Global estimates for 2017 indicated that there were 295,000 maternal
deaths, 35 per cent lower than in 2000 with a decline in global maternal
mortality ratio from 342 to 211 deaths per 100,000 live births (World
Health Organization (WHO) 2019). Maternal hemorrhage is the leading
direct cause of maternal death worldwide, representing 27% (20-36) of
maternal deaths ( Say L, et al. Lancet 2014).
Multiple large retrospective population cohorts have identified risk
factors invariably associated with maternal hemorrhage including mode of
delivery, prolonged labor, chorioamnionitis, and twins among others
(Briley A, et al. BJOG 2014). Factors such as maternal BMI, race or
ethnicity, pregnancy induced hypertension, and maternal age have not
been consistently associated with increased PPH and require more
research, especially given the relationship between maternal obesity,
gestational diabetes, pregnancy induced hypertension and PPH.
Over 80% of cases of primary PPH are preventable and are due to uterine
atony. Active management of the third stage is the gold standard for
prevention of PPH. Among women at low risk it is not clear whether
active management provides benefit, as with women at mixed risk or at
high risk for PPH (RR 0.34, 0.14-0.87) (Begley CM, et.al. Cochrane
2019). The WHO has published evidence-based recommendations for
management of PPH and have included use of an effective uterotonic with
oxytocin being the preferred agent with alternatives used in specific
circumstances when oxytocin is not available (Who, 2018). Most recently,
use of tranexamic acid has been introduced for prevention and treatment
of PPH with a potential to reduce risk of severe PPH by 50% and
maternal death by 20%. (Shakir H, et. al. Lancet 2017). These evidence
based interventions have been endorsed by professional organizations and
the WHO, and have contributed to a progressive decrease in maternal
mortality secondary to hemorrhage.
Assessment of risk for hemorrhage incorporates risk factors and
appropriate protocols according to risk, implementing preventive
measures on an individualized basis. It has been demonstrated that
successful implementation requires more than identifying risk factors
and their interdependence. Attention to organizational context,
involvement of entire health care team, and increased recognition of the
role of organizational leadership have been identified as basic
components (Main EK, et al. AJOG 2017).
In this issue of BJOG, Neary et. al. (BJOG 2020 xxxx) address the
important aspect of quality and clinical applicability of risk
assessment tools using a structured review that included systematic
assessment for bias, sample size and both internal and external
validation following a standardized methodology established by PRISMA
and CHARMS. The authors concluded that current risk assessment protocols
have deficiencies related to general obstetrical applicability and lack
of external validation. They recommend development of more broadly
applicable and appropriately validated risk assessment protocols that
would applicable to the general obstetrical population.
Evidenced based risk assessment and corresponding protocols during the
antepartum, intrapartum and most importantly immediately after delivery,
has the potential of contributing to the prevention of over 80% of
maternal deaths attributable to maternal hemorrhage.
No disclosures: A completed disclosure of interest form is
available to view online as supporting information.