A Roadmap to Combat

Postpartum Haemorrhage
between 2023 and 2030
A Roadmap to Combat
Postpartum Haemorrhage
between 2023 and 2030
A Roadmap to combat postpartum haemorrhage between 2023 and 2030.
ISBN XXX-XX-X-XXXXXX-X

© World Health Organization 2023

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Contents

Acknowledgments v
Acronyms and abbreviations vi
Executive Summary vii
1. Introduction and rationale 1
1.1 Postpartum haemorrhage: a global public health concern 1
1.2 Why is a Roadmap needed to combat postpartum haemorrhage? 1
1.3 Target audience 3
1.4 Objective and scope of the Roadmap 3
2. How the Roadmap was developed 4
2.1 Contributors to the Roadmap 4
2.2 Identifying gaps in strategic areas 4
2.3 Building consensus on priority gaps and solutions 6
2.4 Integrating priority solutions into a Roadmap and Call-to-Action 7
3. Structure of the Roadmap 9
3.1 Strategic area: Addressing priority research gaps 9
3.2 Strategic area: Addressing priority gaps in norms and standards 11
3.3 Strategic area: Addressing implementation bottlenecks 13
3.4 Strategic area: Closing advocacy gaps 19
3.5 Consolidated Roadmap 23
4. A Global Call-to-Action 25
5. Implementation of the Roadmap 28
5.1 Global leadership and governance 28
5.2 Adaptation for local context 28
5.3 Anticipated impact of the Roadmap 29
6. Disseminating the Roadmap and Call-to-Action 30
7. Monitoring and evaluating impact 31
8. References 33
Annexes 35

iii
Acknowledgments

The World Health Organization (WHO) gratefully acknowledges the contributions of many individuals
and organizations to the development of this Roadmap.
WHO extends sincere thanks to the members of the Steering Committee: Sabaratnam Arulkumaran,
Jolly Beyeza-Kashesya, Michel Brun, Rizwana Chaudhri, Sue Fawcus, Hadiza Galadanci (co-chair),
Caroline Homer, Pete Lambert, Cammie Lee, Elliot Main, Richard Mugahi, Suellen Miller (co-chair),
Alison Morgan, Angela Nguku, Hriskesh Pai, Daisy Ruto, Patricia Titulaer, and Pauline Williams.
We appreciate the feedback provided by a large number of international stakeholders during the
Summit that took place in Dubai in March 2023 as part of the Roadmap development process. The
institutional affiliations of all Summit participants including the Steering Committee are in Annex 1 of
this Roadmap.
Special thanks for contributing to the prioritization processes before and during the Summit are due
to the following WHO staff – Allisyn Moran, Uzma Syed, and Sachiyo Yoshida (Department of Maternal,
Newborn, Child and Adolescent Health) and external contributors – Ampersand Health Science
Writing Pty Ltd (Jenny Ramson), Centro de Estudios de Estado y Sociedad (CEDES) (Edgardo Abalos),
Centro Rosarino de Estudios Perinatales (Monica Chamillard, Virginia Diaz, Celina Gialdini, Julia
Pasquale), Concept Foundation (Lester Chinery, Metin Gülmezoglu), Institute of Clinical Effectiveness
and Health Policy (Caitlin R. Williams), University of Birmingham (Arri Coomarasamy, Adam Devall),
and University of California, San Francisco (Dilys Walker).
The preparation of background materials, facilitation at the Summit, and drafting the Roadmap
document before it was reviewed by the Steering Committee and WHO coordination team was
conducted by Boston Consulting Group (Guervan Adnet, Johanna Benesty, Sarah Chamberlain,
Louis-Victor Dorat, Raphaelle Kemoun, Hachani Rim, and Asher Steene).
WHO administrative support was provided by Angelica Flores and external event organizers (ATOP)
provided organisation support for the Summit.
WHO communications support was provided by Natalie Bailey, Svetlin Kolev from the WHO
Department of Sexual and Reproductive Health and Research and Victoria Holdsworth (consultant).
Editing and proofreading was provided by XXX, XXX.
Overall coordination of the Roadmap development process was provided by Ioannis Gallos, Olufemi
Oladapo, and Mariana Widmer, WHO Department of Sexual and Reproductive Health and Research.
Funding for the development of the Roadmap was provided by MSD for Mothers and the Bill and
Melinda Gates Foundation.

v
Acronyms and abbreviations

CHNRI Child Health and Nutrition Research Initiative

CSO Civil society organisation
EML Essential Medicines List
ENAP Every Newborn Action Plan
EPMM Ending Preventable Maternal Mortality
GDG Guideline development group
HIC High-income country
HRP UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development
and Research Training in Human Reproduction
HSC Heat-stable carbetocin
IMNHC International Maternal Newborn Health Conference
LMIC Low- and middle-income country
MMR Maternal mortality ratio
MoH Ministry of Health
NGO Non-governmental organisation
PPH Postpartum Haemorrhage
R&D Research and development
SDG Sustainable Development Goal
TPP Target Product Profile
TPoP Target Policy Profile
TXA Tranexamic acid
UHC Universal Health Coverage
WHO World Health Organization

vi
Executive Summary

Introduction and rationale

Postpartum haemorrhage (PPH) – commonly defined as a blood loss of 500 ml or more within 24
hours of birth – affects one in every six women giving birth. It remains the leading cause of maternal
mortality, accounting for over 20% of all maternal deaths reported globally. Death from PPH is
largely preventable and has been nearly eliminated in high-income countries (HICs). Yet women
in low- and middle-income countries (LMICs) continue to be disproportionately affected. Nearly
all maternal deaths from PPH occur in sub-Saharan Africa and south Asia. The reported global
maternal mortality ratio (MMR) of 216 maternal deaths per 100,000 live births in 2020 means that
countries are significantly off-track in achieving the 2030 MMR target for sustainable development.
Additionally, progress in maternal mortality reduction has stalled over the past 5 to 10 years and
future projections through 2030 are concerning. Decisive actions are desperately needed to change
this trajectory.
Despite the clear need to tackle the leading cause of maternal death, global PPH efforts have failed
to gain traction. There are key knowledge gaps regarding how best to prevent, detect, and treat PPH.
The PPH innovation landscape over the last 30 years has been stagnant. Research investments on
what works and how best to deliver proven PPH interventions are generally scarce and fragmented.
This fragmentation complicates efforts to unify global recommendations and support national
policies to improve PPH care and outcomes. Developers of norms and standards at global, regional,
and national levels continue to individually invest in costly and time-consuming evidence syntheses,
leading to guidance documents that are not always consistent. This tends to create uncertainties for
the intended end-users, especially in LMICs – policymakers at Ministries of Health, health managers,
and health care providers – who may struggle with which guidance to adopt. Implementation
of effective interventions is further hampered by multidimensional barriers that extend beyond
adoption of global norms. These barriers are not well understood, as they are often contextual and
sometimes dependent on political processes outside the typical remit of those leading PPH efforts.
As demonstrated in other disease areas, advocacy initiatives by civil society and non-governmental
organisations could be powerful catalysts for global action, but these are generally underutilised for
PPH. Concerted effort to establish clear agendas for these four strategic areas could lend structure
and coherence to the field.
In recognition of the growing need for global action to improve the quality of PPH care, the World
Health Organization (WHO) worked together with several stakeholders to develop this Roadmap,
outlining global-level research, normative, implementation, and advocacy goals, activities, and
milestones from 2023 to 2030, to address key PPH priorities and fast-track progress towards the
SDG 3.1 target. This Roadmap establishes an innovative, solution-driven, and customised strategic
framework that centres PPH high-burden country maternal health goals and priorities, and points
investments into critical areas of health systems, with special emphasis on LMICs. The Roadmap aims
to align efforts and foster cooperation among all partners working in the PPH space to deliver PPH
agendas, by pursuing the required technical, investment, and political objectives that will deliver on
the core priorities of ongoing global initiatives for maternal and newborn health.

vii
How the Roadmap was developed
The development of this Roadmap was based on a scientific review of the status of PPH across
four strategic areas (research, norms and standards, implementation, and advocacy), and input
received from online and in-person consultations of a large group of stakeholders working in these
areas at international and country levels. To ensure that each area was robust and reflected the
global community’s consensus on key priorities for united action, a systematic multi-step process
was applied to independently define future agendas for each of the four strategic areas. A Steering
Committee set up by WHO advised on the methods for identifying and prioritising gaps in research,
norms and standards, implementation, and advocacy. WHO staff ensured compliance of the methods
with WHO internal procedures. WHO established and engaged a broad range of stakeholders –
Ministries of Health, research institutions and academia, innovators from industry and private sector,
professional associations, non-governmental associations, and donor agencies – in a participatory
process that culminated in a global convening to define the future of PPH.
The development process for the research agenda followed WHO’s systematic approach for
undertaking research priority-setting. An initial set of research questions was developed from
input received from a broad range of stakeholders, and research gaps derived from PPH guidelines,
systematic reviews, analysis of PPH medicines and devices in the pipeline, and unaddressed
questions from previous prioritisation exercises. A total of 72 research questions that emerged after
removing duplicates and harmonising similar questions, were then scored by the same stakeholders
according to set criteria, to arrive at 30 questions that form the basis of further prioritisation at an
in-person convening of stakeholders.
Published international and national guidelines that met specified criteria were systematically
reviewed to identify gaps in existing PPH recommendations and assess consistency across
guidelines. In addition, the evidence underpinning each PPH recommendation was updated to
identify new impactful evidence that justifies updating of existing recommendations.
A multi-pronged strategy was deployed to better understand barriers to implementation.
First, a framework of essential pre-requisites for successful implementation of existing PPH
recommendations was developed. Then, international and in-country stakeholders were surveyed
to understand to what extent these pre-requisites were met for recommended interventions. Survey
responses were triangulated with data from health facilities to understand whether recommended
interventions were reaching women at the bedside. To understand contextual challenges responsible
for slow uptake and deployment of evidence-based recommendations, three country case studies
– Nigeria, Pakistan, and Tanzania – were conducted. In addition, exemplar countries that saw
remarkable progress in reducing the burden of PPH were studied to identify lessons on how to
address implementation bottlenecks.
A stakeholder mapping exercise was conducted to identify key organisations and initiatives across
the current global PPH advocacy land­scape. This analysis highlighted the limitations and gaps in the
current ecosystem. In parallel, other global health advocacy ecosystems were also mapped, to serve
as a benchmark and help identify successful advocacy efforts that could be replicated for PPH.
The outputs from the above activities underpinned the discussions among over 130 stakeholders at
the Global Summit on PPH, convened by WHO from 7–10 March 2023 in Dubai, United Arab Emirates.
These outputs were presented at plenary and breakout sessions to help stakeholders make informed
decisions on the highest priority gaps, the corresponding set of solutions, and clear agendas for
collective action. This Roadmap reflects synthesised evidence, stakeholders’ input, and further
refinement of proposed solutions and course of action after the Summit.

Structure of the Roadmap

The Roadmap outlines the key priorities and strategies to combat PPH burden and associated
adverse outcomes as agreed by the stakeholders at the 2023 Global PPH Summit, structured around

viii A Roadmap to Combat Postpartum Haemorrhage between 2023 and 2030

four interlinked strategic areas (research, norms and standards, implementation, and advocacy)
that are necessary to catalyse efforts and fast-track attainment of country goals to avert maternal
death. Under each strategic area, the Roadmap describes activities and put forward specific actions
and deliverables for the period 2023 to 2030. The figure below provides an overview of these actions
and deliverables. Specific details on each of the strategic areas (summarised below) can be found in
relevant section of this document.

Strategic area: Addressing priority research gaps

Research is fundamental to achieving progress for any health condition. Stagnancy in research,
including implementation research, can have an impact on women’s outcomes relating to PPH,
and has the potential to impair initiatives for reducing PPH burden and its contribution to maternal
mortality. Aligning on priority PPH research gaps along three tracks (innovation, implementation,
and cross-cutting) was identified as important to focusing investment to reduce research wastes
and shortening the time it takes to meaningfully respond to public health needs. Fifteen research
questions were identified as particularly critical for advancing actionable knowledge around PPH
through 2030 (and beyond 2030 for research priorities related to innovations which by default tend
to take longer). The top question per track called for: research on the comparative effectiveness and
safety of alternative routes of tranexamic acid administration for the treatment of PPH [innovation];
identifying barriers and facilitators to the uptake of recommended interventions (and best
implementation strategies for addressing those barriers) [implementation]; and determining the
effectiveness of a bundle approach for PPH treatment [cross-cutting].The next step will be for WHO to
frame the top 15 questions from the perspectives of future policy development or updates, outlining
the best research designs and priority outcomes that will drive future policymaking decisions. The
funding gaps for this research agenda will be carefully assessed before the agenda is shared with
funding agencies. It is expected that funding agencies will use these research priorities as the basis
for launching call(s) for research proposals by the first quarter of 2024. Results for the first batch
of funded research proposals are anticipated to be published and disseminated by 2027 or sooner,
depending on the scope of the individual research. Progress in research and development in the
context of these research priorities will be monitored, and by 2030, a review of any pending or new
research gaps will be conducted. This strategic area is closely linked to that on addressing normative
gaps relating to PPH as results of the prioritised research will be matched with their integration into
global and national policies to influence practices on a continual basis.

Strategic area: Addressing priority gaps in norms and standards

To address gaps and inconsistency in guidance issued to end-users by international bodies,
enhanced collaboration among key PPH guideline developers is needed, particularly among those
working at the international level (WHO, FIGO, ICM). To this end, WHO will establish a Steering Group
to explore the feasibility of joint publication of consolidated PPH guidelines that takes into account
previously underrepresented topics and evidence from LMICs. The Steering Group will review and
agree on the scope of the guidelines and propose membership of the guideline panel by the last
quarter of 2023. The collaborating organisations are expected to pool resources to commission
evidence synthesis and development of evidence profiles from the first through last quarter of 2024.
An ambitious goal was set for the publication of the consolidated PPH guidelines in early 2025.
In the interim, WHO and partners will continue to respond to new, impactful evidence on PPH, to
issue individual standalone recommendations through their current internal procedures (e.g., WHO
living guidelines approach) until the consolidated guidelines are published. Once published, these
consolidated guidelines will then be subjected to a living guidelines approach for incorporation
of evidence that emerge from the funded research priorities described above. To avoid any delays
in translating knowledge into practice, particularly in countries where this is a key bottleneck to
progress, WHO and key stakeholders (e.g., USAID, Concept Foundation, MSD for Mothers) will review
the PPH policy contexts of countries with high burden of PPH and maternal mortality and provide the
Executive Summary ix
technical and financial support needed to update PPH policies and adapt them for the local context.
An ambitious goal of achieving up-to-date PPH policies in at least 20 high-burden countries is set for
the last quarter of 2024. This effort is expected to set up a model for engagement of stakeholders and
expand to other LMICs on as-need basis through 2030.

Strategic area: Addressing implementation bottlenecks

Implementation of proven interventions and strategies was widely recognized as the most significant
challenge to achieving better PPH outcomes. Yet addressing implementation bottlenecks was
acknowledged as the singular, potentially most impactful of all strategic areas. The multifactorial and
contextual nature of the implementation bottlenecks means that they do not easily lend themselves
to global solutions. Recognising that there are many implementation barriers that need addressing at
the country level, stakeholders identified and prioritised five categories of implementation barriers
for global action. These include lack of clear national policy and leadership (including lack of
national targets, systematic collection of data to measure progress, or mechanisms to translate
global guidelines for country use); weak procurement and supply chain systems (PPH commodities
suffer from non-availability, stock-out, and substandard quality); poor staffing, training, and
supervision of healthcare providers (outdated licensing and regulatory infrastructure barring
task-sharing of PPH interventions, and lack of trained, empowered and motivated health workforce);
inequities and poor access to good quality care (persistent disparities, lack of access for
disadvantaged populations, and poor engagement of private sector); and women’s limited rights
and social status in the society (unfavourable legal, social, and cultural norms and obstacles
limiting women’s life choices and options about pregnancy and childbirth).
Priority actions to strengthen national policy and leadership for PPH include creating a PPH
framework to structure treatment response and interventions; adapting national guidelines to
local context and disseminating them from subnational level through the last mile; and developing
and deploying an efficient and sustainable monitoring system at scale in 2025, including common
indicators, systematic data collection, and a common measurement platform, to be able to track
progress against targets. To enhance procurement and supply chain, proposed actions include
scaling-up access to quality-assured commodities through strong coordination between partners,
increased investments, and new procurement initiatives. Efforts should cover devices, drugs, and
blood products. Other key actions include enhancing training and capacity building to strengthen
knowledge and expertise in PPH management and implementing broader human resource strategies
to address shortages of competent professionals (midwives, nurses, doctors), focusing on enhancing
healthcare infrastructure to strengthen facilities; improving transportation and referral systems;
and supporting the development of financing plans that abolish user fees and broaden insurance
coverage, reducing out-of-pocket expenses for key PPH products (e.g., expanding health system
coverage to PPH medicines/devices). While it was acknowledged that strategies to improve women’s
rights and social status will have a major impact on overall health outcomes for women, beyond PPH,
they were unlikely to be achieved in the short- to medium terms. Nonetheless, priority actions that
can be undertaken in the short-term include advocating for women to be at the centre of the political
agenda; raising awareness of PPH in the general population to help reduce delays in care-seeking
(e.g., through patient information leaflets); and ensuring that maternal care benefits from sustained
funding.

Strategic area: Closing advocacy gaps

There is currently no unifying force in the PPH space to drive the PPH agenda and aggregate funding.
A strong advocacy push is therefore needed at different levels. PPH needs to be elevated on global
political agendas; advocacy towards Ministries of Health must highlight the importance of quality-
assured procurement and up-to-date PPH guidelines and tools; adherence to guidelines must
be promoted with healthcare workers; and awareness of PPH must be increased in the general

x A Roadmap to Combat Postpartum Haemorrhage between 2023 and 2030

population. By Q4 2024, a global branding strategy and a global advocacy framework for reducing
maternal mortality from PPH should be developed. This strategy should include elements such as a
strong accountability system, targeted messaging, and tailored materials. All PPH stakeholders need
to be involved in the advocacy effort. Governments must play a key role in driving the response, with
women and communities at the centre. Finally, PPH efforts should not be implemented in isolation,
but rather be used as an entry point to address a broader maternal health agenda to reduce the
burden of maternal death and ill-heath.

A Global Call to Action

To amplify the priority actions enumerated above, a consensus-driven Global Call-to-Action that
clearly and compellingly articulates the actionable expectations from a wide array of stakeholders
and the urgency to act on the Roadmap was developed. This Call-to-Action is meant to publicly
outline the rationale for change, show evidence that change is possible, and distil what is required
to achieve the goals by each of the following stakeholder groups: women and women’s group,
Ministries of Health and national regulatory agencies, implementors (including non-governmental
organisations and civil society organisations, professional associations, guideline developers, the
research community, innovators in industry and private sector , donors, and the overall international
community. It outlines the key learnings that emerged from the PPH Summit and call for immediate
action to ensure effective and coordinated efforts towards eliminating preventable deaths from PPH.

Implementation and monitoring of the Roadmap

Successful implementation of this Roadmap will require concerted and coordinated efforts from
all stakeholders. WHO will serve as an initial catalyst for key activities in the short-term, including
through helping to establish structure for global leadership and governance around the Roadmap.
WHO will also work closely with Ministries of Health, relevant national agencies, and national
professional associations to develop normative materials that are adapted for local contexts to
kick-start implementation. However, longer-term actions will require commitments from additional
stakeholder groups.
Dissemination of the Roadmap began with the International Maternal newborn Health Conference
8–11 March 2023 in Cape Town, South Africa, and will be continued through the WHO website, other
conferences and convenings, WHO regional and country offices, Ministries of Health, professional
organizations, WHO collaborating centres, other United Nations agencies, and NGOs, among others.
Planned dissemination activities include translation into all six official UN languages and publication
in peer-reviewed journal articles. These dissemination activities will help to ensure generalised
awareness of the Roadmap among all relevant stakeholder groups.
Implementation of the Roadmap and progress toward key milestones will be monitored through a
common measurement platform, to be developed as one of the initial milestones in the Roadmap.
This common platform, composed of a monitoring framework and core set of key indicators, will
serve as a central accountability mechanism for the Roadmap. Interim monitoring data will be fed
into the updates made to the Roadmap in 2026–2027, which will more clearly define key activities and
milestones in the final years leading up to 2030.
If nothing changes, an estimated half million women will die from PPH by the close of the SDG era.
Millions more will suffer long-lasting consequences of traumatic birth experiences. The Roadmap
offers a vision of a different future, one where women no longer must die from a condition that is
both preventable and treatable. This future is possible. The Roadmap shows what is needed to get
there.

Executive Summary xi
Figure: High-level milestones in the Roadmap to combat PPH between 2023 and 2030

Figure. High-level milestones in the Roadmap to combat PPH between 2023 and 2030

xii A Roadmap to Combat Postpartum Haemorrhage between 2023 and 2030

1. Introduction and rationale

1.1 Postpartum haemorrhage: the relation between maternal mortality and

a global public health concern coverage of specific reproductive health-care
Postpartum haemorrhage (PPH), commonly services as well as assessment of observed
defined as a blood loss of 500 ml or more within versus expected maternal mortality as a
24 hours after birth, is the leading cause of function of Socio-demographic Index (SDI).
maternal mortality worldwide. Each year, about
14 million women experience PPH resulting in 1.2 Why is a Roadmap needed to
about 70,000 maternal deaths globally [1]. Even
combat postpartum
haemorrhage?
when women survive, they often need urgent
surgical interventions to control the bleeding Despite the ambition to end preventable
and may be left with long-term consequences, maternal deaths by 2030, many countries are not
both physical (e.g., life-long reproductive on track to meet their SDG-3 maternal mortality
disability, bladder injury, postpartum infection, targets. The current global maternal mortality
anaemia), and psychological (e.g., post- ratio (MMR) of 216 per 100,000 live births in 2020
traumatic stress disorder). The risk of PPH is far from the 2030 target of not more than 70
and PPH-related morbidity and mortality per 100,000 live births, and alarmingly, progress
disproportionately affects women in LMICs, has stalled over the past 5 to 10 years [3]. This
especially those who lack access to quality care. stagnation means that without rethinking the
Indeed, nearly all maternal deaths (~80%) from future and taking appropriate actions at global
bleeding after childbirth occur in LMIC, mostly and country levels, the 2030 MMR target will not
from sub-Saharan Africa and south Asia [2] it is be met.
imperative to comprehensively assess progress Limited progress has been made in the field
toward reducing maternal mortality to identify of PPH care over the last decade. Research
areas of success, remaining challenges, and is essential to improve understanding of
frame policy discussions. We aimed to quantify the condition and develop new prevention,
maternal mortality throughout the world by diagnosis, and treatment strategies. However,
underlying cause and age from 1990 to 2015. PPH research horizons have remained
Methods We estimated maternal mortality at the somewhat stagnant. Heat-stable carbetocin
global, regional, and national levels from 1990 (HSC) and tranexamic acid (TXA) are the only
to 2015 for ages 10–54 years by systematically new PPH medicines shown to be effective
compiling and processing all available data for PPH management over the last 30 years.
sources from 186 of 195 countries and territories, Evidence with potential to significantly change
11 of which were analysed at the subnational policies and modify the landscape of PPH care
level. We quantified eight underlying causes in LMIC has been scarce. While international
of maternal death and four timing categories, developmental partners tend to have similar
improving estimation methods since GBD objectives regarding PPH, efforts are often
2013 for adult all-cause mortality, HIV-related misaligned because of a lack of cohesive
maternal mortality, and late maternal death. coordination at and between global and country
Secondary analyses then allowed systematic levels. Academic researchers and innovators
examination of drivers of trends, including in industry often are uncertain what type of

1
evidence to generate and how to connect in their practice. Financial barriers continue
evidence to policy decision-making, leading to limit access to life-saving maternity care.
to research waste and delays in translating Communities are rarely engaged in this process
research ideas to impact. Target product to raise awareness. Effectively addressing these
profiles (TPPs) [4] and target policy profiles challenges often requires cross- and multi-sector
(TPoPs) [5] are supposed to provide guidance approaches.
for researchers, product developers, and
Advocacy is crucial for promoting awareness
policymakers. Yet TPPs have not generally been
of PPH and generating momentum for action.
described prior to R & D of PPH interventions
Raising community awareness of the dangers
and the concept of TPoPs is relatively new to
of PPH and the need for timely response can
those who make research funding decisions. In
galvanise local action to improve transportation
short, there is no shared vision on what the ideal
infrastructure, abolish user fees for maternity
future PPH products or interventions should
care, and develop safe blood systems. Advocacy
be, what is in the pipeline, and what evidence is
also encompasses advocating for policies and
needed to influence global recommendations.
resources that support research, guideline
Reputable normative documents are available adoption, and effective implementation of
to set standards of care and provide guidance recommended interventions. However, efforts
on use of evidence-based interventions. WHO led by civil society organisations (CSOs) and
has kept its PPH guideline portfolio up to date non-governmental organisations (NGOs) are
using a ‘living’ approach since 2017 and provided disjointed because of lack of clarity on PPH
support for inclusion of new PPH medicines priorities.
in WHO Essential Medicines List. Several
Overall, the research, normative, implemen­
international organisations and countries have
tation, and advocacy concerns are crucial
also independently developed their own PPH
components for alleviating the burden of PPH,
guidelines. The evidence base and methodology
but there has not been a dedicated agenda
used by these guideline developers often differ,
for each of these strategic areas until now.
leading to inconsistencies across guidelines and
In recognition of the growing need for global
variability in clinical practices. Consequently,
action to improve the quality of PPH care, the
end-users are often uncertain of which guideline
UNDP-UNFPA-UNICEF-WHO-World Bank Special
to adopt. Delayed or haphazard guideline
Programme of Research, Development and
adoption undermines health care providers’
Research Training in Human Reproduction (HRP),
ability to deliver quality evidence-based care.
Department of Sexual and Reproductive Health
Interventions that hold potential to significantly and Research, World Health Organization (WHO)
reduce PPH-related morbidity and death have worked together with several stakeholders to
proved difficult to embed and scale in health develop this Roadmap, outlining global-level
systems in LMICs. For example, while HSC research, normative, implementation, and
and TXA hold promise to reduce morbidity advocacy goals, activities, and milestones from
and deaths in LMICs, country-level uptake 2023 to 2030, to address key PPH priorities and
has thus far been limited. Implementation of fast-track progress towards the SDG 3.1 target.
effective interventions is further hampered
This Roadmap establishes an innovative,
by multidimensional bottlenecks that stretch
solution-driven, and customised strategic
beyond guideline adoption. Outdated
framework that centres PPH high-burden
licensing and regulatory authorisations
country maternal health goals and priorities,
may bar implementation of evidence-based
and points investments into critical areas of
recommendations (including full scope of
health systems, with special emphasis on LMICs.
task sharing where there are human resource
The Roadmap aims to align efforts and foster
gaps). Healthcare providers often lack the
cooperation among all partners working on PPH
necessary resources and tools, ongoing
to deliver PPH agendas, by pursuing the required
support, and feedback to implement guidelines
technical, investment, and political objectives

2 A Roadmap to Combat Postpartum Haemorrhage between 2023 and 2030

that will deliver on the core priorities of ongoing It is a high-level plan with the major milestones
global initiatives for maternal and newborn that must be attained to achieve the planned
health. impact. It is not a detailed project plan that
outlines everything that needs to happen,
1.3 Target audience but rather includes key ingredients to be
This Roadmap is intended for leading actors in actionable. These include alignment on the
public health and all stakeholders working in the goals to be achieved; a timeline with major
PPH ecosystem: the international community, milestones and sequencing of activities, roles,
funders, researchers, innovators and industry, and responsibilities; interdependency between
professional associations and guideline topics; and clear indications of how success will
developers, implementors (including civil society be measured.
and non-governmental organisations), Ministries This Roadmap focuses on a common set of
of Health, but also the general population, priorities defined during the Global Summit
particularly women. The Roadmap should on Postpartum Haemorrhage (PPH Summit)
serve as a valuable resource for governments, in March 2023. These priorities span four
ministries, national, regional and local health strategic areas: research, norms and standards,
authorities, directors of public health institutes, implementation, and advocacy. The Roadmap
public health associations, and other relevant identifies the solutions and catalysing actions
organisations and agencies to adapt to fit the needed to resolve lingering challenges and
needs of their respective contexts. dramatically reduce mortality and severe
morbidity from PPH. It builds on – and is not
1.4 Objective and scope of the a replacement for – ongoing global, regional,
Roadmap and national initiatives to improve quality
This Roadmap serves three key purposes: and outcomes for leading causes of maternal
(1) Align the field around key priorities and mortality and morbidity. Additionally,
actions required to meet shared goals and the Roadmap is intended to function as a
objectives; mechanism to promote collaboration and
establishment of coalitions to improve maternal
(2) Focus work on key activities to remove
health, not just for PPH, but across the broader
duplication of efforts in the PPH space; and
maternal and newborn health agenda.
(3) Engage stakeholders to advance PPH work
across countries.

1. Introduction and rationale 3

2. How the Roadmap
was developed

A systematic process was followed to develop guidelines, Cochrane reviews, analysis

this Roadmap. Briefly, the process included of medicines and devices in the pipeline,
(i) the selection of contributors; (ii) the and unaddressed questions from previous
systematic identification of research, norms, research prioritisation exercises [6]. Summit
implementation, and advocacy gaps to support participants were asked to submit additional
prioritisation efforts; (iii) a Global Summit to questions. The long list was curated to reach
obtain consensus on the top priority gaps and a consolidated list of 72 research questions
align on a common set of solutions to address (Annex 1). These 72 questions were divided into
those gaps; and (iv) the translation of the three tracks: 22 cross-cutting, 26 innovation
prioritised gaps and solutions into a Roadmap and 24 implementation questions, building
and a Call-to-Action. on the existing and validated Child Health and
Nutrition Research Initiative (CHNRI) categories
2.1 Contributors to the Roadmap (discovery, delivery, description, development)
A Steering Committee was established by the [7], reframed into more salient language. The 72
WHO to provide oversight and methodological research questions were scored and prioritised
guidance before, during, and after the Global by applying the CHNRI methodology [8,9]
PPH Summit. In parallel, a Scientific Committee Switzerland. Its aim was to develop a method
was established to conduct and support the that could assist priority setting in health
landscaping work to identify and map and research investments. The first version of the
summarise research knowledge gaps, innovation CHNRI method was published in 2007–2008. The
pathways, PPH products and interventions, aim of this paper was to summarize the history
PPH guidelines and tools, country-level of the development of the CHNRI method and its
implementation, and ongoing advocacy key conceptual advances. Methods The guiding
initiatives. The development of this Roadmap principle of the CHNRI method is to expose the
was based on a scientific review of the status of potential of many competing health research
PPH across the four strategic areas (research, ideas to reduce disease burden and inequities
norms and standards, implementation, and that exist in the population in a feasible and
advocacy), and rich contributions input received cost-effective way. Results The CHNRI method
from online and in-person consultations of a introduced three key conceptual advances that
large group of stakeholders working in these led to its increased popularity in comparison to
strategic areas at international and country other priority-setting methods and processes.
levels. The list of contributors can be found in First, it proposed a systematic approach to
Annex 1. listing a large number of possible research
ideas, using the \”4D\” framework (description,
2.2 Identifying gaps in the delivery, development and discovery research.
strategic areas Summit participants were asked to assess the
Research and development 72 suggested questions against five criteria
(answerability, effectiveness, deliverability,
To identify research gaps, an initial long list of
impact, and equity) through an online survey.
417 research questions was developed, with
Each answer was attributed a score based on
questions extracted from research priorities
respondents’ assessment for each of the five
derived from WHO and other international

4
criteria. The top-10 ranked questions per track update of the evidence base underpinning
were identified to be further discussed and existing PPH recommendations and identify
prioritised during the Summit. which recommendations are high priority
for update based on evidence-driven
Norms and standards ‘intelligence gathering.’ This exercise helped
WHO commissioned a mapping of evidence- to determine whether there is any shift in the
based guidelines to determine the level of evidence base that could impact the existing
consistency of PPH recommendations across recommendations. Second, was to review new
evidence-based guidelines. After a systematic evidence from the literature and determine its
literature search, nine guidelines which met potential to influence new global guidelines
certain pre-specified criteria and published on PPH. Based on this work, the following
after 2012 were included in the analysis recommendations met the criteria for high
(Annex 2): WHO, International Federation priority for update:
of Gynecology and Obstetrics (FIGO), Royal ▶▶ Carbetocin (100 µg, IM/IV) for prevention of
College of Obstetricians and Gynaecologists PPH for all births in contexts where its cost
(RCOG), National Institute for Health and is comparable to other effective uterotonics
Care Excellence (NICE), American College of (covers two identified interventions related
Obstetrics and Gynaecology (ACOG), The Society to carbetocin).
of Obstetricians and Gynaecologists of Canada
(SOGC), Collège National des Gynécologues et ▶▶ Tranexamic acid (0.5–1.0 g IV), in addition
Obstétriciens Français (CNGOF), Japan Society to oxytocin, at caesarean section to reduce
of Obstetrics and Gynecology (JSOG), and blood loss in women at increased risk of PPH.
Royal Australian and New Zealand College of ▶▶ Transfusion of 4 units of red blood cells
Obstetricians and Gynaecologists (RANZCOG). and 12–15 mL/kg fresh frozen plasma in the
Sixty-nine (69) individual recommendations presence of continuing haemorrhage when
across all guidelines were identified. For each blood test results are unavailable.
recommendation, all nine guideline documents
▶▶ Intraoperative cell salvage (autologous blood
were scrutinized to determine whether (1)
transfusion) when significant blood loss is
they recommended in favour of or (2) against
anticipated, such as in cases of placenta
the intervention in question, or (3) they
praevia or placenta accreta.
considered the evidence as insufficient to make
a recommendation, or (4) they simply did not ▶▶ Administration of intravenous iron for
include a recommendation for that specific postpartum anaemia.
intervention.
Implementation
This mapping exercise resulted in
To understand the contextual challenges
the identification of 11 consistent1
responsible for slow uptake of PPH evidence and
recommendations (out of 69) and four
evidence-based recommendations as well as
inconsistent2 recommendations across the
other country-level implementation bottlenecks,
guidelines. Several interventions are not
three case studies of countries representing
currently recommended at all in most of the
different contexts – Nigeria, Pakistan, and
guidelines. These discrepancies reflect the
Tanzania – were commissioned by WHO.
need to progress to a common core set of
These case studies generated the necessary
global guidelines to facilitate their in-country
information to understand on-the-ground
implementation.
implementation challenges, but also to learn
The second phase of preparatory work had from those who have been successful in tackling
two objectives. The first was to conduct an these challenges, as they relate to old as well as
newly introduced PPH tools in different settings.
1
Consistent: at least 5 out of the 9 guidelines made a
recommendation on the intervention and were aligned.
2
Inconsistent: at least two guidelines had contradicting
Conversely, to assess the contributions of health
recommendations. system policies and programmes, financing,

2. How the Roadmap was developed 5

human resources, intervention coverage, quality 2.3 Building consensus on priority
of care and contextual factors to declines in gaps and solutions
maternal mortality ratios and neonatal mortality The outputs from the above activities
rates, seven Maternal Mortality and Neonatal underpinned the discussions among over 130
exemplar countries were analysed to identify stakeholders at the Global Summit on PPH,
best practices. These are Bangladesh, Nepal, convened by WHO from 7-10 March 2023 in
India, Morocco, Ethiopia, Niger, and Senegal. Key Dubai, United Arab Emirates. These outputs
drivers identified for maternal mortality decline were presented at plenary and breakout
include increased facility births, improved sessions to help stakeholders make informed
access to skilled providers, and increased decisions on the highest priority gaps, the
availability of uterotonics. corresponding set of solutions, and clear
In parallel, an online survey on barriers to agendas for collective action. This Roadmap
implementation of evidence-based interventions reflects synthesised evidence, stakeholders’
conducted among the Summit participants. input, and further refinement of proposed
Respondents were asked to assess the solutions and course of action after the Summit.
implementation of 20 clinical interventions WHO convened the PPH Summit to review
recommended by WHO, answering a set of R&D progress for PPH innovations in the
six questions for each intervention and four pipeline and define the evidence requirements
additional questions if a medicine or device is for policy changes, identify and align on top
involved in the intervention (see Annex 3 for the priority research gaps in PPH; identify and
full list of interventions in rows and questions/ align on top priority gaps in PPH norms and
barriers in columns). For each recommended standards; identify and align on top priority
intervention, each question was attributed a implementation gaps in PPH and identify
score based on respondent’s assessment. Scores strategies for equitable and sustainable access
for each pair of (intervention; question) were to effective interventions; identify and align on
then summed up across respondents, divided top priority advocacy gaps in PPH and identify
by the total number of responses, and finally sustainable strategies to address these gaps;
positioned to populate a heatmap (see Annex summarize challenges and develop a clear
3) to help visualize priority gaps. During the Roadmap for addressing them; and form strong
Summit, participants were presented with the coalitions and boost funding streams to address
heatmaps, as well as data collected from health PPH challenges.
facilities in Nigeria, Pakistan, and Tanzania that
illustrated the extent to which each clinical Summit discussions were organised around
intervention was available at bedside in each the product introduction value chain, starting
setting. with research and development, then moving
to norms and standards, implementation, and
Advocacy advocacy.

To achieve a shared understanding of priority

Research and development
PPH advocacy gaps, an overview of the PPH
advocacy landscape was developed to identify The top ten research questions for each track
the key active organizations and initiatives and were further prioritised to reach a list of top
to highlight the limitations and critical gaps of five questions per track. For each track, the top
the current ecosystem. A benchmark of other ten research questions were reviewed through
health sector ecosystems was also conducted to explanatory briefs that included the rationale
identify successful advocacy efforts that could and problem statement for the research
be replicated for PPH. questions. Based on the additional information
provided, participants had the opportunity
to individually select a set of five questions
to prioritize and rank-order them from 1 to 5.
After the initial vote, the results were discussed,

6 A Roadmap to Combat Postpartum Haemorrhage between 2023 and 2030

and changes were sometimes made to reach 2.4 Integrating priority solutions
consensus on a list of top five research questions into the Roadmap and
per track (e.g., second vote after clarification of Call-to-Action
some misunderstanding around wording, swap During the Summit, the concept of a Roadmap,
between questions). key ingredients to make a Roadmap actionable
and why one is needed were presented.
Norms and standards Participants were then asked to develop high
A panel of representatives from professional level agendas for each of the four strategic
associations discussed alignment of priorities areas – research, norms and standards,
for PPH recommendations. A plenary Q&A implementation, and advocacy, discussing (1)
session also helped to surface priorities for new milestones and sequencing (what to do and by
recommendations and updates for WHO and when), and (2) roles and responsibilities (who
other international bodies. will do it) – based on the outputs from the
previous sessions.
Implementation
The complementary key deliverable of the
A panel of representatives from Ministries of
Summit was a consensus-driven Call-to-Action
Health discussed challenges in implementing
that clearly and compellingly articulates the
life-saving interventions in their respective
actionable expectations from a wide array
countries. The challenges raised included poor
of stakeholders and the urgency to act on
supply management (especially regarding
the Roadmap. This Call-to-Action is meant to
uterotonics), weak referral systems, and issues
publicly outline the rationale for change, show
with retention and training of health care
evidence that change is possible, and outline
providers helped to inform the prioritisation of
what is required from different stakeholders. The
implementation bottlenecks.
ingredients for the Call-to-Action were collated
Out of a longer list of implementation barriers electronically from all participants following
categorised into four key themes (national a presentation and discussion of the case for
context, programme and investment, change, proof of the possibility, right ask of the
commodities, and service delivery (Figure 2), right people, and evidence that this is the right
participants discussed and consensually agreed time to act. Summit participants agreed to all be
on five categories of implementation barriers signatories of the Call-to-Action.
that are amenable to global solutions and
Immediately following the Summit, work began
actions; and laid out future concrete steps.
to further elaborate the Roadmap across the
four agendas, leveraging inputs from Summit
Advocacy
participants, feedback from the Steering and
A panel discussion brought together NGOs and Scientific Committees on the meeting report,
CSOs to share their on-the-ground experience. targeted interviews, meeting with donors, and
Panel participants shared examples of additional desk research. Similarly, the Call-
successful initiatives implemented at local level To-Action document was developed based on
and learnings from their experience. Further the numerous contributions made by Summit
contributions from Summit participants built on participants and was then refined based on
the key lessons shared by the panelists and led feedback from the Steering and Scientific
to consensus on future priority actions. Committees.

2. How the Roadmap was developed 7

Table 1. Categories of implementation barriers
Implementation Category of implementation barriers
theme

A. ▶▶ A1. Women’s rights and social status (e.g., lack of education, low social status,
National context constrained women’s choices around pregnancy and childbirth)
▶▶ A2. Legislative and non-health policy measures (e.g., lack of laws protecting women
from gender-based violence, early marriages, women’s political power)
▶▶ A3. Emergency situations (e.g., conflict or humanitarian setting, COVID19)
▶▶ A4. National health policy and leadership (e.g., health sector governance, leadership
skills, health policies, policy advocacy)
B. ▶▶ B1. Technical PPH guidelines (e.g., guidelines out of date, requiring local data, not
Programme and linked to subnational implementation)
Investment ▶▶ B2. Programme Development from pilot to scale up (e.g., no handover/exit strategy,
vertical programmes)
▶▶ B3: Equity and access to care (e.g., persistent disparities, limited data, lack of access
to care for vulnerable and marginalized groups, lack of engagement with the private
sector)
▶▶ B4: Investment (stagnant government expenditure, lack of sustainability of externally
funded programmes)
C. ▶▶ C1. Regulatory (e.g., poor post-marketing surveillance, non-harmonized regulatory
Commodities pathways, complex or inexistent regulatory pathways for devices)
▶▶ C2. Procurement and supply chain (e.g., lack of availability of blood or blood
products, weak procurement systems in lower-level facilities, lack of communication
between hospital management and healthcare providers in terms of stockouts)
▶▶ C3. Quality (e.g., poor quality products, cold chain difficult to maintain, little incentive
for manufacturers to obtain WHO PQ or SRA)
▶▶ C4. Affordability and out of pocket expenditures (e.g., lack of free delivery care,
unaffordable private sector when the only provider available, certain commodities not
provided by government)
D. ▶▶ D1. Job aids for guideline implementation (e.g., lack of expertise for guideline
Service delivery adaptation to clinical protocols; clinical protocols not available, accessible, usable or
appropriate)
▶▶ D2. Referral pathways between levels of care and community (e.g., unclear when
and where to go/refer for delivery or emergency (women and providers), transport
issues, referral pathways not used effectively)
▶▶ D3. Staffing, training & supervision of healthcare providers (e.g., acquiring and
maintaining skills, roles/status of midwives and nurses, human resources for health in
remote areas)
▶▶ D4. Audit and feedback (e.g., private providers not regulated, accountable; limited
local capacity to use data for decision-making)

8 A Roadmap to Combat Postpartum Haemorrhage between 2023 and 2030

3. Structure of the Roadmap

This Roadmap sets out key priority actions to to reduce research wastes and shortening the
combat PPH burden and associated adverse time it takes to meaningfully respond to public
outcomes as agreed by stakeholders at the health needs. Fifteen research questions were
2023 Global PPH Summit. It is informed by and identified as particularly critical for advancing
structured around four interlinked strategic actionable knowledge around PPH through 2030
areas (research, norms, implementation, and (and beyond 2030 for research priorities related
advocacy) that are necessary to catalyse efforts to innovations which by default tend to take
and fast-track attainment of country goals to longer).
avert maternal death. Under each strategic
There is need for fully funded joint research
area, the Roadmap describes activities and put
agenda to support the top 15 priority research
forward specific actions and deliverables for
questions identified by stakeholders (Table 1).
the period 2023 to 2030, and thus presents a
This does not mean that research questions
cornerstone and reference document over the
that did not make it to the top 15 should not be
next 7 years. The Roadmap identified shared
researched, but rather that these 15 are time-
priorities and potential synergistic actions at
sensitive questions that need to be answered
country and regional levels to make a difference
for the field to progress. Should all prioritised
to the stagnated maternal mortality ratio
15 questions be answered, then the next in line
over the last 5-10 years. It sets out essential
should be prioritised, pursuant to the needs of
activities that are result-oriented which need
the evolving context.
to be implemented by a range of actors,
including ministries of health, implementers, As the field moves to execute on the top priority
research institution and academia, professional questions, several considerations should be
organizations, women and women’s groups, applied. First, the short-term priority should
government and non-government actors. be to focus on where PPH-related mortality are
clustered, with particular focus on temporising
The following section details out the priority
measures and strengthening referral systems.
actions for each of the four strategic areas which
Second, the feasibility and utility of establishing
are then consolidated into the Roadmap.
a research network for PPH should be assessed
(for example, through the launch of WHO multi-
3.1 Strategic area: Addressing
country trial platforms, as done for COVID-19).
priority research gaps
Third, women and CSOs should be included
Research is fundamental to achieving progress in the process of implementing the research
for any health condition. Stagnancy in research, agenda (e.g., development of the research
including implementation research, can have protocol through interpretation of the research
an impact on women’s outcomes relating to findings). Lastly, transparency should be
PPH, and has the potential to impair initiatives improved, especially on innovation pathways
for reducing PPH burden and its contribution – providing more clarity on what evidence is
to maternal mortality. Aligning on priority PPH required for both drugs and devices, to influence
research gaps along three tracks (innovation, global guidance – and what is expected from the
implementation, and cross-cutting) was innovators.
identified as important to focusing investment

9
The immediate step to address these priorities conduct a rapid scan of ongoing research to
is for WHO and partners to start the preparatory understand whether there are ongoing studies
work that will lead to the launch of calls poised to respond to the priority research
for proposals in the first quarter of 2024 to questions. WHO and partners will also articulate
implement the research agenda. Preparatory the ideal research for each priority question
activities will include refining the framing of the and provide guidance on research design.
15 prioritized research questions to improve Additionally, WHO will draft target policy profiles
clarity. In parallel, WHO and partners will (TPoPs) to give an indication of the research

Table 2. Top 15 priority research questions by track

Track Ranking Research question
What is the comparative effectiveness and safety of alternative routes of
1
administration of tranexamic acid (TXA) in the treatment of PPH?
What is the effectiveness and safety of heat-stable carbetocin for PPH
2 treatment in women who received heat-stable carbetocin for PPH
prevention?
What is the comparative effectiveness of uterine balloon tamponade devices
3 compared to other tamponade interventions (such as suction devices) in the
Innovation
reduction of PPH-related maternal morbidity and mortality?
Can clinical criteria for haemodynamic instability facilitate earlier
4 PPH diagnosis and improved PPH outcomes compared to blood loss
measurement alone?
What strategies are most effective for engaging the private sector in the
5 development of new PPH medicines, devices, and diagnostics in low- and
middle-income countries?
What are the implementation barriers and facilitators affecting the adoption
1
and use of evidence-based recommendations for PPH management?
What are the optimal strategies to ensure access to quality-assured PPH
medicines (including Universal Health Coverage/Essential Packages for
2
Health Services and Health Benefit Package) in low- and middle-income
countries?
What are the most effective advocacy strategies to improve the uptake and
3 ensure sustainment of evidence-based practices for PPH management at the
Implementation
country level?
What is the effectiveness and cost of pre-service and in-service training
programmes for frontline healthcare workers (paramedics, general practice
4
doctors, community health workers, midwives, nurses) to manage and refer
women with PPH?
What are the most effective implementation strategies to improve uptake
5 and sustainment of recommended evidence-based interventions for PPH
management, including in humanitarian settings?
What is the effectiveness of a strategy of early detection and first response
1 treatment using a bundle of recommended interventions for improving PPH-
related outcomes?
What is the effectiveness and safety of a diagnostic algorithm (e.g. shock
2 index) and early detection strategies (e.g. Modified Early Obstetric Warning
Score) in improving clinical detection and management of PPH?
Cross-cutting What is the effectiveness of checklists in improving PPH quality of care and
3
PPH-related outcomes compared to current standard of care?
What is the effectiveness of Maternal and Perinatal Death Surveillance and
4
Response programmes in the reduction of maternal deaths due to PPH?
What is the effectiveness and safety of tranexamic acid (TXA) in the
5 prevention of PPH in general obstetric population and in women at high risk
of PPH (e.g. anaemic women)?

10 A Roadmap to Combat Postpartum Haemorrhage between 2023 and 2030

requirements for future policy decision-making as WHO and FIGO/ICM. These global guidelines
and what guidance could potentially look like if a could focus on a joint core set of high-level
given research question were to be addressed. recommendations that are consistent across
guideline developers, with details placed as
To ensure appropriate data and evidence are
remarks to those recommendations. There
generated, WHO will clarify innovation pathways
is a strong need for enhanced collaboration
and the type of data required to inform a WHO
across international guideline developers.
recommendation as well as for populating a
A good first step would be sharing evidence
dossier for WHO Prequalification listing. WHO
synthesis work to avoid duplication of efforts,
and partners will conduct a rapid funding
with a longer-term objective of jointly publishing
need assessment to determine the high-level
consolidated global guidelines (notably across
budget required to execute the research
WHO, FIGO and ICM). The second level of
agenda. As part of that assessment, existing
guidance is national guidelines, that adopt,
funding commitments and resulting funding
adapt, and contextualise global guidelines to
gaps will be mapped. As the detailed research
individual country settings. The third level is the
agenda is developed, it will be socialised with
translation of recommendations into guidance
donors for input and feedback. It is expected
on evidence-based clinical practice, through
that donors will prepare calls for proposals to
guideline derivatives (such as protocols, job aids,
conduct priority research. Donors are expected
toolkits, or handbooks). It should be noted that
to coordinate in a donor coordination forum to
women’s perspectives and LMIC realities must
ensure that the full research agenda is captured
be better included in the process of guideline
in their calls for proposals and that there is no
development.
duplication.
The risk of PPH can be lowered through
Donors are expected to launch the calls for
preventative interventions to reduce PPH risk
proposals in the first quarter of 2024 and
factors during preconception and antenatal
research grantees will execute the research
care but these areas are largely absent from
agenda starting in 2024. While some results
current sets of PPH guidelines (which focus on
will become available earlier than others, most
the intrapartum and immediate postpartum
research should take from 2–4 years to complete,
periods). Instead, relevant recommendations (for
with the bulk of new evidence expected by 2027.
example, on treatment of anaemia) are usually
As research results are published, WHO will
included in guidelines pertaining to these
conduct iterative updates of its PPH guideline
other periods. To facilitate the development of
portfolio to reflect emerging evidence. Progress
comprehensive PPH programmes and policies,
in research and development in the context of
relevant recommendations in these other
these research priorities will be monitored, and
guidelines could be incorporated in the PPH
by 2030, a review of any pending or new research
guidelines. In addition, there are critical topics
gaps will be conducted. This strategic area is
with limited to no recommendations in current
closely linked to that on addressing normative
set of guidelines. These include detection of
gaps relating to PPH as results of the prioritised
PPH, use of blood transfusion for PPH treatment
research will be matched with their integration
(when significant blood loss is anticipated, as in
into global and national policies to influence
cases of placenta praevia or placenta accreta),
practices on a continual basis.
and administration of intravenous iron for
3.2 Strategic area: Addressing postpartum anaemia. There is also a need for
priority gaps in norms and further guidance on uterine tamponade devices,
standards implementation considerations, and health
system aspects (including emergency response).
Three levels of guidance are required for an
optimal translation of evidence into practice. The evidence base underpinning current
The first level is global guidelines, that are recommendations, especially those related to
published by different guideline developers such established practices, is dominated by evidence

3. Structure of the Roadmap 11

Figure
Figure1.
1: Key activities
Key activities andand milestones
milestones for thefor the research
research agenda agenda

Q1 2023 Q2 2023 Q3 2023 Q4 2023 2024 2025 2026 2027 2028 2029 2030

Key PPH Launch of the Roadmap Calls for proposals Publication & dissemination of results Review of
milestones Summit (incl. top priority research to conduct top completed for the first batch of funded research pending/new
agenda) @ IMNHC priority research for integration into global guidelines research gaps

Refine the framing of top priority research questions

Conduct a screening of ongoing research

WHO & Articulate the ideal research questions and designs and develop TPoPs
Partners

Clarify and disseminate innovation pathways

Assess the funding gaps

Socialize joint research agenda with funding agencies

Donors to prepare calls for proposals to conduct priority research

Research grantees to execute funded research agenda

Grantees to publish research results

WHO & other guideline developers to conduct iterative updates of living guidelines

Milestones non contingent on new funding Milestones contingent on new funding Interdependencies Iterative process

12 A Roadmap to Combat Postpartum Haemorrhage between 2023 and 2030

derived from high-income countries which target launch date for these joint guidelines is
may not always be generalisable to LMIC. The the first quarter of 2025.
research community should make deliberate
Once the consolidated guidelines have
efforts to design and conduct future trials in
been published, they will need to be widely
LMIC and should focus evidence generation
disseminated for implementation. A global
on the parts of the patient pathway where
launch campaign will be organized in 2025 with
most deaths occur and where there is a dearth
webinars and regional workshops. During the
of sufficient data (i.e., in the community,
same year, guideline derivatives (e.g., policy
around referral and emergency transport, and
briefs) will be developed by the organizations
emergency caesarean section).
participating in the process in conjunction with
Starting from the third quarter of 2023, WHO WHO Regional Offices. WHO Regional Offices will
will establish a Steering group comprising also coordinate the translation of guidelines into
of nominees of global guidelines developers all WHO official languages and implement other
to explore internal mechanisms across language requests on a case-by-case basis.
organisations to decide on the feasibility of
In the interim, WHO and partners will continue
joint publication of consolidated guidelines,
to respond to new, impactful evidence on PPH,
considering the organisations different
to issue individual standalone recommendations
operating models, guideline development
through their current internal procedures
processes, and guideline methodologies. By
(e.g., WHO living guidelines approach) until
the end of the third quarter of 2023, provided a
the consolidated guidelines are published. To
joint publication of consolidated guidelines is
avoid any delays in translating knowledge into
feasible, the Steering Group will review existing
practice particularly in countries where this
PPH recommendations to agree on the scope
is a key bottleneck to progress, WHO and key
of the recommendations to be included in the
stakeholders (e.g., USAID, Concept Foundation,
consolidated guidelines. A standard guideline
MSD for Mothers) will review the PPH policy
development procedure, that comply with and
contexts of countries with high burden of
respect internal approval procedures of all
PPH and maternal mortality and provide the
participating organizations, will be followed
technical and financial support to update PPH
to develop these joint guidelines. The Steering
policies and adapt them to local context. An
group will propose the membership of the
ambitious goal of achieving up to date PPH
consolidated guidelines panel, and other
policies in at least 20 high-burden countries
potential contributors, such as guideline
is set for the last quarter of 2024. This effort is
methodologists, systematic review teams,
expected to set up a model for engagement
external peer review group, and observers.
of stakeholders and expand to other LMIC on
From the last quarter of 2023 and during the
as-need basis through 2030.
course of 2024, the participating organisations
will pool resources and commission systematic 3.3 Strategic area: Addressing
evidence syntheses for priority questions implementation bottlenecks
and development of evidence profiles
While there are substantial gaps in research
(including evidence domains covering efficacy/
and there is room for improvement in existing
effectiveness, importance of priority outcomes
norms and standards development processes,
driving the recommendations, acceptability,
implementation bottlenecks are perhaps the
feasibility, impact on equity, resource use and
most challenging of the four strategic areas.
cost-effectiveness). By the fourth quarter of
At the PPH Summit, failure in implementation
2024, it is expected that the evidence profiles will
of evidence-based interventions was widely
be ready for the guideline panel to review the
recognized by stakeholders as the most
evidence and formulate new and update existing
significant challenge to achieving better
recommendations. These will then undergo
PPH outcomes. Addressing barriers to
peer-review and external consultation. The
implementation was acknowledged as the

3. Structure of the Roadmap 13

 Figure 2: Key activities and milestones for the normative agenda
Figure 2. Key activities and milestones for the normative agenda

Q1 23 Q2 23 Q3 23 Q4 23 Q1 24 Q2 24 Q3 24 Q4 24 2025 2026 2027 2028 2029 2030

Key PPH Launch of the Roadmap (incl. Publication of WHO recommendations Publication and updating of consolidated guidelines and
milestones Summit normative agenda) @ IMNHC actioning new, impactful evidence derivative tools

WHO to establish a steering group to explore internal mechanisms across organizations and decide on feasibility of joint publications

Steering group to review and agree on scope of guidelines, considering broader PPH framework

Steering group to propose membership of guideline development groups, and other contributors to the consolidated guideline

Joint guideline developing organisations to commission evidence synthesis and development of evidence profiles

Guideline panel to meet to formulate recommendations

Consolidated guideline to be published by the organisations

WHO and key stakeholders to provide technical support to countries for adoption of guidelines and adaptation to local context

Milestones not contingent on new funding Milestones contingent on funding Interdependencies Iterative process

14 A Roadmap to Combat Postpartum Haemorrhage between 2023 and 2030

singular, potentially most impactful out of the regarding scope of practice, and adjusting health
four strategic areas. sector budgets. The highly contextual nature of
many implementation barriers means that they
Implementation of proven interventions
are not easily amenable to global action.
requires input from several actors and multiple
layers of collaboration to be successful. For In acknowledgment of the many implementation
example, implementing of an effective clinical barriers that need addressing, stakeholders
practice requires not just the training of at the PPH Summit prioritised five categories
health care providers, but also could include of implementation barriers as those that are
reconfiguring of clinical workflows, integrating critical for global action. The priority actions
multidisciplinary teams, engaging facility to address these key barriers were also
leadership, broadening legal authorisations enumerated as summarised below.

Key barriers Priority actions

a. Lack of clear national health policy and Priority actions for building clear national health
leadership: In most instances, specific national policy and leadership should start with creating a
PPH targets do not exist, and data are not collected PPH framework to structure treatment response and
systematically to measure progress. There is also a interventions. This global framework can help to
disconnect between global and national guidelines. organise and coordinate national efforts. In parallel,
Strengthened national health policy and leadership is an efficient and sustainable global monitoring
needed to ensure PPH is included in national agendas system needs to be developed that includes common
with clear leadership and champions at national and indicators, systematic data collection, and a common
subnational levels. measurement platform, to track country progress
against targets. As WHO updates global normative
guidance, national guidelines need to be adapted
to local context and disseminated to all levels of the
health system, from national and subnational levels
through to last mile health facilities. WHO and other key
stakeholders will lead an ongoing network of Ministry of
Health champions who will spearhead this work.
b. Weak procurement and supply chain systems: As national leadership infrastructure is being built,
PPH commodities face availability issues, and the international community needs to collaborate to
frequent stockouts lead to unnecessary referrals improve access to quality-assured PPH commodities.
from one health facility to another. The focus on This will require strong coordination between partners,
affordability tends to come at the expense of quality. increased investments, and expansion of existing or
The availability of blood and blood products is also new procurement initiatives. Efforts should cover
an issue that needs to be addressed to allow for rapid devices, drugs, and blood products. In addition,
transfusion when required. Activities undertaken national- and subnational-level procurement and supply
within this category should ensure that quality chain systems need to be strengthened (e.g., setting
commodities are available and affordable at all levels up adequate blood banks). As a first step, WHO and
of the health system. partners (e.g., UNFPA and the Global Fund) will scope
possible solutions (both new and existing procurement
mechanisms), with the objective of a focused
procurement initiative to be launched in 2026.
c. Poor staffing, training, and supervision of Ensuring availability of quality commodities will only
healthcare providers: Many countries do not result in meaningful change if there are competent
have sufficient well-trained, empowered, and health care providers available to deliver relevant
motivated healthcare workers – essential to the services. Ongoing efforts are needed to strengthen
delivery of quality care. Pre-service training may not current pre- and in-service training programmes, and
adequately cover PPH detection, prevention and bolster them with supportive supervision, mentoring,
management, and in-service training opportunities and other professional development opportunities.
are often limited to select staff. Insufficient numbers, These activities must be supplemented by broader
distributions, and poor retention of healthcare human resource strategies to address chronic shortages
workers also pose an ongoing challenge, with remote of qualified health professions (midwives, nurses,
areas most acutely affected. Lastly, in many settings, doctors).
the suboptimal roles, social, and regulatory status of
nurses and midwives does not permit this cadres of
health care worker to offer lifesaving care within their
competency.

3. Structure of the Roadmap 15

Key barriers Priority actions
d. Inequities and poor access to care: There are Healthcare infrastructure also needs to be enhanced
persistent and unjust disparities in access to care, to strengthen facilities (this may include renovations
for instance between rural and urban populations, to modernise aging structures or building additions to
or within a given setting (e.g., in urban slums). meet greater demand) and improve transportation and
There is a human rights imperative to address the referral systems, which are woefully underdeveloped
stark inequities that vulnerable and marginalised in many places. Governments must also take bold seps
populations face. For example, in some settings, to develop financing plans that abolish user fees and
public sector health facilities are not readily broaden insurance coverage, reducing out-of-pocket
accessible because of distance and women must expenses for key PPH products (e.g., expanding health
patronise private sector facilities where user fees are system coverage to PPH medicines/devices) and
not covered by national insurance schemes. improving equity.
e. Women’s rights and social status in the society: All stakeholders must come together as tireless
There are several unfavourable legal, social, and advocates for women’s rights. Women must be at the
cultural norms and obstacles that limit women’s life centre of the political agenda, be it at subnational,
choices and options about pregnancy and childbirth. national, or international level. Several upstream
These include women’s low social status, limited contributory factors to PPH, such as anaemia and
access to education or educational opportunities, grandmultiparity, can be directly traced to women’s
and limited opportunity to participate in the lack of rights and low social status. Further, many of the
workforce in some settings, as well as inadequate implementation challenges to PPH reduction persist
state support for paid maternity leave in other because of long-standing passivity around women’s
settings. Cultural norms may also constrain women’s health and wellbeing. Ongoing advocacy can help to
choices around pregnancy and childbearing, for ensure maternal health is no longer overlooked and
instance by valorising rapid repeat pregnancy, benefits from sustained funding.
discouraging or delaying care-seeking, and allowing
insufficient recovery time after birth before
resumption of household chores.

Key activities and milestones Measurement platform: Between now and the
end of Q4 2024, WHO, FIGO, ICM, Ministries of
Establishment of clear national health policy
Health, and national professional societies will
and leadership
work jointly on a scoping exercise to define the
Development of a PPH framework: By the third contours of a global measurement platform for
quarter of 2023, WHO and key stakeholders will monitoring changes in practice performance,
draft a first version of a PPH framework. Unlike health outcomes, and inequities with
high-burden communicable diseases such as sustainability plans for in-country leadership.
HIV, TB, and malaria, no holistic framework has This scoping exercise could include, for instance,
ever been formalised for PPH. This can lead to a the mapping of existing PPH indicators collected
response that is not addressing all contributory by different archetype countries, to be then
factors (e.g., limited guidance on antenatal and able to define and agree on a joint list of PPH
intrapartum prevention; overlooking risk factors indicators. To increase the likelihood of these
such as anaemia, placenta praevia, and placenta indicators being measured by the highest
accreta). In addition, it results in a fragmented number of countries, existing metrics and data
approach to prevention and treatment that may collection efforts should be leveraged to the
not be comprehensive. Effective interventions extent possible. Defining concrete PPH targets
will need to be mapped against this framework, will also be critical to provide countries with
which will expose areas that require new an aspirational objective and targets to reach.
recommendations. There will also be an As an example, UNAIDS HIV targets (90/90/90)
opportunity to use this framework to structure were instrumental in raising awareness on
future iterations of the WHO guidelines and “what good looks like” and creating momentum
report progress on health outcomes along the to adequately resource national strategies
patient journey. The PPH framework will then be to reach ambitious yet realistic targets. The
refined based on the feedback received. scoping phase should also focus on determining
data reporting frequency; data disaggregation

16 A Roadmap to Combat Postpartum Haemorrhage between 2023 and 2030

levels (e.g., by population strata, level of health high-burden countries, and WHO Country Offices
system); and roles and responsibilities for data will play an instrumental role in supporting
curation, analysis, and production of regular local workshops and the development of
progress reports. A high-level budget should be contextualized materials.
developed, for both building and managing the
Strengthening procurement and supply chain
measurement platform.
systems
The scoping phase will be followed by a design
Pooled procurement and market shaping: WHO
and pilot phase. The design phase will focus on
and global partners who currently play a role in
further developing elements of design that will
pooled procurement such as the Global Fund
have been discussed in the scoping phase. These
and UNFPA will conduct a scoping exercise
will also include technological design choices for
by Q4 2023 to assess potential solutions to
the platform and specifics on data management
nudge procurement of PPH commodities
(e.g., where data should be stored, data privacy
towards higher quality products and to
considerations). Before launching at full scale,
increase international financing for these
it will be helpful to pilot the measurement
commodities. Even within existing pooled
platform in a few representative geographies.
procurement initiatives, multiple models
The design and pilot phase will likely run until
exist. For HIV, TB and malaria, Global Fund-
Q4 2024, with a global launch planned for 2025.
eligible countries can use Global Fund grant
The global measurement platform will also be
funding to procure commodities through
a critical tool to measure progress against the
Global Fund’s Pooled Procurement Mechanism
priorities set out in this Roadmap.
(PPM). Products available through PPM are
Guideline adoption and adaptation: To support sources by a dedicated Global Fund team
guideline dissemination and implementation that optimizes market shaping objectives
in-country, WHO and key stakeholders will including affordability, availability and quality.
continuously lead a network of Ministries of Importantly, all of these commodities have
Health Summit champions. This network will been approved by a global stringent regulatory
oversee collecting country needs on what WHO authority (e.g., WHO Prequalification or US
and other guideline developers need to do FDA). Countries may also use Global Fund grant
to support country adoption and adaptation funding to procure commodities through their
of global guidance. When new guidelines are own national procurement channels. Lastly,
issued by WHO and other global guideline countries may use domestic funds to procure
developers, the network will organize regional Global Fund-listed commodities on PPM
workshops and webinars to present the and benefit from the commercial conditions
guidelines and offer dedicated support to help negotiated by the Global Fund and therefore
countries contextualize new recommendations. take advantage of lower prices achieved through
Specifically, WHO will produce user-friendly pooled procurement. Various regional pooled
compilations of guidelines to increase adherence procurement initiatives were also launched
to recommendations including an updated and during the COVID-19 pandemic, in particular
electronically available version of the ‘Managing in Africa. These processes go beyond mere
Complication in Pregnancy’ handbook. The procurement and are critical contributors to
network will leverage WHO Regional and deliberate market shaping through activities
Country Offices to support the translation of such as multi-year tender-based sourcing,
global documents into non-English languages, supplier relationship management, and the
the development of derivative products such enforcement of quality assurance and quality
as policy briefs that give further detail on control requirements. During the scoping
the recommended interventions and their phase, all of these mechanisms will be analysed.
rationale or operational manuals that serve as This will inform a discussion on the relative
practical implementation handbooks for health merits of potential solutions to increase
practitioners. A particular focus will be placed on international financing to procure higher-

3. Structure of the Roadmap 17

quality PPH commodities. Currently most PPH provide intravenous medication) but legislative
medicines and devices are procured by domestic and regulatory change has lagged. WHO and
governments using domestic funds. Trade-offs partners will continuously advocate for the
between promoting regional or global pooling need to have an established evidence-based
of demand and procurement and reinforcing regulatory framework at country level for skilled
country procurement capabilities should birth attendants and for countries to implement
therefore be carefully assessed and consider a national competency and standards
key dimensions such as country ownership. framework that recognizes the key role played
In terms of scope, the exercise might be more by midwives.
meaningful if taking into account maternal
Support to training: WHO along with FIGO, ICM,
health commodities more broadly, or even more
Ministries of Health, and national professional
generally essential medicines. After the scoping
societies will continuously work to strengthen
phase and depending on which solutions have
pre- and in-service training of healthcare
been prioritized, WHO and global partners
workers as part of continuous professional
will launch a full design phase that will define
development, by developing and maintaining a
specific elements of design based on the
full suite of tools to support enhanced quality of
preferred solution. This will be followed by a
care, leveraging in-person training and digital
pilot phase in 2024-2025 before full-scale roll-out
tools as required. This will involve developing
in 2026.
mentoring networks and creating communities
Quality-assurance of commodities: Between of practice to share experiences and learnings,
now and the end of 2024, WHO and key hosting webinars on a regular basis, promoting
stakeholders, including Ministries of Health, remote coaching, organising hands-on
will set standards for in-country regulators teamwork training and simulation exercises,
to expedite the approval of commodities, particularly as part of obstetric emergency
both medicines and devices, which have response teams.
Stringent Regulatory Authority (SRA) approval
Engendering equity and improving
or WHO Prequalification status. WHO and
access to care
partners will provide support to Ministries of
Health to develop supply chain guidance that Reduction of out-of-pocket expenses: By the
mandates the procurement of quality-assured end of Q4 2023, WHO and key stakeholders will
commodities. Recognizing that the regulation of conduct a scoping exercise to define potential
medical devices and blood/blood products can options for innovative ways of reducing out-of-
be complex and difficult to navigate, WHO and pocket expenses for pregnancy and childbirth
partners will also map, suggest improvements, care. The scoping exercise will include a rapid
and fill gaps in global supply chain guidance landscaping phase that will investigate current
on quality procurement of devices and blood successful models in select exemplar countries
products, also to improve clarity and ensure where out-of-pocket expenses are limited. It
a consistent level of stringency across global will also detail some of the key financial barriers
guidance. hampering access to care in select high-burden
countries, such as user fees or restrictive
Enhancing staffing, training, and supervision insurance schemes which can be localized,
of healthcare providers time-bound or contributory, thereby leaving out
Expanded role of midwifery: From now until large portions of unemployed or marginalised
the end of 2024, WHO, along with FIGO, ICM, populations. Best practices and solutions will be
Ministries of Health, and national professional assessed based on feasibility of implementation
societies will support a push for the expansion and expected impact. In 2024, WHO and key
of the legislation and regulation governing stakeholders will codify these best practices
midwifery and other cadres such as nurses. ICM and innovative ways of reducing out-of-pocket
published a scope of practice and competencies expenses and formalise the circumstances
for midwives (including for instance the ability to under which each solution should be deployed,

18 A Roadmap to Combat Postpartum Haemorrhage between 2023 and 2030

as part of a broader Universal Health Coverage certain drugs (e.g., intravenous oxytocin or
(UHC) agenda. In 2025, WHO and partners will TXA). A strong advocacy push is therefore
pilot some of these initiatives, for instance at needed so that all skilled birth attendants can
subnational level in some priority geographies. participate in the delivery of care to their fullest
capacity. Second, advocacy efforts should focus
Elevating women’s rights and social status
on Ministries of Health and relevant national
Advocacy for women’s rights and increased health agencies to promote the need to update
awareness: Elevating women’s health on national guidelines to reflect the latest global
political agendas will require coordinated guidance and best available evidence. Third,
advocacy efforts at all levels. WHO and key strong advocacy is needed to advance the role
stakeholders will support ongoing efforts and of the midwife and ensure adequate training
join new initiatives to increase decision-makers’ and support. Fourth, the critical importance of
awareness of PPH, why it matters, how to the availability, affordability, and quality of PPH
minimise the risk of PPH, and how to adequately medicines, supplies, and technologies should
manage PPH. These efforts will insist on the be elevated to ministerial level. Lastly, within
need to have up-to-date national guidelines, the broader population, awareness around
reflective of the latest evidence available, but recognising PPH, addressing risk factors, and
also the need to procure quality commodities the need for timely care seeking should be
(e.g., uterotonics) and strengthen referral reinforced.
systems. In the general population, advocacy
Advancing this ambitious advocacy agenda
efforts will focus on communicating what PPH
requires that all stakeholders be engaged and
is and why timely care matters, to help reduce
work synergistically to gain traction. Critically,
delays in seeking care. Advocacy campaigns will
women should be at the centre of the advocacy
also raise awareness on how to minimize the
agenda. Women’s movements can help drive
risk of death due to PPH, for instance by giving
attention to PPH and hold governments
birth in health facilities. To that effect, WHO and
accountable. Civil society and communities
partners will support global, regional, and local
can raise general awareness and foster
campaigns, and develop blueprints of patient
political leadership. Ministerial commitment is
leaflets that can then be tailored to local needs.
particularly important so PPH is identified as
3.4 Strategic area: Closing a priority and adequately resourced. Evidence
advocacy gaps and data generation are helpful catalysts for
governmental action, so researchers, too, have
Advocacy efforts can help raise awareness
a part to play. Such joint and coordinated action
about the importance of timely and effective
can drive meaningful change.
management of PPH, as well as the availability
and accessibility of lifesaving interventions To be most effective, advocacy approaches
such as uterotonics, blood transfusions, and will need to be tailored to each setting,
surgical procedures. Advocates can work to prioritising those with the greatest burden
ensure that healthcare providers are trained (e.g., marginalised and rural communities).
in the prevention and management of PPH, Advocacy activities can include, among others,
that facilities have the necessary supplies and an international “PPH day” and regional
equipment, and that policies and guidelines convenings (e.g., PPH Summit in Africa).
prioritise maternal health and safety. However, advocacy efforts must reach beyond
the PPH ecosystem, targeting other ministries
Specifically, advocacy efforts should be
(e.g., transport, finance) and involving a broader
focused on five major areas. First, they should
set of stakeholders from across maternal and
be targeted at policymakers and politicians to
newborn health. The PPH community should
support the removal of legislative and regulatory
also leverage connections with other health
barriers hindering access to lifesaving care.
priorities and investments made in support of
In some settings, frontline workers such as
other programmatic priorities (e.g., vaccine cold
midwives are not permitted to administer
chain capacity). Sustainable financing to support

3. Structure of the Roadmap 19

Figure3:3.Key
Figure Key activities
activities andand milestones
milestones for
for the the implementation
implementation agenda agenda

Q1 2023 Q2 2023 Q3 2023 Q4 2023 2024 2025 2026 2027 2028 2029 2030

PPH Launch of Roadmap (incl. Launch PPH Launch of common New procurement initiative
Topics Summit implementation agenda) @ IMNHC Framework measurement platform

WHO and key stakeholders to draft first version of PPH framework with recommended
interventions along the patient pathway to focus implementation efforts in-country
National health
policy WHO/FIGO/ICM/MoHs/National Professional Societies to scope, design, pilot and launch a common measurement platform for monitoring
& leadership changes in practice performance, health outcomes, and inequities with sustainability plans for in-country leadership

WHO and key stakeholders to lead the network of MoH Summit champions for PPH guideline adaptation and adoption including
workshops and translations, and support to guideline dissemination and implementation in-country

WHO and partners (e.g., UNFPA, GFF) to scope solutions WHO and partners (e.g., UNFPA, GFF) to explore leveraging
Procurement & for procurement of maternal health commodities existing procurement initiatives for PPH
Supply Chain
WHO and key stakeholders, particularly MoHs to set standards for in country regulators to approve
commodities with SRA approval or WHO-PQ listing and mandate use of QA commodities

Staffing, Training WHO/FIGO/ICM/MoHs/National Professional Societies to support expanded legislation and regulation of midwifery and other cadres and
strengthen pre-service, in-service training as part of continuous professional development

Equity & access to

care WHO and key stakeholders to identify innovative solutions to promote the removal of user fees for pregnancy care and
complications and more comprehensive insurance schemes, within the larger context of countries need to meet UHC targets
Women's rights &
status WHO and key partners to advocate for women to be at the centre of the political agenda and raise awareness in general population and
reduce delays in seeking care (e.g., through patient information leaflets)

20 A Roadmap to Combat Postpartum Haemorrhage between 2023 and 2030

PPH advocacy is critical to achieve gains and group will design specific PPH branding that can
maintain them in the long run. be used to visually support all PPH advocacy
efforts going forward. This will include a
Key activities and milestones recognizable logo and colour scheme. Materials
In the immediate term, three main initiatives will to support awareness campaigns, whether they
be launched. First, a global branding strategy be through workshops, webinars, or training
for reducing maternal mortality due to PPH sessions, will use the new PPH branding. These
alongside a global advocacy framework will be materials will be tailored to different audiences.
developed. Second, an advocacy framework Advocacy framework for regional and local levels:
for the regional and national levels will be The global advocacy strategy and framework
created. Third, an international PPH Day will be will serve as a comprehensive toolbox of pre-
established. designed materials, tailored messaging, and
Global branding strategy and advocacy compelling visuals that can serve advocacy
framework for reducing PPH-related maternal objectives at all levels. However, messaging will
mortality: A joint, coordinated global PPH be more powerful if it is tailored to local contexts
advocacy strategy can help to unify fragmented and situations. The global framework will
advocacy efforts and conflicting or confusing provide modular content that can be adapted
messaging. This strategy should be seen as as needed. Over the course of 2024–2025, the
an umbrella under which global, regional, and advocacy working group, along with other
local efforts can be amplified. It will provide interested stakeholders, will work towards
important guidance on how to advocate to developing content and materials that can serve
different stakeholder groups and will build regional and local advocacy efforts. There will
on years of successful advocacy efforts and be an iterative process whereby regional and
lessons learnt from other areas in health. A local actors will provide feedback that will help
first step will be to set up an advocacy working adjust and refine the global framework.
group by the third quarter of 2023 with WHO, Global PPH Day: World Malaria Day and World
other multilaterals, civil society organisations Immunization Day have been crucial to raise the
(CSOs), non-governmental organisations (NGOs), profile and awareness of these public health
and, importantly, grassroots organisations. concerns. The PPH community has expressed
This working group will be responsible for interest in establishing a Global PPH Day that
developing the branding strategy and advocacy can be used to raise awareness, communicate
framework over the course of 2024. The strategy and celebrate achievements, announce new
and advocacy framework will contain several discoveries, share learnings and testimonies,
building blocks. They will articulate compelling mobilise the community to address outstanding
and evidence-based messaging to advocate challenges, and support resource mobilisation
for the update and adaptation of national efforts. A Global PPH day can also raise the
guidelines, legislative and regulatory changes profile of PPH and elevate it on political agendas.
that remove barriers to quality care (for example, In Q3 2023, UN agencies and partnerships will
on the role of midwifery), and faster delivery work with the UN Secretariat to find a suitable
of innovations to LMICs. This comprehensive date for a Global PPH Day. Once a date has been
toolbox will also contain tailored messaging identified, WHO and partners will prepare a
that captures powerful stories from the voices dossier that addresses all the requirements to
of young generations and which can be used apply for the creation of a global PPH Day. This
for targeted messaging to key populations. will happen over the course of 2024. WHO and
To ensure sustained results, the framework partners will then prepare the organisation of a
will outline roles and responsibilities as well first PPH Day, with 2025 as a target launch year.
as accountability mechanisms. Global and The first PPH Day will also serve as a launch
local champions such as high-profile goodwill pad for the PPH branding strategy. That event
ambassadors will be designated to support and associated preparatory activities will be
advocacy efforts. Importantly, the working repeated on an annual basis.

3. Structure of the Roadmap 21

Figure
Figure 4:4.Key
Keyactivities
activities
andand milestones
milestones for
for the the advocacy
advocacy agenda agenda

Q1 2023 Q2 2023 Q3 2023 Q4 2023 2024 2025 2026 2027 2028 2029 2030

PPH Launch of the Roadmap (incl. Global branding strategy 1st Global Regional and local Update of frameworks
Topics Summit advocacy agenda) @ IMNHC and advocacy framework PPH day advocacy frameworks

Create global
branding strategy
WHO and key stakeholders to set up an advocacy working group,
for reducing
responsible for branding strategy and global advocacy framework creation
maternal mortality
due to PPH, and
global advocacy Working group to design, develop, and launch branding
framework strategy and global advocacy framework creation

Create advocacy
framework for Key stakeholders to develop regional & local
regional and frameworks once global framework is finalised
national level

Organise Global WHO and key stakeholders to select targeted date for annual PPH Day
PPH Day (incl.
townhall in Africa)
WHO and key stakeholders to syndicate, communicate on, and organise annual PPH day

Milestones non continent on new funding Milestones contingent on funding Interdependencies Iterative process

22 A Roadmap to Combat Postpartum Haemorrhage between 2023 and 2030

3.5 Consolidated Roadmap
The subsections above describe key activities
and milestones for each of the four strategic
areas. Yet the strategic areas are not envisioned
as distinct workstreams running in parallel.
Rather, they are interdependent, and activities
in one strategic area feed into and advance
activities in other strategic areas. For example,
emerging research evidence informs the
development and publication of new global
norms and standards, which in term must be
adapted for local contexts and implemented.
The global PPH framework and common
measurement platform for monitoring and
evaluation both contribute to data-driven
advocacy efforts, which can then garner needed
political support to drive further normative and
implementation efforts.
Figure 5 provides a high-level overview of some
of the anticipated interdependencies and
synergies between the activities in each of the
four strategic areas. This is not intended as a
comprehensive accounting of all the ways the
strategic areas may interlink and support one
another, but instead offers several illustrative
examples from 2023 to 2030.

3. Structure of the Roadmap 23

Figure
Figure5. Overall high-level
5. Overall milestones
high-level to reduceto
milestones the PPH burden
reduce and associated
the PPH burden and maternal deaths from
associated 2023 through
maternal deaths2030
from 2023 through 2030

24 A Roadmap to Combat Postpartum Haemorrhage between 2023 and 2030

4. A Global Call-to-Action

Ensuring the audacious agenda outlined in this ▶▶ A strong advocacy push is required at
Roadmap is achieved will require concerted all levels to elevate the profile of PPH,
action from all stakeholders. This Global Call to improve care, strengthen collaboration
to Action outlines key learnings from the PPH across facilities and promote facility births,
Summit and describes concrete activities for and ensure women are managed at the
each stakeholder group and demonstrates that right level of care. This will require effective
everyone has a role to play. collaboration among all PPH stakeholders
and strong political leadership.
The following key learnings emerged from the
PPH Summit: ▶▶ The international community should come
together to improve the availability and
▶▶ Women and community voices need to
affordability of quality PPH commodities
be included in all steps – from defining the
(including medicines, devices, and blood
research agenda to developing guidelines,
products). While there are many barriers to
removing implementation bottlenecks, and
implementation of existing tools that need
supporting advocacy efforts, so that services
addressing (e.g., fully capacitated workforce,
better serve their needs.
reduction of out-of-pocket expenditure), this
▶▶ PPH causes are well known and can is a prerequisite for improved quality of care
be prevented through interventions at all levels of the health system.
across the continuum of care starting
▶▶ A fully funded joint research agenda should
from preconception care to antenatal,
be developed around the 15 priority research
childbirth and postpartum care. While lots
questions that emerged from the Summit,
of interventions are known to be effective,
including determining the effectiveness
there are many barriers to implementation of
of a bundle approach to early detection
existing tools that need addressing (e.g., fully
and treatment, identifying barriers and
capacitated workforce, reduction of out-of-
facilitators to the uptake of evidence (and
pocket expenditure).
assessing implementation strategies for
▶▶ PPH challenges cannot be solved in isolation, addressing those barriers), and evaluating
but rather as part of a broader maternal the safety and effectiveness of alternative
and newborn health agenda. Other sectors routes of administration for tranexamic acid
must be involved, including transport and (TXA) and heat-stable carbetocin (HSC) for
finance. PPH treatment in women who had already
▶▶ There is a need for a unifying force in the received it for PPH prevention. It should focus
PPH space to drive the PPH agenda and on generating quantitative and qualitative
aggregate funding. Donors committed evidence in low- and middle-income
to stronger coordination of their PPH countries’ settings and the most critical
investments which could be achieved points of the woman’s pathway where deaths
through a coordination forum. Existing and disabilities occur.
initiatives such as the Every Newborn Action ▶▶ Global PPH guideline developers should
Plan and the Ending Preventable Maternal align on a core set of recommendations,
Mortality initiative could be leveraged. consistent across guidelines, that can be

25
 contextualised into national guidelines and ▶▶ An effective PPH response to change the
further translated into clinical practice tools projected adverse outcomes by 2030 requires
(e.g., protocols and job aids). A first step will an efficient and sustainable monitoring
be to reduce duplication of efforts by sharing system at scale – including common
the evidence synthesis work underpinning measurement indicators, systematic data
PPH recommendations. collection, and a common measurement
platform – to track progress against
▶▶ Guideline updates should address current
targets. This measurement platform will
gaps such as recommendations to address
be instrumental to provide the tools and
antenatal and intrapartum risk factors
data to be able to track progress against the
for PPH (e.g., anaemia prevention and
milestones included in the Roadmap.
treatment, diagnosis of abnormally situated
(praevia) or morbidly adherent (accreta) Summit Participants call on the international
placenta), accuracy of PPH detection community to acknowledge the consensus that
methods (incl. blood loss measurement), and emerged from the Summit, which is reflective
aspects of health systems such as referral, of a broad and inclusive participation by all
transport and task shifting. stakeholders. They specifically call for the
following actions:

Key actions to ensure effective and coordinated efforts towards eliminating preventable deaths
Stakeholder
from postpartum haemorrhage

▶▶ Identify a leading organisation, consortium, or collaboration, that will be responsible

for driving a unified PPH agenda and aggregating funding as part of a broader maternal
and newborn health agenda.
▶▶ Launch coordinated and unified initiatives to strengthen advocacy and increase PPH
International awareness.
community

▶▶ Share learnings from experience, take part in advocacy campaigns

▶▶ Participate in solution design, especially women from low-income settings
▶▶ Seek safe delivery and demand social accountability for maternal and newborn
services (e.g., facility based antenatal, childbirth, and postnatal care services)
Women &
Women’s groups
▶▶ Strengthen country leadership and accountability on PPH (incl. detailed targets,
monitoring system, domestic financing, advocacy) and coordinate efforts with
partners
▶▶ Ensure national guidelines are updated, contextualised to local settings, and well
disseminated
▶▶ Steer national procurement to quality-assured medicines & devices, ensure
Ministries of
Health
appropriate staffing, training, and equipment of health facilities, and work to improve
supply chain reliability and efficiency

▶▶ Develop new approaches to address priority gaps

▶▶ Increase advocacy on PPH through unified voice or platform
▶▶ Form coalitions with governments and professional organizations to develop action
Implementers plans for national and subnational levels
(incl. NGOs &
CSOs)

26 A Roadmap to Combat Postpartum Haemorrhage between 2023 and 2030

 Key actions to ensure effective and coordinated efforts towards eliminating preventable deaths
Stakeholder
from postpartum haemorrhage

▶▶ Promote adherence to recommended interventions

▶▶ Support collaboration, knowledge dissemination, and communities of practice (incl.
across countries), acting as convening bodies
▶▶ Support coordinated ongoing and continuous locally led capacity building for health
Professional workers, with accountability measures
associations

▶▶ Ensure and maintain alignment between PPH recommendations through enhanced

collaboration between guideline developers (starting with sharing the evidence
synthesis work and jointly building the evidence ecosystem for PPH)
▶▶ Consolidate PPH recommendations, and continuously update or develop new
recommendations as new, impactful evidence emerges, addressing all opportunities to
intervene in the ‘natural history’ of PPH
Guideline
developers ▶▶ Support development of national guidelines on PPH, consistent with global
recommendations
▶▶ Execute the PPH research agenda and focus efforts on research priorities that address
implementation barriers and bottlenecks, and on better coordinating innovation
research
▶▶ Ensure research is contextualised and directed towards least served communities, via
the engagement of women and frontline health workers, especially midwives
Research ▶▶ Strengthen global collaboration across researchers, industry, and innovators to
community accelerate impact
▶▶ Focus PPH R&D efforts on fit-for-purpose, demand-driven, innovations that will
address unmet public health needs, via strengthened involvement of health workers,
especially midwives
▶▶ Make commodities more affordable and accessible, especially for low-income
settings, where their effectiveness should also be tested
Industry & ▶▶ Commit to generating the evidence required to inform health policy development
innovators processes at global and country levels
▶▶ Increase financial commitments, channelling investments to identified priority gaps
(incl. implementation and scale up of proven PPH commodities, strengthening of safe
blood systems, and advocacy).
▶▶ Strengthen coordination across donors to avoid duplication of efforts and amplify
impact. Contemplate creating a consortium to allow a single point of contact for
countries.
Donors ▶▶ Reinforce engagement and alignment with governments to better address local
needs and secure their commitment to reach agreed targets.

Signatories: Participants at the Global Summit on PPH, 7–10 March, Dubai, UAE

4. A Global Call-to-Action 27
5. Implementation of the
Roadmap

The activities laid out in this Roadmap are further defined, as will concrete accountability
ambitious and illustrate the urgent need mechanisms.
for transformational change. Successful
The PPH landscape is complex, and many
implementation will require concerted effort
stakeholders are responsible for advancing
by all stakeholders across the international,
multiple agendas outside of PPH, while
national, and subnational levels. Successful
remaining accountable to varied constituencies.
implementation will also require sustained
Roadmap leadership and governance must
donor commitment as many of the priority
reflect this reality.
activities outlined in the Roadmap are
contingent on additional funding to support 5.2 Adaptation for local context
their execution.
Successful translation of the Roadmap into
As part of the development process of the national health policies and health services
Roadmap, implementation considerations were depends on well-planned, participatory,
identified for each strategic area. Below are consensus-driven processes of adaptation.
some key pointers, which may help stakeholders Countries may choose to, for example, define
prepare for implementation. national-level versions of the global goals
and milestones outlined in the Roadmap, and
5.1 Global leadership and integrate them into existing national strategies.
governance WHO will support national and subnational
The Roadmap is multi-faceted, requiring efforts to integrate the Roadmap into new and
coordinated actions across a wide range of existing strategies. Any adaptations to country
stakeholders over the next seven or more years. goals and milestones should be reflected in the
Strong leadership and governance are essential. monitoring and evaluation platform, to reduce
During the development of the Roadmap, WHO reporting burden.
was identified as the responsible body for many The Roadmap specifies top global research
immediate next steps. While WHO will act as priorities. However, specific contexts may have
a catalyst and drive the launch of these initial different, more pressing research concerns (e.g.,
activities, other organisations will need to be to managing PPH in conflict and humanitarian
identified to spearhead efforts, assure progress, settings). National research funding agencies
and rally support for the key priority actions. may need to adapt the list of research priorities
Roles and responsibilities will need to be further to address local needs. The Roadmap should
articulated. It should be noted that a lot of the not be interpreted as a binding list of approved
priority activities included in the Roadmap will research items, but rather a snapshot of current
be contingent on additional funding to support global research needs.
their execution.
Similarly, global guidelines provide high-level
It will be important to establish a governance norms and standards around PPH prevention
structure that clearly delineates which and treatment, based on the best available
stakeholders will lead activities across each research evidence. Yet national guidelines,
of the four strategic areas in the Roadmap. clinical protocols, and job aides need to be
Roles and responsibilities will need to be adapted and tailored for local context. WHO

28
will support efforts to update national norms 5.3 Anticipated impact of
and standards, as well as develop appropriate the Roadmap
protocols and job aids. National professional In 2022, an estimated 70,000 women died due
associations and implementors are key partners to PPH. If nothing changes, an additional half a
in this work and should be actively involved in million women will die by the close of the SDG
developing these materials. era, from a condition that is both preventable
Local stakeholders will need to identify the and treatable. These women will leave behind
most pressing barriers and bottlenecks to families and communities that are weaker for
implementation in their contexts, and work their absence. Millions of women will suffer from
together to develop effective solutions. long-lasting consequences of traumatic birth
Ministries of Health may be particularly experiences and the inability of their health
well-positioned to convene relevant local systems to respond effectively. Alarmingly, data
stakeholders. The global leadership and from some countries suggest that rates of PPH
governance structure for the Roadmap provides are increasing, painting an even bleaker picture
one option for how to organise local efforts, but of the years ahead.
other structures may be more appropriate given The Roadmap offers a vision of a different future.
existing norms and institutions. In this future, countries have taken strong action
Partial contextualisation of advocacy efforts to address upstream risk factors for PPH and
is already anticipated in the Roadmap, to prepare health systems to respond quickly
through the development of regional and local and effectively when PPH does occur. Frontline
advocacy frameworks. Yet these will still need health workers are trained and capacitated to
to be tailored further for and within national detect and treat PPH, and supported by robust
settings. Advocates will also need to translate referral and transport systems that get women
the frameworks into concrete messages with to higher-level care in a timely fashion. Women
local salience and determine the best routes no longer die because a needed drug is stocked
for dissemination. Market segmentation and out or of poor quality. This future is possible. The
targeted messaging can help to improve the Roadmap shows what is needed to get there.
impact of advocacy efforts. Advocates should This Roadmap cannot eliminate PPH entirely –
also pay attention to messenger effects no plan can. Yet timely and coordinated action
and select the most appropriate type of on each of the strategic areas in the Roadmap
communicator and venue to assure impact. can help reduce the impact of PPH on women’s
health and wellbeing. Women and families who
are currently among the most marginalised
in the world stand to gain the most from
implementation of the Roadmap, with important
dividends for community-wide development and
empowerment.

5. Implementation of the Roadmap 29

6. Disseminating the Roadmap
and Call-to-Action

The Roadmap was launched, along with the will be provided to any WHO regional office
WHO Call-to-Action at the International Maternal willing to translate the full Roadmap into any
Newborn Health Conference held 8–11 May of these languages. In addition, journal articles
2023 in Cape Town, South Africa. Dissemination presenting each strategic areas (including
will continue through future conferences development and identification of priorities)
and webinars organized by WHO and other and key implementation considerations will
stakeholders, including Summit participants. be considered, in compliance with WHO’s open
access and copyright policies. Relevant WHO
WHO will also develop tools to aid adaptation
clusters, departments, and partnerships, such
of the Roadmap to local contexts, including
as the Partnership for Maternal, Newborn and
an evidence brief on implementation of the
Child Health (PMNCH), will also be part of this
Roadmap in the most affected regions and
dissemination process.
countries. The Roadmap and tools will be
disseminated through WHO regional and To ensure this recommendation has an
country offices, Ministries of Health, professional impact on maternal health at country level,
organizations, WHO collaborating centres, other coordinated action between international
United Nations agencies, and NGOs, among agencies, Ministries of Health, and key maternal
others. The Roadmap will be published on the and perinatal health stakeholders is required.
WHO/HRP website, and highlighted as part of WHO staff at Headquarters, Regional, and
the monthly WHO/HRP News. This newsletter Country level, as well as international agency
currently reaches over 8000 subscribers partners and international professional societies
including clinicians, programme managers, (e.g., FIGO and ICM, national professional
policymakers, and health service users from associations) can support national stakeholders
around the world. WHO documents are also in developing or revising existing national
routinely disseminated during meetings guidelines or protocols, and optimising their
and scientific conferences attended by WHO implementation in response to the Roadmap.
maternal and perinatal health staff. Context-specific tools and toolkits may be
required in addition to standard tools to
The Roadmap documents will be translated
support the implementation of the Roadmap
into the six UN languages for dissemination
recommendations in humanitarian emergencies
through the WHO regional and country offices
by stakeholders.
and during meetings organized by, or attended
by, WHO coordinating staff. Technical assistance

30
7. Monitoring and
evaluating impact

In 2015, Ending Preventable Maternal Mortality Moreover, indicators should be common across
(EPMM), a global multi-partner initiative to geographies and time, to allow for consistent
improve maternal health and wellbeing and monitoring and benchmarking.
achieve the SDG target for MMR, outlined broad
Establishing the monitoring framework is
strategies for maternal health programmes
challenging, in no small part because there
[10]. As part of its monitoring framework,
are few universal indicators for PPH. However,
EPMM has established coverage targets and
research studies on PPH (for example, the
milestones to track progress to 2030. EPMM’s
E-MOTIVE Trial [11]) have developed monitoring
monitoring framework aligns with the targets
frameworks around access and quality of PPH
and milestones in the Every Newborn Action
care that could provide useful examples for
Plan (ENAP) launched in September 2020. The
developing the core set of indicators, as well as
PPH Roadmap complements these efforts by
providing important insight into data collection
focusing efforts related to PPH as the major
burden and feasibility of different proposed
contributor to maternal mortality.
indicators. Newly emergent evidence on the
The PPH Roadmap outlines an ambitious validity and feasibility of indicators included
agenda to accelerate action on PPH. To maintain within the EPMM monitoring framework may
momentum, it will be critical to define a core also prove useful [12, 13]. Given the challenge
set of indicators and comprehensive monitoring and opportunity presented here, establishing
framework to track progress and evaluate the core set of indicators and common
impact. measurement platform is a key milestone
early in the Roadmap. As an immediate next
Developing the core set of indicators presents
step, WHO, FIGO, ICM, Ministries of Health,
a unique opportunity for monitoring and
and national professional societies will need
evaluation professionals. Indicators need to be
to convene to scope potential indicators for a
both granular enough to track implementation
common measurement platform for monitoring
outputs and outcomes along the theory of
changes in practice performance, health
change toward proposed impact in reducing
outcomes and inequities. Scoping efforts should
MMR, while also general enough to draw
include definition clear sustainability plans for
from existing data collection efforts to
country leadership.
reduce monitoring and reporting burden.

31
9. References

[1] Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. Global causes of maternal death:
A WHO systematic analysis. Lancet Glob Heal 2014;2:323–33. https://doi.org/10.1016/S2214-
109X(14)70227-X.
[2] Kassebaum NJ, Barber RM, Dandona L, Hay SI, Larson HJ, Lim SS, et al. Global, regional, and
national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of
Disease Study 2015. Lancet 2016;388:1775–812. https://doi.org/10.1016/S0140-6736(16)31470-2.
[3] World Health Organization (WHO), Unicef, UNFPA, World Bank Group, UNDESA/Population
Division. Trends in Maternal Mortality 2000 to 2020. Geneva: 2023.
[4] World Health Organization. WHO Target Product Profiles, Preferred Product Characteristics, and
Target Regimen Profiles: Standard Procedure. 1.02. Geneva: 2020.
[5] Dolley S, Hartman D, Norman T, Hudson I. DAC Target Policy Profile (TPoP). DAC Trials, The
Global Health Network; 2021. https://doi.org/10.48060/tghn.2.
[6] Souza JP, Widmer M, Gülmezoglu AM, Lawrie TA, Adejuyigbe EA, Carroli G, et al. Maternal and
perinatal health research priorities beyond 2015: an international survey and prioritization
exercise. Reprod Health 2014;11:61. https://doi.org/10.1186/1742-4755-11-61.
[7] Rudan I, Gibson JL, Ameratunga S, El Arifeen S, Bhutta ZA, Black M, et al. Setting priorities in
global child health research investments: Guidelines for implementation of CHNRI method. Croat
Med J 2008;49:720–33. https://doi.org/10.3325/cmj.2008.49.720.
[8] Rudan I. Setting health research priorities using the CHNRI method: IV. Key conceptual advances.
J Glob Health 2016;6. https://doi.org/10.7189/jogh.06.010501.
[9] World Health Organization. A Systematic Approach for Undertaking a Research Priority-Setting
Exercise: Guidance for WHO Staff. Geneva: World Health Organization; 2020.
[10] Chou D, Daelmans B, Jolivet RR, Kinney M, Say L. Ending preventable maternal and newborn
mortality and stillbirths. BMJ 2015;351:19–22. https://doi.org/10.1136/bmj.h4255.
[11] Bohren MA, Lorencatto F, Coomarasamy A, Althabe F, Devall AJ, Evans C, et al. Formative
research to design an implementation strategy for a postpartum hemorrhage initial response
treatment bundle (E-MOTIVE): study protocol. Reprod Health 2021;18:149. https://doi.
org/10.1186/s12978-021-01162-3.
[12] Jolivet RR, Gausman J, Adanu R, Bandoh D, Belizan M, Berrueta M, et al. Multisite, mixed
methods study to validate 10 maternal health system and policy indicators in Argentina,
Ghana and India: A research protocol. BMJ Open 2022;12:1–13. https://doi.org/10.1136/
bmjopen-2021-049685.
[13] Jolivet RR, Gausman J, Langer A. Recommendations for refining key maternal health policy
and finance indicators to strengthen a framework for monitoring the Strategies toward Ending
Preventable Maternal Mortality (EPMM). J Glob Heal 2021;11:02004. https://doi.org/10.7189/
jogh.11.02004.

32
Annex 1.
List contributors
Title Names Organization Country

Steering Committee Members

Ms. Angela Ndunge Nguku White Ribbon Alliance Kenya Kenya
Ms. Cammie Sien-Mun Lee Results for Development (R4D) USA
Ms. Daisy Jerop Ruto Jhpiego, Smiles for Mothers Kenya
Dr. Elliott Kingwill Main Stanford University USA
Prof. Hadiza Galadanci Bayero University Nigeria
Dr. Hrishikesh Pai Federation of Obstetric and Gynaecological Societies of India India
Dr. Jolly Beyeza-Kashesya International Federation of Gynecology and Obstetrics Uganda
Dr. Michel Claude Brun United Nations Population Fund Switzerland
Mrs. Patricia Titulaer International Confederation of Midwives Netherlands
Dr. Pauline Margaret Williams Independent Pharmaceutical Medicine Consultant United Kingdom
Mr. Peter Alan Lambert Monash University Australia
Dr. Richard Mugahi Government of Uganda Uganda
Prof. Rizwana Chaudhri Shifa Tameer e Millat University Pakistan
Prof. Sabaratnam Arulkumaran St. George Hospital United Kingdom
Prof. Suellen Miller University of California USA
Prof. Susan Fawcus Cowbray Maternity Hospital South Africa
All other contributors
Dr. Adam James Devall University of Birmingham United Kingdom
Dr Adeniyi Aderoba World Health Organization (AFRO) Congo-Brazzaville
Prof. Ahmed Fawzy Galal Alexandria University Egypt Egypt
Dr. Ahmet Metin Gülmezoglu Concept Foundation Switzerland

33
Title Names Organization Country
Dr. Allisyn Carol Moran World Health Organization (HQ) Switzerland
Dr. Alongkone Phengsavanh Faculty of Medicine, University of Health Sciences Lao DPR
Ms. Amanda Cafaro Bill and Melinda Gates Foundation USA
Ms. Amelia Anne Schellpfeffer Bill and Melinda Gates Foundation USA
Dr. Anders Seim Health and Development International Norway
Prof. Anderson Pinheiro University of Campinas, Caism-Unicamp, São Paulo Brazil
Dr. Andrew Craig Sutcliffe Medtrade United Kingdom
Prof. Andrew David Weeks University of Liverpool United Kingdom
Mr. Andrew Phillip Storey Clinton Health Access Initiative United Kingdom
Dr. Anne Beatrice Kihara International Federation of Gynecology and Obstetrics Kenya
Dr. Anupama Prasad Government of India India
Ms. Aparna Kamath Grand Challenges Canada Canada
Prof. Arri Coomarasamy University of Birmingham United Kingdom
Mrs. Aseema Mahunta Behra Centre for Catalyzing Change India
Prof. Ashok Kumar Indian College of Obstetricians and Gynaecologists India
Mr. Bhavin Rameshkumar Vaid Ferring Pharmaceuticals Switzerland
Dr. Blami Dao Jhpiego Burkina Faso
Dr. Bouchra Assarag Global exemplars Morocco
Ms. Caitlin R. Williams Institute for Clinical Effectiveness and Health Policy (IECS-Argentina) Argentina
Ms. Catharine Howard Taylor MSD for Mothers USA
Prof. Catherine Deneux National Institute for Health and Medical Research France
Dr. Chandani Anoma Jayathilaka World Health Organization (SEARO) India
Dr. Christine Fawzy Al Kady Médecins Sans Frontières Lebanon
Mr. Dale Halliday Unitaid Switzerland
Dr. Dalya Idris Hassan Eltayeb Government of Sudan Sudan
Dr. David Ntirushwa Centre Hospitalier Universitaire de Kigali (CHUK) Rwanda
Mrs. Deborah Anne Armbruster USAID USA
Ms. Denitza Tzvetanova Andjelic Unitaid Switzerland

34 A Roadmap to Combat Postpartum Haemorrhage between 2023 and 2030

Title Names Organization Country
Prof. Dilys Margaret Walker University of California, San Francisco USA
Mr. Dirk Christiaan De Villiers Sinapi Biomedical South Africa
Dr. Edgardo Javier Abalos Centro de Estudios de Estado y Sociedad (CEDES) Argentina
Dr. Edward KimutaI Serem Government of Kenya Kenya
Ms. Edwina Florence Conteh International Confederation of Midwives Sierra Leone
Ms. Elaine Cathleen Scudder International Rescue Committee USA
Dr. Elhadji Thierno Mbengue Government of Senegal Senegal
Mrs. Etenesh Gebreyohannes Hailu Government of Ethiopia Ethiopia
Dr. Fadhlun Mohamed Alwy Al-Beity Muhimbili University of Health and Allied Sciences Tanzania
Prof. Farhana Dewan Obstetrical and Gynaecological Society of Bangladesh Bangladesh
Dr. Fatema Rahman Government of Bangladesh Bangladesh
Dr. Fernando Althabe World Health Organization (HQ) Switzerland
Prof. George Justus Hofmeyr University of Botswana Botswana
Dr. Grethe Berger Heitmann ExAC Norway
Mr. Guervan Adnet Boston Consulting Group France
Ms. Hadijah Nakatudde ICM Regional Uganda
Dr. Hadil Y.M. Ali Government of Palestine Palestine
Dr. Hani Wahib Fawzi International Federation of Gynecology and Obstetrics United Kingdom
Ms. Hema Srinivasan Medaccess United Kingdom
Prof. Hoang Thi Diem Tuyet Hung Vuong Hospital Vietnam
Prof. Ian Gray Roberts London School of Hygiene and Tropical Medicine United Kingdom
Prof. Iffath Abbasi Hoskins American College of Obstetricians and Gynaecologists USA
Dr. Ioannis Gallos World Health Organization (HQ) Switzerland
Dr. Ishraq Rabeia Ahmed Elsebai Goverment of Yemen Yemen
Dr. Jeanne Ann Conry International Federation of Gynecology and Obstetrics USA
Mr. Jeffrey Loren Jacobs MSD for Mothers USA
Dr. Jeffrey Michael Smith Bill and Melinda Gates Foundation USA
Ms. Jennifer Akuamoah-Boateng Bill and Melinda Gates Foundation USA

Annex 1. List contributors 35

Title Names Organization Country
Ms. Jill Victoria Jones UK MRC United Kingdom
Dr. João Paulo Souza World Health Organization (PAHO) Brazil
Dr. Joe Fitchett Institut Pasteur de Dakar Senegal
Dr. John Edward Varallo Jhpiego USA
Ms. Joyce Wangari Nganga WACI-Health Kenya
Dr. Kamo Dumo Angau Hospital in Lae Papua New Guinea
Dr. Karima Gholbzouri World Health Organization (EMRO) Egypt
Dr. Katharine Dorinda Shelley PATH USA
Mr. Lester Chinery Concept Foundation Switzerland
Mr. Louis-Victor Dorat Boston Consulting Group France
Dr. Lumaan Sheikh Aga Khan University Pakistan
Ms. Maria Angelica Flores World Health Organization (HQ) Switzerland
Prof. Maria Fernanda Escobar Vidarte Fundacion Valle del Lili Colombia
Prof. Maria Isabel Rodriguez Center for Reproductive Health Equity, OHSU USA
Dr. Maria Magdalena Botha Sinapi Biomedical Pty Ltd South Africa
Dr. Mariana Widmer World Health Organization (HQ) Switzerland
Dr. Mario Philip Festin College of Medicine at the University of the Philippines Philippines
Mr. Martyn Philip Smith Reproductive Health Supplies Coalition USA
Dr. Mary-Ann Etiebet MSD for Mothers USA
Dr. May Raouf Dubai Health Authority (WHO Collaborating Centre) UAE
Mrs. Megan Ella Rauscher Thinkwell USA
Prof. Michelle McIntosh Monash University Australia
Prof. Nasser Mahmoud Badawi Elkholy Ain Shams University Hospitals Egypt
Dr. Naushin Farooq Government of Pakistan Pakistan
Dr. Nee Mariam Roumane MME Al-Habbo Government of Chad Chad
Dr. Neena Raina World Health Organization (SEARO) India
Dr. Nihfadh Issa Kassim Government of Tanzania Tanzania
Ms. Noha Hosny Hassanein Organon Egypt

36 A Roadmap to Combat Postpartum Haemorrhage between 2023 and 2030

Title Names Organization Country
Dr. Norbert Richard Ngbale Government of Central African Republic Central African Republic
Dr. Olufemi Oladapo World Health Organization (HQ) Switzerland
Dr. Pascale Allotey World Health Organization (HQ) Switzerland
Ms. Patricia Imperatrice Carney Organon USA
Dr. Paul Oyere Moke Government of Congo Congo-Brazzaville
Prof. Peter Kyobe Waiswa Makerere University Uganda
Dr. Phineas Ferdinand Sospeter Government of Tanzania Tanzania
Prof. Pisake Lumbiganon Asia & Oceania Federation of Obstetrics & Gynaecology Thailand
Dr. Pius Okong Government of Uganda Uganda
Ms. Rachel Mary Smith Burnet Institute Australia
Prof. Rachid Bezad University Mohammed V Morocco
Ms. Robyn Tracy Churchill USAID USA
Dr. Rodolfo de Carvalho Pacagnella Universidade Estadual de Campinas, UNICAMP Brazil
Mrs. Romane Théoleyre Unitaid Switzerland
Mr. Russell Davies Mably Medtrade United Kingdom
Dr. Sam Ononge Makerere University Uganda
Dr. Samuel Oyeniyi Federal Government of Nigeria Nigeria
Dr. Sara Rushwan Concept Foundation Switzerland
Ms. Sarah Chamberlain Boston Consulting Group USA
Dr. Sheela Vishwanath Mane Anugraha Nursing Home India
Dr. Shivaprasad Goudar KLE University India
Ms. Song Li Government of China China
Dr. Suzanne Jacob Serruya World Health Organization (PAHO) Uruguay
Prof. Timothy John Draycott Royal College of Obstetrics and Gynaecology United Kingdom
Mrs. Trude Gro Thommesen International Confederation of Midwives Norway
Dr. Uzma Syed World Health Organization (HQ) Switzerland
Ms. Victoria Holdsworth World Health Organization (HQ) Switzerland
Dr. Virginia Diaz Centro Rosarino de Estudios Perinatales (CREP) Argentina

Annex 1. List contributors 37

Title Names Organization Country
Mr. Vishal Shah Ferring Pharmaceuticals India
Dr. Wang Ai-Ling Government of China China
Prof. Yoswa Mbulalina Dambisya The East Central and Southern Africa Health Community Tanzania
Prof. Zahida Qureshi University of Nairobi Kenya

38 A Roadmap to Combat Postpartum Haemorrhage between 2023 and 2030

 Annex 2.
Research prioritization flowchart

Annex 2: Research prioritization flowchart

39
 Annex 3.
Mapping of PPH recommendations

Annex 3: Identification of published norms and standards to inform mapping of PPH recommendations

40

51
Annex 4. Heatmap of results from barriers to implementation survey
Score scale Low <45% <65% <75% <85% +85% High

Annex 4: Heatmap of results from barriers to implementation survey

Question
Local Healthcare
support from Inclusion in workers Training & Healthcare
Inclusion in stakeholders national Job aids awareness & experience facilities
national acting as Registration EMLs or Availability / available at trust in Affordability of healthcare staffing &
guidelines Champions and licence equivalents? Procurement facility level effectiveness & quality workers equipment
Oxytocin injection for PPH prevention
89% 83% 91% 90% 72% 79% 88% 73% 82% 68%
Q01 and treatment
Ergometrine injection for PPH
prevention and treatment (if oxytocin 63% 56% 67% 63% 44% 52% 59% 52% 55% 48%
Q02 is unavailable)
Fixed-dose oxytocin and ergometrine
combination injection for PPH
55% 52% 57% 56% 40% 48% 52% 45% 50% 44%
prevention and treatment (if oxytocin
Q03 is unavailable)
Heat-stable carbetocin injection for
Recommended intervention

PPH prevention (if oxytocin is

46% 49% 50% 47% 34% 39% 45% 43% 40% 38%
unavailable or quality cannot be
Q04 guaranteed)
Oral misoprostol for PPH prevention
and treatment (if oxytocin is
84% 80% 81% 82% 74% 77% 81% 77% 78% 72%
unavailable or did not stop the
Q05 bleeding)
Isotonic crystalloids for fluid
84% 81% 83% 82% 75% 77% 82% 79% 79% 73%
Q06 resuscitation of women with PPH
Tranexamic acid injection plus
79% 79% 80% 78% 70% 72% 75% 75% 71% 71%
Q07 standard care for PPH treatment
Oxytocin in combination with
controlled cord traction for retained 85% 82% 85% 85% 78% 78% 82% 78% 78% 73%
Q08 placenta
Uterine balloon tamponade (UBT) for
62% 62% 60% 58% 49% 52% 57% 52% 49% 46%
Q09 refractory PPH treatment

41
 Non-pneumatic anti-shock garment
(NASG) as temporizing measure for 55% 54% 54% 52% 39% 44% 48% 44% 42% 41%
Q10 definitive PPH care
Uterine artery embolization for
56% 52% 44% 52% 39% 38%
Q11 refractory PPH treatment
Bimanual uterine compression as
temporizing measure before definitive 75% 72% 69% 71% 66% 62%
Q12 PPH care
External aortic compression as
temporizing measure for definitive PPH 61% 57% 52% 54% 47% 49%
Q13 care
Surgical interventions (laparotomy or
compressive sutures or hysterectomy) 76% 74% 68% 75% 61% 57%
Q14 for refractory PPH treatment
Abdominal uterine tonus assessment
for early identification of uterine atony 80% 78% 76% 78% 77% 72%
Q15 for all women postpartum
Controlled cord traction is the
recommended method for removal of 74% 75% 73% 75% 74% 70%
Q16 the placenta in caesarean section
Uterine massage for conservative
87% 86% 84% 86% 85% 79%
Q17 treatment of PPH
Formal protocols at health facilities for
80% 79% 76% 79% 75% 69%
Q18 prevention and treatment of PPH
Formal protocols for referral of women
to a higher level of care for treatment 79% 78% 73% 79% 73% 67%
Q19 of PPH
Simulations of PPH treatment for pre-
service and in-service training 69% 70% 66% 71% 66% 61%
Q20 programmes

Score represents aggregate level of agreement. For instance, there is general agreement (82%) that healthcare workers are trained and experienced to give oxytocin injection for PPH
prevention and treatment; however, there is little agreement (39%) that healthcare workers are trained and experienced to perform uterine artery embolization for refractory PPH
treatment.

42 A Roadmap to Combat Postpartum Haemorrhage between 2023 and 2030

For more information, please contact:
Department of Sexual and Reproductive Health and Research
World Health Organization
Geneva
Switzerland
Email: srhmph@who.int