Clinical and healthcare systems-level interventions for postpartum hemorrhage prevention and management in Nigeria: a systematic review of effectiveness and implementation outcomes

Background: Postpartum hemorrhage (PPH) remains the leading cause of maternal mortality globally and in Nigeria. Although clinical interventions may address PPH, less is known about their implementation within routine health systems. The objective of this systematic review was to synthesize the implementation research outcomes of interventions for PPH prevention and management in Nigeria for healthcare providers and patients. Methods: This systematic review of interventions for PPH in Nigeria searched seven electronic databases (i.e., Embase, Web of Science, MEDLINE, Global Health, Cochrane Library, PubMed, and PAIS) without date restrictions. Peer-reviewed studies reporting implementation and service outcomes, including adoption, sustainability, fidelity, and effectiveness, were included. Data were extracted on intervention type, setting, implementation, service and client outcomes. Risk of bias was assessed and visualized (via ROBVIS tool). Evidence suggested comparable effectiveness between misoprostol and oxytocin for low-risk women. Device-based interventions, including the non-pneumatic anti-shock garment, were associated with improved stabilization and reduced mortality. Healthcare Systems-level interventions that include standardized care protocols in clinical management of PPH, particularly multicomponent bundled interventions such as the E-MOTIVE bundle and AMTSL, demonstrated high adoption and were associated with reductions in severe PPH. Implementation outcomes were infrequently reported (5 of 31 articles). Overall risk of bias was low-to-moderate. Conclusions: There was a notable gap in the evaluation and reporting of IS outcomes as well as the assessment of the patient's perspective from the receipt of interventions. Translation of effective PPH interventions may be constrained by limited implementation evaluation in Nigeria, particularly in primary-level care settings. Substantial lack of evidence exists in regions that bear a disproportionately high burden of PPH mortality. Systematic Review Registration: Open Science Framework (DOI 10.17605/OSF.IO/CYS2M).