Trends in postpartum hemorrhage and manual removal of the placenta and the association with childbirth interventions: A Dutch nationwide cohort study

Background: Because the cause of increasing rates of postpartum hemorrhage (PPH) and manual placental removal (MROP) is still unknown, we described trends in PPH, MROP, and childbirth interventions and examined factors associated with changes in rates of PPH and MROP. Methods: This nationwide cohort study used national perinatal registry data from 2000 to 2014 (n = 2,332,005). We included births of women who gave birth to a term singleton child in obstetrician-led care or midwife-led care. Multivariable logistic regression analyses were used to examine associations between characteristics and interventions, and PPH ≥ 1000 mL and MROP. Results: PPH rates increased from 4.3% to 6.6% in obstetrician-led care and from 2.5% to 4.8% in midwife-led care. MROP rates increased from 2.4% to 3.4% and from 1.0% to 1.4%, respectively. A rising trend was found for rates of induction and augmentation of labor, pain medication, and cesarean section, while rates of episiotomy and assisted vaginal birth declined. Adjustments for characteristics and childbirth interventions did not result in large changes in the trends of PPH and MROP. After adjustments for childbirth interventions, in obstetrician-led care, the odds ratio (OR) of PPH in 2014 compared with the reference year 2000 changed from 1.66 (95% CI 1.57–1.76) to 1.64 (1.55–1.73) among nulliparous women and from 1.56 (1.47–1.66) to 1.52 (1.44–1.62) among multiparous women. For MROP, the ORs changed from 1.51 (1.38–1.64) to 1.36 (1.25–1.49) and from 1.56 (1.42–1.71) to 1.45 (1.33–1.59), respectively. Conclusions: Rising PPH trends were not associated with changes in population characteristics and rising childbirth intervention rates. The rising MROP was to some extent associated with rising intervention rates.