Sulastri Sulastri, Lilis Suryani, Rohaya Muhede, Salmiani Abdul Manaf, Irnawati Irnawati, Irma Seriana, Cut Yuniwati, Cut Sriyanti

Postpartum Hemorrhage in Labor: Analyzing Risk Factors Across Demographic Groups

Introduction

Postpartum hemorrhage in labor: analyzing risk factors across demographic groups. Analyze Postpartum Hemorrhage (PPH) risk factors across demographic groups. This study links PPH to clinical causes (uterine atony, retained placenta) and maternal anemia, crucial for midwife-led care.

Abstract

Postpartum hemorrhage (PPH) is a critical obstetric emergency and a major contributor to maternal mortality. Understanding risk factors across demographic groups is essential for guiding clinical surveillance. This study aimed to analyze the association between demographic and clinical factors, including maternal hemoglobin level, age, parity, weight, neonatal birth weight, and clinical causes of PPH based on the 4T framework (Tone, Tissue, Trauma, Thrombin), and the incidence of PPH among postpartum women. An observational cross-sectional study was conducted on 40 postpartum women who delivered vaginally at a Midwife Independent Practice (PMB) in Banda Aceh, Indonesia, between February and September 2021. Total sampling was applied. Data were collected through direct observation and clinical records. PPH was defined as estimated blood loss ≥500 mL within two hours after delivery. Statistical analysis included chi-square tests and odds ratio (OR) calculations. The prevalence of PPH in this sample was 42.5%. Perineal rupture was the most common clinical finding (77.5%), followed by retained placenta (12.5%) and uterine atony (10%). A significant association was found between clinical causes and the incidence of PPH (p = 0.001). Maternal anemia (Hb <12 g/dL) was significantly associated with PPH (p = 0.018; OR = 7.5), indicating a high-risk subgroup. Other demographic factors, age, parity, maternal weight, and neonatal birth weight were not significantly associated with PPH (p > 0.05). PPH was significantly associated with clinical causes, particularly uterine atony and retained placenta, as well as maternal anemia. These findings support the need for routine antenatal hemoglobin screening and strengthened postpartum monitoring in midwife-led clinical settings to improve early detection and response to bleeding risks.

Review

This study addresses a critically important topic in maternal health: postpartum hemorrhage (PPH) and its associated risk factors. Given PPH's significant contribution to maternal mortality, understanding these factors, particularly in specific clinical settings like midwife independent practices in Indonesia, is highly valuable. The research clearly articulates its aim to analyze the association between demographic and clinical factors with PPH incidence. A notable strength is the incorporation of the 4T framework for categorizing clinical causes and the specific focus on potentially modifiable factors such as maternal hemoglobin level. The finding of a high PPH prevalence (42.5%) in this sample, coupled with the significant association of maternal anemia (OR=7.5) and specific clinical causes like uterine atony and retained placenta, provides compelling data supporting targeted interventions. While the study tackles an essential issue, several methodological limitations warrant critical consideration. The cross-sectional design inherently restricts the ability to infer causality, only associations, rather than direct cause-and-effect relationships. A significant concern is the very small sample size (N=40), which severely limits the generalizability of the findings and the statistical power to detect true associations, potentially explaining the non-significant results for factors like age, parity, and maternal weight. Furthermore, the reliance on total sampling from a single midwife independent practice introduces potential selection bias and further restricts the external validity of the results. The definition of PPH based on estimated blood loss, while common, can be subjective, and the abstract's statement that "perineal rupture was the most common clinical finding (77.5%)" followed by the conclusion that PPH was "particularly associated with uterine atony and retained placenta" requires clearer articulation of the individual contributions of these clinical causes to the overall significant association. Despite these limitations, the study's identification of maternal anemia as a strong risk factor for PPH, with a substantial odds ratio, is a crucial finding that has immediate clinical implications. This strongly supports the recommendation for routine antenatal hemoglobin screening and heightened postpartum monitoring, particularly in midwife-led settings. To build upon this preliminary work, future research should employ larger, multi-center prospective cohort designs to enhance generalizability, establish stronger causal links, and overcome the statistical power issues observed here. Further investigation into the specific prevalence and impact of perineal rupture as a direct cause of PPH, beyond just a common finding, would also be beneficial. Such rigorous follow-up studies are essential to translate these initial observations into robust evidence-based guidelines for PPH prevention and management.

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