Despite advances in obstetric care, postpartum haemorrhage (PPH), which is excessive bleeding after childbirth, continues to be the leading cause of maternal deaths worldwide. The World Health Organization (WHO) estimates that it is responsible for nearly one in four maternal deaths, with India accounting for 12% of this toll.
In 2023, the WHO and partners launched the Roadmap to Combat Postpartum Haemorrhage 2023–2030, a strategy aimed at reducing preventable deaths by strengthening health systems, scaling up proven interventions, and addressing barriers such as weak supply chains, limited training, and inequities in access. On October 5 this year, WHO issued new consolidated guidelines that call for “earlier detection, faster intervention, and bundled care protocols” to save lives, shifting away from reliance on visual estimation of blood loss and delayed responses.
Systemic gaps persist
“Every minute counts in PPH,” says Sandhya Vasan, head of obstetrics & gynaecology at SIMS Hospitals, Chennai. “In cities, outcomes have improved, but in peripheral locations, systemic failures remain. Blood and medicines may not be available at the right time, referral paths are slow, and sometimes, early warning signs are missed. These are health systems issues more than medical mysteries.”
Shanta Bhaskaran, senior consultant at Apollo Women’s Hospital, Chennai, points out that many hospitals lack standardised maternal care, PPH kits, and trained teams. “Visual estimations of blood loss are grossly inaccurate. The ‘golden hour’ after delivery must be treated with vigilance, including calculating the obstetric shock index,” she says. “Cold chain failures for uterotonics and the rising rates of C-sections and obesity also add to the crisis.”
Prevention and management
The WHO continues to recommend Active Management of the Third Stage of Labour (AMTSL), which includes uterotonic administration, controlled cord traction, and uterine massage. “Carbetocin — a synthetic, longer-lasting version of the hormone oxytocin used to prevent excessive bleeding after childbirth, particularly following a Cesarean section, by causing the uterus to contract — is the first choice where storage allows, but alternatives such as oxytocin, methylergometrine, prostaglandins, and misoprostol are all effective if given on time by trained staff,” Dr. Vasan explains.
Dr. Bhaskaran stresses that misoprostol, being cheap, oral, and heat-stable, is especially useful in rural or low-resource settings. “Uterotonics (medications that cause the uterus to contract) are effective, but only if dosing is correct and drug potency is maintained,” she adds.
The WHO’s updated guidelines place emphasis on acting early, diagnosing PPH not only by measuring 500 ml blood loss but also when 300 ml is accompanied by abnormal vital signs. Calibrated drapes, standardised PPH bundles, and simulation training are highlighted as tools for rapid response.
Research also points to newer interventions. “Tranexamic acid, when given within three hours of birth, significantly reduces deaths from bleeding,” Dr. Vasan notes, citing the WOMAN trial — a large randomised trial that showed tranexamic acid (TXA) reduces the risk of death from PPH by about one-third when given early after childbirth. Balloon tamponade devices and non-pneumatic anti-shock garments are lifesaving tools that can stabilise women until definitive care is reached.
Survival after PPH often comes at a cost. “Women may face long-term consequences such as chronic anaemia, organ damage, infertility, or Sheehan’s syndrome leading to amenorrhoea,” says Dr. Vasan. “Psychological impacts– anxiety, depression and post-traumatic stress are also common, but poorly addressed in health systems that focus only on discharge.” Dr. Bhaskaran adds that recovery is often under-researched: “Lactation failure, cardiovascular impacts and emotional strain on families remain invisible outcomes.”
Policy priorities
Experts say that the path forward lies not only in medical innovation but in health system reform. Dr. Vasan underscores the need for “reliable supply chains, written protocols, and routine team drills.” Dr. Bhaskaran highlights the importance of structured referral systems, simulation-based training, and regular audits of both maternal deaths and near misses.
The WHO’s 2025 guidelines recommend the MOTIVE bundle — Massage, Oxytocic drugs, Tranexamic acid, Intravenous fluids, Vaginal/genital tract exam, and Escalation to be initiated immediately upon PPH diagnosis. “These are straightforward steps that work if implemented consistently,” Dr. Vasan says.
While the Roadmap and updated guidelines provide a framework, implementation remains uneven. As WHO has emphasised, preventing PPH deaths will require political will, investment in frontline staff, and closing the gap between policy and practice.
As Dr. Bhaskaran puts it, “The mantra should be: anticipate, prevent, perform and update. Only then can we transform PPH from a leading cause of death into a preventable complication.”
Published – October 13, 2025 06:10 pm IST
