Implementation bottlenecks severely hinder WHO postpartum hemorrhage recommendations, especially for non-oxytocin uterotonics and refractory PPH interventions.

Despite evidence-based World Health Organization (WHO) recommendations for postpartum hemorrhage (PPH) prevention, detection, and treatment, PPH remains the leading cause of maternal mortality globally, especially in low-resource settings. This persistent mortality suggests a significant gap in the implementation of these crucial guidelines. Current standards often fall short due to systemic issues, rather than a lack of effective interventions. This study aimed to precisely identify the specific implementation bottlenecks hindering the uptake of WHO recommendations to inform targeted actions and improve maternal health outcomes.

Researchers employed a multi-level framework, integrating public policy, implementation science, and health behavior principles, to develop a survey assessing bottlenecks to specific WHO recommendations. Surveys were completed by 102 global stakeholders and 246 healthcare workers across three high-burden countries. Additionally, 2039 direct observations of clinical practice were conducted in these countries to validate perceived bottlenecks against actual practice. An a priori interpretive threshold of 75% was set; if less than 75% of respondents indicated a bottleneck was not a severe impediment, it was considered a significant barrier to implementation.

Survey responses from 102 global stakeholders and 246 healthcare workers, alongside 2039 direct observations, revealed significant variation in adherence to WHO recommendations. Oxytocin for PPH prevention and treatment demonstrated strong national policy support, with >75% of respondents noting its inclusion in national guidelines, Essential Medicines Lists, regulatory approval, and support from national champions. However, other uterotonics lacked similar support. > Tranexamic acid for PPH treatment was found to be significantly underutilized, likely due to a combination of compounding bottlenecks. Respondents reported extensive bottlenecks for refractory PPH interventions, with <75% across nearly all assessed categories. The most substantial and consistently identified bottlenecks included the availability and procurement of essential medicines and devices, their affordability and quality, the presence of adequate job aids, and the availability of qualified staff. Observed clinical practice generally corroborated these stakeholder perceptions, highlighting the real-world impact of these barriers.