason for ICU admissions, with incidences of 4% after vaginal deliveries and 6.5% after cesarean sections. Alarmingly, 52% of maternal deaths are linked to three preventable causes: hemorrhage, sepsis, and hypertensive disorders. PPH can rapidly become fatal, capable of killing a healthy woman within minutes. The World Health Organization estimates that 25% of maternal deaths are due to PPH, affecting approximately 14 million women globally each year. Global impact and statistics PPH poses a significant threat to mothers worldwide, with 1 in 6 women experiencing this condition. It remains the leading cause of maternal mortality, particularly in low- and middle-income countries. Current trends indicate that we are falling short of achieving the WHO's maternal mortality rate (MMR) target of fewer than 70 deaths per 100,000 live births by 2030. Complications of postpartum hemorrhage The complications arising from PPH include:
Trends in maternal mortality in Malaysia In Malaysia, maternal mortality rates have significantly decreased, thanks to improvements in the healthcare delivery system. Data from the Ministry of Health shows a drop from 1,080 maternal deaths per 100,000 live births in 1933 to 21.1 in 2019. However, the number of cases has persisted, with an increase during the COVID-19 pandemic to 26.0 in 2022. Causes of postpartum hemorrhage The four primary etiologies of PPH are:
Risk factors for postpartum hemorrhage Several risk factors increase the likelihood of PPH, including:
Dr Harlina notes, “Even if you're a first timer, you still have risk because you do not know how you're going to perform. As compared to maybe if this is the second or the third.” Early recognition and management of PPH Uterine atony accounts for 70-80% of primary PPH. After birth, uterine contraction is essential for controlling bleeding. If the uterus is atonic, uterine vessels remain open, resulting in significant blood loss. “If it’s still very flabby, then it might be the cause of PPH,” Dr Harlina advises. Any blood loss greater than 500 mL after vaginal delivery warrants immediate investigation. PPH is a preventable tragedy that requires heightened awareness and early intervention. As maternal health professionals, it is imperative to recognize the signs of PPH and implement preventive measures to safeguard the lives of mothers and their families. |
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