Development, Field-Testing and Piloting of a refractory postpartum haemorrhage management package: the PPH ReAct (PPH Refractory Action) study

Every six minutes a mother dies from excessive bleeding after childbirth in low-resource countries, in the prime of her life and often leaving behind a young family. When a mother dies in childbirth, her infant has less than a 20% chance of surviving past the first month. Excessive bleeding after childbirth, or postpartum haemorrhage (PPH), is the commonest reason why mothers die worldwide.

Effective treatment can stop bleeding in most women. However, those who continue to bleed despite 'first response' treatment are thought to have refractory PPH and are the women who die or suffer major complications. We have developed a provisional management package for these women, called the 'PPH ReAct' package.

We wish to refine this management package, develop an implementation strategy for this, field-test these and finally pilot the approach in 5 health facilities in Kenya.

The WHO published "Recommendations for the Prevention and Treatment of Postpartum Hemorrhage" in 2012 to provide evidence-informed recommendations for managing PPH. However, adherence to these recommendations is currently limited by a number of challenges. Challenges and proposed solutions

1) Many women continue to bleed despite 'first response' management of PPH --> Solution: A refractory PPH treatment package

2) Delayed or inconsistent use of treatments for refractory PPH management --> Solution: A refractory PPH management (the PPH ReAct) package that uses simplified approaches and a checklist to ensure consistent and timely assessments and treatments.

3) Many care providers and organisations struggle to provide effective care for women with refractory PPH, despite treatments being available --> Solution: Deeper understanding of challenges, and a strategy for changing behaviours of healthcare professionals and organisations using behavioural science frameworks.

4) Lack of evidence and confidence that the proposed approach can improve usage of effective treatments for treatment of refractory PPH --> Solution: A study for the refractory PPH treatment package to ensure an increase usage of life-saving treatment by the healthcare professionals and organisations. This study could generate the necessary evidence that will give healthcare practitioners and policy makers the confidence to implement and scale-up the programme.

5) Limited scale-up and coverage --> Solution: Engagement of strong partners: World Health Organisation, Jhpiego, Behavioural Scientists, Health Ministries and Concept Foundation

Our aim is to develop, refine and evaluate an effective approach to managing refractory PPH. Despite concentrated efforts, PPH remains the leading cause why mothers die or suffer major complications during childbirth. Most women with PPH respond to initial treatments.

However, a substantial number of women do not, and these are the women who suffer die or suffer major complications. There is an unmet need to define the optimal approach for managing refractory PPH. Furthermore, a management approach could achieve its intended goals only if it is widely accepted and used in everyday practice; thus a meaningful strategy for implementing this approach is necessary.

We therefore propose the development, refinement and piloting of a refractory PPH management package and implementation strategy.