Categorizing differences in postpartum hemorrhage management and associated clinical factors

To examine whether there is variation in postpartum hemorrhage (PPH) management and whether differences are associated with patient-level factors and delivery hospital.

This is a retrospective cohort study of patients delivered at ≥20 weeks of gestation at any of four hospitals within one Connecticut healthcare system, with evidence of PPH, and receipt of intervention from 2012 to 2023. Patients with placenta accreta spectrum disorders, obstetric anal sphincter injuries, or stillbirth were excluded. The primary dependent variable was type of PPH treatment administered and structured as a four-level categorical variable: (1) usual care treatment including synthetic oxytocin infusion and uterine massage; (2) receipt of less aggressive medication treatment with uterotonics only; (3) receipt of more aggressive medication treatment with uterotonics only; and (4) any procedure with or without medication use. Although hysterectomy is considered a later-stage procedure in the setting of PPH, patients undergoing hysterectomy were included in the procedure group because insufficient cases of hysterectomy did not allow separate grouping. Maternal sociodemographic, clinical and pregnancy factors, and delivery hospital site were compared across the four-level PPH treatment categories. Bivariate analyses and crude and adjusted multinomial logistic regression analyses were performed.

Of 110,690 delivery encounters, 10,829 (9.8%) had documented evidence of study-defined PPH. Of these deliveries, 10,075 (93.0%) met eligibility criteria and were included in the analysis: 4941 (49.0%) received usual care treatment, 2982 (29.6%) received less aggressive medication use only, 1308 (13.0%) received more aggressive medication use only, and 844 (8.4%) underwent procedure(s) with or without medication use. There was a wide range in the number of medication types and doses received, as well as a wide spectrum of the number and types of procedures employed. Adjusted multinomial logistic regression analyses showed significant differences in patient-level factors (e.g., maternal age, race and ethnicity, gestational age, placenta previa, hypertensive disorders, and in vitro fertilization [IVF]) and delivery hospital among different types of PPH management.

There is significant variation in the management of PPH, and differences are associated with patient-level factors and delivery hospital type and region, which may be a proxy for clinical management and available resources.