Updated WHO Guidelines Yet Maternal Deaths Persist: 31-Country Study Reveals Gaps in PPH and Hypertensive Disorder Care

Are we closing the gap on preventable maternal deaths, or are critical interventions failing to reach the bedside? Despite years of updated global guidance, postpartum hemorrhage (PPH) and hypertensive disorders of pregnancy (HDP) continue to claim thousands of lives worldwide. A new rapid assessment spanning 31 countries offers a sweeping look at national progress—and persistent obstacles—in reducing maternal mortality.

Study Overview: A Panoramic Policy Perspective

This multi-country survey, conducted from January to May 2022, drew on the expertise of national teams from sub-Saharan Africa, South and Southeast Asia, and Latin America and the Caribbean. The study measured how well countries have integrated World Health Organization (WHO) recommendations for PPH and HDP into national policy, supply chains, and training, with special attention to private sector engagement.

Key Findings: Progress and Persistent Gaps

Essential Drug Availability: While oxytocin, the primary uterotonic for PPH, is now regularly available in most public (77%) and private (84%) facilities, magnesium sulfate (MgSO₄)—the gold standard for HDP—lags behind, especially in private settings (58% public, 45% private). Misoprostol access has nearly doubled since 2012, but newer treatments like tranexamic acid and heat-stable carbetocin are not yet widely adopted.

Guideline Implementation: Most countries now include updated WHO recommendations for PPH and HDP in their national guidelines. However, only 45% have incorporated newer strategies like heat-stable carbetocin, and just 13% include umbilical vein oxytocin injection for retained placenta.

Midwifery Scope and Training: The scope of midwifery practice, especially for life-saving interventions such as manual placenta removal and initial MgSO₄ dosing, has seen little expansion in the past decade. Many regions still lack consistent, competency-based training for both public and private sector providers.

Quality Assurance and Reporting: Systems for drug quality and data reporting remain much weaker in the private sector. Only about half of countries estimate that private facilities report key PPH and HDP indicators to their national health information systems.

Implications for Clinical Practice

For frontline clinicians, these findings highlight ongoing risks: stockouts of critical drugs, variability in provider skills, and gaps in quality assurance can directly impact patient outcomes. The private sector, which provides a significant share of maternity care in low- and middle-income countries, is often left out of national reporting and oversight—potentially undermining progress toward global maternal mortality targets.

What Needs to Change?

The study recommends a pivot toward:

Prioritizing the integration of updated global guidelines into all sectors.

Expanding midwives’ ability to provide essential emergency care.

Strengthening procurement and supply chain systems for medicines.

Enhancing collaboration and data reporting between public and private sectors.

Conclusion

Despite real progress, the road to ending preventable maternal deaths is far from over. Addressing persistent gaps in drug availability, provider scope, and private sector engagement is critical for making evidence-based care a universal reality.

Key points

Oxytocin is now available in most facilities, but magnesium sulfate access remains inconsistent.

National policies often include WHO updates, but implementation—especially in the private sector—lags.

Midwives’ scope for emergency interventions like MgSO₄ dosing and manual placenta removal has not expanded significantly.

Private sector facilities underperform in quality assurance and health information reporting.

Coordinated public-private strategies and improved supply chains are urgently needed to close the gap between policy and practice.

Citation: Sharma G., Noriega A., Somji A. et al. Prevention and management of postpartum hemorrhage and hypertensive disorders of pregnancy: results from a 31-country rapid assessment. BMC Pregnancy Childbirth. (2026). https://doi.org/10.1186/s12884-026-09679-w