title: Increasing incidence of postpartum hemorrhage: the Dutch piece of the puzzle.
abstract: BACKGROUND
  An increase of postpartum hemorrhage (PPH) has been reported in many high-income countries. In addition to this data, this study reports on trends in the incidence of PPH in the Netherlands in 2000-2013, and examines the extent to which temporal changes in risk indicators could explain a possible change in incidence of PPH.
  
  
  METHODS
  We used data from the Dutch Perinatal Registry, which contains prospectively collected antenatal, peripartum and neonatal data of 95-99% of all women and neonates in the Netherlands. We selected births ≥22 weeks of gestation from January 2000 until December 2013. Changes in the incidence of PPH and its risk indicators were studied over time. Main outcome measure was PPH, defined as blood loss >1000 mL within 24 h following delivery.
  
  
  RESULTS
  The data comprised 2 406 784 women. The incidence of PPH rose significantly from 4.1% in 2000 to 6.4% in 2013 (p < 0.0001). The incidence of previously identified risk indicators for PPH increased over time. Manual removal of placenta was strongly associated with PPH (OR 29.3, CI 28.8-29.8). The incidence of PPH-related blood transfusion decreased remarkably.
  
  
  CONCLUSIONS
  In line with international observations, Dutch data suggest a considerable increase in the incidence of PPH which can only partly be explained by the studied risk indicators. The decreasing incidence of obstetric blood transfusion suggests an increased incidence of blood loss of 1000-1500 mL.
authors.affiliation: Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands. gielvs@gmail.com.
authors.forename: Giel
authors.initials: G
authors.lastname: van Stralen
authors.affiliation: Department of Internal Medicine, Reinier de Graaf Hospital, Delft, The Netherlands.
authors.forename: Joost F
authors.initials: JF
authors.lastname: von Schmidt Auf Altenstadt
authors.affiliation: Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands.|Department of Obstetrics, Wilhelmina Children Hospital Birth Center, Division Woman and Baby, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Kitty W M
authors.identifier: http://orcid.org/0000-0002-1377-4625
authors.initials: KW
authors.lastname: Bloemenkamp
authors.affiliation: Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Jos
authors.identifier: http://orcid.org/0000-0002-6746-3259
authors.initials: J
authors.lastname: van Roosmalen
authors.affiliation: Perined, Utrecht, The Netherlands.
authors.forename: Chantal W P M
authors.initials: CW
authors.lastname: Hukkelhoven
mesh_terms: D036861:Delivery, Obstetric / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D015994:Incidence; D007749:Labor Stage, Third; D009426:Netherlands / Q000453:epidemiology; D006473:Postpartum Hemorrhage / Q000453:epidemiology*; D011247:Pregnancy; D012042:Registries; D012307:Risk Factors; D012720:Severity of Illness Index
keywords: Postpartum hemorrhage; rising incidence; risk indicators; safe motherhood; the Netherlands; trends