Trends in Postpartum Hemorrhage in High Resource Countries: A Review and Recommendations From the International Postpartum Hemorrhage Collaborative Group

There is considerable evidence for increasing trends in the incidence of postpartum hemorrhage (PPH) over time. The aim of the present study was to investigate trends in the frequency and the severity of PPH in developed countries, and to assess potential causes for any observed trends.

There was an increasing trend in PPH in Australia, Canada, the United Kingdom, and the United States. The increased incidence of PPH was limited solely to immediate/atonic PPH in Australia, Canada, and the United States. Increasing rates of severe adverse outcomes due to PPH were found in Australia, Canada, the United Kingdom, and the United States.

The key recommendations of the Collaborative Group are as follows: in future revisions of the International Classification of Diseases, there should be separate codes for atonic PPH and other forms of PPH that occur in the first 24 hours after delivery of the placenta. Separate codes are also required for morbidly adherent placenta including placenta accreta, increta, and percreta. A standardized definition of PPH should be used in all countries. Research is needed to determine how current definitions are applied in practice to the coding of data. Improved methods of data collection are required including assessment of severity. Additional studies are required to determine whether increases in rate of PPH have occurred in other countries, and to evaluate the role of potential risk factors of PPH including obesity, increased duration of labor, and changes in management of the second and third stage. A key to reducing the severity of PPH and preventing adverse outcomes is enhanced training of maternity care staff in the assessment of blood loss and the monitoring of women following childbirth. Physicians should be more aware of the likelihood that the frequency and severity of PPH has increased and be more vigilant. The reported increased incidence of PPH is especially a problem in small hospitals with few deliveries. Such hospitals have limited access to equipment or drugs and lack adequate management protocols to treat women with unexpected severe PPH.