PPH is excessive vaginal bleeding of greater than 500 ml after childbirth. Even a small amount of blood loss can be life-threatening for anemic women—the great majority of women in the developing world. Annually, PPH is a major cause of the more than 500,000 maternal deaths that occurr, responsible for approximately 25% of all maternal deaths globally. Nearly 34% of maternal deaths in Africa and more than 30% in Asia are due to PPH. 

Caused by a variety of conditions, immediate PPH—excessive bleeding directly following childbirth or within the first 24 hours—is the most common type, and 80% of immediate PPH is caused by uterine atony (failure of the uterus to contract properly after delivery). Factors that can contribute to PPH due to uterine atony are high parity, PPH in a previous delivery, a large fetus, multiple fetuses, or excessive amniotic fluid. Other causes include retained placenta, inverted or ruptured uterus, and cervical, vaginal, or perineal lacerations. However, the majority of cases occur in women without these factors who otherwise have normal pregnancies and labors. “Secondary” PPH, defined as hemorrhage after the first 24 hours but less than 6 weeks postpartum, can be produced by retained placental fragments and infection. 

Evidence-Based Interventions to Prevent PPH
Evidence-based interventions suitable for low-resource settings are available that reduce the incidence of PPH and can be implemented by skilled providers or trained community health workers. These include the use of AMTSL by a skilled provider, or use of misoprostol by women who give birth without a skilled provider. Uterotonics (such as oxytocin and misoprostol) cause uterine contractions and have long been used to treat uterine atony and reduce the amount of blood lost following childbirth. Use of a uterotonic drug immediately after the delivery of the newborn is one of the most important interventions to prevent PPH.

AMTSL has been shown to decrease the incidence of PPH by up to 66%. The procedure involves three basic steps: injection of a uterotonic agent (preferably oxytocin) within one minute following the delivery of the baby; delivery of the placenta with controlled cord traction and counter-traction to the uterus; and massage of the uterus after delivery of the placenta, with palpation of the uterus to assess the need for continued massage for the two hour period following delivery of the placenta.

Recent WHO recommendations approve administration of misoprostol by a health worker trained in its use for PPH prevention in the absence of a skilled provider who can perform AMTSL. Misoprostol tablets are ideally suited for PPH treatment at home births and in resource-poor settings due to their ease of use, effectiveness and safety.

Several interventions have shown the feasibility of an approach that educates women on the need for a skilled provider at birth, provides counseling on use of and distribution of misoprostol to be used in the event that the birth takes place without a skilled provider, and follows up women after birth. Findings conclude that use of skilled providers (and thus AMTSL) increases, and women who do not have access to skilled providers still have the protection against PPH afforded by misoprostol.  

Key MCHIP PPH Activities

• Developed the MCHIP Strategy for Accelerating Scale-Up of Interventions to Prevent and Treat PPH to sustain and expand gains made in PPH prevention through USAID partners and other collaborators.
• Created a Quality of Care Assessment Tool that includes observation of providers’ use of AMTSL.
• Expanded and scaled up AMTSL activities in high priority countries.

¹  Rajbhandari S, et al, Expanding uterotonic protection following childbirth through community-based distribution of misoprotol: Operations research study in Nepal. Int J Gynecol Obstet (2009). doi:10.1016/j.igo 2009.11.006

² Sanghvi H, et al, Prevention of postpartum hemorrhage at home birth in Afghanistan. Int J Gynecol Obst (2009). Doi:10.1016/j.igo.2009.12.003