Step 2: Create Enabling Policy Environment
To improve care for women and the ability of providers to prevent and manage PPH, an adequate enabling environment—including resources and policies—must be established.
Integrate PPH-relevant interventions where possible: Working through the national PPH TAG, integrate PPH strategies into existing maternal and newborn health programs to increase the likelihood that interventions for PPH are sustainable and are integrated rather than vertical. The strategy will need to define stages or phases for implementation at all levels along the continuum of care. With the range of PPH prevention and management interventions, integration into existing services, trainings, behavior change communication campaigns, and management information systems (MIS) will expand coverage and save resources.
Combine approaches for greater impact: Policies need to define the PPH-related interventions that are authorized at each level of care (including the home) and by each type of birth attendant (including a family member or the woman herself). Based on the national situation, governments may need to make decisions about which approach to promote at each point of care (home to facility) and by each type of birth attendant (family member or traditional birth attendant to SBA). For example, in settings where a large proportion of births are not attended by SBAs, distribution of misoprostol through antenatal care (ANC) clinics may be promoted. This approach will only be effective, however, if most women attend ANC late in pregnancy when misoprostol could be distributed. In Tanzania, 92% of women presented early in pregnancy for an ANC visit, but only 52% visited after 32 weeks and received misoprostol.4 A modeling exercise for sub-Saharan Africa estimated that a comprehensive intervention package (health facility strengthening and community-based services) would reduce deaths due to PPH or sepsis after delivery by 32% (compared to just health facility strengthening alone [12% reduction]).5
Develop policies that allow a range of providers to offer PPH-related care: Policies need to be in place that ensure access to PPH prevention and treatment interventions by all women giving birth, regardless of the type of birth attendant or the place a woman chooses to give birth. To do this, policies must support authorization of different cadres of providers to provide defined interventions for prevention and treatment of PPH. For example, in 2009, the Ministry of Health in Mali decreed that AMTSL and oxytocin could be used for the prevention of PPH by doctors, midwives, obstetric nurses and matrons (auxiliary midwives), increasing national coverage of AMTSL.
Ensure that service delivery guidelines are up to date: National service delivery guidelines should reflect state-of-the-art and evidence-based interventions for prevention and treatment of PPH. These may be adapted from global reference materials, such as publications developed by the WHO. Ministries of Health need to disseminate copies to all levels of the health care system to ensure compliance with the guidelines.
Address logistics needs for drugs, instruments and equipment: Ensure both oxytocin and misoprostol are on the national Essential Drugs List and are tracked through national logistics management information systems. Although misoprostol is often available in countries for other uses, registration of the drug for importation and use for PPH prevention and treatment is needed.
Program Pitfalls and Lessons Learned: Policy for PPH Programming
• Having a clear understanding of PPH prevalence by place of birth and type of birth attendant will greatly assist policy makers in defining policy for ensuring maximum access to PPH prevention and treatment interventions.
• Ensuring the integration of PPH-related interventions into broader maternal and newborn health programs will ensure maintenance and sustainability.
• Policy should ensure uterotonic drug coverage for all births, including births in vulnerable and marginalized populations.
– To ensure access to PPH prevention and treatment interventions, MOH policies need to promote provision of selected interventions at all points of care and by all types of birth attendants.
– The most effective way to prevent PPH and reduce morbidity and mortality from PPH is to promote attendance by SBAs for all births. However, countries with high rates of home deliveries without a skilled provider may need to provide additional focus on PPH prevention at home births until more births are attended by SBAs.
– If a large proportion of births are not attended by skilled providers and there is an existing network of community health workers (CHWs) or volunteers, it is possible to work with existing community-based providers and networks to achieve high coverage of PPH prevention and to reach disadvantaged segments of the community at higher risk of poorer outcomes.6
• Policies cannot be implemented unless logistical and training concerns are first addressed.
• For new projects or studies involving misoprostol, it is important to identify the source of sufficient quantities of tablets as well as to address drug registration issues.
• Use all of the available resources and materials to facilitate implementation—training and counseling materials, program implementation guides, evaluation tools and posters.