Postpartum haemorrhage remains leading cause of maternal deaths in Kerala: Report 

Postpartum haemorrhage (PPH) has been a leading cause of maternal deaths in Kerala for the better part of the last decade, according to a report prepared by the Kerala Federation of Obstetrics and Gynaecology.

PPH is defined as a “blood loss of 500 ml or more within 24 hours after birth, while severe PPH is defined as a blood loss of 1,000 ml or more within the same timeframe,” by the World Health Organization.

PPH was not a leading cause of maternal deaths in Kerala only during two years: 2019-2020, when suicides took over marginally and 2015-2016 when respiratory illnesses took the lead.

Seventeen of the 133 maternal deaths recorded in 2019-2020 were due to PPH and 19 were due to suicide.

PPH deaths were the largest contributors till 2010-2011— recording a high of 31 deaths in 2010-2011 and 2011-2012 each. Hypertensive diseases secured the second place in almost every year.

The report titled Confidential Review of Maternal deaths was released last year.

Malappuram district has remained consistent in recording the highest maternal deaths every year since 2011. In 2019-2020, it recorded 25 deaths, followed by Kottayam (13), Thiruvananthapuram (13) and Palakkad (12).

The year before that, Malappuram recorded 43 deaths, followed by Kozhikode (20), Palakkad (18) and Thrissur (16). Only in 2010 was Malappuram not the poorest performer. At 27 maternal deaths, it was a close second to Palakkad, which recorded 30.

The report said:

In interpreting the cause of death, the primary cause is taken into consideration even though the final cause also may be relevant. For instance, a patient who had atonic PPH and later obstetric hysterectomy, recovered but died after a few days due to pulmonary embolism; we have taken the stand that it should be included under PPH as it was the primary cause which set the ball rolling. 

Maternal mortality ratio has come down significantly in the state to 28 in 2019-2020, from 38.4 in 2010-2011. Total maternal deaths recorded at the start of the decade stood at 186, which came down to 133 last year. Of the total 1,076 maternal deaths in the past decades, 17.56 per cent were due to PPH.

“In spite of near total hospital deliveries, very good antenatal coverage, improvement in blood transfusion facilities and many developments in technology to arrest the bleeding,” deaths due to PPH have remained a persistent concern.

PPH deaths were highest in the 20-29 age group. This is also the age group that has the highest number of deliveries.

At 46 per cent, atonic PPH — “failure of the uterus to contract following delivery” leading to excessive bleeding — is the most common type of obstetric haemorrhage.

Moreover, a third of PPH deaths were recorded in caesarean births, highlighting “the importance of practicing safe caesarean section technique and postoperative monitoring.”

PPH being a leading cause of maternal death is not only a country-wide trend but has also been seen in other low-income countries. According the National Health Portal of India, PPH accounts for 35 per cent of all maternal deaths.

However, the high number of maternal suicides recorded in 2019 has many concerned. The report noted that it was not “due to the classical postpartum depression.”

It listed marital disharmony, domestic quarrels and a “wide use of mobile phones which facilitate contact between emotionally unstable youngsters leading to extramarital sexual contact and pregnancy” as leading factors.

Between 2010 and 2020, nine per cent of all maternal deaths in Kerala were due to suicide. 

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