Postpartum haemorrhage remains at forefront of maternal deaths in India; here’s why

Though India has achieved a significant reduction in maternal deaths since 1990, postpartum haemorrhage (PPH) remains the leading cause of maternal deaths in the country with women dying within a few hours after childbirth.

Countries with little preparedness towards medical emergencies are at the highest risk, reports have said.

With the country celebrating maternal mental health this week, it is alarming that a medical condition can quickly turn a healthy delivery into a medical nightmare where the birthing parent could lose their life just after giving birth.

According to the National Health Portal of India, PPH accounts for nearly 35 percent of maternal deaths in the country.

The most disturbing fact is how a woman can suddenly go into a state of physical shock even when the clinical picture post-childbirth remains stable, experts have said.

Why is it the number one cause of maternal death?

Severe bleeding after childbirth is the leading cause of maternal death in the world, not just India, the World Health Organisation (WHO) has said.

It is clinically defined as a blood loss of 500 ml or more within the first 24 hours of childbirth.

Deaths from PPH are highly preventable, but prevention largely depends on the availability of emergency care.

Hence, the cases are more common in low- and middle-income countries.

Among the major causes of PPH in India is the vast occurrence of undiagnosed anemia among women who get pregnant. The pre-existing low reserves of iron in the blood can drastically change a seemingly moderate clinical emergency.

Speaking to DH, Dr. Hrishikesh Pai, a gynaecologist & IVF Specialist at Lilavati Hospital (Mumbai) explained: “Non-anemic women can tolerate 800-1000 ml blood loss while an anemic woman can decompensate quickly with only 400-500 ml loss. So, the prevention of PPH starts much before taking the patient to the delivery table. The treating doctor has to aggressively manage anemia through oral iron supplements, intravenous iron if needed, tracking nutrition and serial hemoglobin monitoring throughout pregnancy.”

As per studies, anemia affects around 50 percent Indian women, with many of them remaining undiagnosed.

Apart from anemia, there are unexpected clinical events that can make women lose a pool of blood. 

Medical scholars have identified four T’s that can cause PPH – 

• Uterine Tone: when the uterus fails to contract and stop the placental blood vessels, leading to blood loss.

• Uterine Trauma: Sometimes, injury to the vagina, cervix or uterus can cause the blood to collect somewhere inside a concealed area and it can result in bleeding.

• Left out placental tissue: In some cases, the placenta doesn’t fully detach from the uterine wall and this causes bleeding.

• Thrombin problem: If a woman has an undiagnosed blood clotting condition, it can also cause unexpected bleeding.

While many of these unexpected factors are not controllable, they can be prevented or timely managed.

A major block in preventing PPH is missing signs of excessive bleeding until it results in a systematic shock.

“Calibrated blood collection drapes and bags for measuring blood have made things easy for us. It enables us to recognise blood loss earlier and act promptly, much before the patient develops severe shock or coagulopathy,” said Dr. Pai.

Delayed identification, underestimation of blood loss, failure to identify, no treatment for maternal anemia and non-standardised emergency response systems are common causes that lead to maternal deaths in many maternal death audits, the expert said.