Step 1: Advocate with Evidence

Preventing tragic maternal deaths due to postpartum hemorrhage (PPH) begins with gaining stakeholders’ buy-in. It is often necessary to advocate for these lifesaving interventions to be introduced into the national public health system.

Demonstrate that PPH is a public health priority:

    • Hemorrhage is a leading direct cause of maternal deaths in the world. 14 million women in developing countries experience PPH—26 women every minute.1

    • PPH is preventable through use of simple interventions that should be offered to all women at the time of birth.

    • PPH is treatable, but requires rapid recognition and care to prevent life-threatening consequences; a woman can die from PPH in just two hours.

    • PPH is unpredictable; therefore, every pregnant woman needs care during childbirth from a skilled birth attendant (SBA).2 However, in developing countries, almost 50% of deliveries occur at home without an SBA.3 Women giving birth without an SBA are at increased risk of dying from complications including PPH.

Promote evidence-based interventions for PPH prevention and management:

    • PPH prevention can reduce PPH-related deaths through: active management of the third stage of labor (AMTSL) by an SBA; and birth preparedness and complication readiness counseling, PPH prevention counseling, and antenatal provision of misoprostol for use at the time of birth when delivery with an SBA is not possible.

    • PPH management can further reduce PPH-related deaths through: a number of interventions mainly available within facilities with skilled providers; and basic or comprehensive emergency obstetric and newborn care (BEmONC or CEmONC) services.

Provide evidence to key stakeholders and decision-makersto assist in shaping policy. This can be done by:

    • Organizing information sessions that provide the evidence base for recommended PPH prevention and treatment interventions.

    • Conducting a series of technical updates presenting data on: maternal mortality ratio (MMR); country- or region-specific PPH prevalence and rates of skilled attendance at birth; global evidence on PPH prevention and management; and results from PPH prevention and management research and projects.

    • Conducting surveys that study existing practices, policies and training curricula to understand where the country is in terms of PPH prevention and/or treatment.

    • Designing research to help policymakers, program managers and health service administrators understand factors that inhibit access to adequate, affordable interventions for PPH preventions and treatment, especially for vulnerable populations.

    • Identifying innovative interventions and approaches that can be tested and evaluated to demonstrate safety and program feasibility in their context such as: oxytocin in the Uniject® device; reducing misoprostol dosage; introducing the non-pneumatic anti-shock garment; and mainstreaming the use of the condom tamponade. Governments should choose a strategic approach that suits their situation, such as beginning with a demonstration project or pilot.

Develop champions for PPH prevention: To ensure that PPH is on the national agenda, it is helpful to have champions at the national level who are convinced of the evidence and can persuasively advocate to decision makers for PPH interventions. Key government officials, members of professional associations, pre-service and in-service educational programs, and influential clinicians can all be powerful champions.

Discuss with government counterparts, global agencies, donors, educational institutions, professional associations, local nongovernmental organizations, and maternal health stakeholders to generate support. It is important to build commitment among technical leaders at the national level before beginning programming, keeping in mind that some partners remain focused on certain programmatic approaches, and that the evidence base continues to evolve. In many countries, a national PPH Technical Advisory Group (TAG) was created through which stakeholders from the Ministry of Health and implementing partners could guide the program process.

Program Pitfalls and Lessons Learned: Advocacy

    • Champions at the national level are essential for introducing new policy for PPH prevention and treatment.

    • PPH interventions should be promoted at the national and local level as part of an overall safe motherhood campaign. They should be seen as complementary to an ongoing program to expand skilled attendance and ensure the availability of CEmONC.

    • Interventions should be designed to expand coverage of a uterotonic for all births and include efforts to reach vulnerable and marginalized populations.

    • Commitment at the national level to scale up the intervention is essential from the start if the intervention is found to be successful.

    • Strong partnership from the beginning can result in sense of ownership among a wide range of partners and facilitate more rapid adoption and expansion.

    • Surveys on prevailing practices for managing the third stage of labor are powerful advocacy tools.

Postpartum Hemorrhage Prevention and Management: Evidence and Action
2011 | MCHIP | 58 slides
This MCHIP technical presentation was developed as a resource to: describe the global mortality burden of PPH; present current evidence and action to prevent PPH; share key evidence and action to manage PPH; and discuss key elements in a comprehensive program to reduce deaths from PPH.
[read more >]
Program Brief: PPH Prevention and Management
2011 | Maternal and Child Health Integrated Program (MCHIP) | 2p
This 2-page MCHIP program brief summarizes the key facts, issues and interventions for PPH prevention and management and it is aimed at policymakers. It is complemented by the advocacy presentation.
[read more >]
Respectful Maternity Care: The universal rights of childbearing women
No Date | The White Ribbon Alliance for Safe Motherhood
Website
The White Ribbon Alliance for Safe Motherhood addresses disrespect and abuse during maternity care with advocacy documents and a charter for maternal human rights.
[read more >]
Scope of Work for the Prevention of PPH at Home Births Technical Advisory Group (TAG)
No date | Afghanistan Ministry of Health | 1p
This SOW defines 2 phases of teechnical advisory group support to the MOH on PPH prevention for home births. It can be adapted by other countries seeking to establish a TAG.
[read more >]
Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting Report, 21–25 February 2011
2011 | MCHIP | 125p
This meeting covers covers the content, discussions and recommendations from the regional meeting held in Addis Adaba in February 2011. The report includes: 1)  interventions for impact in obstetric health; and 2) helping babies breathe (HBB) regional training of trainers (TOT) for Africa.
[read more >]
PPH Advocacy Presentation: Postpartum Hemorrhage
2011 | Maternal and Child Health Integrated Program (MCHIP) | 34 slides
This advocacy presentation was developed by MCHIP to capture the key issues for policymakers on PPH prevention and management.
[read more >]
PPH Technical Brief: PPH Prevention and Management
2011 | Maternal and Child Health Integrated Program (MCHIP) | 8p
This MCHIP technical brief summarizes the current clinical evidence for country programs to consider when addressing PPH is a priority to reduce maternal mortality. There is a range of both well-known and emerging prevention and management interventions available—in addition to broader strategies such as skilled birth attendance, birth preparedness, and emergency obstetric care—to countries to address their specific settings and challenges.
[read more >]
Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: National Programs in Selected USAID Program-Supported Countries
2011 | MCHIP | 152p
A country-level landscape analysis was conducted from January to March 2011 in 31 countries across Africa, Asia and Latin America, including 23 MCHIP priority countries facing the highest disease burden. The purpose of this analysis was to document progress in national scale-up of PPH- and PE/E-reduction programs in all MCHIP and MCHIP-affiliated programs around the world. It is anticipated that the questionnaire used in this analysis will be repeated on a semi-annual to annual basis in an effort to maintain current information.
[read more >]
Program Implementation Guidance: PPH Prevention and Management
2011 | MCHIP | 11p
This guidance document was developed to assist program teams to develop projects and interventions to address PPH. It directs users through a series of steps and guides them on where to access relevant resources in the toolkit. This version was updated in December 2011.
[read more >]
Annotated Bibliography: Postpartum Hemorrhage: Prevention and Management
2010 | Maternal and Child Health Integrated Program (MCHIP) | 24p
This annotated bibliography is the result of an evidence review of nearly 200 articles on topics related to postpartum hemorrhage (PPH) prevention and management. After an extensive technical review, the 20 most important articles are abstracted in Section 1 to highlight the key findings and implications for public health programming. Other important articles are listed as references in Section 2.
[read more >]
WHO Statements regarding the Use of Misoprostol for Postpartum Hemorrhage Prevention and Treatment
2009/10 | The World Health Organization (WHO) | 2p
These 2 statements by WHO explain the current WHO position regarding misoprostol use after childbirth to prevent PPH and should be read together. WHO recommends the use of misoprostol in settings where it is not possible to use oxytocin or another injectable uterotonic. Health workers who will administer misoprostol should be trained in its correct use after birth of the baby and to avoid its administration before birth at incorrect doses, and in identifying and managing its side-effects.
[read more >]
Technical Report: Final Assessment on the Feasibility of Auxillary Midwives Using the AMTSL in Mali
2008 | Ministry of Health | 73p
This assessment aimed at documenting the efficiency and the safety of matrones using AMTSL in the prevention of PPH in order to extend this procedure to all regions. The data from the final evaluation has been compared with the information gathered during the baseline survey in order to evaluate the changes that occurred, after the intervention, in the providers’ practice, with a particular focus on matrones.
[read more >]
Preventing Postpartum Hemorrhage
2007 | ACCESS Program | 4p
This 4-page brief presents evidence on PPH prevention for two contexts: when women give birth with skilled provider at home or in a facility. Where there is a skilled provider: one of the most important prevention measures is having a skilled provider present at birth. In addition to using the WHO partograph to monitor labor, the appropriately trained skilled provider is less likely to perform procedures such as episiotomy or operative vaginal delivery without clear indications.
[read more >]
Joint Statements from FIGO/ICM on Prevention of Postpartum Hemorrhage
2006 | International Federation of Gynecology & Obstetrics (FIGO) | 1p
ICM and FIGO have jointly released 3 statements about PPH prevention: 1. A 1-page statement that active management of the third stage of labour is proven to reduce the incidence of postpartum haemorrhage, the quantity of blood loss, and the use of blood transfusion. AMTSL should be offered to women since it reduces the incidence of postpartum haemorrhage due to uterine atony. FIGO/ICM will promote active management of the third stage of labour and take action to prevent postpartum haemorrhage.
[read more >]