Excessive bleeding is the main cause of women dying in childbirth, yet the global guidelines to tackle postpartum haemorrhage (PPH) are inadequate and outdated.

To rectify this, the World Health Organization (WHO) and its partners have developed the world’s first PPH roadmap, and aim to have new global guidelines by the first quarter of 2025.

“Severe bleeding in childbirth is one of the most common causes of maternal mortality, yet it is highly preventable and treatable,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “This new roadmap charts a path forward to a world in which more women have a safe birth and a healthy future with their families.”

The roadmap focuses on four strategic areas – research, norms and standards, implementation and advocacy.

Around 70,000 women die every year as a result of this excessive bleeding, with over 85% of these deaths in sub-Saharan Africa and South Asia. 

Risk factors include anaemia, placental abnormalities, and other complications in pregnancy such as infections and pre-eclampsia. 

Yet the current guidelines are largely silent on how to prevent PPH. Anaemia, or severe iron deficiency, affects 37% of pregnant women around the world – and in some places in South Asia, is as high as 80%. This could be rectified by giving vulnerable pregnant women high-quality prenatal vitamins that include iron.

Lack of trained health workers and medicines

Many countries lack the medicines and trained health workers to stem the excessive bleeding.

Research conducted in four African countries by Dr Hadiza Galadanci, a Nigerian obstetrician, found that many healthcare workers struggled to recognise how much blood loss is too much – and over half the women who experienced PPH were never diagnosed.

“If bleeding starts, it needs to be detected and treated extremely quickly,” according to the WHO. “Too often, however, health facilities lack necessary healthcare workers or resources, including lifesaving commodities such as oxytocin, tranexamic acid or blood for transfusions.”

To address the frequent stock-outs of PPH medicines, the WHO and global partners involved in pooled procurement – such as the Global Financing Facility (GFF), Reproductive Health Supplies Coalition and UNFPA – will conduct a scoping exercise by the end of the year to work out how to “nudge procurement of PPH commodities towards higher quality products and to increase international financing for these commodities”. 

Extending the scope of midwives

One of the measures that the WHO is working on to address the lack of trained health workers is for the scope of practice of midwives to be extended. The International Federation of Gynecology and Obstetrics (FIGO), International Confederation of Midwives (ICM), and ministries of health and national professional societies are assisting with this.

The ICM recently published a scope of practice and competencies for midwives that includes providing intravenous medication, for example.

“Addressing postpartum haemorrhage needs a multi-pronged approach focusing on both prevention and response – preventing risk factors and providing immediate access to treatments when needed – alongside broader efforts to strengthen women’s rights,” said Dr Pascale Allotey, WHO Director for Sexual and Reproductive Health. 

“Every woman, no matter where she lives, should have access to timely, high-quality maternity care, with trained health workers, essential equipment and shelves stocked with appropriate and effective commodities – this is crucial for treating postpartum bleeding and reducing maternal deaths.”

The Bill and Melinda Gates Foundation (BMGF) recently released a report advocating for a simple package of care to be adopted by countries to stem PPH.

Five treatments are conventionally used to stop the bleeding – uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, and genital tract examination. 

“But those interventions were being delivered sequentially – and far too slowly,” according to the report, which advocates for them all to be applied at the same time.

Image Credits: UN Photo/Kibae Park/Flickr.