Abstract
BackgroundGuidelines recommend that women at high risk of postpartum haemorrhage deliver at facilities able to handle heavy bleeding. However postpartum haemorrhage is often unexpected. This study aims to compare outcomes and health service use related to transfusion of ≥4 units of red blood cells between women delivering in tertiary and lower level hospitals.MethodsThe study population was women giving birth in public hospitals in New South Wales, Australia, between July 2006 and December 2010. Data were obtained from linked hospital, birth and blood bank databases. The exposure of interest was transfusion of four or more units of red cells during admission for delivery. Outcomes included maternal morbidity, length of stay, neonatal morbidity and need for other blood products or transfer to higher care. Multivariable regression models were developed to predict need of transfusion of ≥4 units of red cells using variables known early in pregnancy and those known by the birth admission.ResultsData were available for 231,603 births, of which 4309 involved a blood transfusion, with 1011 (0.4%) receiving 4 or more units. Women giving birth in lower level and/or smaller hospitals were more likely to receive ≥4 units of red cells. Women receiving ≥4 units in tertiary settings were more likely to receive other blood products and have longer hospital stays, but morbidity, readmission and hysterectomy rates were similar.Although 46% of women had no identifiable risk factors early in pregnancy, 20% of transfusions of ≥4 units occurred within this group. By the birth admission 70% of women had at least one risk factor for requiring ≥4 units of red cells.ConclusionsOverall outcomes for women receiving ≥4 units of red cells were comparable between tertiary and non-tertiary facilities. This is important given the inability of known risk factors to predict many instances of postpartum haemorrhage.
Highlights
Guidelines recommend that women at high risk of postpartum haemorrhage deliver at facilities able to handle heavy bleeding
This study aims 1) to examine the outcomes and health service use of women receiving a large volume transfusion in response to a serious Postpartum Haemorrhage (PPH) according to place of birth and 2) to identify risk factors for women at risk of large volume transfusion (≥4 Units) using risk factors available in early pregnancy, and at the birth admission
Maternal and pregnancy characteristics associated with receiving 4 or more units of red cells included older maternal age, history of uterine surgery, chronic conditions, previous postpartum haemorrhage, placental abnormalities in the current pregnancy, use of assisted reproductive technology and gestational hypertension (Table 1).Overall the distribution of number of units transfused in the birth admission was similar between tertiary and non-tertiary facilities (Figure 1)
Summary
Guidelines recommend that women at high risk of postpartum haemorrhage deliver at facilities able to handle heavy bleeding. This study aims to compare outcomes and health service use related to transfusion of ≥4 units of red blood cells between women delivering in tertiary and lower level hospitals. Current guidelines recommend that women identified as being at high risk of haemorrhage deliver in centres with an onsite transfusion laboratory and facilities to handle a massive haemorrhage [2,3,4,5]. Postpartum haemorrhage is often unexpected and can occur at facilities with varying abilities to handle a haemorrhage, including access to red blood cells and other blood products. It would be useful to know the health system impacts of large haemorrhages occurring outside of tertiary centres and the associated maternal and neonatal outcomes. Few studies have considered the impact of large volume transfusion on health system usage and outcomes
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