Obstetric hemorrhage: improving care by collaborating across borders

Abstract

Postpartum hemorrhage (PPH) is a major, largely preventable cause of severe maternal morbidity and mortality in high-income countries. This thesis investigates whether international differences in severe maternal outcomes due to PPH can be partly explained by variations in second- and third-line management strategies. Using quantitative and qualitative benchmarking between France and the Netherlands, two countries with comparable healthcare quality but different outcomes, the research explores how clinical practice influences results.

The studies demonstrate substantial variation in national guidelines regarding prevention, diagnosis, treatment thresholds, uterotonics, uterus-sparing interventions, transfusion strategies, and overall guideline quality. Earlier and more aggressive use of second-line treatments and uterus-sparing interventions in France may partly explain its lower incidence of severe outcomes compared with the Netherlands, although high hysterectomy rates warrant caution.

Further analyses identify improvable care factors in maternal deaths due to PPH, particularly delays in diagnosis and treatment, suboptimal surgical skills during caesarean sections, and organisational shortcomings. The thesis highlights the value of international collaboration, standardised definitions, high-quality evidence-based guidelines, and repeated audit cycles. It concludes with recommendations to improve prevention, timely intervention, surgical training, and cross-border data sharing to optimise maternal outcomes after postpartum hemorrhage.