Editorial

Postpartum haemorrhage: aligning for renewed action

The Lancet Global Health

Lancet Global Health 2025; 13: e1781

https://doi.org/10.1016/S2214-109X(25)00417-6

October 5 marked the first World Postpartum Haemorrhage Day. Postpartum haemorrhage (PPH) is the leading cause of maternal mortality globally, despite being largely preventable. Addressing it will be key to achieving the currently unreachable Sustainable Development Goal of reducing the maternal mortality ratio to less than 70 per 100 000 livebirths. In recognition of this fact, WHO in 2023 launched a Roadmap to Combat Postpartum Haemorrhage, which aimed to tackle knowledge gaps in prevention, detection, and treatment of PPH; align fragmented efforts around guidelines and recommendations; and harness intersectoral experience, including that of civil society and professional organisations, to map a way forward.

In addition to the advent of World Postpartum Haemorrhage Day itself, another of the key outputs of the Roadmap is a set of new, consolidated guidelines for the prevention, detection, and treatment of PPH. The guidelines, introduced in a Comment this month by Aris Papageorghiou and colleagues, were produced jointly, for the first time, between WHO, the International Federation of Gynecology and Obstetrics (FIGO), and the International Confederation of Midwives (ICM).

One key innovation in the guidelines is the introduction of a new threshold for intervention. PPH was hitherto defined by WHO as blood loss of 500 mL or more from the genital tract within 24 h after birth, which is often visually estimated. Yet new evidence suggests that use of a lower threshold could have the potential to save more lives by prompting earlier intervention. In an Article in this month's issue, Kristie-Marie Mammoliti and colleagues used data from the E-MOTIVE trial to study the timing of PPH diagnosis across 39 hospitals in Nigeria, Kenya, Tanzania, and South Africa. The authors observed that the median time from vaginal birth to PPH diagnosis was about half as long in Nigeria, Tanzania, and Kenya (15 or 17 min) as it was in South Africa (30 min). Notably, the former three countries used a diagnostic blood loss threshold of 300 mL or more, combined with at least one abnormal clinical sign, whereas the South African centres mostly used a threshold of 500 mL. Additionally, an individual participant data meta-analysis published in The Lancet this month found that objectively measured blood loss of 300 mL or more has a higher sensitivity for predicting death or life-threatening complications from postpartum bleeding than a threshold of 500 mL. Similar specificity could be reached by combining this lower threshold with any other abnormal haemodynamic sign (pulse >100 beats per min, systolic blood pressure <100 mm Hg, diastolic blood pressure <60 mm Hg, or shock index >1·0). The new consolidated guidelines formally recommend a threshold of 300 mL blood loss—using calibrated drapes for objective measurement—and the presence of one or more abnormal vital signs as a signal to intervene.

The alignment of WHO with the two leading professional organisations in women's health is a welcome step forward in the quest for concerted action on PPH. The guidelines also present an opportunity to bring prevention into equal focus with treatment, suggest Franka Cadee and colleagues in a further Comment in this issue. Excitement over the success of the E-MOTIVE trial, with its first-response treatment bundle, may have shifted focus downstream in the cascade of events that lead to PPH, they propose. Equally important should be the upstream prevention windows offered during antenatal care. The guidelines devote three pages to antenatal prevention, via testing for anaemia and iron supplementation, and they do include alternative recommendations depending on the health system context (eg, the availability of full blood count testing). However, they also assume that pregnant women access the WHO-recommended eight high-quality antenatal care visits in the first place, which most women in LMICs still do not. Cadee and colleagues also point to the high prevalence of substandard or falsified uterotonic drugs in LMICs, which is a major barrier to the success of a first-response treatment bundle.

Publication of the consolidated guidelines is an important milestone on the Roadmap to Combat PPH. To maximise its impact, this alliance of stakeholders—in collaboration with national policy makers, educators, and health workers—will need to realise the critical implementation elements of the Roadmap. Tackling supply chain issues, access to antenatal care, and the persistent low status of women in many countries are more daunting goals that require dedication, patience, and hope.