WHO recommendation on the use of simulations of PPH treatment for pre-service and in-service training programmes

WHO recommendation on the use of simulations of PPH treatment for pre-service and in-service training programmes


The use of simulations of PPH treatment is recommended for pre-service and in-service training programmes. 

(Weak recommendation, very-low-quality evidence)​


Publication history

First published: September 2012

Updated: No update planned

Assessed as up-to-date: September 2012



The GDG acknowledged that the implementation of formal protocols is a complex process which will require the local adaptation of general guidelines.

The GDG placed a high value on the costs of simulation programmes and acknowledged that there are different types of simulation programmes. Some programmes are hi-tech, computerized and costly while others are less expensive and more likely to be affordable in low- and middle-income countries. The GDG identified improvement in communication between health care providers and patients and their family members as an important priority in the training of health care providers in PPH management.

The GDG recommended monitoring the use of prophylactic uterotonics. This recommendation is based on experience from other areas of health care, particularly child health, where content-based health indicators are common and regarded as useful for programmatic purposes. The suggested indicator is calculated as the number of women receiving prophylactic uterotonic drugs after birth divided by all women giving birth.



Postpartum haemorrhage (PPH) is defined as blood loss of 500ml or more within 24 hours after birth. PPH is the primary cause of nearly one-fifth of all maternal deaths globally. Most of these deaths occur during the first 24 hours after birth. The majority could be prevented through the use of prophylactic uterotonics during the third stage of labour, and by timely and appropriate management. The primary goal of these recommendations is to provide a foundation for the implementation of strategic policy and programme developments for interventions shown to have been effective in reducing the burden of PPH. Health professionals responsible for developing national and local protocols and health policies constitute the main target audience of this document. Obstetricians, midwives, general medical practitioners, health care managers and public health policy-makers, particularly in under-re-sourced settings are also targeted. The guidance provided is evidence-informed and covers topics related to the management of PPH that were selected and prioritized by an international, multidisciplinary group of health care workers, consumers and other stakeholders. This document establishes general principles of PPH care and it is intended to inform the development of protocols and health policies related to PPH.



The recommendation was developed using standardized operating procedures in accordance with the process described in the “WHO handbook for guideline development”, based on the GRADE approach (1, 2) Outcomes used for this recommendation were the prioritized outcomes from the WHO recommendations on prevention and treatment of postpartum haemorrhage (2012).(3)

Trials relevant to the key question were screened by review authors, and data on relevant outcomes and comparisons were extracted. (4,5) Evidence profiles (in the form of GRADE tables) were prepared for comparisons of interest.

WHO convened a Guideline Development Group (GDG) meeting in March 2012. This group of independent experts used the evidence profiles to assess evidence on effects on the pre-specified outcomes. GDG members discussed the balance between desirable and undesirable effects, overall quality of supporting evidence, values and preferences, magnitude of effect, balance of benefits versus disadvantages, resource usage, and feasibility, to formulate the recommendation. Remarks were added to clarify the recommendation, and aid implementation.

Further information on procedures for developing this recommendation are available here.


Recommendation question

For this recommendation, we aimed to answer the following question:

  • For all women giving birth (P), does the use of  simulations of PPH treatment for health-services training programmes (I) compared to standard training programmes (C) improve maternal outcomes (O)?


Evidence summary

A literature search did not reveal any research evidence for or against the use of PPH simulation programmes. Those contributing to the WHO Technical Consultation considered the PPH simulation programmes to be generally useful and unlikely to be harmful.


Further information on evidence supporting this recommendation are available here.


Implementation considerations


  • The successful introduction of evidence-based policies related to the prevention and management of PPH into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
  • An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
  • Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.


Related links

WHO recommendations on prevention and treatment of postpartum haemorrhage (2012) - full documentand evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice


Related resources

VIDEO: Active management of third stage of labour

Education material for teachers of midwifery. Managing postpartum haemorrhage.


Other WHO content related to these recommendations

Education material for teachers of midwifery



Research implications

The GDG did not identify any research priorities related to this recommendation.



  1. WHO Handbook for Guideline Development (second edition). Geneva: World Health Organization; 2014.
  2. Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401-6. Epub 2011/01/05. doi: 10.1016/j.jclinepi.2010.07.015. PubMed PMID: 21208779.
  3. WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva: World Health Organization, 2012.
  4. Andreatta P, Gans-Larty F, Debpuur D, Ofosu A, Perosky J. Evaluation of simulation-based training on the ability of birth attendants to correctly perform bimanual compression as obstetric first aid. Int J Nurs Stud. Oct;48(10):1275-80.
  5. Toledo P, McCarthy RJ, Burke CA, Goetz K, Wong CA, Grobman WA. The effect of live and web-based education on the accuracy of blood-loss estimation in simulated obstetric scenarios. Am J Obstet Gynecol. Apr;202(4):400 e1-5.
  6. Deering SH, Chinn M, Hodor J, Benedetti T, Mandel LS, Goff B. Use of a postpartum hemorrhage simulator for instruction and evaluation of residents. J Grad Med Educ. 2009 Dec;1(2):260-3.
  7. Blum R, Gairing Burglin A, Gisin S. Simulation in obstetrics and gynecology - a new method to improve the management of acute obstetric emergencies. Ther Umsch. 2008 Nov;65(11):687-92. 
  8.  Maslovitz S, Barkai G, Lessing JB, Ziv A, Many A. Improved accuracy of postpartum blood loss estimation as assessed by simulation. Acta Obstet Gynecol Scand. 2008;87(9):929-34.
  9. Crofts JF, Bartlett C, Ellis D, Winter C, Donald F, Hunt LP, et al. Patient-actor perception of care: a comparison of obstetric emergency training using manikins and patient-actors. Qual Saf Health Care. 2008 Feb;17(1):20-4. 46. Crofts JF, Ellis D, Draycott TJ, Winter C, Hunt LP, Akande VA. Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomised controlled trial of local hospital, simulation centre and teamwork training. BJOG. 2007 Dec;114(12):1534-41.
  10. Birch L, Jones N, Doyle PM, Green P, McLaughlin A, Champney C, et al. Obstetric skills drills: evaluation of teaching methods. Nurse Educ Today. 2007 Nov;27(8):915-22.
  11. Johanson R, Akhtar S, Edwards C, Dewan F, Haque Y, Jones P. MOET: Bangladesh--an initial experience. J Obstet Gynaecol Res. 2002 Aug;28(4):217-23. 97. Johanson RB, Menon V, Burns E, Kargramanya E, Osipov V, Israelyan M, et al. Managing Obstetric Emergencies and Trauma (MOET) structured skills training in Armenia, utilising models and reality based scenarios. BMC Med Educ. 2002 May 20;2:5.
  12. Maslovitz S, Barkai G, Lessing JB, Ziv A, Many A. Recurrent obstetric management mistakes identified by simulation. Obstet Gynecol. 2007 Jun;109(6):1295-300. 10. Anderson ER, Black R, Brocklehurst P. Acute obstetric emergency drill in England and Wales: a survey of practice. BJOG. 2005 Mar;112(3):372-5.
  13.  Jyothi NK, Cox C, Johanson R. Management of obstetric emergencies and trauma (MOET): regional questionnaire survey of obstetric practice among career 52 obstetricians in the United Kingdom. J Obstet Gynaecol. 2001 Mar;21(2):107-11.
  14. Black RS, Brocklehurst P. A systematic review of training in acute obstetric emergencies. BJOG. 2003 Sep;110(9):837-41.
  15. Macedonia CR, Gherman RB, Satin AJ. Simulation laboratories for training in obstetrics and gynecology. Obstet Gynecol. 2003 Aug;102(2):388-92. 116. Letterie GS. How virtual reality may enhance training in obstetrics and gynecology. Am J Obstet Gynecol. 2002 Sep;187(3 Suppl):S37-40.



WHO Reproductive Health Library. WHO recommendation on the use of simulations of PPH treatment for pre-service and in-service training programmes (last revised 2012). The WHO Reproductive Health Library; Geneva: World Health Organization.