‘Postpartum haemorrhage remains a major challenge in areas with limited access to healthcare facilities’

Postpartum haemorrhage (PPH) is one of the major causes of maternal death across the globe. According to a 2020 study published in The Lancet Global Health Journal, India accounts for approximately 19 per cent of global maternal deaths, with PPH as the leading cause.

The World Health Organization (WHO) defines PPH as a “blood loss of 500 ml or more within 24 hours after birth, while severe PPH is defined as a blood loss of 1,000 ml or more within the same timeframe.”

The global health body maintains that every year, about 14 million women experience PPH resulting in about 70,000 maternal deaths globally. Even when women survive, they often need urgent surgical interventions to control the bleeding and may be left with a life-long reproductive disability, the UN Health body maintains.

“Postpartum hemorrhage (PPH) is a condition that occurs when there is excessive bleeding after the delivery of a baby,” Dr. Nandita P Palshetkar, Medical Director & consultant IVF specialist, Boom IVF centre, told Financial Express.com.

‘A serious and potentially life-threatening complication’

According to Dr. Palshetkar, PPH is a serious and potentially life-threatening complication of childbirth that requires immediate medical attention.

There are several reasons for the occurrence of PPH:

Uterine atony: This is the most common cause of PPH and occurs when the uterus fails to contract after delivery, resulting in excessive bleeding.

Trauma: Sometimes, trauma during delivery can cause PPH, such as when the uterus or cervix tears, or when the perineum is severely lacerated.

Uterine inversion: This occurs when the uterus turns inside out after delivery, which can cause severe bleeding.

Placenta accreta: This is a condition in which the placenta is attached too deeply to the uterine wall, making it difficult to remove after delivery and increasing the risk of PPH.

“Risk factors for PPH include a history of PPH, multiple pregnancies, large babies, prolonged labor, and certain medical conditions, such as hypertension or diabetes. It is important to receive proper medical care during pregnancy and delivery to minimise the risk of PPH,” she added.

What is the status of Postpartum haemorrhage in India?

PPH is a major cause of maternal mortality and morbidity in India. According to the latest data from the National Health Mission, PPH accounts for approximately 20 percent of maternal deaths in the country.

“In absolute terms, this translates to about 12,000 women dying from PPH every year in India. The number of PPH cases is on the rise due to the birthing age of women, higher BMI, high birth weight (macrosomia), inadequate prenatal care, poor nutrition, lack of skilled birth attendants, delays in seeking medical care, and limited access to emergency obstetric services. There is commonly an underestimation of visible blood loss by as much as 50% resulting in delay in recognition and management of PPH,” Dr. Palshetkar told Financial Express.com.

She also informed that the government has launched various initiatives, such as the Janani Shishu Suraksha Karyakram (JSSK) program, which provides free maternal and neonatal care services to women and children in government health facilities. Additionally, the government has also introduced the use of oxytocin, a medication that helps prevent and treat PPH, in all public health facilities, she added.

“Despite these efforts, PPH remains a significant challenge in India, especially in rural areas where access to healthcare is limited. There is a need for continued efforts to improve maternal healthcare services and raise awareness among women about the risks of PPH and the importance of seeking medical care during and after delivery,” she told Financial Express.com.

Dr. Mahesh Gupta, Gynaecologist and Senior High-Risk Pregnancy Expert, Tertiary Referral Centre for Placenta Accreta Spectrum, Matis Multi-Speciality Hospital, Ahmedabad, told Financial Express.com that the Indian scenario for PPH and death due to PPH is not impressive.

“When we compare to the Western world, we are far behind to lower our Maternal Mortality Ratio. But, in the recent past, we are trying to achieve and almost achieved the set goal for SDG and MDG. Now, the MMR is almost 130 maternal deaths per one lac birth. This is the national average and differs state-wise,” Dr. Gupta said.

What are some of the antepartum and intrapartum risk factors for Postpartum Haemorrhage?

According to Dr. Palshetkar, Antepartum and intrapartum risk factors are two categories of factors that can increase the risk of postpartum hemorrhage (PPH).

Antepartum risk factors are those that exist before labor and delivery, while intrapartum risk factors are those that occur during labor and delivery. Antepartum risk factors include maternal conditions or factors that can make a woman more likely to experience PPH during or after delivery, such as anemia, placenta previa, or coagulation disorders, she explained.

In contrast, intrapartum risk factors are related to the process of labor and delivery itself, such as prolonged labor, instrumental delivery, or shoulder dystocia. The management and prevention of PPH for antepartum and intrapartum risk factors may differ. For example, managing anemia or coagulation disorders during pregnancy may help prevent PPH caused by these factors, while managing a prolonged second stage of labor may help prevent PPH caused by intrapartum factors.

“It is important for healthcare providers to identify these risk factors early on and take appropriate measures to prevent and manage PPH during and after delivery,” she told Financial Express.com.

What are the symptoms of Postpartum hemorrhage?

According to Dr. Palshetkar, the most common symptom of PPH is heavy or excessive bleeding from the vagina. This bleeding may be accompanied by passing large blood clots or tissue from the vagina.

“Women experiencing PPH may also experience increased heart rate or palpitations, low blood pressure, and pale or clammy skin. She may also feel cold and shivery with shortness of breath, abdominal pain, nausea or vomiting, and anxiety. It’s important to note that not all women experience symptoms of PPH, especially in cases of slow, gradual bleeding. Therefore, it’s crucial to monitor a woman’s blood loss after delivery and to seek medical attention immediately if there are any concerns or signs of excessive bleeding. Early detection and prompt management of PPH can save lives and prevent serious complications,” she told Financial Express.com.

Are enough drugs and treatment options available for Postpartum hemorrhage in India?

According to Dr. Palshetkar, institutional deliveries have played a crucial role in reducing maternal mortality rates (MMR). However, for severe postpartum hemorrhage (PPH) cases, multi-speciality care is necessary, and India has several treatment options available, both medical and surgical.

“Despite this, the management of PPH is an evolving field, and evidence-based approaches and newer advances are being developed. The current situation highlights the need for research on newer approaches to tackle PPH, which can be implemented effectively alongside existing practices. Therefore, there is still a need for more medical management options that can act rapidly in controlling bleeding, particularly for severe cases of PPH,” she added.

Meanwhile, Dr. Gupta told Financial Express.com that enough drugs are available in India to treat Postpartum Haemorrhage like Oxytocin, Carbetocin, Prostaglandins, Misoprostol, Trenaxaemic acid.

“These all are ergotonics, which makes the uterus contract, uterine contraction will stop PPH. But in a few cases despite giving all drugs, the uterus fails to contract. Such cases are to be taken for a surgical line of treatment and specific surgeries are to be done to save the life of a pregnant mother,” he revealed.

What are the challenges of treating Postpartum haemorrhage in India?

Dr. Palshetkar emphasised that PPH is a major challenge in India, and treating it can be difficult due to various reasons, including:

Early recognition of PPH: Early recognition of PPH is crucial for timely treatment, but in many cases, it goes unnoticed or is not identified until it is too late. This can lead to delayed treatment and increase the risk of complications.

Infrastructure for conducting many surgical procedures: India has a vast population, and many healthcare facilities lack the infrastructure for conducting many surgical procedures required for treating PPH. This leads to inadequate care for women with PPH, especially in rural areas.

Lack of experienced staff and blood banks in many parts of India: Many parts of India lack experienced healthcare staff and blood banks, which are essential for managing PPH effectively. The unavailability of blood products can increase the risk of mortality in women with PPH.

Late initiation of referrals to better equipped centers: Referrals to better-equipped centers are often initiated too late, leading to delayed treatment and an increased risk of complications.

Increased recovery time after surgical interventions: Surgical interventions are often required to manage PPH, but these can lead to increased recovery time and prolonged hospital stays, which can delay the mother’s joyous journey with the infant and increase the need for additional hospital resources.

“Overall, addressing these challenges requires a concerted effort from healthcare providers, policymakers, and communities to improve maternal healthcare services, increase access to trained personnel and equipment, and raise awareness about the importance of seeking medical care during and after delivery. We also recommend at least 4 doctor visits, however, seeing your gynecologist on a monthly basis is a good practice,” she added.

According to Dr. Gupta, awareness and sensitisation of this condition is extremely important.

“Antenatal Anaemia should be corrected, all high risk cases should be identified in advance so as to transfer them to proper centres, all maternity cases must be handled by qualified and trained personnel with supervision, blood bank and pathology laboratory should be within a reasonable distance, there should be surgically skilled Doctors, should be called for as and when needed,” he told Financial Express.com.

What more needs to be done in this area?

Dr. Palshetkar stressed that improving maternal health outcomes in high-risk cases in India requires addressing several factors.

“One such factor is the need for education and training to increase the number of doctors capable of handling complex cases. In addition, greater awareness is necessary around newer medical treatment options, such as Carbetocin for prophylaxis and coagulation factor VII in case of severe PPH and emergency situations,” she said.

Ensuring access to these medical management options is also crucial, particularly in hospitals with less advanced infrastructure facilities, she told Financial Express.com.

“Finally, reducing the time spent in recovery postpartum is essential, as prolonged hospital stays can cause significant emotional and financial strain on families. By addressing these critical areas, it may be possible to improve maternal health outcomes and ensure the safe delivery of newborns in India,” she said.

According to Dr. Gupta, proper referral system should be established to transfer the serious patient and regular training seminars and surgical workshop to train medical graduates on rare surgeries

“Myself as a Postpartum subject expert, must say that no woman should die when giving birth. So all gynaecologist federations, societies and government should form a group to keep vigil over maternal death, should set a goal for the coming 3 or 5 years, review all deaths, and scrutinise all deaths to learn, and how it can be reduced,” he added.

According to the latest data from the National Health Mission, PPH accounts for approximately 20 percent of maternal deaths in the country. 

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