Step 1: Advocate with Evidence
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.