Neema was 27 years old and a mother of one when she experienced postpartum haemorrhage after the birth of her second child. Soon after delivery, she began bleeding heavily, and the bleeding did not stop. Her care team had to act quickly to control the haemorrhage, replace the blood she was losing and stabilise her. Neema survived.
Postpartum haemorrhage, or PPH, is excessive bleeding after childbirth and remains one of the leading causes of maternal death globally. The World Health Organization (WHO) estimates that PPH affects millions of women every year and causes nearly 45,000 deaths. Many of these deaths are preventable.
PPH has traditionally been defined as blood loss of 500 millilitres or more within 24 hours after birth, while blood loss of 1,000 millilitres or more is considered severe PPH. Primary PPH occurs during the first 24 hours. Significant bleeding can also develop after this period, sometimes weeks after a woman has returned home.
In Kenya, obstetric haemorrhage remains one of the major causes of maternal death. This means that preventing maternal deaths from PPH must go beyond encouraging women to deliver in health facilities. The facilities themselves must be able to recognise bleeding quickly and provide emergency treatment when it occurs.
Although certain factors increase the likelihood of postpartum haemorrhage, it is important to remember that PPH can occur in women with no identifiable risk factors at all. This is why every birth, not only those classified as “high risk”, should take place within a health system that is prepared to recognise excessive bleeding early and respond without delay.
The most common cause of PPH is uterine atony. After the placenta is delivered, the uterus should contract firmly to compress the blood vessels that supplied it. When this does not happen, severe bleeding can follow. Other causes include genital tract tears, retained placental tissue, uterine rupture, and clotting disorders. Clinically, these are often grouped as the “four Ts”: tone, trauma, tissue and thrombin.
Risk factors associated with PPH include prolonged or very rapid labour, an overdistended uterus from multiple pregnancy or a large baby, previous postpartum haemorrhage, placental abnormalities, previous uterine surgery including Caesarean section, advanced maternal age, obesity, and disorders that affect blood clotting.
Early recognition and treatment
Anaemia is particularly important. It may not directly cause PPH, but a woman who enters labour already anaemic has less ability to tolerate blood loss. Even a level of bleeding that might be survived by a woman with a normal haemoglobin level may lead to rapid deterioration in a woman who is severely anaemic.
High-quality antenatal care provides opportunities to identify anaemia and other conditions that may make haemorrhage more dangerous. WHO recommends at least eight antenatal contacts. Iron and folic acid supplementation, appropriate nutrition and timely treatment of anaemia can ensure that women enter labour with greater physiological reserves should bleeding occur.
A pregnant woman and her family should know where she intends to deliver, how she will get there, where she will be referred if complications arise and how emergency transport can be accessed. Women identified as being at higher risk should deliver in facilities capable of providing comprehensive emergency obstetric care, including surgery and access to blood.
One of the major challenges in managing PPH is delayed recognition. Blood loss can be underestimated, particularly when assessment relies only on visual observation. Maternity facilities should therefore have systems for measuring blood loss and monitoring changes in a woman’s pulse, blood pressure and general condition after delivery.
Health systems preparedness
Some women will require blood transfusion. Others may require procedures to control bleeding or emergency surgery. In severe cases, the difference between survival and death may depend on whether blood is available, whether an operating theatre is functioning and whether the appropriate clinical team can respond immediately.
This is why a strong and reliable referral system is key. A woman can reach a health facility and still die if that facility cannot provide the care she needs and there are delays transferring her to a higher-level hospital. Emergency transport, communication between facilities and clear referral pathways must therefore form part of PPH preparedness. Communities also have an important role. Families can support antenatal attendance, understand that heavy postpartum bleeding, weakness, dizziness, fainting or increasing illness after delivery require urgent medical attention, develop emergency transport plans before labour and participate in voluntary blood-donation initiatives.
Community health workers can reinforce anaemia prevention, birth preparedness, danger-sign recognition and early referral. Their role is also important after women return home, particularly because secondary PPH can develop after discharge.
But governments and health systems must carry the larger responsibility. Every maternity facility should have adequately trained staff, reliable uterotonics and tranexamic acid, equipment to measure blood loss, intravenous fluids, functioning referral systems and dependable access to safe blood and blood products.
Clinical teams must regularly practise responding to obstetric haemorrhage so that when an emergency occurs, staff already know who will assess the woman, administer medicines, secure intravenous access, obtain blood, arrange theatre and activate referral when necessary.
Preventing deaths from postpartum haemorrhage therefore requires action across the entire continuum of care: preventing and treating anaemia during pregnancy, identifying risk early, preparing women and families for delivery, preventing excessive bleeding during childbirth, recognising haemorrhage quickly and ensuring that emergency treatment is immediately available.
