Developing solutions in response to challenging contexts

Improving Prevention and Management of Postpartum Hemorrhage in Madagascar


The Challenge

Although postpartum hemorrhage (PPH), or excessive bleeding after childbirth, is the leading cause of maternal mortality worldwide, most PPH deaths can be avoided through prevention and timely, appropriate management by healthcare providers. While studies often find inconsistent provider adherence to best practices for PPH prevention, detection, and management despite training on protocols, they rarely focus on the psychological drivers of healthcare provider behavior. A provider’s environment, including structural constraints, physical context, and social influences, may shape how they provide care and their adherence to known clinical protocols. 

In Madagascar, high fertility and mortality rates mean that a 15-year-old girl has a 1-in-60 lifetime risk of dying from a maternal cause. Under the USAID-funded Breakthrough RESEARCH project, we sought to identify the behavioral barriers that may inhibit facility-based providers from consistently following best practices and to develop solutions that are responsive to the challenging context in which providers work.

Our Approach

We interviewed rural and peri-urban health providers, supervisors, postpartum women, community health workers, and traditional birth attendants to understand the constraints basic health center providers face in following best practices to prevent, detect, and manage PPH and to identify features of the environment shaping their clinical decision-making and behavior. These insights informed an iterative co-design process, in collaboration with midwives, to generate a set of behavioral solutions which could improve the quality of care they give to laboring women.


Based on behavioral insights from our formative research, we designed a set of solutions that are responsive to the context. These solutions included:

  • A PPH risk and consequence visualization exercise.
  • A custom-built uterotonic timer to facilitate consistent and timely drug administration to prevent PPH.
  • Badges allowing overburdened health providers to easily assign specific support roles to family members.
  • A glow-in-the-dark simplified algorithm poster for PPH management. 

Read more about our process for developing these solutions here.

This set of provider support tools was launched in 10 clinics in Madagascar in late 2020 as part of the broader Advancing Postpartum Hemorrhage Care intervention package, implemented in collaboration with the USAID-funded Health Evaluation and Applied Research Development (HEARD) project. The implementation pilot revealed high adoption of the three support tools by providers and strong satisfaction with their usefulness and appropriateness for the setting. In interviews, providers shared that they felt their relationship with clients’ families had improved, their work was made easier, and they were more prepared to prevent and manage PPH.


This project highlights the need for innovative solutions to address the behavioral barriers providers face in complying with best practices to prevent, detect, and manage PPH, particularly in light of the challenging circumstances under which they work. Collaborative co-creation processes and iterative testing ensure that new interventions are best positioned for impact and are specific to and responsive to the needs of providers and their clients. These tools are designed to fit health workers’ contexts and together contribute to a more enabling environment to improve quality of care and health outcomes for women in labor.

Interested in our work applying behavioral science to global health? Email or tweet at @ideas42 to join the conversation.