Severe Acute Maternal Morbidity and Postpartum Hemorrhage

For every woman who dies of postpartum hemorrhage (PPH), many more suffer shortand long-term consequences even when well managed. During the 1990s, the concept of severe adverse maternal morbidity (SAMM) emerged in response to the need for a more sensitive marker of quality of maternity care than maternal death1,2. This concept and the accompanying acronym have the advantage of drawing attention to surviving women’s health and are applicable in both resource rich and poor countries. As such, SAMM has had increased interest worldwide over the past 5 years, especially in lower income settings such as Brazil3, Indonesia4 and several African countries5,6; at the same time, it is highlighted in a WHO report aiming to quantify the global problem7. The UK is one of the few countries in which every maternal death has been investigated by the Confidential Enquiry into Maternal Death (CEMD) for six decades. In most other developed countries, death from PPH has become too rare for adequate and contemporaneous surveillance of local services. For example, the annual number of maternal deaths from hemorrhage fell from 40 to three in the UK over the past 50 years8, and only 14 deaths were attributed to hemorrhage in the 2003–2005 CEMD triennium. In the 2006–2008 period which recorded nine deaths, only five were attributable to PPH. Currently, the overall maternal mortality rate in the UK is around 11/100,000 maternities with 0.39 deaths/100,000 attributable to hemorrhage, the lowest since the CEMD began in 19529. Obstetric hemorrhage currently represents the sixth leading cause of direct maternal deaths in the UK. Despite a rising cesarean section rate, the actual number of deaths from hemorrhage and genital tract trauma (including ruptured uterus) has declined slightly (although not statistically so) or is static. Lower death rates may be due to recommendations made in previous reports. Within the UK, in 2003 Scotland established a national prospective audit of severe morbidity in parallel to the CEMD. The total SAMM rate varied with time, ranging from 4.5/1000 births in 2003 to 6.2/1000 in 2006, with the rate being 5.88/1000 for 2006–200810. This fluctuation is largely due to changes in the rates of major obstetric hemorrhage (MOH, defined as blood loss of more than 2.5 liters), which initially peaked in 2006 (4.9/1000 live births) and has been declining steadily since to 4.3/1000 births. The Scottish authors characterize many cases of severe morbidity as ‘great saves’ rather than ‘nearmisses’. Although the audit’s threshold for MOH is higher than most other studies, this survey provides a means to monitor trends and is more likely to reflect the burden of severe disease than the extreme ‘tip of the iceberg’ represented by death.