By PPH Foundation

A woman can walk into a maternity ward after an apparently healthy pregnancy, deliver her baby without any obvious complication and, within minutes, begin losing a dangerous amount of blood.

There may have been no dramatic warning during pregnancy. No obvious indication that she was about to experience a serious complication. This unpredictability is one of the challenges of postpartum haemorrhage, PPH, and a reminder that being considered low risk does not mean a woman is free from the possibility of severe bleeding after childbirth.

PPH is excessive bleeding following childbirth and can occur for several reasons. The most common is uterine atony, where the uterus fails to contract effectively after delivery. Other causes include tears to the genital tract, retained placental tissue and abnormalities affecting blood clotting. While certain conditions can increase the likelihood of PPH, they cannot identify every woman who will experience it.

According to a population-based retrospective cohort study by Patterson et al. (2020), severe PPH occurred even among women who had none of the identified risk factors. The study, which examined more than 700,000 births, found that 0.7 percent of women without identified risk factors experienced severe PPH. The researchers concluded that some cases could not be predicted from the recognized risk factors, highlighting the importance of monitoring all women after childbirth.

This is an important distinction in maternal care. Risk assessment remains valuable because it allows health workers to anticipate and prepare for potential complications. But the absence of a recognized risk factor should never be interpreted as an assurance that PPH will not occur.

According to Yunas et al. (2025), in a systematic review and meta-analysis published in The Lancet involving 327 studies and more than 847 million women, PPH has multiple causes and associated risk factors. The researchers identified conditions including anaemia, previous PPH, caesarean birth, multiple pregnancy, placenta praevia and sepsis among factors associated with increased risk. Their findings also demonstrate the complexity of predicting PPH and the need for approaches that combine prevention, early detection and rapid treatment.

As Prof. Moses Obimbo, Professor at the University of Nairobi and End PPH Initiative Project Lead explains, “Most women who develop postpartum haemorrhage have no known hereditary risk, and genetics should never be viewed as the sole cause of postpartum haemorrhage. However, the growing evidence that family history may increase susceptibility reminds us that comprehensive antenatal assessment is essential.”

But even comprehensive assessment has its limits. Some complications emerge only during or after delivery, which makes the period immediately following childbirth particularly important.

According to the World Health Organization's 2025 consolidated guidelines on PPH, health workers should move towards earlier identification of abnormal bleeding rather than waiting until blood loss becomes severe or a woman develops obvious signs of shock. WHO recommends diagnosing PPH when blood loss reaches at least 300 millilitres and is accompanied by an abnormal haemodynamic sign, or when blood loss reaches 500 millilitres or more. The guidelines also recommend objective measurement of blood loss, including the use of calibrated collection drapes, because visual estimation alone can underestimate the amount of blood lost (WHO, 2025).

The emphasis on early recognition is supported by emerging evidence on how quickly PPH can develop after birth.

According to Mammoliti et al. (2025), in an observational study conducted within the E-MOTIVE trial, the median time from vaginal birth to diagnosis of PPH in Kenya was 17 minutes. The findings illustrate how quickly excessive bleeding can become apparent and why health workers need to remain vigilant in the immediate period after delivery.

For Prof. Obimbo, this preparedness must be part of routine maternity care. “Routine readiness to measure and respond to bleeding, rather than waiting for it to worsen, is the key to saving lives,” he says.

That readiness involves more than simply watching for visible blood. It requires health workers to measure blood loss accurately, monitor the mother's vital signs and recognise deterioration early. It also requires essential medicines and equipment to be available and blood and blood products to be accessible when a transfusion becomes necessary.

According to WHO (2025), once PPH is diagnosed, treatment should begin rapidly using a first-response bundle that includes uterine massage, oxytocic medicines, tranexamic acid, intravenous fluids, examination to determine the source of bleeding and escalation of care where necessary. The approach is designed to prevent delays at a time when the woman's condition can deteriorate quickly.

For women and their families, the lesson is not that PPH is inevitable or that every birth should be approached with fear. Rather, it is that an apparently uncomplicated pregnancy does not eliminate the possibility of an emergency after delivery.

For health systems, the message is even clearer. If PPH cannot always be predicted, preparedness cannot be reserved for women considered high risk. Every woman giving birth needs appropriate monitoring, and every maternity facility needs the capacity to recognise abnormal bleeding and respond without delay.

The question, therefore, should not only be, “Did this woman have risk factors?”It should also be, “Were we prepared when she began to bleed?” A woman may have had a healthy pregnancy. She may have had no identifiable risk factors. She may have delivered without difficulty. Yet within minutes, everything can change.

And when it does, early recognition, rapid treatment and a prepared health system can make the difference between an emergency that is successfully managed and a tragedy that could have been prevented.

References

Mammoliti, K. M., et al. (2025). When are postpartum haemorrhages diagnosed? A nested observational study within the E-MOTIVE cluster-randomised trial. The Lancet Global Health, 13(11), e1946–e1954.

Patterson, J. A., Ford, J. B., Schluter, P. J., et al. (2020). Risk factors for severe postpartum haemorrhage: A population-based retrospective cohort study. Australian and New Zealand Journal of Obstetrics and Gynaecology, 60(4), 522–532.

World Health Organization. (2025). Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage. World Health Organization.

Yunas, I., Islam, M. A., Sindhu, K. N., et al. (2025). Causes of and risk factors for postpartum haemorrhage: A systematic review and meta-analysis. The Lancet, 405(10488), 1468–1480.

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