Postpartum Hemorrhage Trends and Outcomes in the United States, 2000–2019

OBJECTIVE: To analyze temporal trends in and risk factors for postpartum hemorrhage and to analyze the association of risk factors with postpartum hemorrhage-related interventions such as blood transfusion and peripartum hysterectomy. METHODS: This repeated cross-sectional study analyzed delivery hospitalizations from 2000 to 2019 in the National (Nationwide) Inpatient Sample. Trends analyses were conducted using joinpoint regression to estimate the average annual percent change (AAPC) with 95% CIs. Unadjusted and adjusted survey-weighted logistic regression models were performed to evaluate the relationship between postpartum hemorrhage risk factors and likelihood of 1) postpartum hemorrhage, 2) postpartum hemorrhage that requires blood transfusion, and 3) peripartum hysterectomy in the setting of postpartum hemorrhage, with unadjusted odds ratios and adjusted odds ratios with 95% CIs as measures of association. RESULTS: Of an estimated 76.7 million delivery hospitalizations, 2.3 million (3.0%) were complicated by postpartum hemorrhage. From 2000 to 2019, the rate of postpartum hemorrhage increased from 2.7% to 4.3% (AAPC 2.6%, 94% CI 1.7-3.5%). Over the study period, the proportion of deliveries to individuals with at least one postpartum hemorrhage risk factor increased from 18.6% to 26.9% (AAPC 1.9%, 95% CI 1.7-2.0%). Among deliveries complicated by postpartum hemorrhage, blood transfusions increased from 5.4% to 16.7% from 2000 to 2011 and then decreased from 16.7% to 12.6% from 2011 to 2019. Peripartum hysterectomy among hospitalized individuals with postpartum hemorrhage increased from 1.4% to 2.4% from 2000 to 2009, did not change significantly from 2009 to 2016, and then decreased significantly from 2.1% to 0.9% from 2016 to 2019 (AAPC -27.0%, 95% CI -35.2% to -17.6%). Risk factors associated with postpartum hemorrhage and transfusion and hysterectomy in the setting of postpartum hemorrhage included prior cesarean delivery with previa or placenta accreta, placenta previa without prior cesarean delivery, and antepartum hemorrhage or placental abruption. CONCLUSION: Postpartum hemorrhage and related risk factors increased over a 20-year period. Despite the increased postpartum hemorrhage rates, blood transfusions, and hysterectomy rates decreased in recent years.