FIGURE 2-1 Global estimates of the causes of maternal deaths.

SOURCE: World Health Organization, 1999.

PPH is the excessive loss—usually of 500 milliliters or more—of blood from the genital tract within 24 hours of delivery (World Health Organization, 1998). If uncontrolled, hemorrhage can quickly lead to shock and death, which generally occurs within 7 days of childbirth. Because of the difficulty of measuring blood loss, a more practical definition of PPH is any blood loss that causes a physiological change such as low blood pressure that threatens a woman’s life (McCormick et al., 2002). Immediate PPH is most commonly due to uterine atony, inadequate contraction of the uterus, and a retained placenta or placental fragments (McCormick et al, 2002). Other causes include damage to the genital tract such as cervical tears, perineal lacerations, and episiotomy. Even relatively mild PPH can aggravate existing anemia caused by poor nutritional intake of iron and folate, hookworm infestation, malaria, or repeated short birth intervals. Women who survive hemorrhage frequently suffer from chronic anemia.

Severe anemia, common in developing countries, contributes to high mortality from postpartum hemorrhage. Delivery at home without a skilled birth attendant can result in long delays in obtaining emergency treatment. When the first measures such as use of drugs to stop the bleeding or bimanual compression of the uterus are not taken or are not effective, uterine artery ligation or hysterectomy may be needed, both of which require access to comprehensive essential care services that may involve significant expense and travel. When blood transfusions are required, women are