The WOMAN Trial: Clinical and Contextual Factors Surrounding the Deaths of 483 Women Following Post-Partum Hemorrhage in Developing Countries

The etiology of maternal mortality is postpartum hemorrhage in approximately 8.0% of cases in developed countries and 19.7% in developing countries. As a leading cause of maternal death, its prevention and early treatment are a priority. As part of the WOMANTrial, a randomized trial of tranexamic acid to treat postpartum hemorrhage, information on the causes ofmaternal death was recorded. The aim of this study was to review the circumstances of maternal death inmore than 20,000 women in 21 countries. The WOMAN Trial demonstrated that tranexamic acid reduced maternal death in women with postpartum hemorrhage. The study took place between 2010 and 2016 in 193 hospitals in 21 countries and recruited 20,060 women who were 16 years or older and were diagnosed with postpartumhemorrhage following vaginal or cesarean deliveries. In cases ofmaternal death, obstetricians were asked to record the cause of death and provide a brief narrative of the circumstances surrounding the death. Of the 20,060 women recruited for the trial, 12,343 were from Africa, 6030 from Asia, and 1049 from Europe. A total of 483 deathswere recorded, with case fatality rates of 3.0%(n = 375) in Africa and 1.7%(n = 105) in Asia; there were no deaths in the European cohort. Narratives were obtained for 52% of the recorded deaths. The odds of maternal death were 5 times higher in cases involving stillbirths versus live births (odds ratio = 5.26, 95%confidence interval = 4.34 6.39). The risk of death was also associated with more than 1000 mL of blood loss, a systolic blood pressure of <90 mm Hg, and hemodynamic instability. Among the 483 deaths, 13.3% were women who died within 3 hours of delivery and 59.8% who died between 3 and 24 hours after delivery. Women who gave birth outside of a participating hospital were 3 times more likely to die than those who gave birth at a participating hospital (odds ratio = 3.12, 95% confidence interval = 2.55 3.81). Based on the narratives, women who gave birth elsewhere were often in critical condition upon their arrival at a participating hospital. Bleeding was the most common cause of death for 346 women (72%). Bleeding was the cause of death for 91% of women who died within 3 hours of delivery and 83% of those who died within 24 hours of delivery. The primary cause of bleeding was uterine atony (53.2%). On average, women who died lost 2.1 L of blood (SD = 0.9 L, median = 2 L, interquartile range = 1.5 2.5 L) versus 1.2 L of blood for women who lived (SD = 0.6 L, median = 1 L, interquartile range = 0.8 1.5 L). More women who died received blood transfusions than those who lived (92.1% vs 53.8%). The narratives noted that blood was often unavailable for transfusion because of blood shortages or the family's inability to purchase blood. In this study, blood loss was observed to be the leading cause of death in women fromAfrica and Asia. Achieving mortality rates in developing countries similar to those in developed countries will require attention to issues such as late presentation due to births outside of hospitals and the lack of blood for transfusion.