WHO recommendations for the prevention and treatment of postpartum haemorrhage
The revised 2012 WHO recommendations for the prevention and treatment of postpartum haemorrhage are based on the best available evidence in the published literature. All known methods of controlling postpartum haemorrhage have been considered in the recommendations. The guidelines include recommendations for each of the critical issues related to postpartum haemorrhage.
RHL guideline appraisal by Kumar S, Dadhwal V, Sharma JB, Mittal S
Postpartum haemorrhage (PPH) continues to be the leading cause of maternal mortality, accounting for at least 30% of all maternal deaths, almost all of which occur in low- and middle-income countries (1). In a great majority of cases, PPH is caused by atony of uterus. In a small number of women genital tract trauma (i.e. vaginal or cervical lacerations), uterine rupture, retained placental tissue, or maternal coagulation disorders may also result in PPH. Improving health care for women during childbirth in order to prevent and treat PPH is an essential step towards the achievement of the Millennium Development Goal related to maternal mortality.
Active management of the third stage of labour is the cornerstone for the prevention of PPH. Compared with expectant management, active management of the third stage of labour is associated with a substantial reduction in the occurrence of PPH (2). By preventing and treating PPH, most PPH-associated deaths can be prevented. A large proportion of pregnant women in especially low-income countries deliver at home under the care of birth attendants who are not medically trained and who are not well equipped to manage PPH. Once a woman experiences PPH, the way she is managed varies from centre to centre, depending on the training level and skills of the health-care professionals in each centre. A clear and uniform policy on the management of women with PPH in different circumstances (e.g. absence of a skilled attendant) is essential.
Given the availability of new scientific evidence related to the prevention and treatment of PPH, the aim of the 2012 WHO recommendations is to revise the previous WHO recommendations for the prevention and treatment of PPH and to include new recommendations. This guideline is an update of the “WHO recommendations for the prevention of PPH” published in 2007 (3), and the “WHO guidelines for the management of PPH and retained placenta” published in 2009 (4). For each of the previous WHO recommendations on PPH (2007 and 2009) and for all the newly-added questions, evidence profiles have been prepared based on 22 up-to-date systematic reviews summarized in 70 GRADE tables.
The latest set of guidelines include recommendations for the prevention of PPH, its treatment, and organization of care. There are a total of 32 recommendations, 12 on prevention, 16 on treatment and four on organization of care. Seven of these recommendations are completely new, while the others have been revised in light of new evidence.
The objective of this appraisal was to determine the usefulness of the recommendations in the revised guidelines in terms of improving prevention and management of PPH in under-resourced settings.
The four authors of this appraisal independently applied the AGREE instrument (Appraisal of Guidelines for Research and Evaluation, 2001) (5) to the guidelines. A standardized score for each domain of the AGREE instrument was obtained by combining the scores awarded by each authors for each item within the domains as per the methodology described in the AGREE document. The domains included scope and purpose, stakeholders’ involvement, rigour of development, clarity and presentation, applicability and editorial independence.
The standardized domain scores were as follows: scope and purpose 94; stakeholders’ involvement 46; rigour of development 96; clarity and presentation 96; applicability 67; editorial independence 58. All of the four commentators agreed that the scope and purpose of the guidelines was well-timed and covered areas for which guidance is highly needed. With regard to stakeholders' involvement, there was variation in the scores allocated by each commentator, especially under the headings “patient’s views and preferences” and “piloting the guidelines among target users”. The score for rigour of development varied according to each author's perception about the criteria for selecting evidence and methods used in formulating the recommendations and were graded highly by the authors. All four appraisal writers also gave a high score to the guidelines for clarity and presentation. As to applicability, the authors agreed overall that the guidance can be applied by well-trained childbirth attendants and those working in large secondary and tertiary level health-care facilities. Editorial independence aspect of the guidelines was awarded moderate scores by the authors.
Commenting on the overall assessment of the guidelines, the authors noted that there was a need for specific guidance for the prevention and management of PPH in settings where a large proportion of women deliver at home under the care of semi-skilled and unskilled birth attendants and all of them strongly agreed with guideline recommendations.
Overall, the revised WHO recommendations for the prevention and treatment of postpartum haemorrhage are based on the best current evidence available in the published literature. All known methods of controlling PPH have been considered in the recommendations. The guidelines include recommendations for each of the critical issues related to PPH.
4.1 Scope and coverage of the guideline
Since a large number of drugs have been used for controlling PPH, a specific recommendation on best agent for managing PPH is not possible. However, recommendations are of high standard based upon the best evidence available.
The development of these recommendations involved 130 stakeholders who participated in the online preliminary survey (representing all WHO regions), and 25 experts who participated in the WHO Technical Consultation. The authors noted that a formal process of declaration of conflict of interest had taken place by the members of the panel that had developed the recommendations. A total of 7 out 25 temporary advisers had declared that they were involved in academic work related to the topic of the guideline, but this involvement was not considered to be a conflict of interest. All members declared that they had no commercial or financial interests that were directly or indirectly related to the topic of the meeting/guideline.
With regard to the influence of external funding sources on guideline development, the authors noted that USAID and Gynuity Health Projects had provided partial financial support towards the development of the guidelines and had their observers present in the consultation meeting. Although these observers did not participate in the voting process, the presence of representatives of external funders at the meeting influenced the authors of this appraisal to accord moderate scores for editorial independence. Overall, the recommendations are independent of external influences and editorial bias. The Cochrane Pregnancy and Childbirth Group helped in updating the reviews.
4.2 Implementation of the recommendations
The recommendations note that there is a need for new primary research projects in different contexts to study the implementation of the recommendations. Birth attendants trained in clinical skills needed to care for women during pregnancy and childbirth (doctors, nurses and midwives) can easily adopt these guidelines in their practice. However, semi-skilled birth attendants or those without clinical skills who often care for woman in labour at small health-care facilities in under-resourced settings may not be able to fully benefit from these guidelines.
4.3 Recommendations for further updates of the guidelines
WHO collaborated with international agencies such as the International Federation of Gynecology and Obstetrics (FIGO) in developing these guidelines. The process of dissemination of recommendations has been clearly stated. The effectiveness of the dissemination strategies included in the guidelines should be evaluated. Future updates of the guidelines could include more specific guidance for semi-skilled or non-medically trained birth attendants.
- Khan KS, Wojdyla D, Say L, Gulmezogh AM, Van Look PFA. WHO analysis of causes of maternal death: a systematic review. The Lancet 2006;367:1066-1074.
- Begley CM, Gyte GML, Murphy DJ, Devane D, McDonald SJ, McGuire W. Active versus expectant management for women in the third stage of labour. Cochrane Database of Systematic Reviews 2010;Issue 7. Art. No.: CD007412; DOI: 10.1002/14651858.CD007412.pub2.
- World Health Organization. WHO recommendations for the prevention of postpartum haemorrhage. Geneva: WHO; 2007.
- World Health Organization. WHO guidelines for the management of postpartum haemorrhage and retained placenta. Geneva: WHO; 2009; Available at: http://whqlibdoc.who.int/publications/2009/9789241598514_eng.pdf
- The AGREE Collaboration. Appraisal of Guidelines for Research and Evaluation. AGREE Instrument. Available at: http://www.agreecollaboration.org/instrument/
This document should be cited as: Kumar S, Dadhwal V, Sharma J, Mittal S. WHO recommendations for the prevention and treatment of postpartum haemorrhage: RHL commentary (last revised: 1 February 2013). The WHO Reproductive Health Library; Geneva: World Health Organization.