Regional differences in severe postpartum hemorrhage: A nationwide comparative study of 1.6 million deliveries

Background: The incidence of severe postpartum hemorrhage (PPH) is increasing. Regional variation may be attributed to variation in provision of care, and as such contribute to this increasing incidence. We assessed reasons for regional variation in severe PPH in the Netherlands. Methods: We used the Netherlands Perinatal Registry and the Dutch Maternal Mortality Committee to study severe PPH incidences (defined as blood loss ≥ 1000 mL) across both regions and neighborhoods of cities among all deliveries between 2000 and 2008. We first calculated crude incidences. We then used logistic multilevel regression analyses, with hospital or midwife practice as second level to explore further reasons for the regional variation. Results: We analyzed 1599867 deliveries in which the incidence of severe PPH was 4.5%. Crude incidences of severe PPH varied with factor three between regions while between neighborhoods variation was even larger. We could not explain regional variation by maternal characteristics (age, parity, ethnicity, socioeconomic status), pregnancy characteristics (singleton, gestational age, birth weight, pre-eclampsia, perinatal death), medical interventions (induction of labor, mode of delivery, perineal laceration, placental removal) and health care setting. Conclusions: In a nationwide study in The Netherlands, we observed wide practice variation in PPH. This variation could not be explained by maternal characteristics, pregnancy characteristics, medical interventions or health care setting. Regional variation is either unavoidable or subsequent to regional variation of a yet unregistered variable

Pre-eclampsia increases the risk of postpartum haemorrhage: a nationwide cohort study in the Netherlands.

Postpartum haemorrhage is a leading cause of maternal morbidity and mortality worldwide. Identifying risk indicators for postpartum haemorrhage is crucial to predict this life threatening condition. Another major contributor to maternal morbidity and mortality is pre-eclampsia. Previous studies show conflicting results in the association between pre-eclampsia and postpartum haemorrhage. The primary objective of this study was to investigate the association between pre-eclampsia and postpartum haemorrhage. Our secondary objective was to identify other risk indicators for postpartum haemorrhage in the Netherlands.A nationwide cohort was used, containing prospectively collected data of women giving birth after 19 completed weeks of gestation from January 2000 until January 2008 (n =  1,457,576). Data were extracted from the Netherlands Perinatal Registry, covering 96% of all deliveries in the Netherlands. The main outcome measure, postpartum haemorrhage, was defined as blood loss of ≥1000 ml in the 24 hours following delivery. The association between pre-eclampsia and postpartum haemorrhage was investigated with uni- and multivariable logistic regression analyses.Overall prevalence of postpartum haemorrhage was 4.3% and of pre-eclampsia 2.2%. From the 31 560 women with pre-eclampsia 2 347 (7.4%) developed postpartum haemorrhage, compared to 60 517 (4.2%) from the 1 426 016 women without pre-eclampsia (odds ratio 1.81; 95% CI 1.74 to 1.89). Risk of postpartum haemorrhage in women with pre-eclampsia remained increased after adjusting for confounders (adjusted odds ratio 1.53; 95% CI 1.46 to 1.60).Women with pre-eclampsia have a 1.53 fold increased risk for postpartum haemorrhage. Clinicians should be aware of this and use this knowledge in the management of pre-eclampsia and the third stage of labour in order to reach the fifth Millenium Developmental Goal of reducing maternal mortality ratios with 75% by 2015

Maternal and pregnancy characteristics of the study population (n = 1.457.576) and the association between these characteristcs and postpartum haemorrhage.

<p> Missing values of postpartum haemorrhage and pre-eclampsia are exluded.</p><p>²test between pre-eclampsia and no pre-eclampsia, P ≤ 0.0001. X</p><p>²test between pre-eclampsia and no pre-eclampsia,, P =  0.01. X</p

Multivariate analysis on the association between pre-eclampsia and postpartum haemorrhage and subgroup of women with non-induced spontaneous delivery.

<p> Adjusted for pre-eclampsia, maternal age, parity, ethnicity, socioeconomic status, multiple pregnancy and gestational age.</p><p>% CI; 1.68 to 2.44). Subgroup non-induced emergency caesarean section OR 1.55 (95% CI; 1.16 to 2.06). Subgroup induced spontaneous delivery OR 1.46 (95% CI; 1.36 to 1.58). Subgroup induced assisted delivery OR 1.61 (95% CI; 1.41 to 1.84). Subgroup induced emergency caesarean section OR 1.40 (95% CI; 1.17 to 1.68). Subgroup elective caesarean section OR 0.98 (95% CI; 0.86 to 1.12). Adjusted risk of pre-eclampsia for postpartum haemorrhage in other subgroups: Subgroup non-induced assisted delivery OR 2.02 (95</p

Postpartum characteristics of the study population (n = 1.457.576) and the association between these characteristcs and postpartum haemorrhage.

<p> Missing values of postpartum haemorrhage and pre-eclampsia are excluded.</p><p>²test between pre-eclampsia and no pre-eclampsia, P ≤ 0.0001. X</p

Annual rates of pre-eclampsia (PE), 2000–2008.

<p>Annual rates of pre-eclampsia (PE), 2000–2008.</p

Labour characteristics of the study population (n = 1.457.576) and the association between these characteristcs and postpartum haemorrhage.

<p> Missing values of postpartum haemorrhage and pre-eclampsia are excluded</p><p>²test between pre-eclampsia and no pre-eclampsia, P ≤ 0.0001 X</p

Regional differences in severe postpartum hemorrhage : A nationwide comparative study of 1.6 million deliveries

Background: The incidence of severe postpartum hemorrhage (PPH) is increasing. Regional variation may be attributed to variation in provision of care, and as such contribute to this increasing incidence. We assessed reasons for regional variation in severe PPH in the Netherlands. Methods: We used the Netherlands Perinatal Registry and the Dutch Maternal Mortality Committee to study severe PPH incidences (defined as blood loss ≥ 1000 mL) across both regions and neighborhoods of cities among all deliveries between 2000 and 2008. We first calculated crude incidences. We then used logistic multilevel regression analyses, with hospital or midwife practice as second level to explore further reasons for the regional variation. Results: We analyzed 1599867 deliveries in which the incidence of severe PPH was 4.5%. Crude incidences of severe PPH varied with factor three between regions while between neighborhoods variation was even larger. We could not explain regional variation by maternal characteristics (age, parity, ethnicity, socioeconomic status), pregnancy characteristics (singleton, gestational age, birth weight, pre-eclampsia, perinatal death), medical interventions (induction of labor, mode of delivery, perineal laceration, placental removal) and health care setting. Conclusions: In a nationwide study in The Netherlands, we observed wide practice variation in PPH. This variation could not be explained by maternal characteristics, pregnancy characteristics, medical interventions or health care setting. Regional variation is either unavoidable or subsequent to regional variation of a yet unregistered variable