Leiden University Scholarly Publications

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Vries, P.L.M. de (2026)

Obstetric hemorrhage: improving care by collaborating across borders

Doctoral Thesis
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...Show morePostpartum 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.
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Maternal mortality
Severe maternal outcome
International benchmarking
Human errors
Postpartum hemorrhage
Improvable care factors
All authors
Vries, P.L.M. de
Supervisor
Akker, T.H. van den; Deneux-Tharaux, C.
Committee
Bonnet, M.P.; Goffinet, F.; Hamming, J.F.; Lutke Holzik, M.; Bom, J. van de
Qualification
Doctor (dr.)
Awarding Institution
Faculty of Medicine, Leiden University Medical Center (LUMC), Leiden University
Date
2026-01-13
Title of host publication
Safe Motherhood
ISBN (print)
9789083601557
DOI
doi:10.60602/1887-4286791

Funding

Sponsorship
Canon, Medical Systems Nederland, Chipsoft, Stichting Oranjekliniek, Bridea Medical, Safe Motherhood Series, ICT-HCTS