Postpartum haemorrhage
Heavy bleeding after a baby is born. It is one of the most common complications of childbirth. It is also a leading cause of death for mothers worldwide, and most of those deaths happen in low- and middle-income countries.
Also called Postpartum hemorrhage · PPH
- Condition
- In this atlas
Overview
Technical summary
Two definitions appear in this atlas and each belongs to its source. WOMAN let hospitals treat a woman as having PPH on a clinical diagnosis, based on estimated blood loss of more than 500 mL after vaginal birth or 1000 mL after caesarean section, or any loss that compromised haemodynamic stability. That is the trial eligibility wording, not WHO wording. WHO 2025 Recommendation 22 gives a "therapeutic definition" meant to start treatment, built on objectively measured blood loss: 300 mL or more with any abnormal haemodynamic sign, or 500 mL or more, whichever occurs first within 24 hours after birth. The older rule of thumb is a loss of more than 500 mL within 24 hours. The two burden figures from WHO (2023 and 2025) have different bases and are kept as separate claims.
Recognition
Bleeding is often noticed late when blood loss is judged by eye. WHO says visual estimation is frequently inaccurate and recommends measuring blood loss objectively (Recommendation 21).
Assessment
WHO 2025 Recommendation 22 uses objectively measured loss of 300 mL or more with any abnormal haemodynamic sign (pulse above 100 beats a minute, shock index above 1, systolic pressure below 100 mmHg or diastolic pressure below 60 mmHg), or 500 mL or more, whichever occurs first within 24 hours after birth, with particular vigilance during the first 2 hours.
Burden
WHO's 2023 recommendations say there were an estimated 287 000 maternal deaths worldwide in 2020, most of them in the world's least developed countries. WHO says obstetric haemorrhage is the leading cause of maternal mortality, accounting for 27% of all maternal deaths occurring worldwide each year, and that most of these deaths are due to postpartum haemorrhage. WHO estimates that about 14 million women experience PPH each year.
Applies to Maternal- Women who died of maternal causes worldwide (2020 estimate) and women who experience postpartum haemorrhage each year (WHO estimate).
- Not stated in the source
- Worldwide. WHO says most deaths occurred in the world least developed countries.
- Pregnancy, childbirth and the postpartum period
- Gestational age Not reported
- Postnatal age Not reported
- Certainty method
- Not assessed
- Limitations
- These are WHO estimates in an executive summary, not counts. The 27% is a share for obstetric haemorrhage as a whole, and the passage dates only the 287 000 figure to 2020. The 2025 WHO statement that PPH accounts for nearly one fifth of all maternal deaths has a different basis and is a separate claim. The two figures are not combined or reconciled. The sources WHO cites were not read.
- Last checked
- 2026-10-11
- Next evidence check due
- Not scheduled
Sources and citations (1)
-
- Locator
- Executive summary, Introduction, para 1
- How it applies
- WHO 2023 recommendations, CC BY-NC-SA 3.0 IGO; short quotation with attribution.
- Retrieved
- Source effective date
- Not reported
- Source state
- Current
- Snapshot hash
36364aa61f4e3b6dc00561e5a5d6aff380639230952bda6cab1db58d81c66ad8- Reuse basis
- Licensed CC BY-NC-SA 3.0 IGO, as stated in the PDF and in the IRIS record. Only short quotations with attribution are used, and neither the PDF nor the pages are committed. The non-commercial and share-alike terms need a licensing decision before any text is adapted.
WHO's 2025 consolidated guideline says postpartum haemorrhage accounts for nearly one fifth of all maternal deaths worldwide and is the main cause of maternal death in most low-income countries. It says about 80% of related deaths occur in low- and middle-income countries, particularly in sub-Saharan Africa and South Asia.
Applies to Maternal- Maternal deaths worldwide, with the share attributed to postpartum haemorrhage, and the share of related deaths in low- and middle-income countries.
- Not stated in the source
- Worldwide, with a focus on low- and middle-income countries, particularly in sub-Saharan Africa and South Asia.
- Pregnancy, childbirth and the postpartum period
- Gestational age Not reported
- Postnatal age Not reported
- Certainty method
- Not assessed
- Limitations
- The 2025 text gives no year for these figures and cites a reference that was not read. The 2023 WHO figure (obstetric haemorrhage as 27% of maternal deaths) has a different basis and is a separate claim. The two are not combined or reconciled.
- Last checked
- 2026-10-11
- Next evidence check due
- Not scheduled
Sources and citations (2)
-
Supports Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage
- Locator
- Executive summary, Introduction, para 1: nearly one fifth of maternal deaths
- How it applies
- WHO 2025 consolidated guideline, CC BY-NC-SA 3.0 IGO; short quotation with attribution.
- Retrieved
- Source effective date
- Not reported
- Source state
- Current
- Snapshot hash
2049fb40dff7e97712c98cb58907ef662161627197a5e143ec50045abb1931de- Reuse basis
- Licensed CC BY-NC-SA 3.0 IGO, as stated in the PDF and in the IRIS record. Only short quotations with attribution are used, and neither the PDF nor the pages are committed. The non-commercial and share-alike terms need a licensing decision before any text is adapted.
-
Supports Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage
- Locator
- Introduction, para 4: about 80% of related deaths in low- and middle-income countries
- How it applies
- WHO 2025 consolidated guideline, CC BY-NC-SA 3.0 IGO; short quotation with attribution.
- Retrieved
- Source effective date
- Not reported
- Source state
- Current
- Snapshot hash
2049fb40dff7e97712c98cb58907ef662161627197a5e143ec50045abb1931de- Reuse basis
- Licensed CC BY-NC-SA 3.0 IGO, as stated in the PDF and in the IRIS record. Only short quotations with attribution are used, and neither the PDF nor the pages are committed. The non-commercial and share-alike terms need a licensing decision before any text is adapted.
Clinical links
Each link reports what one cited claim says about one population. "Evaluated for" means studied, not shown to work. These links do not show that anything is effective or right for you.
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Claim, not a settled fact Recommended for this: Objective measurement of postpartum blood loss
Applies to Maternal- All women giving birth. Recommendation 21 covers routine objective measurement. Recommendation 22 applies its criteria within 24 hours after birth, with particular vigilance in the first 2 hours. WHO says the available studies were in women giving birth vaginally and that the criteria have some limitations for caesarean section.
- Not stated in the source
- Global (WHO guidance intended to inform national and subnational policy).
- Childbirth and the first 24 hours after birth
- Gestational age Not reported
- Postnatal age Not reported
WHO 2025 recommends routine objective measurement of blood loss after birth for all women giving birth, to improve the detection and prompt treatment of postpartum haemorrhage (Recommendation 21, category Recommended, Revalidated from the 2023 recommendation). WHO names calibrated drapes for women having vaginal birth as one method. The recommendation is for measuring blood loss, not for a particular product. WHO adds that measurement works only when it is linked with a standardized treatment approach.Limitations. Most of the available evidence is from vaginal birth; WHO says measurement at caesarean birth is also clinically important. WHO says current evidence does not support the diagnostic accuracy of alternatives such as blood collection trays and jars. The evidence tables (Web Annex A, Section 4.1) were not read. The wording is identical to Recommendation 1 of the 2023 document, which WHO integrated unchanged. WHO 2025 labels each recommendation with one of four categories and a development status. These are not GRADE strength labels, so the claim certainty is left not assessed.
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Claim, not a settled fact Recommended for this: PPH detection and first-response treatment bundle
Applies to Maternal- All women having a vaginal birth. WHO says the supporting evidence comes largely from vaginal births in secondary-level facilities and that more research is needed to recommend bundle care at caesarean birth.
- Health facilities. The evidence is largely from secondary-level facilities; WHO says recognition and treatment are equally relevant in primary care, community and home settings.
- Global (WHO guidance intended to inform national and subnational policy).
- Childbirth and the first hours after birth
- Gestational age Not reported
- Postnatal age Not reported
WHO 2025 recommends a standardized and timely approach to managing postpartum haemorrhage for all women having a vaginal birth (Recommendation 29, category Recommended, Revalidated from the 2023 recommendation). The approach combines an objective assessment of blood loss with a treatment bundle supported by an implementation strategy. The first-line bundle includes rapid uterine massage, an oxytocic medicine and tranexamic acid, intravenous fluids, examination of the genital tract and escalation of care.Limitations. The supporting evidence is largely from vaginal births in secondary-level facilities; WHO says more research is needed before recommending bundle care at caesarean birth, although each treatment is separately recommended. The trial behind this recommendation included multiple implementation and health system strengthening strategies, so the recommended package is more than the drape and the medicines. WHO says its evidence on measuring blood loss comes largely from trials using calibrated drapes. WHO 2025 labels each recommendation with one of four categories and a development status. These are not GRADE strength labels, so the claim certainty is left not assessed.
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Claim, not a settled fact Evaluated for this: PPH detection and first-response treatment bundle
Applies to Maternal- Patients having a vaginal delivery in the study hospitals. Hospitals were randomly assigned to the package or to usual care. The abstract reports results among hospitals and patients with data, not for all randomised deliveries. The registry describes its research participants as health care providers attending vaginal births, a different basis from the paper.
- Secondary-level hospitals.
- Kenya, Nigeria, South Africa and Tanzania.
- Childbirth and the first hours after birth
- Gestational age Not reported
- Postnatal age Not reported
E-MOTIVE tested a package, not a single product. The package was a calibrated blood-collection drape for early detection, a bundle of first-response treatments, and a strategy to help hospitals use them. 80 secondary-level hospitals in Kenya, Nigeria, South Africa and Tanzania were randomly assigned to the package or to usual care. "Among hospitals and patients with data", severe bleeding (1000 mL or more), laparotomy for bleeding or death from bleeding occurred in 1.6% of patients with the package and 4.3% with usual care (risk ratio 0.40, 95% CI 0.32 to 0.50). Postpartum haemorrhage was detected in 93.1% against 51.1% (rate ratio 1.58, 1.41 to 1.76), and the bundle was used in 91.2% against 19.4% (rate ratio 4.94, 3.88 to 6.28).Limitations. The effect belongs to the whole package (drape, bundle and implementation strategy) and cannot be split by component, so none of it is credited to the drape or to tranexamic acid alone. Randomisation was by hospital. Only the NEJM abstract was read, because the full text returned HTTP 403 and was not retrieved another way, so analysis methods are not described. The percentages are results among hospitals and patients with data and are not counts of individual patients. The registry gives 99659 enrolled (actual), describes the research participants as health care providers attending vaginal births, and lists no masking; the paper reports 210,132 vaginal deliveries. These are different bases and are not reconciled. The primary outcome is a composite, so the abstract gives no separate effect on maternal death.
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Claim, not a settled fact Evaluated for this: Tranexamic acid for treating postpartum haemorrhage
Applies to Maternal- Women aged 16 years and older with a clinical diagnosis of postpartum haemorrhage after a vaginal birth or caesarean section. WOMAN specified that the diagnosis could rest on clinically estimated blood loss of more than 500 mL after vaginal birth or 1000 mL after caesarean section, or any blood loss sufficient to compromise haemodynamic stability. This is the trial eligibility wording, not a WHO definition. The fundamental eligibility criterion was the clinician uncertainty about whether to use tranexamic acid in that woman. The overall result covers every treatment time.
- Hospitals (193 in the paper).
- Hospitals in 21 countries. The paper site list names Nigeria, Pakistan, Uganda, Kenya, Cameroon, Sudan, United Kingdom, Tanzania, Nepal, Zambia, Albania, Democratic Republic of Congo, Bangladesh, Ethiopia, Burkina Faso, Jamaica, Ghana, Papua New Guinea, Egypt, Colombia and Cote d'Ivoire.
- Postpartum, treated within hours of birth or later
- Gestational age Not reported
- Postnatal age Not reported
In the WOMAN trial, women with heavy bleeding after birth who were given tranexamic acid were less likely to die of bleeding than women given a placebo. 155 of 10 036 women (1.5%) died of bleeding with tranexamic acid, against 191 of 9985 (1.9%) with placebo. The risk ratio was 0.81 (95% confidence interval 0.65 to 1.00, p=0.045). The authors named death due to bleeding as the key secondary outcome. The upper end of the interval touches 1.00, and the primary outcome, death from any cause or hysterectomy, did not differ clearly between the groups (separate claim).Source problem. A cited source is corrected. Check the sources before relying on this claim.
Limitations. Death due to bleeding is a cause-specific secondary outcome. The primary composite showed no clear difference. The upper confidence bound is 1.00. The planned sample of 15 000 was raised to 20 000 during the trial to estimate this effect, after hysterectomy decisions were found to be often made at the time of randomisation. The authors state that they pre-specified this outcome and the time-to-treatment subgroups before un-blinding. Clinicians recorded the immediate cause of death, the main cause if there were several. The trial was double-blind. The paper also gives an adjusted risk ratio of 0.78 (95% CI 0.62 to 0.98). Adverse events, including thromboembolic events, did not differ significantly between groups in WOMAN. Pfizer is among the funders and made the trial drug. Analysed numbers are those printed for this analysis (10 036 and 9985); some randomised women were excluded from analysis and the paper prints no total. Source correction: the Lancet printed a correction to this paper (a Department of Error notice; the online article was corrected on 5 May 2017). It changes one number in the procedures section, the tranexamic acid concentration, from 10 mg/mL to 100 mg/mL. The correction notice lists this one change and no other, and the text read for this claim is the corrected text. The source state shows Corrected for that reason.
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Claim, not a settled fact Evaluated for this: Tranexamic acid for treating postpartum haemorrhage
Applies to Maternal- Women aged 16 years and older with a clinical diagnosis of postpartum haemorrhage after a vaginal birth or caesarean section. WOMAN specified that the diagnosis could rest on clinically estimated blood loss of more than 500 mL after vaginal birth or 1000 mL after caesarean section, or any blood loss sufficient to compromise haemodynamic stability. This is the trial eligibility wording, not a WHO definition. The fundamental eligibility criterion was the clinician uncertainty about whether to use tranexamic acid in that woman. The overall result covers every treatment time.
- Hospitals (193 in the paper).
- Hospitals in 21 countries. The paper site list names Nigeria, Pakistan, Uganda, Kenya, Cameroon, Sudan, United Kingdom, Tanzania, Nepal, Zambia, Albania, Democratic Republic of Congo, Bangladesh, Ethiopia, Burkina Faso, Jamaica, Ghana, Papua New Guinea, Egypt, Colombia and Cote d'Ivoire.
- Postpartum, treated within hours of birth or later
- Gestational age Not reported
- Postnatal age Not reported
The primary outcome of WOMAN was death from any cause or hysterectomy within 42 days, counted in the methods from randomisation. Tranexamic acid did not clearly reduce it. 534 women in the tranexamic acid group and 546 in the placebo group had the outcome, a risk ratio of 0.97 (95% CI 0.87 to 1.09, p=0.65). Hysterectomy alone was also not reduced (358 with tranexamic acid and 351 with placebo, risk ratio 1.02, 95% CI 0.88 to 1.07 as printed, p=0.84). The fewer deaths from bleeding seen in this trial did not show up in this combined outcome.Source problem. A cited source is corrected. Check the sources before relying on this claim.
Limitations. The composite joins death with hysterectomy. The authors expected hysterectomy decisions made at the time of randomisation to dilute any effect on hysterectomy. No composite outcome record exists in this atlas, so no finding rows are entered, and this composite is never placed on the all-cause death outcome. The printed placebo percentage differs between the abstract (5.5%) and the results text (5.6%) and is not used. The hysterectomy interval is printed identically in the abstract and the results text as 0.88 to 1.07 around a ratio of 1.02, which is not symmetric; it is recorded as printed and was not recomputed, and the table itself was not located. The denominators printed for the composite are 10 032 (tranexamic acid, Table 3) and 9985 (placebo). Source correction: the Lancet printed a correction to this paper (a Department of Error notice; the online article was corrected on 5 May 2017). It changes one number in the procedures section, the tranexamic acid concentration, from 10 mg/mL to 100 mg/mL. The correction notice lists this one change and no other, and the text read for this claim is the corrected text. The source state shows Corrected for that reason.
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Claim, not a settled fact Recommended for this: Tranexamic acid for treating postpartum haemorrhage
Applies to Maternal- Women with postpartum haemorrhage after vaginal birth or caesarean section. WHO aligns the diagnosis with its objective criteria (Recommendations 21 and 22) and no longer relies on clinical estimation alone, so this population is not identical to the clinically diagnosed women in WOMAN. Treatment is started within 3 hours of birth, counted from the time of birth.
- Settings where emergency obstetric care is provided. Intravenous use only.
- Global (WHO guidance intended to inform national and subnational policy).
- Postpartum, within 3 hours of birth
- Gestational age Not reported
- Postnatal age Not reported
WHO, FIGO and ICM recommend, in the 2025 consolidated guideline (Recommendation 27), giving tranexamic acid into a vein early, within 3 hours of birth, in addition to standard care, for women with postpartum haemorrhage after vaginal birth or caesarean section. The category is Recommended. WHO remarks give 1 g (100 mg/mL) at 1 mL per minute, with a second 1 g dose if bleeding continues after 30 minutes or restarts within 24 hours. The 3 hours are counted from the time of birth, intravenous use only, and the medicine should be avoided with a clear contraindication. This is a treatment recommendation. WHO 2025 does not recommend the medicine for prevention (separate claim).Limitations. WHO labels this recommendation Edited, meaning an existing recommendation with no new impactful evidence, edited for clarity. The 2017 WHO wording said clinically diagnosed and carried the label strong recommendation, moderate quality of evidence; the 2025 text aligns diagnosis with the objective criteria of Recommendations 21 and 22, so its population is not identical to WOMAN clinically diagnosed women. WHO 2025 labels each recommendation with one of four categories and a development status. These are not GRADE strength labels, so the claim certainty is left not assessed. The guideline is co-published with FIGO and ICM; WHO is recorded as issuer because no organisation records exist yet for the other two. WHO web annexes with the evidence base were not read. Supersession was checked only by one IRIS keyword search on 2026-10-11, which listed no later WHO PPH guideline among the newest items it returned. This is not a thorough search.
Record details
- Record id
maternal:postpartum-hemorrhage- Content hash
2d95343541f5ff80e03812e337d81834f9ff5f866dcab8c6e552a02237192fbe