Barriers and bottlenecks to implementation of WHO recommendations for prevention, detection, and treatment of postpartum hemorrhage: a mixed-methods triangulation study

Abstract Background The World Health Organization develops evidence-based recommendations for postpartum hemorrhage (PPH) prevention, detection, and treatment. However, persistently high PPH-related mortality suggests recommendations are poorly implemented, especially in low-resource settings. This study aimed to identify implementation bottlenecks to inform action. Methods Drawing on public policy, implementation science, and health behavior, we constructed a multi-level framework to identify bottlenecks affecting recommendation uptake. This informed the development of a survey assessing which bottlenecks affected specific WHO recommendations. Surveys were completed by global stakeholders and by health care workers in three high-burden countries. We also analyzed direct observations of clinical practice from those countries to see how bottlenecks affected practice. An a priori interpretive threshold of 75% was selected to indicate a bottleneck was not a severe impediment to implementation. Results Surveys from 102 global stakeholders and 246 health care workers, as well as 2039 direct observations of clinical practice revealed variation in adherence to WHO recommendations, with some through-lines. Oxytocin for PPH prevention and treatment was perceived to have national policy support (> 75% for inclusion in national guidelines and Essential Medicines Lists, regulatory approval, and support from national champions) but other uterotonics were not. Tranexamic acid for PPH treatment was found to be underutilized, likely due to compounding bottlenecks. Respondents reported extensive bottlenecks to refractory PPH interventions (< 75% across nearly all bottlenecks). The most substantial bottlenecks were availability/procurement of medicines and devices, affordability and quality of medicines and devices, presence of job aids, and availability of qualified staff. Observed practice generally aligned with stakeholder perceptions. Conclusions National policy bottlenecks strongly mediated implementation in clinical practice. Policy change addressing gaps in commodity procurement and availability of trained clinicians is critical. Efforts addressing only one part of the implementation ecosystem are unlikely to drive transformative change.