Prevention and Treatment of Postpartum Hemorrhage: New Advances for Low-Resource Settings

Suellen Miller, CNM, PhD; Felicia Lester, MPH, MS; Paul Hensleigh, MD, PhD


J Midwifery Womens Health. 2004;49(4) 

In This Article

Abstract and Introduction

Postpartum hemorrhage due to uterine atony is the primary direct cause of maternal mortality globally. Management strategies in developed countries involve crystalloid fluid replacement, blood transfusions, and surgery. These definitive therapies are often not accessible in developing countries. Long transports from home or primary health care facilities, a dearth of skilled providers, and lack of intravenous fluids and/or a safe blood supply often create long delays in instituting appropriate treatment. We review the evidence for active management of third-stage labor and for the use of specific uterotonics. New strategies to prevent and manage postpartum hemorrhage in developing countries, such as community-based use of misoprostol, oxytocin in the Uniject delivery system, the non-inflatable antishock garment to stabilize and resuscitate hypovolemic shock, and the balloon condom catheter to treat intractable uterine bleeding are reviewed. New directions for clinical and operations research are suggested.

Vivio and Williams' recent commentary in this Journal[1] discussed the controversy among US-based midwives about the International Confederation of Midwives (ICM) and the International Federation of Gynaecologists and Obstetricians (FIGO) Joint Statement: Management of the Third Stage of Labor to Prevent Postpartum Haemorrhage.[2] As the authors stated, it is difficult to comprehend how postpartum hemorrhage can be the primary direct cause of maternal death, given the resources available to women who give birth in the United States. However, the situation in a resource-rich setting like the United States is far different from the resources available in the developing world, where most maternal mortality occurs. The lack of skilled attendants at delivery who can provide even the minimum of care, long transport times to facilities that can manage uterine atony or severe lacerations of the genital tract, and unattended obstructed labor leading to a ruptured uterus conspire to elevate postpartum hemorrhage to its position as the number one killer of women during childbirth. These structural factors are exacerbated by the prevalence of anemia, which is estimated to affect half of all pregnant women in the world, with that figure rising to 94% in Papua New Guinea, 88% in India, and 86% in Tanzania.[3] Anemia is rarely detected or treated during pregnancy and often exacerbated by malarial and other parasitic diseases.[4] Although the vast majority of cases of postpartum hemorrhage have no identifiable risk factor, young age at marriage[5,6] and low contraceptive use among many women in the developing world result in high total fertility rates, which results in more grand multiparas giving birth in low-resource countries compared with more developed countries.[7] Prevention of postpartum hemorrhage in developing countries is a critical goal.

In this article we discuss the problem of postpartum hemorrhage in the developing world and describe some of the newer technologies and strategies that are being developed for the management and treatment of postpartum hemorrhage in low-resource settings. We report on information from recent international meetings, such as the Bellagio meeting on reduction of maternal mortality,[8] the 2003 FIGO XVII World Conference of Gynecologists and Obstetricians, and the JHPIEGO/United States Agency for International Development-sponsored "Preventing Postpartum Hemorrhage: From Research to Practice" meeting in Bangkok, Thailand, January 2004.


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