Fatal Obstetrical Hemorrhage: A 20-Year Analysis From Ontario

Obstetric hemorrhage is a leading cause of pregnancy-related death. This study examined the characteristics, subtypes, and timing of obstetrical hemorrhagic deaths within a universal health care system.

Secondary analysis of a retrospective cohort study of linked administrative data, in which 485 post-pregnancy deaths over a 20-year period were identified. Obstetric hemorrhage deaths within 365 days of birth were reviewed by at least 3 clinicians to determine the main cause and timing of death.

Of 485 post-pregnancy deaths, 46 (9.5%) were attributed to obstetric hemorrhage, representing 27% of pregnancy-related deaths (46 of 169). All 46 obstetric hemorrhage deaths occurred within 12 days postpartum, with 26 deaths (56.5%) on the day of delivery. The top causes of fatal obstetrical hemorrhage were 9 (19.6%) amniotic fluid embolisms, 6 (13.0%) placental abruptions, and 5 (10.9%) uterine ruptures; but in 14 (30%) cases, the main cause was uncertain. Of all fatal hemorrhages, 3 (6.5%) began antepartum, 17 (37.0%) intrapartum, and 20 (43.5%) postpartum. Deaths were higher in more materially deprived neighbourhoods (39.1% in quintile 5 vs. 6.5% in quintile 1). Obstetric hemorrhage deaths were highest for Sunday deliveries (3.7 per 100 000 births, rate ratio 3.8; 95% CI 0.8-18.8), followed by Monday deliveries (2.7 per 100 000, rate ratio 2.7; 95% CI 0.5-13.9).

Obstetric hemorrhage remains a major contributor to pregnancy-related deaths, with most fatalities occurring very early postpartum. This study provides important insights into maternal post-pregnancy deaths due to obstetric hemorrhage in Ontario over a 20-year period.