Original Research
Blood Transfusion During Pregnancy, Birth,
and the Postnatal Period
Jillian A. Patterson, BScAdv(Hons), MBiostat, Christine L. Roberts, MBBS, DrPH,
Jennifer R. Bowen, MBBS (Hons), FRACP, David O. Irving, MSc, PhD, James P. Isbister, BSc(Med) Hons, MB BS Hons,
Jonathan M. Morris, MBChB, PhD, and Jane B. Ford, BA(Hons), PhD
OBJECTIVES: To identify risk factors for transfusion and
trends in transfusion rates across pregnancy and the
postnatal period.
METHODS: Linked hospital and birth data on all births
in hospitals in New South Wales, Australia, between 2001
and 2010 were used to identify blood transfusions for
women during pregnancy, at birth, and in the 6 weeks
postpartum. Poisson regression was used to identify risk
factors for red cell transfusion in the birth admission.
Separate models were fitted for cesarean and vaginal
births.
RESULTS: Between 2001 and 2010, there were 12,147
transfusions across 891,914 pregnancies, with a transfu-
sion rate of 1.4%. The transfusion rate increased steadily
from 1.2% in 2001 to 1.6% in 2010. The majority of
transfusions (91%) occurred during the birth admission,
and 81% of these transfusions were associated with
a diagnosis of hemorrhage. Women with bleeding or
From the Kolling Institute, University of Sydney, the Royal North Shore
Hospital, the University of Sydney, and the Australian Red Cross Blood Service,
Sydney, New South Wales, Australia.
Supported by a Partnership Grant from the Australian National Health and
Medical Research Council NHMRC (#1027262), the Australian Red Cross,
and the NSW Clinical Excellence Commission. Christine L. Roberts is supported
by a NHMRC Senior Research Fellowship (#1021025). Jane B. Ford is sup-
ported by an ARC Future Fellowship (#120100069).
The authors thank the NSW Ministry of Health for access to the population
health data and the NSW Centre for Health Record Linkage for linking the data
sets.
An earlier version of these findings was presented in poster form at the Society for
Pediatric and Perinatal Epidemiologic Research 26th Annual Meeting, June 17–
18, 2013, Boston, Massachusetts.
Corresponding author: Jillian A. Patterson, BScAdv(Hons), MBiostat, Clinical
& Population Perinatal Health Research, c/o University Department of O&G,
Building 52, Royal North Shore Hospital, St Leonards, New South Wales 2065,
Australia; e-mail: jillian.patterson@sydney.edu.au.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2013 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/14
126 VOL. 123, NO. 1, JANUARY 2014
platelet disorders (vaginal: number transfused 529, rela-
tive risk [RR] 7.8, 99% confidence interval [CI] 6.9–8.7,
cesarean: n5592, RR 8.7, CI 7.7–9.7) and placenta previa:
(vaginal n573, RR 4.6, CI 3.4–6.3, cesarean: n5875, RR
5.7, CI 5.1–6.4) were at highest risk of transfusion. Among
vaginal births, increased risk was evident for forceps
(n51,036, RR 2.8, CI 2.5–3.0) or vacuum births
(n51,073, RR 1.9, CI 1.7–2.0) compared with nonopera-
tive births.
CONCLUSIONS: Rates of obstetric blood product trans-
fusion have increased by 33% since 2001, with the
majority of this associated with hemorrhage. Women
with bleeding or platelet disorders and placenta previa
are at increased risk of transfusion and should be treated
accordingly.
(Obstet Gynecol 2014;123:126–33)
DOI: 10.1097/AOG.0000000000000054
LEVEL OF EVIDENCE: II
B
lood for transfusion is a limited, costly resource,
and its use has specific risks.1,2 Internationally, this
has led to increased efforts to reduce unnecessary
blood use across many disciplines.3 Transfusion of
red blood cells generally has decreased in Australia
in recent years4; however, there is evidence of increas-
ing rates of maternal red blood cell transfusion around
childbirth.5 This trend has also been observed in the
United States, Canada, Finland, and Ireland, particu-
larly in the context of postpartum hemorrhage.6–12
Between 1998 and 2009 in the United States, there
was a steep increase in transfusions during a delivery
admission (from 0.3% to 1.0%).12 The obstetric blood
transfusion rate in Australia in 2002 was 0.88%, which
was higher than contemporaneous rates reported in
other countries, including the United States (0.46%
in 2003),7 Canada (0.63% in 2004),13 and Ireland
(0.84% in 2003).11 Reasons for the higher rate are
unknown, although they may relate to differences in
OBSTETRICS & GYNECOLOGY
data collection. Obstetric transfusions tend to be
urgent, unpredictable, and occur in otherwise healthy
women.14
A small number of population-based studies have
identified risk factors for blood transfusion in the
maternity setting, including mode of delivery, pla-
centa previa, antepartum hemorrhage, anemia, multi-
ple pregnancies, and the extremes of maternal
age.10,15,16 Population data provide a valuable source
of data for studies of trends and risk factors for
uncommon outcomes such as transfusion.17 These
studies typically look only at the birth admission
and are unable to estimate the transfusion burden
associated with antenatal and postpartum hospitaliza-
tions. Few studies have considered blood products
other than red cells.
This study aims to explore recent trends in blood
and blood product transfusion and the use of blood
products throughout pregnancy and the postnatal
period in women whose pregnancy ended in a regis-
tered birth (beyond 20 weeks of gestation). We also
examine the risk factors for transfusion during the
birth admission.
MATERIALS AND METHODS
The study population included women giving birth in
New South Wales hospitals between January 2001
and December 2010. New South Wales is the most
populous state in Australia, with more than 7 million
residents and approximately 90,000 births per year.
“Birth data” including maternal characteristics, preg-
nancy, and birth were obtained from the Perinatal
Data Collection. The Perinatal Data Collection is
a statutory population-based collection of all births
in New South Wales of at least 20 weeks of gestation
or 400 g birth weight. These data were linked to “hos-
pital data” from the Admitted Patients Data Collec-
tion. The Admitted Patients Data Collection is
a census of all hospital discharges in New South Wales
and records information on diagnoses and procedures
associated with these discharges. Up to 20 of the 55
available diagnoses and procedures for each discharge
are coded according to the International Classification
of Diseases, 10th Revision, Australian Modification
and the Australian Classification of Health Interven-
tions. The New South Wales Centre for Health
Record Linkage performed probabilistic data linkage
between the two data sets.18 For this study, rates of
incorrect and missed links were less than 5 per 1,000.
Hospital admissions were classified as antenatal,
birth, or postnatal to allow for examination of the
different blood product use at each stage of preg-
nancy. Antenatal admissions were those that occurred
VOL. 123, NO. 1, JANUARY 2014
from 20 weeks of gestation and ended with the mother
being discharged before the birth. Birth admissions
were separated into those with a prolonged antenatal
component (greater than 4 days) and those admitted
4 days or less before delivery. Postnatal admissions
were admissions occurring after the initial discharge
of the mother but within 6 weeks of the birth.
Admissions involving transfusion of blood products
were identified from the hospital data using Australian
Classification of Health Interventions procedure
codes.19 “Blood transfusion” refers to the administra-
tion of packed red cells or whole blood and “platelets
and coagulation factors” include platelets, coagulation
factors, and other serum (including fresh-frozen
plasma); “blood products” is used to refer to transfu-
sion of either or both of these. Blood transfusion (sen-
sitivity 83.1%, specificity 99.9%) and administration of
platelets and coagulation factors (sensitivity 73.1%,
specificity 100%) are well ascertained in the hospital
data.17 The quality of reporting of use of other blood-
derived products (including leukocytes, gamma glob-
ulin) is unknown and so use of these products was not
considered. Women with iron deficiency anemia
were identified from the hospital data and women
with bleeding or platelet disorders were identified
by International Classification of Diseases, 10th
Revision, Australian Modification codes for condi-
tions such as thalassemia, hemolytic and aplastic
anemias, coagulation defects, and idiopathic throm-
bocytopenic purpura (see the Appendix, available
online at http://links.lww.com/AOG/A454). Ante-
partum hemorrhage included placental abruption or
other antepartum hemorrhage. Women without
Packed cells only
Packed cells and platelets or coagulation factors
Platelets or coagulation factors only
16
Transfusion rate per
14
1,000 deliveries
12
10
8
6
4
2
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year
Fig. 1. Rate of transfusions per 1,000 deliveries, New South
Wales 2001–2010. The transfusion rate increased signifi-
cantly over this time period overall (P,.001), for packed
cells alone (P5.003), and packed cells in conjunction with
other products (P,.001) but not for other blood products
alone (P5.1). This includes any transfusion during the
antenatal period, birth admission, and postnatally.
Patterson. Obstetric Blood Transfusion. Obstet Gynecol 2014.
Patterson et al Obstetric Blood Transfusion 127
Table 1. Characteristics of Pregnancies by Blood Product Transfusion Status During Pregnancy, New South
Wales, 2001–2010

Packed Red Cells Platelets or Any Blood No Blood Rate/1,000

Variable or Blood Coagulation Factors Products Products Deliveries (99% CI)

Total pregnancies 11,760 (100.0) 1,648 (100.0) 12,147 (100.0) 879,767 (100.0) 14 (13.3–13.9)
Maternal age (y)
Younger than 20 612 (5.2) 42 (2.5) 626 (5.2) 33,500 (3.8) 18 (16.7–20.0)
20–34 8,392 (71.4) 1,084 (65.8) 8,682 (71.5) 658,286 (74.8) 13 (12.7–13.3)
35 or older 2,756 (23.4) 522 (31.7) 2,839 (23.4) 187,981 (21.4) 15 (14.2–15.5)
Private patient
Yes 2,602 (22.1) 472 (28.6) 2,724 (22.4) 296,410 (33.7) 9 (8.7–9.5)
No 9,158 (77.9) 1,176 (71.4) 9,423 (77.6) 583,357 (66.3) 16 (15.5–16.3)
Smoker
Yes 1,963 (16.7) 197 (12.0) 2,002 (16.5) 121,511 (13.8) 16 (15.4–17.0)
No 9,767 (83.1) 1,442 (87.5) 10,113 (83.3) 756,086 (85.9) 13 (12.9–13.5)
Multiple birth
Yes 612 (5.2) 92 (5.6) 631 (5.2) 13,383 (1.5) 45 (41.0–49.1)
No 11,148 (94.8) 1,556 (94.4) 11,516 (94.8) 866,384 (98.5) 13 (12.8–13.4)
Nulliparous
Yes 5,608 (47.7) 738 (44.8) 5,812 (47.8) 369,525 (42.0) 15 (15.0–16.0)
No 6,136 (52.2) 907 (55.0) 6,317 (52.0) 509,032 (57.9) 12 (11.9–12.6)
Previous cesarean
delivery
Yes 1,726 (14.7) 361 (21.9) 1,792 (14.8) 119,573 (13.6) 15 (14.0–15.6)
No 10,034 (85.3) 1,287 (78.1) 10,355 (85.2) 760,194 (86.4) 13 (13.1–13.7)
Bleeding or platelet
disorders
Yes 1,132 (9.6) 291 (17.7) 1,275 (10.5) 7,713 (0.9) 142 (133.3–150.4)
No 10,628 (90.4) 1,357 (82.3) 10,872 (89.5) 872,054 (99.1) 12 (12.0–12.6)
Antepartum
hemorrhage
Yes 1,045 (8.9) 238 (14.4) 1,084 (8.9) 22,179 (2.5) 47 (43.4–49.8)
No 10,715 (91.1) 1,410 (85.6) 11,063 (91.1) 857,588 (97.5) 13 (12.5–13.0)
Placenta previa
Yes 962 (8.2) 228 (13.8) 979 (8.1) 8,485 (1.0) 103 (96.2–110.7)
No 10,798 (91.8) 1,420 (86.2) 11,168 (91.9) 871,282 (99.0) 13 (12.4–12.9)
Iron deficiency
anemia
Yes 715 (6.1) 54 (3.3) 721 (5.9) 4,654 (0.5) 134 (123.3–145.0)
No 11,045 (93.9) 1,594 (96.7) 11,426 (94.1) 875,113 (99.5) 13 (12.6–13.2)
Gestational age at
birth (wk)
20–32 736 (6.3) 207 (12.6) 791 (6.5) 13,436 (1.5) 56 (51.1–60.1)
33–36 1,182 (10.1) 283 (17.2) 1,266 (10.4) 42,836 (4.9) 29 (26.9–30.6)
37 or more 9,842 (83.7) 1,158 (70.3) 10,090 (83.1) 823,495 (93.6) 12 (11.8–12.4)
Delivery type
Normal vaginal 5,226 (44.4) 491 (29.8) 5,341 (44.0) 537,476 (61.1) 10 (9.5–10.2)
Cesarean 4,343 (36.9) 947 (57.5) 4,588 (37.8) 246,130 (28.0) 18 (17.7–18.9)
Prelabor 2,319 (19.7) 583 (35.4) 2,484 (20.4) 141,349 (16.1) 17 (16.5–18.1)
Intrapartum 2,023 (17.2) 364 (22.1) 2,103 (17.3) 104,779 (11.9) 20 (18.7–20.7)
Instrumental 2,176 (18.5) 206 (12.5) 2,202 (18.1) 96,308 (10.9) 22 (21.3–23.4)
Forceps 1,068 (9.1) 102 (6.2) 1,081 (8.9) 32,663 (3.7) 32 (29.8–34.3)
Vacuum 1,108 (9.4) 104 (6.3) 1,121 (9.2) 63,645 (7.2) 17 (16.1–18.5)
Induction
Yes 3,794 (32.3) 540 (32.8) 3,910 (32.2) 236,932 (26.9) 16 (15.6–16.8)
No 7,966 (67.7) 1,108 (67.2) 8,237 (67.8) 642,835 (73.1) 13 (12.3–13.0)
Birth weight (for
gestation)
Small 895 (7.6) 165 (10.0) 959 (7.9) 83,218 (9.5) 11 (10.5–12.2)
(continued )

128 Patterson et al Obstetric Blood Transfusion OBSTETRICS & GYNECOLOGY

Table 1. Characteristics of Pregnancies by Blood Product Transfusion Status During Pregnancy, New South
Wales, 2001–2010 (continued )
Packed Red Cells Platelets or Any Blood No Blood Rate/1,000
Variable or Blood Coagulation Factors Products Products Deliveries (99% CI)

Average 9,039 (76.9) 1,294 (78.5) 9,333 (76.8) 703,661 (80.0) 13 (12.8–13.4)
Large 1,826 (15.5) 189 (11.5) 1,855 (15.3) 92,888 (10.6) 20 (18.5–20.6)
Hospital of birth
Tertiary 5,934 (50.5) 982 (59.6) 6,157 (50.7) 358,695 (40.8) 17 (16.4–17.4)
Regional 2,844 (24.2) 210 (12.7) 2,906 (23.9) 188,394 (21.4) 15 (14.5–15.8)
Urban or other 1,488 (12.7) 182 (11.0) 1,522 (12.5) 119,278 (13.6) 13 (11.9–13.3)
Private 1,494 (12.7) 274 (16.6) 1,562 (12.9) 213,400 (24.3) 7 (6.8–7.7)
CI, confidence interval.
Denominator5pregnancies.

bleeding disorders, antepartum hemorrhage, placenta
previa, hypertension, and diabetes were considered to
have no prior indication for transfusions. Age and ges-
tational age groups were determined based on clinical
relevance and women were classified as private patients
if they received private obstetric care in a public or
private hospital.
Rates were calculated per 1,000 deliveries and
proportions are proportion of deliveries unless other-
wise specified. Multiple births (twins or higher-order
multiples) were counted as a single delivery. Trends
were assessed using the Cochran Armitage test for
trend. Significance was set at a50.01. A multivariable
Poisson regression model with robust variances was
used to identify factors associated with higher use of
blood product transfusions; factors that were signifi-
cant with a 0.2 in a univariate model were included in
the initial multivariable model and removed in a step-
wise fashion until only variables significant at a 0.01
remained. This was performed separately for vaginal
and cesarean deliveries to account for possible differ-
ences in decision-making based on physical location
(operating room compared with birth unit) and differ-
ing criteria for postpartum hemorrhage (a common
indication for blood transfusion). In the International
Classification of Diseases, 10th Revision, Australian
Modification, postpartum hemorrhage is defined as
blood loss of 750 mL or more after cesarean delivery
or 500 mL or more after vaginal birth.20 Women with
missing data for possible confounding factors were
excluded from this analysis. All analyses were per-
formed in SAS 9.3. Ethical approval was obtained
from the New South Wales Population and Health
Services Research Ethics Committee.
RESULTS
In the period 2001–2010, there were 891,914 deliver-
ies to 578,207 women involving 1,117,939 admis-
sions. The blood product transfusion rate was 1.4%
(99% confidence interval [CI] 1.3–1.4) of deliveries
with 11,529 mothers receiving a transfusion in
12,147 pregnancies or the postnatal period. During
the time period, 286 women had more than one deliv-
ery involving a transfusion, including 50 (17%)
women with a bleeding disorder. Blood products were
transfused in 484 antenatal admissions, 667 prolonged
birth admissions, 10,715 birth admissions, and 600
postnatal admissions. The transfusion rate was highest
for the birth admission (12.0/1,000 deliveries) com-
pared with the antenatal (0.5/1,000 deliveries), pro-
longed birth admissions (0.87/1,000 deliveries), and
postnatal admissions (0.7/1,000 deliveries). Ninety-
one percent (11,382) of transfusions occurred in the
birth admission, whereas 3.9% were antenatal and
4.8% were postnatal transfusions.
The transfusion of blood products at any stage
during pregnancy, birth, or the postnatal period
increased steadily from 1.2% in 2001 to 1.6% in 2010
(P#.001) (Fig. 1). When considering only birth admis-
sion, the rate increased from 11.0 per 1,000 in 2001 to
15.3 per 1,000 in 2010 (P,.001). There has been little
change in the type of products used with the majority of
women (86%) receiving only packed red cells, whole
blood, or both, packed cells making up the majority of
this (99.4%). There was a significant increase in the num-
ber of women receiving packed cells alone (P5.003) or
in conjunction with other blood products (P,.001), but
not in those receiving other products alone (P5.1).
When compared with red cell use, platelets and coagu-
lation factors were more commonly used among women
aged 35 years and older, private patients, multiparous
women, and those having a cesarean delivery (Table 1).
Where blood product transfusion occurred during preg-
nancy, this usually occurred in a single admission
(98.6%) with less than 0.4% of deliveries involving three
or more admissions involving transfusions.

VOL. 123, NO. 1, JANUARY 2014 Patterson et al Obstetric Blood Transfusion 129
Table 2. Factors Associated With Blood or Blood Product Transfusion in the Birth Admission, New South
Wales, 2001–2010

Vaginal Deliveries Cesarean Deliveries

Not Multivariable Model Not Multivariable Model
Transfused Transfused Transfused Transfused
Relative Relative
Factor n (%) n (%) Risk 99% CI n (%) n (%) Risk 99% CI
Maternal age (y)
Younger than 20 427 (6.2) 28,076 (4.5) 1.2 (1.02–1.34) 154 (3.5) 5,239 (2.1) 1.5 (1.23–1.87)
20–35 5,210 (75.5) 484,563 (77.1) 1 (Reference) 2,820 (65.0) 169,740 (69.2) 1 (Reference)
35 or older 1,268 (18.4) 116,070 (18.5) 1.1 (1.00–1.18) 1,366 (31.5) 70,456 (28.7) 1.2 (1.07–1.27)
Private patient 1,386 (20.1) 187,206 (29.8) 0.8 (0.68–0.86) 1,146 (26.4) 107,489 (43.8) 0.8 (0.67–0.85)
Smoker 1,105 (16.0) 93,757 (14.9) 1.1 (1.04–1.25) 694 (16.0) 27,103 (11.0) — —
Australian-born 4,587 (66.4) 444,368 (70.7) 0.8 (0.75–0.87) 2,940 (67.7) 174,578 (71.1) 0.9 (0.80–0.96)
Multiple birth 230 (3.3) 4,857 (0.8) 2.8 (2.36–3.41) 356 (8.2) 8,314 (3.4) 1.7 (1.44–1.98)
Nulliparous 3,719 (53.9) 257,193 (40.9) 1.4 (1.32–1.54) 1,746 (40.2) 110,360 (45.0) 0.7 (0.60–0.74)
Previous cesarean 377 (5.5) 22,879 (3.6) 1.8 (1.58–2.09) 1,297 (29.9) 96,415 (39.3) 0.7 (0.66–0.81)
delivery
Bleeding or platelet 529 (7.7) 4,967 (0.8) 7.8 (6.93–8.73) 592 (13.6) 2,833 (1.2) 8.7 (7.69–9.76)
disorder
Iron deficiency 344 (5.0) 3,337 (0.5) — — 258 (5.9) 1,399 (0.6) — —
anemia
Chronic 75 (1.1) 4,235 (0.7) — — 99 (2.3) 3,687 (1.5) — —
hypertension
Pregnancy 1,009 (14.6) 48,872 (7.8) 1.6 (1.45–1.74) 884 (20.4) 32,244 (13.1) 1.5 (1.38–1.68)
hypertension
Any diabetes 434 (6.3) 32,426 (5.2) — — 388 (8.9) 20,623 (8.4) — —
Placenta previa 73 (1.1) 939 (0.1) 4.6 (3.44–6.26) 875 (20.2) 7,495 (3.1) 5.7 (5.12–6.40)
Antepartum 354 (5.1) 13,157 (2.1) 1.9 (1.63–2.16) 656 (15.1) 8,662 (3.5) 2.2 (1.96–2.51)
hemorrhage
Augmentation of 988 (14.3) 63,152 (10.0) 1.3 (1.17–1.42) 260 (6.0) 15,519 (6.3) — —
labor
Induction 2,756 (39.9) 188,769 (30.0) 1.5 (1.36–1.56) 860 (19.8) 46,537 (19.0) 1.1 (1.01–1.28)
Intrapartum * * * * 1,996 (46.0) 104,563 (42.6) 1.3 (1.21–1.47)
cesarean
delivery
Prolonged labor 665 (9.6) 28,522 (4.5) — — 145 (3.3) 5,102 (2.1) — —
Regional analgesia 2,194 (31.8) 149,589 (23.8) — — * * * *
Birth weight (for
gestation)
Small 508 (7.4) 60,251 (9.6) 0.7 (0.65–0.82) 357 (8.2) 22,286 (9.1) 0.8 (0.71–0.94)
Average 5,389 (78.0) 510,541 (81.2) 1 (Reference) 3,246 (74.8) 188,551 (76.8) 1 (Reference)
Large 1,008 (14.6) 57,917 (9.2) 1.7 (1.57–1.88) 737 (17.0) 34,598 (14.1) 1.3 (1.15–1.42)
Gestational age
(wk)
Less than 33 186 (2.7) 6,218 (1.0) 1.8 (1.49–2.21) 488 (11.2) 5,440 (2.2) 2.7 (2.36–3.15)
33–36 403 (5.8) 24,933 (4.0) 1.2 (1.02–1.35) 774 (17.8) 17,425 (7.1) 1.7 (1.53–1.93)
37 or more 6,316 (91.5) 597,558 (95.0) 1 (Reference) 3,078 (70.9) 222,570 (90.7) 1 (Reference)
Delivery type
Vaginal 4,850 (70.2) 536,014 (85.3) 1 (Reference) * * * *
Forceps 1,036 (15.0) 32,338 (5.1) 2.8 (2.51–3.04) * * * *
Vacuum 1,073 (15.5) 63,364 (10.1) 1.6 (1.50–1.81) * * * *
† † † †
Year of birth 1.0 (1.04–1.06) 1.0 (1.02–1.05)
Hospital type
Tertiary 3,409 (49.4) 260,617 (41.5) 1.1 (0.98–1.18) 2,312 (53.3) 94,631 (38.6) 1.1 (0.93–1.22)
Metropolitan 1,718 (24.9) 141,423 (22.5) 1 (Reference) 971 (22.4) 46,050 (18.8) 1 (Reference)
Regional 971 (14.1) 94,078 (15.0) 1.2 (1.11–1.38) 425 (9.8) 24,725 (10.1) 1.3 (1.09–1.48)
Private 807 (11.7) 132,591 (21.1) 0.6 (0.53–0.73) 632 (14.6) 80,029 (32.6) 0.6 (0.53–0.78)
CI, confidence interval.
Reference categories are absence of risk factor unless otherwise specified.
— Indicates that risk factor is not retained in multivariable model.
* Adjustment for this risk factor was not applicable for this mode of delivery.
†
Year treated as a continuous variable; for trends, see Figure 1.

130 Patterson et al Obstetric Blood Transfusion OBSTETRICS & GYNECOLOGY

 Rates of transfusion in the birth and postnatal
period were high in women having a hysterectomy in
the birth admission (896.2/1,000 such deliveries,
n5439), in which blood products had been transfused
antenatally (187.5/1,000, n563) and when a postpar-
tum hemorrhage occurred in the birth admission
(135.3/1,000, n58,388). In women with no prior indi-
cation, the transfusion rate was 9.5 per 1,000 deliver-
ies (n56,927). Among birth admissions with fewer
than a 4-day antenatal stay involving transfusion,
80.8% included a hemorrhage diagnosis. Women
who received transfusions in birth or postnatal admis-
sion were in the hospital longer than those who did
not (median days [interquartile range] birth 5 [4, 5]
compared with 3 [2, 5], postnatal 3 [2, 5] compared
with 2 [0, 3]).
Full data on possible confounders were available
for 885,389 deliveries (99.3%) and were included in
our risk factor analysis. Overall, 28.1% of women
delivered by cesarean (n5249,775). Considering all
births after adjusting for maternal factors, forceps
delivery was associated with the highest risk of trans-
fusion of all modes of birth when compared with non-
instrumental vaginal delivery followed by intrapartum
cesarean delivery, vacuum delivery, and prelabor
cesarean delivery (Table 2). Across both vaginal and
cesarean deliveries, women with bleeding or platelet
disorders or placenta previa were at increased risk of
transfusion. Among vaginal births, forceps deliveries
and multiple births were also associated with more
than doubling of the risk of transfusion, whereas
among cesarean deliveries, preterm births at less than
33 weeks of gestation and antepartum hemorrhage
were associated with a more than doubling of risk.
Nulliparous women were at greater risk of transfusion
when delivering vaginally as were women with a pre-
vious cesarean delivery (Table 2).
When included in the model, iron deficiency
anemia was associated with an increased risk of
transfusion (vaginal: number transfused5344, relative
risk 7.1 [6.2–8.2]; cesarean: n5258, relative risk 4.7
[3.7–5.8]), leaving other estimates largely unchanged.
However, identification of women with iron defi-
ciency anemia has low sensitivity (5.7–12.0%)21 and
so this was excluded from the final model.
DISCUSSION
Transfusion of blood or blood products occurred in
one in every 71 deliveries in New South Wales between
2001 and 2010 with the majority of these related to
hemorrhage. The majority of transfusions occurred
during the birth admission, which is unsurprising given
the large proportion associated with postpartum hem-
VOL. 123, NO. 1, JANUARY 2014
orrhage, which typically occurs within 24 hours after
birth. The transfusion rate among women with no prior
indication for blood transfusion was 1.0%, indicating
that transfusion in otherwise healthy women is not
uncommon.
Over the last 10 years there has been a 33%
increase in the use of blood and blood products
throughout pregnancy. Obstetric patients use a small
proportion of the blood supply overall (3–4%)22; how-
ever, there is potentially increasing demand in this
subpopulation at a time when resources are becoming
more limited.1 One possible explanation for the
increase is the changing maternal population with
more older mothers, women with previous cesarean
deliveries, and having more comorbid conditions6,11;
however, we found that the trend persisted when
changes in these factors were taken into account. Sim-
ilarly, Kuklina et al7 found the increasing trend in
transfusion between 1998 and 2005 in the United
States persisted despite adjustment for confounders.
Another possible reason for the increase in trans-
fusion is the recent increase in postpartum hemor-
rhage, which has been observed both in New South
Wales23 and internationally.6,8,11,13 Because the major-
ity of transfusions are performed in admissions with
a diagnosis of hemorrhage, an increase in postpartum
hemorrhage would likely lead to an increase in blood
transfusions as has been observed elsewhere.8,9 The
increase in transfusion is also possibly linked to
increased severity of postpartum hemorrhage.9,11
The increase in transfusion rates may also reflect
a change in practice with clinicians using less restric-
tive criteria for transfusion than in the past. We were
unable to assess changes in transfusion thresholds;
however, given the growing awareness of risks and
costs associated with transfusion,1,2 it would be ex-
pected that changing practice would reduce transfu-
sion rates. Interestingly, the slight dip in transfusion
rates in 2008 coincided with a statewide initiative to
decrease obstetric transfusions24; however, this decline
was not maintained.
Risk factors identified in this study were consistent
with previous studies.10,16,25–27 Of note, vaginal birth after
cesarean delivery carried a higher risk of transfusion
than repeat cesarean delivery,10,16,27 and cesarean and
instrumental delivery had a higher risk of transfusion
than noninstrumental vaginal delivery.10,16,26 Higher
rates of transfusion were found for preterm deliveries26
and are possibly related to anemia, which is a risk factor
for both preterm birth and transfusion.28
We found the rate of transfusion to be much
lower in private hospitals compared with public,
which is consistent with lower-risk women giving
Patterson et al Obstetric Blood Transfusion 131
birth in appropriate settings.29–31 In Australia, tertiary
obstetric care is only available in public hospitals.
Tertiary hospitals had the highest rates of transfusion
of platelets and coagulation factors, which may reflect
increased complexity of cases in these hospitals or
better access to products in the larger centers.
This study reflects the population burden of
blood and blood product use in obstetrics in Australia.
The use of longitudinally linked data allowed for the
examination of blood product use within pregnancy.
Validated and reliably collected information was
available. The large number of women in the sample
allowed for adjustment by a range of risk factors.
Administrative data sets however lack clinical detail
such as quantity of blood transfused, indication for
transfusion, and hemoglobin measurements, which
would provide insight into the severity of patients
requiring transfusion.
Obstetric transfusion represents a small propor-
tion of overall blood use; however, use of blood in
obstetrics is rising and there is potential for this to
continue as postpartum hemorrhage rates continue
to increase. Because it has not been possible in this
study to determine the exact indications and “trig-
gers” for red cell transfusions, it is difficult to opine
as to the appropriateness of many of the transfusions.
Clearly, in exsanguinating hemorrhage, transfusion
is essential and a life-saving measure with questions
revolving more around hemodynamic and coagulo-
pathic parameters. On the other hand, in hemody-
namically stable patients in whom hemorrhage has
been controlled or is not the problem, the issues of
patient blood management and transfusion are dif-
ferent. Some reduction in transfusion rates may be
possible through increased awareness of transfusion
risk factors and treatment of anemia during preg-
nancy and adherence to principles of patient blood
management. Additional reduction in blood use
may be achievable through exploring variation in
blood use between hospitals.
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