**5. Discussions**

The postpartum hemorrhage (PPH) in I-Tuporn et al. [31] study, which was conducted in the Chiang Rai Regional Hospital in 2017, was 2.61%. It was lower than the study in Chonburi Hospital (4.95%) [28] and Maharat Nakorn Ratchasima Hospital (6.67%) [26], but it was related to the report of Bhumibol Adulyadej Hospital (1.98%) [25] and the report of Calvert et al. [36] that presented Asia's regional PPH rate of 1.90% [36].

Emergency hysterectomy for the treatment of severe hemorrhage from vaginal delivery was not reported widely in Chiang Rai Regional Hospital or Sakon Nakhon province. It was presented only some years ago and reported only a few cases. However, the maternal death rate in Sakon Nakhon province from 2015 to 2018

was higher than the standard criterion of 17 per 100,000 infant live births. It was decreased in the year 2019 to 15.12 per 100,000 infant live births after this hospital used a risk score tool with 8 predictors by I-Tuporn et al. [31] to detect earlier PPH and early treatment as blood loss over 250 mL from the collector bag.

The risk score tool for the prediction of PPH in Thailand had five studies [25–29]. They were developed in different settings. They had some similar risk factors for the detection of PPH. The study of I-Tuporn et al. [31] developed the risk score tool with 8 predictors, covering the cause of PPH (4 T's and 7 steps of the clinical prediction model of Steyerberg [32, 33] and by comparison with the standard monogram of Biguzzi [34], Sittipan [28], and Suta et al. [27]) I-Tuporn et al. [31] risk score tool could be used in low-resource cities with various ethnic groups, as in Chiang Rai and Sakon Nakhon province, which are in the north and northeast of Thailand, respectively.

The results of the Chiang Rai and Sakon Nakhon provinces study after 1 year of follow-up showed that the maternal death rate in Sakon Nakhon province had decreased to normal criterion, and there were no reports of PPH-related hysterectomy cases in these two provinces.
