Postpartum hemorrhage (PPH) is defined by the World Health Organization (WHO) as blood loss of 500 mL or more following vaginal delivery or 1,000 mL or more following cesarean section.[1] It remains a leading preventable cause of maternal mortality worldwide, accounting for approximately 27% of maternal deaths, particularly in low- and middle-income countries.[2] In Bangladesh, hemorrhage-related maternal mortality showed little improvement between 2010 and 2016, declining from approximately 60 to 53 deaths per 100,000 live births. Nearly two-thirds of these deaths occurred among women who delivered at home, highlighting the need for timely recognition and appropriate obstetric care.[3] The reported prevalence of PPH varies considerably across studies, depending on the diagnostic criteria, methods of blood loss measurement, and characteristics of the study population. A pooled analysis estimated that PPH complicates approximately 6% of deliveries worldwide, although substantial regional variations have been observed.[4] Hospital-based studies have also reported differing rates. A record-based study conducted at a tertiary care hospital in India found a primary PPH rate of 0.73%,[5] while a study from a Brazilian teaching hospital reported a prevalence of 6.8% (131 of 1,936 deliveries).[6] In Bangladesh, a tertiary care hospital in Dhaka reported PPH in 10.24% of deliveries (189 of 1,845), with a considerable proportion of affected women referred from other healthcare facilities.[7] Similarly, a five-year study conducted at a tertiary hospital in Oman documented PPH following both vaginal and cesarean deliveries.[8] Several maternal and obstetric factors are associated with an increased risk of PPH. These include a previous history of PPH, multiple pregnancy, polyhydramnios, fetal macrosomia, grand multiparity, maternal anemia, prolonged or augmented labor, hypertensive disorders, and cesarean delivery.[9] However, the occurrence of PPH cannot always be predicted by identifying these risk factors alone. In the Dhaka-based study, approximately 61% of women who developed PPH had no identifiable risk factors.[7] Similarly, a Brazilian cohort study reported that nearly one-quarter of PPH cases occurred among women classified as low risk at admission. The study suggested that this might be partly due to closer monitoring and more intensive preventive measures among women identified as high risk.[6] Prevention of PPH primarily involves appropriate management of the third stage of labor and the timely administration of prophylactic uterotonic agents. Active management of the third stage of labor has been shown to reduce the incidence of PPH and the need for additional uterotonic treatment compared with expectant management.[10] Among available uterotonic agents, prophylactic oxytocin has been demonstrated to reduce the risk of blood loss of 500 mL or more compared with no uterotonic administration.[11] Other agents and combinations have also been investigated. A network meta-analysis suggested that oxytocin combined with ergometrine and carbetocin may offer greater effectiveness than oxytocin alone for certain bleeding-related outcomes, although their adverse-effect profiles differ.[12] Tranexamic acid has also received considerable attention as an additional preventive and therapeutic option. The TRAAP trial found that prophylactic tranexamic acid following vaginal delivery did not significantly reduce its primary outcome of PPH, although improvements were observed in some secondary bleeding-related outcomes.[13] In contrast, its early administration in women with established PPH has been shown to reduce death due to bleeding.[14] Recent advances have highlighted the importance of early detection and prompt management of PPH. The E-MOTIVE cluster-randomized trial, conducted in 80 hospitals across four African countries, demonstrated that early detection using a calibrated blood collection drape, combined with a standardized first-response treatment bundle, significantly reduced severe PPH and related complications (1.6% vs. 4.3%; risk ratio 0.40).[15] In October 2025, WHO, the International Federation of Gynecology and Obstetrics (FIGO), and the International Confederation of Midwives (ICM) issued consolidated guidelines on the prevention, diagnosis, and treatment of PPH, comprising 51 recommendations that emphasize earlier intervention when blood loss reaches 300 mL in the presence of abnormal vital signs, along with the prompt implementation of a standardized first-response treatment bundle.[1] Although considerable evidence is available regarding the risk factors and preventive strategies for PPH, local data evaluating its prevalence and the effectiveness of preventive measures among women with identifiable risk factors remain limited, particularly in tertiary care settings in Bangladesh. Therefore, this study aimed to determine the prevalence of PPH and evaluate the effectiveness of preventive measures among women with identified risk factors in a tertiary care hospital in Bangladesh.

This prospective descriptive study was conducted in the Department of Obstetrics and Gynaecology at Dhaka Medical College Hospital (DMCH), Dhaka, from January to December 2004. During the study period, 8,501 obstetric admissions were recorded, among which 424 cases of postpartum haemorrhage (PPH) were identified, giving an overall prevalence of approximately 4.98%. Of these, 210 patients were included in the detailed clinical analysis based on the study selection criteria. Selection Criteria Inclusion Criteria 1. Patients admitted to the Department of Obstetrics and Gynaecology, DMCH, for delivery during the study period. 2. Patients who developed postpartum haemorrhage (PPH) following delivery at DMCH or elsewhere 3. Patients with complete clinical and obstetric records available for assessment. Exclusion Criteria 1. Patients admitted with bleeding unrelated to PPH. 2. Patients with secondary PPH. 3. Patients who were unwilling to participate in the study. Data Collection Procedure: Data were collected prospectively from eligible patients using a structured questionnaire and clinical assessment. Relevant information included sociodemographic characteristics, obstetric history, antenatal care, antenatal and intrapartum risk factors, mode of delivery, and the timing of PPH onset. Information regarding preventive measures, management approaches, blood transfusion requirements, balloon tamponade, maternal complications, duration of hospital stay, and neonatal outcomes was also recorded. Patients were monitored during delivery and the postpartum period to document the occurrence and management of PPH. Data Analysis: Collected data were checked, organised, and analysed using appropriate statistical methods. Descriptive statistics were used to summarise the findings. Categorical variables were expressed as frequencies and percentages, while continuous variables were presented as mean ± standard deviation, median, and range, as appropriate. The results were presented in tables, figures, and charts. The study was approved by the Institutional Review Committee of Dhaka Medical College Hospital (DMCH).

Table 1: Distribution of Patients by Age, Socioeconomic Status & Antenatal care (n = 210) Age (years) Number of Patients Percentage (%) Less than 20 years 46 21.90 21–25 years 54 25.71 26–30 years 44 20.95 31–35 years 37 17.61 More than 35 years 29 13.80 Socioeconomic Group Low socioeconomic group 130 61.90 Middle socioeconomic group 50 23.80 High socioeconomic group 30 14.28 Antenatal Care Yes 63 30.00 No 147 70.00 In table 1, the majority of patients (54, 25.71%) were aged 21–25 years, followed by 46 (21.90%) patients aged less than 20 years. Forty-four (20.95%) patients were aged 26–30 years, 37 (17.61%) were aged 31–35 years, and 29 (13.80%) were aged more than 35 years. Regarding socioeconomic status, the majority of patients (130, 61.90%) belonged to the low socioeconomic group, while 50 (23.80%) and 30 (14.28%) belonged to the middle and high socioeconomic groups, respectively. In terms of antenatal care, 63 (30.00%) patients had received antenatal care, whereas the majority (147, 70.00%) had not received any antenatal care. Table 2: Distribution of Patients According to Parity & Gestational Age (n = 210) Parity Number of Patients Percentage (%) Para-0 44 20.95 Para-1 74 35.23 Para-2 55 26.19 Para-3 23 10.95 Para-4 11 5.23 Para-5 3 1.42 Gestational Age (weeks) 31–34 weeks 15 7.14 34–37 weeks 34 16.19 37–40 weeks 140 66.66 More than 40 weeks 21 10.00 Table 2 shows that the majority of patients (74, 35.23%) were para-1, followed by 55 (26.19%) who was para-2. Forty-four (20.95%) patients were para-0, while 23 (10.95%), 11 (5.23%), and 3 (1.42%) patients were para-3, para-4, and para-5, respectively. The majority of patients (140, 66.66%) were between 37 and 40 weeks of gestation. Thirty-four (16.19%) patients were between 34 and 37 weeks, while 21 (10.00%) were beyond 40 weeks and 15 (7.14%) were between 31 and 34 weeks of gestation. Table 3: Analysis of Predisposing Antenatal Risk Factors for PPH Antenatal Factors Number of Patients Percentage (%) Hypertensive disorder 45 21.42 Antepartum hemorrhage 31 14.76 Multiple pregnancy 15 7.14 Polyhydramnios 10 4.76 Intrauterine death 12 5.71 History of previous C/S 26 12.38 Jaundice 08 3.80 In Table 3, among the antenatal risk factors associated with postpartum haemorrhage (PPH), hypertensive disorders were the most common, affecting 45 (21.42%) patients, followed by antepartum haemorrhage (APH) in 31 (14.76%) patients and a history of previous caesarean section in 26 (12.38%) patients. Multiple pregnancy was observed in 15 (7.14%) patients, while intrauterine death was reported in 12 (5.71%). Polyhydramnios and jaundice were present in 10 (4.76%) and 8 (3.80%) patients, respectively. Table 4: Analysis of Intrapartum Risk Factors Among the Study Patients Intrapartum Factors Number of Patients Percentage (%) Obstructed labour 05 2.38 Prolong labour 02 0.95 Retained placenta 32 15.23 Atony of uterus 20 9.52 Traumatic 4 1.90 Table 4 shows retained placenta was the most common, occurring in 32 (15.23%) patients, followed by uterine atony in 20 (9.52%) patients. Obstructed labour was observed in 5 (2.38%) patients, while traumatic causes were identified in 4 (1.90%) patients. Prolonged labour was the least common intrapartum factor, occurring in 2 (0.95%) patients. Table 5: Distribution of Patients by Mode of Delivery and Interval Between Delivery and Onset of PPH (n = 210) Mode of Delivery Number of Patients Percentage (%) Normal vaginal delivery 119 56.66 Assisted vaginal delivery (ventouse) 14 6.66 Caesarean delivery 77 36.66 Interval Between Delivery and PPH Onset Immediate 120 57.14 Within 2 hours 75 35.71 Within 2–24 hours 15 7.14 In Table 5, the majority of patients (56.66%) had normal vaginal deliveries, followed by 77 (36.66%) who underwent caesarean delivery. Assisted vaginal delivery (ventouse) was performed in 14 (6.66%) patients. The majority of cases (57.14%) developed PPH immediately after delivery. Seventy-five (35.71%) patients developed PPH within 2 hours, while 15 (7.14%) developed PPH within 2–24 hours after delivery. The pie chart shows that majority of patients (73.3%) developed postpartum haemorrhage (PPH) in the hospital, whereas 56 (26.7%) patients developed PPH outside the hospital and were subsequently referred for management.Figure 2 shows that the majority of patients (70.00%) were managed medically. Intrauterine hydrostatic balloon tamponade using a condom was performed in 48 (22.85%) patients, while 15 (7.14%) patients underwent caesarean hysterectomy. Table 6: Management of the Patient (n=210) Parameters Mean ± SD Median Range Blood Transfusion (Units) 2.98 ± 1.7 2.5 1.00–9.00 Amount of saline required to make tamponade (ml) 348.33 ± 89.52 — 250–500 Average required saline (ml) 300 — — Table 6 shows that the mean number of blood transfusion units required was 2.98 ± 1.70, with a median of 2.5 units and a range of 1–9 units. The mean amount of saline required for balloon tamponade was 348.33 ± 89.52 mL, ranging from 250 to 500 mL, while the average saline volume required was 300 mL. Table 7: Outcome of the Patients (n=210) Parameters Mean ± SD Median Range Hospital stay (days) 8.37 ± 5.68 6.00 3.00–21.00 Sepsis 0 0 0 Table 7 shows that the mean duration of hospital stay was 8.37 ± 5.68 days, with a median of 6 days and a range of 3–21 days. No cases of sepsis were reported among the 210 patients.

During the study period, 424 of 8,501 obstetric admissions were complicated by PPH, giving a prevalence of 4.99%. This was lower than the rates reported in a tertiary hospital in Dhaka (10.24%) [7] and a Brazilian teaching hospital (6.8%),[6] but higher than those reported in Nigerian referral-level hospitals (3.2%) [16] and a tertiary hospital in India (0.73%).[5] These differences may reflect variations in patient characteristics, referral patterns, and healthcare settings. A total of 210 patients were included in the detailed clinical analysis. Most were aged 21–25 years, while approximately one-fifth were below 20 years. This differs from a Dhaka-based study that reported a higher occurrence of PPH among older women.[7] However, socioeconomic findings were similar, as 61.9% of our patients belonged to the low-income group. Previous studies have identified increased PPH risk at both extremes of maternal age, including women below 18 years in China [17] and those above 35 years following caesarean delivery in Nigeria.[16] A notable finding was that 70% of women had not received antenatal care, compared with 75.13% who had received antenatal care in another Dhaka-based study.[7] An Ethiopian meta-analysis and a recent umbrella review also identified lack of antenatal care as an important factor associated with PPH. [18,19] Among the antenatal risk factors, hypertensive disorders (21.42%), antepartum haemorrhage (14.76%), and previous caesarean section (12.38%) were the most common. A Nigerian study reported a strong association between antepartum haemorrhage and PPH, while a Chinese cohort identified previous caesarean section, placental complications, stillbirth, and prolonged labour as important risk factors. [16,17] However, risk assessment alone cannot identify all women who may develop PPH. A Dhaka-based study found no identifiable risk factors in 60.85% of cases,[7] while a Brazilian study reported that approximately one-quarter of PPH cases occurred among women classified as low risk.[6] Among the documented causes of PPH, retained placenta was the most common (15.23%), followed by uterine atony (9.52%). Although uterine atony is generally considered the leading cause of PPH, placental complications have also been reported frequently in tertiary care settings. A Dhaka-based study documented cases involving retained placenta and uterine atony,[7] while a Chinese cohort found that placenta-related complications accounted for more than half of severe PPH cases.[17] Regarding the mode of delivery, 56.66% of women delivered vaginally, 36.66% underwent caesarean section, and 6.66% had ventouse delivery. Most cases of PPH occurred immediately after delivery (57.14%) or within the first two hours (35.71%), highlighting the importance of close postpartum monitoring. A Nigerian study reported higher PPH rates following caesarean delivery than vaginal delivery (4.0% versus 2.7%).[16] In our study, 73.3% of cases developed within the hospital, while 26.7% were referred after the onset of bleeding elsewhere. This contrasts with the Dhaka-based study, where approximately 42% of cases developed in the hospital.[7] Regarding management, 70% of women were treated medically, while 22.85% required condom-catheter balloon tamponade and 7.14% underwent caesarean hysterectomy. Previous studies have reported favourable outcomes with condom balloon tamponade in low-resource settings.[20] However, a multicountry trial in Uganda, Egypt, and Senegal found no significant reduction in PPH-related surgery or maternal death following its introduction.[21] Another study reported no increased risk of postpartum infection, although higher pain scores were observed among women receiving balloon tamponade.[22] The mean hospital stay was 8.37 days, suggesting a relatively prolonged admission that may be related to the severity of bleeding, associated complications, and additional interventions. No maternal deaths were recorded during the study period, whereas a Nigerian referral-level study reported a maternal mortality rate of 4.8% among women with PPH. [16] Stillbirth occurred in 28.6% of pregnancies in our study, comparable to the approximately 25% reported in Nigerian referral-level hospitals.[16] Previous research has also identified stillbirth as a risk factor for severe PPH. [17] Only 5.71% of women had a documented history of intrauterine death before admission. The coexistence of PPH and stillbirth reflects the complex obstetric complications encountered in tertiary care settings. Overall, effective prevention and management of PPH require early recognition, appropriate intervention, and consistent implementation of recommended clinical practices. Regular healthcare provider training and PPH simulation drills are important for improving maternal outcomes.[8] The E-MOTIVE trial demonstrated that early detection and a standardized first-response treatment bundle, supported by simulation training, readily available PPH kits, and clinical audits, significantly improved outcomes.[15] Since most PPH cases in this study developed within the hospital, strengthening blood loss assessment, standardizing PPH management protocols, and conducting regular multidisciplinary training may help improve the timely recognition and management of PPH. LIMITATIONS OF THE STUDY The study was conducted at a single tertiary care hospital with a relatively small sample size and limited study period, which may restrict the generalizability of the findings. Furthermore, the absence of a comparison group limited the assessment of the effectiveness of preventive and management strategies.

Postpartum haemorrhage remains a significant obstetric complication in tertiary care settings, particularly among young women and those from low socioeconomic groups with inadequate antenatal care. Hypertensive disorders, antepartum haemorrhage, retained placenta, and uterine atony were among the major associated risk factors and documented causes. Although most patients were managed medically, some required balloon tamponade or hysterectomy. The findings highlight the importance of improved antenatal care, early identification of risk factors, appropriate preventive measures, and prompt standardized management to reduce maternal and neonatal complications and improve overall outcomes. Further multicentre studies involving both high-risk and low-risk pregnant women are recommended to establish the prevalence of PPH and evaluate the effectiveness of different preventive interventions

1. World Health Organization. Consolidated Guidelines for the Prevention, Diagnosis and Treatment of Postpartum Haemorrhage. Geneva: WHO; 2025. 2. Say L, Chou D, Gemmill A, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323-e333. 3. Jabeen S, Siddique AB, Hossain AT, et al. Haemorrhage-related maternal mortality in Bangladesh: levels, trends, time of death, and care-seeking practices based on nationally representative population-based surveys. J Glob Health. 2023;13:07001. 4. Calvert C, Thomas SL, Ronsmans C, Wagner KS, Adler AJ, Filippi V. Identifying regional variation in the prevalence of postpartum haemorrhage: a systematic review and meta-analysis. PLoS One. 2012;7(7):e41114. 5. Ramani S, Vijaya B. Prevalence and outcome of primary postpartum haemorrhage in a tertiary care hospital: a hospital record based study. New Indian J OBGYN. 2023;9(2):308-313. 6. Martins RIL, Novais JSM, Reis ZSN. Postpartum hemorrhage in electronic health records: risk factors at admission and in-hospital occurrence. Rev Bras Ginecol Obstet. 2024;46:e-2024ao14. 7. Pervin M, Ahmed N, Zahan RR, Banik A. Trends of postpartum haemorrhage and its management in tertiary care hospital, Bangladesh. Sir Salimullah Med Coll J. 2025;33(1):53-60. 8. Fenn MG, Al Falahi M, Al Hinai T, Al Shukaili L, Al Riyami N. Postpartum hemorrhage following vaginal and cesarean section deliveries at a single tertiary hospital: a five-year cross-sectional study. Oman Med J. 2024;39(6):e695. 9. Ende HB, Lozada MJ, Chestnut DH, et al. Risk factors for atonic postpartum hemorrhage: a systematic review and meta-analysis. Obstet Gynecol. 2021;137(2):305-323. 10. Begley CM, Gyte GML, Devane D, McGuire W, Weeks A, Biesty LM. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev. 2019;2:CD007412. 11. Westhoff G, Cotter AM, Tolosa JE. Prophylactic oxytocin for the third stage of labour to prevent postpartum haemorrhage. Cochrane Database Syst Rev. 2013;(10):CD001808. 12. Gallos ID, Papadopoulou A, Man R, et al. Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis. Cochrane Database Syst Rev. 2018;12:CD011689. 13. Sentilhes L, Winer N, Azria E, et al. Tranexamic acid for the prevention of blood loss after vaginal delivery. N Engl J Med. 2018;379(8):731-742. 14. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105-2116. 15. Gallos I, Devall A, Martin J, et al. Randomized trial of early detection and treatment of postpartum hemorrhage. N Engl J Med. 2023;389(1):11-21. 16. Adebayo T, Adefemi A, Adewumi I, et al. Burden and outcomes of postpartum haemorrhage in Nigerian referral-level hospitals. BJOG. 2024;131(Suppl 3):64-77. 17. Liu CN, Yu FB, Xu YZ, et al. Prevalence and risk factors of severe postpartum hemorrhage: a retrospective cohort study. BMC Pregnancy Childbirth. 2021;21:332. 18. Tolossa T, Fetensa G, Zewde EA, Besho M, Jidha TD. Magnitude of postpartum hemorrhage and associated factors among women who gave birth in Ethiopia: a systematic review and meta-analysis. Reprod Health. 2022;19:194. 19. Demissie DB, et al. Global burden, disparities, and determinants of postpartum haemorrhage among women who gave birth: an umbrella review of systematic reviews and meta-analyses. Front Reprod Health. 2025;7:1721550. 20. Mishra N, Gulabani K, Agrawal S, Shrivastava C. Efficacy and feasibility of Chhattisgarh balloon and conventional condom balloon tamponade: a 2-year prospective study. J Obstet Gynaecol India. 2019;69(5):421-426. 21. Anger HA, Dabash R, Durocher J, et al. The effectiveness and safety of introducing condom-catheter uterine balloon tamponade for postpartum haemorrhage at secondary level hospitals in Uganda, Egypt and Senegal: a stepped wedge, cluster-randomised trial. BJOG. 2019;126(13):1612-1621. 22. Anger HA, Durocher J, Dabash R, et al. Postpartum infection, pain and experiences with care among women treated for postpartum hemorrhage in three African countries: a cohort study of women managed with and without condom-catheter uterine balloon tamponade. PLoS One. 2021;16(2):e0245988.