Global maternal mortality declined by 40

INTRODUCTION:Globally, 1 in 5 maternal deaths are attributable to major postpartum hemorrhage (PPH), despite widespread uterotonic use. Intrauterine tamponade is recommended as second-line therapy for refractory atonic PPH. Uterine balloon tamponade (UBT) achieves hemostasis through intrauterine pressure. Conversely, the vacuum-assisted hemorrhage-control device (VHD) promotes uterine contraction through negative pressure. Limited data compare these modalities. We compared the clinical effectiveness of UBT and VHD in refractory atonic PPH. MATERIAL AND METHODS:This retrospective cohort study was conducted at the National University Hospital in Singapore and included all women treated for primary PPH with either the UBT or VHD between January 2020 and September 2025, during which ROTEM-guided transfusion and E-MOTIVE-aligned practices were implemented. The composite morbidity endpoint, comprising transfusion of ≥4 units of packed red blood cells (PRBC), plasma or cryoprecipitate administration, examination under anesthesia, high dependency or intensive care unit admission, or device failure was compared between groups with logistic regression adjusted for placenta previa major and cesarean delivery. RESULTS:Fifty-three women met inclusion criteria (33 UBT, 20 VHD). The composite morbidity outcome occurred less frequently with VHD than UBT (45.0% versus 75.8%; unadjusted OR 0.26, 95% CI 0.08-0.86, p = 0.03); after adjusting for placenta previa major and cesarean delivery, this difference was no longer statistically significant (adjusted OR 0.38, 95% CI 0.10-1.41, p = 0.15). Baseline characteristics were similar except for higher rates of placenta previa (45.5% versus 5.0%) and cesarean delivery (78.8% versus 50.0%) in the UBT group. Median estimated blood loss at device insertion was comparable (1500 mL). Among secondary outcomes, VHD was associated with lower median PRBC transfusion (1 vs. 2 units, p = 0.009), fewer women receiving ≥4 PRBC units (5.0% versus 36.4%, p = 0.02), fewer plasma transfusions (5.0% versus 36.4%, p = 0.02), shorter device indwelling duration (10.1 versus 24.3 h, p < 0.001), shorter hospital stay (54 versus 72 h, p = 0.007), and fewer high-dependency admissions (45.0% versus 72.7%, p = 0.04). CONCLUSIONS:The VHD demonstrated outcomes comparable to balloon tamponade in managing refractory atonic PPH, with lower transfusion requirements and shorter hospitalization. VHD may be a useful component of standardized PPH protocols incorporating the E-MOTIVE bundle and ROTEM-guided transfusion, warranting further evaluation in broader clinical settings.

Excessive bleeding after childbirth, known as postpartum haemorrhage (PPH), can turn an uncomplicated birth into a catastrophe. Each year, PPH occurs in an estimated 27 million women worldwide-17 million after vaginal birth and 10 million during or after caesarean birth. An estimated 43 000 women die from PPH annually, translating to a death every 12 min. The pooled prevalence of PPH at vaginal birth is 12·6% (95% CI 10·1-15·2) and at caesarean birth 30·9% (95% credible interval 24·9-37·6), based on the conventional definition of PPH. Common causes of PPH are uterine atony, genital tract trauma, retained placenta, abnormal placentation, and coagulopathy. Risk factors include caesarean birth, multiple pregnancy, anaemia, high maternal BMI, previous PPH, female genital mutilation, sepsis, pre-eclampsia, macrosomia, and inadequate antenatal care. In addition to being the leading cause of maternal mortality worldwide, the consequences of PPH include serious morbidities such as severe anaemia, hysterectomy, organ failure, and long-term psychological trauma. The global economic burden of PPH is estimated at US$10·4 billion (95% credible interval $9·8-13·2 billion) annually, consisting of $3·6 billion ($3·2-6·2 billion) for health systems and $6·8 billion ($6·2-7·5 billion) for societies. Based on a rigorous review of the evidence, WHO has recently redefined PPH as objectively measured blood loss of at least 300 mL plus an abnormal haemodynamic sign, or objectively measured blood loss of at least 500 mL, whichever occurs first. This new definition prioritises early PPH diagnosis and treatment to avert life-threatening maternal outcomes. Comprehensive efforts to address missed opportunities in the prevention, diagnosis, and treatment of PPH are needed to improve outcomes. These efforts include addressing the unmet need for contraception, mitigating modifiable risks such as anaemia, avoiding caesarean sections that are not medically indicated, using effective single uterotonic prophylaxis for all births and combination prophylaxis for women at high risk of PPH, ensuring accurate and objective measurement of blood loss for early PPH diagnosis, and promptly implementing treatment with an evidence-based bundle. The PPH Roadmap (2023-30) provides a global framework for action.

Ethical and human-rights-based approaches form the moral and professional backbone of sexual and reproductive health (SRH). This article explores the evolution of SRH ethics through the application of four foundational bioethical principles: beneficence, non-maleficence, justice, and autonomy, and their implications for clinical practice, policy, and social reform. Drawing on international examples and professional experience, the discussion highlights how ethical reasoning translates into practicalinterventions that promote dignity, equality, and choice for all individuals, particularly women. Historical injustices such as gender-based violence, harmful cultural practices, and inequitable access to care underscore the need for sustained advocacy, education, and institutional accountability. Lessons are drawn from global experiences, including the reform of abortion law in Ireland, the expansion of postpartum intrauterine device (PPIUD) programs, and improvements in maternal mortality governance frameworks. Together, these examples illustrate that rights-based, evidence-driven, and ethically grounded SRH policies are essential to achieving global commitments such as the Sustainable Development Goals. The article concludes by reaffirming the responsibility of healthcare professionals, policymakers, and educators to uphold ethical integrity and human rights in every aspect of reproductive healthcare.

The global unmet need for contraception continues to be unacceptably high at 218 million. The vast majority of these are women living in low and middle income countries, with a particularly high unmet need in the postpartum period. The FIGO PPIUD initiative demonstrated that it is feasible to embed counselling on contraception and insertion of PPIUD in maternity services. Implementation of these services was greatly enhanced by ensuring that counselling was culturally sensitive and appropriately given through specifically trained individuals, that task sharing was maximized in order to increase access, and that a high fundal placement was achieved resulting in low expulsion rates. Financing for contraception in LMICs is currently precarious and vulnerable to international politics. PPIUD is highly cost-effective. Expansion of contraception services including PPIUD has the potential to impact positively on climate change and a country's development profile if expanded on a large scale.

This article outlines a unique example of reverse innovation. Lessons from low- and middle-income countries (LMICs) shaped healthcare practices in a high-income setting. We describe how the FIGO Postpartum Intrauterine Device Initiative, implemented across six LMICs, informed the development of a postpartum contraception program in a UK-based NHS trust. Despite the well-documented benefits of postpartum family planning (PPFP), implementing dedicated PPFP services in the UK has been challenging due to fragmented healthcare funding and cross service integration barriers. The COVID-19 pandemic created an urgent need for adaptation, providing a unique opportunity to rapidly establish a comprehensive local PPFP service. We outline how strategies from LMICs - including task-sharing, provider training, and policy advocacy - were directly applied to overcome these barriers and drive successful implementation. This case study highlights the potential of South-to-North knowledge transfer in driving healthcare innovation, improving contraceptive access, and underscores the importance of global collaboration and adaptive learning in reproductive healthcare.

Objective There are no globally agreed on strategies on early detection and first response management of postpartum haemorrhage (PPH) during and after caesarean birth. Our study aimed to develop an international expert’s consensus on evidence-based approaches for early detection and obstetric first response management of PPH intraoperatively and postoperatively in caesarean birth.Design Systematic review and three-stage modified Delphi expert consensus.Setting International.Population Panel of 22 global experts in PPH with diverse backgrounds, and gender, professional and geographic balance.Outcome measures Agreement or disagreement on strategies for early detection and first response management of PPH at caesarean birth.Results Experts agreed that the same PPH definition should apply to both vaginal and caesarean birth. For the intraoperative phase, the experts agreed that early detection should be accomplished via quantitative blood loss measurement, complemented by monitoring the woman’s haemodynamic status; and that first response should be triggered once the woman loses at least 500 mL of blood with continued bleeding or when she exhibits clinical signs of haemodynamic instability, whichever occurs first. For the first response, experts agreed on immediate administration of uterotonics and tranexamic acid, examination to determine aetiology and rapid initiation of cause-specific responses. In the postoperative phase, the experts agreed that caesarean birth-related PPH should be detected primarily via frequently monitoring the woman’s haemodynamic status and clinical signs and symptoms of internal bleeding, supplemented by cumulative blood loss assessment performed quantitatively or by visual estimation. Postoperative first response was determined to require an individualised approach.Conclusion These agreed on proposed approaches could help improve the detection of PPH in the intraoperative and postoperative phases of caesarean birth and the first response management of intraoperative PPH. Determining how best to implement these strategies is a critical next step.

Globally, there are considerable barriers to accessing safe and effective contraceptive methods. Increased awareness and utilization among obstetricians and gynecologists (OB/GYNs) and allied health professionals of the WHO's tools and guidelines on contraception is a possible avenue to changing this. A cascade‐training model, based on regional training‐of‐trainer workshops followed by national workshops, was used to share key WHO global family planning tools and guidelines among OB/GYNs in 29 countries across three regions—Anglophone Africa, Middle East and Mediterraean, and Francophone West Africa. Monitoring and evaluation was performed through pre‐ and post‐knowledge questionnaires as well as in‐depth interviews of key informants before and after the training was instituted. The training increased both participants' knowledge and understanding of the relevant guidelines, as well as their confidence in using them. Qualitative data suggested that this improved in‐country clinical practice and influenced national policy through dissemination and engagement with country leadership. The cascade‐training model was a practical, locally adaptable means of disseminating up‐to‐date WHO family planning guidelines and tools. It resulted in sustainable changes in many participating countries, including training curriculum updates, policy changes, and increased government engagement with family planning. Future iterations of the initiative would benefit from additional support for multidisciplinary training.

Access to emergency obstetric care, including assisted vaginal birth and caesarean birth, is crucial for improving maternal and childbirth outcomes. However, although the proportion of births by caesarean section has increased during the last few decades, the use of assisted vaginal birth has declined. This is particularly the case in low- and middle-income countries, despite an assisted vaginal birth often being less risky than caesarean birth. We therefore conducted a three-step process to identify a research agenda necessary to increase the use of, or reintroduce, assisted vaginal birth: after conducting an evidence synthesis, which informed a consultation with technical experts who proposed an initial research agenda, we sought and incorporated the views of women's representatives of this agenda. This process has allowed us to identify a comprehensive research agenda, with topics categorized as: (i) the need to understand women's perceptions of assisted vaginal birth, and provide appropriate and reliable information; (ii) the importance of training health-care providers in clinical skills but also in respectful care, effective communication, shared decision-making and informed consent; and (iii) the barriers to and facilitators of implementation and sustainability. From women's feedback, we learned of the urgent need to recognize labour, childbirth and postpartum experiences as inherently physiological and dignified human processes, in which interventions should only be implemented if necessary. The promotion and/or reintroduction of assisted vaginal birth in low-resource settings requires governments, policy-makers and hospital administrators to support skilled health-care providers who can, in turn, respectfully support women in labour and childbirth.

Intrapartum fetal surveillance aims to predict significant fetal hypoxia and institute timely intervention to avoid fetal injury, and do so without unnecessary operative delivery of fetuses at no risk of intrapartum hypoxia. However, the configuration and application of current clinical guidelines inadvertently undermine these aims because of persistent failure to incorporate increased understanding of fetal cardiovascular physiology and adaptations to oxygen deprivation, advances in signal acquisition/processing, and related technologies. Consequently, the field on intrapartum fetal surveillance is stuck in rudimentary counts of the fetal R–R intervals and visual assessment of very common, but nonspecific fetal heart decelerations and fetal heart rate variability. The present authors argue that the time has come to move away from classifications of static morphological appearances of FHR decelerations, which do not assist the thinking clinician in understanding how the fetus defends itself and compensates for intrapartum hypoxic ischaemic insults or the patterns that suggest progressive loss of compensation. We also reappraise some of the controversial aspects of intrapartum fetal surveillance in modern obstetric practice, the current state of flux in training and certification, and contemplate the future of the field particularly in the context of the emerging role of artificial intelligence.

The World Health Organization (WHO) has a mandate to promote maternal and child health and welfare through support to governments in the form of technical assistance, standards, epidemiological and statistical services, promoting teaching and training of healthcare professionals and providing direct aid in emergencies. The Strategic and Technical Advisory Group of Experts (STAGE) for maternal, newborn, child and adolescent health and nutrition (MNCAHN) was established in 2020 to advise the Director-General of WHO on issues relating to MNCAHN. STAGE comprises individuals from multiple low-income and middle-income and high-income countries, has representatives from many professional disciplines and with diverse experience and interests.Progress in MNCAHN requires improvements in quality of services, equity of access and the evolution of services as technical guidance, community needs and epidemiology changes. Knowledge translation of WHO guidance and other guidelines is an important part of this. Countries need effective and responsive structures for adaptation and implementation of evidence-based interventions, strategies to improve guideline uptake, education and training and mechanisms to monitor quality and safety. This paper summarises STAGE's recommendations on how to improve knowledge translation in MNCAHN. They include support for national and regional technical advisory groups and subnational committees that coordinate maternal and child health; support for national plans for MNCAHN and their implementation and monitoring; the production of a small number of consolidated MNCAHN guidelines to promote integrated and holistic care; education and quality improvement strategies to support guidelines uptake; monitoring of gaps in knowledge translation and operational research in MNCAHN.

Placental adhesive spectrum disorders (PASD) are on the increase. Histologically, the placenta may be adherent to the myometrium without intervening decidua (acreta), invade the myometrium (increta) and/or extend beyond the myometrium and seen via the serosa of the uterus or invade into adjacent tissues like the bladder or parametrium (percreta). Since there are difficulties in defining each entity by ultrasound or by histology and also due to the possibility of histology showing different degrees of invasion in the same case, PASD is the term now commonly used and the previous terminology of morbidly adherent placenta is no longer used. The main contributor towards PSAD is previous caesarean section (CS). With the global increase in CS, the incidence of PASD and related morbidity and mortality is on the increase.

Aim To compare the efficacy and safety of dinoprostone vaginal insert (DVI) alone versus DVI with adjunctive sweeping of membranes (ASM) for induction of labor (IOL). Methods Single-center, prospective, randomized controlled trial; women with singleton term pregnancies, cervical dilation >= 1 and <3 cm, intact membranes allocated to either DVI or DVI with ASM. The primary outcome was vaginal delivery within 24 h of insertion. Secondary outcomes included mean time from insertion to delivery, tachysystole, operative delivery for non-reassuring fetal status (NRFS), tocolytics, fetal outcomes, pain information, and subject satisfaction. Results One hundred and four received DVI (Group 1) alone and 104 DVI with ASM (Group 2). The rate of vaginal delivery within 24 h was 53% versus 56%, cesarean rate 8.7% versus 10.6% in Groups 1 and 2 respectively. Although the duration of labor was similar in both groups, about 6% of women required additional ripening with dinoprostone vaginal tablets in Group 2 compared to 11.5% in Group 1 (p-value = 0.2). The frequency of hyperstimulation syndrome, failed induction, analgesic requirements, and fetal outcomes were comparable. The majority (83%-86%) in either cohort were satisfied with their labor experience. Multivariate logistic regression demonstrated a slightly better chance for vaginal delivery within 24 h (odds ratio [OR] 1.22 [95% confidence interval, CI 0.65-2.29]; p-value 0.53] for DVI with ASM, although statistically insignificant. Younger maternal age and multiparity (OR 10.36 [95% CI 4.88-23.67]; p-value <0.0001) contributed to successful IOL. Conclusion DVI with ASM is at least as efficacious as DVI for cervical ripening with no increase in morbidity. Although DVI with ASM group less often needed additional dinoprostone tablets to complete the process of IOL (p-value = 0.2), adjunctive sweeping has not been shown to have a significant impact on the duration of labor or mode of delivery.

Rare clinical events and emergencies could be mimicked at a convenient and predetermined time and place, thus enabling healthcare teams to acquire expertise in managing these events. The idea of practising on manikins before performing a certain task on actual patients dates back to antiquity. The concept of 'team training' originated in the aviation industry. The work environments of aviation and healthcare share more or less similar characteristics such as complexity, stress, time sensitivity, the involvement of multiple personnel and the requirement to work consistently in a highly charged environment. The relatively low frequency and the unpredictability of obstetric emergencies make simulation-based training (SBT) the ideal method for healthcare providers to achieve and maintain competence in managing these events. It has been proven that multi-professional training conducted locally at the unit level rather than training conducted at distant simulation centres is more effective in improving maternal and neonatal outcomes.

Abstract Background Post-partum haemorrhage (PPH) is a leading cause of maternal death worldwide. The WOMAN trial assessed the effects of tranexamic acid (TXA) on death and surgical morbidity in women with PPH. The trial recorded 483 maternal deaths. We report the circumstances of the women who died. Methods The WOMAN trial recruited 20,060 women with a clinical diagnosis of PPH after a vaginal birth or caesarean section. We randomly allocated women to receive TXA or placebo. When a woman died, we asked participating clinicians to report the cause of death and to provide a short narrative of the events surrounding the death. We collated and edited for clarity the narrative data. Results Case fatality rates were 3.0% in Africa and 1.7% in Asia. Nearly three quarters of deaths were within 3 h of delivery and 91% of these deaths were from bleeding. Women who delivered outside a participating hospital (12%) were three times more likely to die (OR = 3.12, 95%CI 2.55–3.81) than those who delivered in hospital. Blood was often unavailable due to shortages or because relatives could not afford to buy it. Clinicians highlighted late presentation, maternal anaemia and poor infrastructure as key contributory factors. Conclusions Although TXA use reduces bleeding deaths by almost one third, mortality rates similar to those in high income countries will not be achieved without tackling late presentation, maternal anaemia, availability of blood for transfusion and poor infrastructure.