Pakistan Must Make Lifesaving Medicines for Postpartum Haemorrhage Available

(AN urgent appeal to strengthen access to lifesaving uterotonics in the month of October when world postpartum partum haemorrhage day is celebrated )

The purpose of this editorial is simple: to urge Pakistan’s health authorities to ensure the timely availability and affordability of essential medicines used to prevent and control postpartum haemorrhage (PPH). A woman should not lose her life after childbirth because a proven lifesaving medicine is unavailable when she needs it most.

5 October is observed as World Postpartum Haemorrhage Day, drawing attention to one of the most immediate and preventable threats to maternal survival. For Pakistan, this issue deserves particular urgency.

According to the Pakistan Maternal Mortality Survey 2019, obstetric haemorrhage accounted for 41 per cent of maternal deaths, making it the leading recorded cause. The survey estimated Pakistan’s maternal mortality ratio at 186 deaths per 100,000 live births during 2017–19. Although more recent WHO estimates show improvement, with the maternal mortality ratio estimated at 155 per 100,000 live births in 2023, Pakistan remains well above the global target of fewer than 70 maternal deaths per 100,000 live births by 2030.

These figures represent mothers, families and communities — and behind them lies a health-system burden that is rarely fully measured.

A major postpartum haemorrhage can rapidly consume hospital resources. Patients may require large quantities of blood and blood products, emergency surgery, anaesthesia, intensive-care admission, prolonged hospitalisation and costly supportive treatment. Operating theatres, specialist manpower, nursing services, ambulances and blood banks are placed under additional pressure.

But the loss of a mother carries a cost that no hospital balance sheet can measure. A newborn may lose the person who was meant to provide nourishment and care, while other children may lose their primary caregiver. Families can face emotional trauma, financial insecurity and the sudden responsibility of raising children without their mother. In many households, the mother’s death can alter the future of an entire family.

For families living far from major hospitals, the problem is even greater. Transportation delays can turn a treatable haemorrhage into irreversible shock. Some women reach tertiary-care hospitals after losing enormous amounts of blood; others, unfortunately, never reach a facility capable of saving them.

The most important principle in PPH is therefore time.

Modern obstetric practice emphasises prevention, early recognition and immediate treatment. The WHO, FIGO and ICM recommendations reinforce the need for rapid recognition of abnormal bleeding and prompt treatment with uterotonics, tranexamic acid, intravenous fluids, uterine massage and timely escalation of care.

This makes the availability of essential uterotonics at the point of childbirth particularly important.

Oxytocin remains the recommended uterotonic of choice when multiple options are available. However, maintaining an uninterrupted cold chain for oxytocin can be challenging in many parts of Pakistan, particularly in remote and resource-limited settings. WHO therefore recommends heat-stable carbetocin for prevention of PPH where reliable cold-chain storage for oxytocin cannot be maintained.

The availability of heat-stable carbetocin could therefore be particularly relevant to Pakistan, where large numbers of women continue to deliver in settings distant from advanced tertiary-care facilities.

There is also a need to reconsider the prolonged absence of ergometrine, a uterotonic that has been familiar to Pakistani obstetricians for many years.

Ergometrine has an established place in obstetric practice and has remained in use of obstetricians in Pakistan for years. Unfortunately its absent from the market for good few years now, without any reason known to us. Its availability would provide clinicians with an additional therapeutic choice. Like all medicines, it needs to be used appropriately and according to the patient’s clinical condition.

The issue is therefore not about choosing one drug over another.

It is about ensuring that doctors and maternity-care providers have appropriate, quality-assured medicines available when minutes matter.

Pakistan already spends substantial resources managing the consequences of severe PPH. Blood and blood products have to be collected, screened and maintained. Emergency operating theatres must be mobilised. Intensive-care beds and expensive equipment may be required. Specialist teams have to be assembled. Hospital stays become longer and considerably more costly.

Early prevention and treatment can reduce this cascade.

A relatively inexpensive medicine, given promptly and appropriately, can prevent substantial blood loss and potentially avert transfusion, surgery, intensive care and prolonged hospitalisation.

But the greatest saving is not financial.

It is the life of the mother.

Pakistan cannot place an advanced tertiary hospital in every village, nor can every maternity facility have an intensive-care unit, interventional radiology or a full surgical team. But every facility where childbirth takes place can be expected to have trained personnel, essential medicines, a standard PPH protocol, reliable referral arrangements and a clear plan for obtaining blood when required.

On World Postpartum Haemorrhage Day, the message for Pakistan should therefore be unequivocal.

I appeal to DRAP, the Ministry of National Health Services, provincial health departments, procurement authorities and all institutions responsible for maternal healthcare to urgently review the availability of essential uterotonics in the country.

Pakistan should ensure uninterrupted access to quality-assured oxytocin, facilitate appropriate availability of heat-stable carbetocin, and restore reliable access to ergometrine where clinically appropriate, alongside tranexamic acid and other essential components of modern PPH management.

This is not simply a matter of medicines.

It is a matter of maternal survival, responsible healthcare planning and national priorities.

We know how postpartum haemorrhage can be prevented and treated. We know that early intervention saves blood, resources and lives.

What we must now ensure is that the means to do so are available wherever a Pakistani woman gives birth.

No mother should die after childbirth because