by Dr. Meenakshi Ahuja
Across the world, maternal health is a key indicator of a nation’s development. While India
has established its roots across various spectrums, we are still amongst several countries
with a high maternal mortality rate – of 113 deaths per 100,000 live births. Although this ratio
has undergone a slight reduction from 2015-17, maternal mortality remains a critical public
health issue requiring urgent addressal.
Postpartum haemorrhage (PPH) is the leading cause of maternal mortality and morbidity,
associated with 20% of India’s and 25% of the world’s total maternal deaths, despite being
preventable. It refers to excessive blood loss of 500 ml or more after vaginal delivery and
1000 ml or more after a caesarean section, within 24 hours of childbirth. Several factors lead
to increased PPH risk, including uterine atony, accounting for 70% of cases, genital tract
trauma (vaginal or cervical lacerations), uterine rupture, retained placenta tissue, multiple
gestation, pregnancy-induced hypertension, or maternal bleeding disorders.
If untreated, the condition can result in complications including anemia and loss of iron
stores, fatigue in the postpartum period, or hypovolemic shock or death in severe cases. It
can also aggravate mental health problems, such as postnatal depression as well as posttraumatic stress disorder. PPH also impacts nursing and breastfeeding for one’s newborn
child. Given the all-encompassing nature of its impact, we must take urgent action to prevent
PPH in India.
Prevention is better than cure. This is especially important given PPH’s swift and sudden
onset. Once the bleeding starts, treatment within the first hour, or ‘the golden hour,’ is critical,
as a woman can bleed to death in two hours or less or go into irreversible shock. Given the
demanding nature of this process, prevention is a wiser alternative. Active management of
the third stage of labour, which should include the use of prophylactic uterotonics, plays an
imperative role in PPH prevention.
Currently, protocol to prevent PPH is heavily reliant on cold-chain storage and distribution (at
2-8° C). It requires frequent dose monitoring and the continuous administration of medicines
via intravenous (IV) drip infusions. This can limit accessibility to quality care in far-flung
regions with limited resources and unpredictable power sources, with infrastructure
unequipped to facilitate this process. Thus, many women face impediments in accessing lifesaving drugs. With the pandemic, such gaps widened. Healthcare resources were diverted
away from non-COVID conditions, drastically impacting maternal care delivery.
Today, new advancements are attempting to bridge these gaps. An innovative room
temperature-stable, single-dose formulation of carbetocin (an uterotonic agent) has been
introduced in India, with promising potential to revolutionize PPH preventive care. Given the
convenience in administration at a single point in time, it can facilitate patient adherence
while enabling ease of delivery. Moreover, it can reduce the time that vulnerable pregnant
women would need to stay in the hospital post-delivery, minimizing risk of infection. This
formulation of carbetocin also forms part of WHO’s recommendations for PPH prevention. It
poses an effective and reliable solution to overcome existing barriers to care delivery, so
access to care can be scaled nationwide, across urban and rural areas alike.
To drive this shift, we must overcome certain barriers including knowledge gaps by educating
healthcare practitioners on the availability and administration of such solutions. With
adequate training and information paired with up-to-date and comprehensive local guidelines
on PPH management, practitioners can be better equipped to support pregnant women with
safer deliveries. This can also streamline doctor-patient conversations wherein the woman
understands the risks of PPH and most suitable treatment options.
Advanced treatment options coupled with woman-centric care can ensure better health
outcomes for the mother and child across India.
Dr. Meenakshi Ahuja, Director, Obstetrics and Gynaecology, Fortis La Femme, New Delhi
