Key messages

• Multicomponent implementation strategies may improve adherence to World Health Organization (WHO) postpartum hemorrhage (PPH) prevention recommendations and probably do not make a difference to intensive care unit (ICU) admissions, need for additional surgeries, or death of the mother. We do not know if multicomponent implementation strategies affect blood loss or blood transfusion.

• We do not know if single-component implementation strategies affect adherence to WHO PPH prevention recommendations, blood loss, or blood transfusion. Single-component implementation strategies may not make a difference to the death of the mother, may increase ICU admissions, and may reduce the need for additional surgeries.

• The small number of studies and differences in data collected across included studies limited our ability to draw any conclusions on effective implementation strategies; however, there were varying degrees of success with identical implementation strategies in different studies, highlighting the need for future research in this area.

What is postpartum hemorrhage (PPH)?

Postpartum hemorrhage is typically defined as blood loss greater than 500 mL within 24 hours after birth.

How is PPH prevented, diagnosed, and treated?

WHO guidelines recommend oxytocin administration immediately after birth to prevent PPH. Some birth facilities use blood collection drapes and scales to measure blood loss; however, many do not have access to these supplies. The treatment of PPH varies based on the severity, underlying cause, and available resources. Most cases of PPH are treated with medications that cause the uterus to contract. In women who do not respond to this medication, uterine balloon tamponade (where a balloon is inflated in the uterus to compress blood vessels and stop bleeding) or surgery is needed.

What are implementation strategies?

Implementation strategies are specific techniques used to increase the acceptance, uptake, and sustainability of a clinical practice or program. Examples include engaging individuals and leaders, changing infrastructure, and training and educating and/or supporting birth attendants.

How are implementation strategies used to prevent, diagnose, and treat PPH?

A wide range of implementation strategies have been used in clinical practice to prevent, diagnose, and treat PPH. Strategies include training and educating skilled birth attendants in evidence-based practices, introducing new equipment to birth facilities, and developing reporting systems to audit health records and provide feedback to healthcare workers.

What did we want to find out?

We wanted to know which, if any, implementation strategies of WHO PPH recommendations are effective in facility-based childbirth settings.

What did we do?

We searched for studies that looked at the effects of implementation strategies of WHO PPH recommendations by birth attendants on people who gave birth in a health facility. We summarized the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes.

What did we find out?

We included 13 studies, which were categorized into three groups based on the implementation strategies used: (1) single strategy versus usual care, (2) multiple strategies versus usual care, and (3) multiple strategies versus enhanced usual care.

We do not know if single-component implementation strategies affect adherence to WHO PPH prevention recommendations, blood loss, or blood transfusion. Single-component implementation strategies may not make a difference to maternal death, may reduce the need for additional surgeries, but may also increase ICU admissions.

Multicomponent implementation strategies may improve adherence to PPH prevention recommendations and probably do not make a difference to ICU admissions, need for additional surgeries, or maternal death. We do not know if multicomponent implementation strategies affect blood loss or blood transfusion.

We found that the same implementation strategies and study approach can increase adherence to WHO guidelines in one setting, not make any difference in another, and even reduce adherence in others.

Many studies lacked a comprehensive framework that linked implementation efforts with adherence to WHO recommendations and patient outcomes; it is doubtful that multicomponent intervention could address all factors that contribute to PPH-related illness or death. It remains unknown whether multiple strategies work in a real-world setting.

What are the limitations of the evidence?

The level of detail of implementation strategies varied, preventing the combining of studies. There were also differences in the people included in the studies according to facility level, volume of births, and type of delivery. Different study contexts made it difficult to measure the true impact of implementation strategies on outcomes.

How up-to-date is this evidence?

The evidence is current to 25 April 2024.