Expanding Postpartum Hemorrhage Prevention to the Community in Resource-Poor Contexts: Critical Considerations and Next Steps

Increasing the proportion of pregnant women with medically skilled care at childbirth is widely regarded as the best strategy for reducing maternal mortality and morbidity in resource-poor contexts. For many countries, however, local conditions necessitate continuing discussion concerning the role of targeted, community-based interventions in efforts to tackle this problem. One such intervention gaining momentum is community-based use of uterotonic drugs to prevent postpartum hemorrhage (PPH). But how this intervention fits within the larger maternal health agenda still needs addressing, as do questions regarding whether, where, and how to proceed. This article presents a usable framework for context-based decision making around PPH prevention, evaluating why and under what circumstances it might make sense to implement uterotonic drugs at the community level. Using Demographic and Health Surveys (DHS) data along with current evidence, we identify four critical considerations for policymakers to take into account: (a) where births are happening, (b) which women are delivering in what settings, (c) capacity of health care systems, and (d) criteria for selecting specific uterotonic drugs. Incorporating these considerations, we propose a checklist to aid policymakers in determining what strategy realistically suits the needs of their particular country contexts. Although a large and rigorous body of evidence supports PPH prevention methods, research gaps remain. Even with sufficient evidence, however, a global consensus may not be reached because of the ongoing debates over community- versus facility-based interventions. Despite these issues, it is still possible to arrive at policy decisions on community- based use of uterotonic drugs by taking a careful, context-based approach. In many settings, implementation of this intervention can be pursued in conjunction with improvements to facility-based care. As a complement to skilled attendance, expanding PPH prevention to the community can be part of a national push to target the reduction of PPH as an achievable goal.