Table Of Contents
Planning & Implementing A PPH Program
Raising The Issue
The responsibility for PPH prevention and treatment guidelines, and the national MNH program strategy, is with the Ministry of Health in every country.
Many stakeholders can raise the PPH issue, however, and help the Ministry start revisiting the national guidelines, strategy and programs. Often some health professionals – doctors, specialist obstetrician-gynecologists, midwives, or nurses – have an interest in PPH, and may become the “national champions” who raise the issue, perhaps with the help of their professional association.
Within a MNH program, one needs to give special attention to the major causes of maternal and newborn ill-health.
One must decide what to do specifically for reduction of eclampsia deaths or newborn asphyxia. PPH control is not a separate program, but part of the MNH care strategy – but careful planning is needed to reduce the deaths from each major disease including PPH.
The content of this website shows how revisiting the national PPH strategy is a first step to reducing PPH deaths.
Keys To Effective Strategy
The strategy must also define how the revised PPH program shall be:
Key Elements In Planning And Implementation
Policy and Governance
- Make sure to review PPH content of national reproductive, maternal, newborn, and child health policies.
- Ensure national PPH policy and strategies include an intentional mix of facility- and community-based PPH prevention and treatment strategies tailored to the country context based on analysis of:
- National/regional PPH burden/causes
- Skilled birth coverage
- Health system structure and functionality
- Offer clear guidance on PPH prevention and management strategies and protocols, including PPH clinical treatment algorithms.
- Specify provider cadres authorized to provide specific PPH prevention and treatment interventions (e.g., community health worker [CHW], nurse, midwife, medical health officer, Obstetrician).
- PPH (and other obstetric emergencies) referral and counter-referral guidelines tailored to system-level with supporting materials.
- Develop a costed and budgeted operational plan for implementing PPH policy.
- Engage public and private sector (e.g., professional associations, private pre-service education/training institutions).
- Conduct financial analysis of proposed PPH strategies/interventions, including:
- Cost of human resources and capacity development (e.g., training needs)
- Costs of commodities and related products/supplies
- Other facility operational costs
- Costs associated with referral
- Determine resource requirements to implement PPH policy (and any specific strategies).
- Advocate for and mobilize PPH resources.
- Develop costed budgeted plan and ensure regular allocation and disbursement of designated funds.
- Remove financial barriers to emergency access to lifesaving treatment, commodities, and referral/transport for women with PPH.
- Specify workforce regulations related to:
- Which provider cadres are authorized to provide specific PPH interventions (e.g., IV uterotonic, uterine balloon tamponade [UBT], IV tranexamic acid [TXA])
- Certification requirements and strategies to build and maintain provider competencies to administer PPH interventions
- Ensure that pre-service and in-service PPH curricula and education materials are up to-date, comprehensive, and competency-based.
- Design and regularly update evidence-based user-friendly PPH continuing professional development materials and job aids.
Policy for PPH Commodities
- Ensure that commodities recommended in standard treatment guidelines/PPH policy are registered for distribution in-country, and are included in national Lists of Essential Medicines and any relevant commodities policies.
Forecasting and Supplies
- Forecast needs and support robust supply systems to ensure essential PPH commodities are available to all health care workers (e.g., county, health centers, and hospitals) without stock-outs.
- Implement robust logistics information system to track the availability of commodities and provide reliable data for forecasting.
Procurement and Use
- Procure quality-assured essential commodities (uterotonics, IV TXA, gloves, IV fluid, and other supplies used in the prevention and treatment of PPH).
- Provide guidance on and monitoring for appropriate storage of essential commodities.
- Ensure immediate onsite access to essential PPH commodities for every woman with PPH (i.e., “stocked ready PPH kits in the maternity/postpartum area"; remove all barriers to immediate access to lifesaving commodities, such as requirement for families to purchase from pharmacy; locking commodities without access 24 hours a day, 7 days a week).
Functional Referral System
- Ensure national PPH policy includes specific referral guidelines (including stabilization) for women with PPH tailored to each health system level and including both public and private sectors.
- Develop and support use of standardized referral communication protocols and tools.
- Allocate funding to support referral processes, including timely emergency transport of women with PPH by a skilled provider and other obstetric complications.
Metrics and Actionable Information Systems
- Ensure availability of high-quality registers and patient records for primary and hospital levels that include essential clinical information for clinical case management and data for calculation of prioritized indicators.
- Define a small number of priority PPH measures for tracking and use at the national level to support national PPH surveillance and inform PPH programming.
- Illustrative PPH indicators for consideration/adaptation at country level include:
- Proportion of (institutional and community) maternal deaths due to PPH
- PPH incidence and case fatality
- Percentage of women delivering in facilities administered postpartum uterotonic
- Potential community-level indicator, based on national policy:
- Percentage of women delivering at home who received immediate postpartum misoprostol for PPH prevention (or oxytocin, if skilled birth attendant present)
Two Clinical Bundles
In December 2017, WHO hosted an expert consultation in Boston, USA. The doctors and midwives present finally agreed that for PPH, there should be two Clinical Bundles for treating PPH. These two bundles are outlined below:
- Give a uterotonic
- Set up an IV infusion (with a crystalloid fluid)
- Give tranexamic acid (TXA)
- Massage the uterus
- Bimanual uterine massage
- Aorta compression
Each of these 4+4 key treatments are all since years recommended by WHO. What is new is how they are recommended as two bundles. Every country must decide which of these life-saving measures they wish to include in their MNH program and if they choose a bundled approach. Every country also needs to decide which procedure should be used at which tier and by which cadre. Other country experiences show the above-mentioned interventions can be safely practiced at the PHC level, by skilled midwives. They are cornerstones of effective, life-saving PPH treatment.
To enable these key clinical treatments, training is not enough. Specific parts of the health system must be strengthened —these include facility readiness, network integration, teamwork and communication, monitoring and local problem solving, and supply chain — and these are covered next.