Table 4.

WHO recommendations on management of postpartum haemorrhage compared with interview participants’ qualitative responses to the questions: think back to the last time that a woman under your care, with a vaginal birth, had a PPH. Could you describe what happened, what did you do and why did you do it?.

Topic	WHO recommendationsa	Kenya	Nigeria	South Africa
Uterotonics	Intravenous oxytocin is the recommended uterotonic drug for the treatment of PPH. If intravenous oxytocin is unavailable, or if the bleeding does not respond to oxytocin, the use of intravenous ergometrine, oxytocin-ergometrine fixed dose, or a prostaglandin drug (including sublingual misoprostol, 800 µg) is recommended.	Most participants mentioned using oxytocin and misoprostol for PPH treatment, but sometimes there are stock out of uterotonics. Maintaining cold chain for oxytocin was identified as a challenge.	All participants mentioned using oxytocin for PPH treatment, but sometimes there are stock outs. A few participants mentioned giving misoprostol if oxytocin does not stop the bleeding. Maintaining cold chain for oxytocin was identified as a challenge.	All participants mentioned using oxytocin for PPH treatment and several mentioned of using misoprostol. Sometimes there are stock out of uterotonics.
Intravenous fluids	The use of isotonic crystalloids is recommended in preference to the use of colloids for the intravenous fluid resuscitation of women with PPH.	All participants mentioned starting IV fluids as a primary response and IV lines were put in on admission	All participants mentioned using IV fluids for PPH treatment. None mentioned when they set the IV lines on women.	All participants mentioned using IV fluids for PPH treatment and the IV lines usually set up early before veins collapsed.
Tranexamic acid	Early use of intravenous tranexamic acid (within 3 h of birth) in addition to standard care is recommended for women with clinically diagnosed postpartum haemorrhage following vaginal birth or caesarean section (10 mg slow IV push over 10 min)	Nearly all participants were aware of benefits of TXA but did not have regular access to TXA on maternity ward because of its high cost. Viewed as only to use in severe cases i.e., refractory PPH and only doctors could administer the TXA. No mention of dose, route, or time.	Nearly all participants were aware of benefits of TXA but did not have regular access to TXA on maternity ward because of its high cost. Viewed as only to use in severe cases i.e., refractory PPH, and only doctors could administer the TXA. No mention of dose, route, or time used. Although it was incorrect, a few mentioned it was most effective when given within 15 min of childbirth	All participants were aware of benefits of TXA (Cyclokapron) and did not have regular access to TXA on maternity ward because of its high cost. Viewed as only to use in severe cases i.e., refractory PPH, and only doctors could administer the TXA. No mention of dose, route, or time
Uterine massage	Uterine massage is recommended for the treatment of PPH.	Most participants mentioned that uterine massage was currently used as first line treatment for PPH, and a few mentioned applying uterine massage and administering oxytocin simultaneously. Several participants mentioned administering bimanual compression for primary PPH management.	Most participants mentioned that uterine massage was currently used as first line treatment for PPH, and a few mentioned applying uterine massage and administering oxytocin simultaneously. A few participants mentioned sometimes they taught women how to massage the uterus. A few participants mentioned administering bimanual compression for primary PPH management.	All participants mentioned that uterine massage was currently used as first line treatment for PPH, and several participants mentioned that uterine massage administered simultaneously with oxytocin. A few participants mentioned administering bimanual compression for primary PPH management.
Clinical protocols for treatment	The use of formal protocols by hospitals for the prevention and treatment of PPH is recommended.	Most participants mentioned using hospital-based standard operating procedures (SOP) for PPH management and having pictorial posters in the labour ward. These SOPs were developed and provided by the Ministry of Health.	Several participants mentioned being aware of clinical protocols of PPH management that were adapted from international guidelines but could not access easily (online version only). Pictorial posters of PPH management steps were available in the labour ward.	All participants mentioned using hospital-based SOPs for PPH management and having pictorial posters in the labour ward. National guideline for PPH management was adapted from international guidelines for PPH.
Clinical protocols for referral	The use of formal protocols for referral of women to a higher level of care is recommended for hospitals.	Participants did not report having access to clinical protocols on the labour ward for referral but thought this would be helpful because many lower-level facilities refer women without complete medical history. All mentioned receiving women with PPH from lower-level facilities, since they worked in tertiary level hospitals.	Participants did not report having access to clinical protocols on the labour ward for referral but thought this would be helpful because many lower-level facilities refer women without complete medical history. All mentioned receiving women with PPH from lower-level facilities, since they worked in tertiary level hospitals. A few mentioned referring women to other hospitals if theatre or beds were unavailable.	Participants did not report having access to clinical protocols on referral in the labour ward but reported his would be helpful as many lower-level facilities refer women without complete medical history. All mentioned receiving women with PPH from lower-level facilities, since they worked in tertiary and District level hospitals. A few mentioned referring women to other hospitals if theatre or beds were unavailable.
Training on PPH treatment	The use of simulations of PPH treatment is recommended for pre-service and in-service training programmes	Over half of the participants in Kenya reported attending an in-service, national Basic Emergency Obstetric Care which has a simulation component and most participants expressed desire more training.	Most participants had not had any in-service on PPH management since their pre-service education, but desired more training	Most participants attended d, 3-day ESMOEa training which has a simulations component. Most participants expressed desire for more training

^a ESMOE, essential steps in the management of obstetric emergencies.