One-Day Training on Prevention and Management of Postpartum Haemorrhage (PPH)

For Health Managers and Lady Health Visitors (LHVs) at Maryam Nawaz Health Clinics across Punjab

1. Introduction

1.1. Background and Rationale

Postpartum haemorrhage (PPH) remains the leading direct cause of maternal mortality in Pakistan, accounting for an estimated 27–30% of maternal deaths. PPH is preventable and treatable when frontline providers can apply evidence-based practices, including Active Management of the Third Stage of Labour (AMTSL), timely use of uterotonics, early recognition of danger signs, initial stabilisation, and prompt referral.
The proposed support responds to a specific request from the Health and Population Department (H&PD), Punjab, to strengthen the capacity of frontline providers working in outsourced Maryam Nawaz Health Clinics (MNHCs). The intervention will build on existing approved and evidence-based materials. It will not develop a new curriculum from scratch; instead, it will support light contextualisation and packaging of relevant content into a practical one-day competency-based module for the MNHC setting.

The approach is informed by international and Pakistan experience. Ethiopia’s integrated model demonstrates the value of embedding PPH care and postpartum family planning into routine maternal services, with midwives as core delivery agents and with commodities, supervision and reporting integrated into existing systems rather than parallel programmes. Similarly, the WHO-endorsed E-MOTIVE model, including its application in Pakistan through Bill and Melinda Gates Foundation (BMGF)-supported work and FIGO’s LDI-REACH programme, provides a strong evidence base for moving from partner-supported pilots towards government-led institutionalisation at scale.

1.2. Why Maryam Nawaz Health Clinics?

The Government of Punjab has revitalised approximately 2,500 Basic Health Units as Maryam Nawaz Health Clinics across all 41 districts. These clinics are a key platform for Punjab’s primary healthcare reform agenda and are often the first point of contact for women seeking antenatal, intrapartum, postnatal and newborn care.

The MNHC network provides a clear opportunity for rapid, province-wide capacity strengthening due to its scale and geographic reach, and because each clinic has an identifiable provider team, including a Health Manager and at least one LHV/Midwife/Nurse Midwife. The proposed training will therefore target approximately 5,000 providers across 2,500 MNHCs.
This concept note focuses on MNHCs/BHUs in line with H&PD’s request. Rural Health Centres, THQ Hospitals, DHQ Hospitals and tertiary facilities are not the primary training target under this TA unless H&PD later expands the scope. However, they are critical referral partners and will be included in referral pathway mapping, emergency escalation protocols, facility readiness planning and supportive supervision linkages.

1.3. The Provider and System Gap

PPH remains a leading cause of preventable maternal mortality not because evidence-based interventions are unavailable, but because they are not consistently applied at first-contact level. Facility-based reviews and programme evidence from Pakistan, Punjab and comparable LMIC settings point to recurring provider and system gaps, including delayed recognition of PPH, inconsistent use of AMTSL, uncertainty around uterotonic administration, weak documentation, variable facility readiness, and unclear referral and counter-referral pathways.

At MNHC level, Health Managers and LHVs/Midwives are not expected to manage advanced obstetric emergencies independently. Their role is to prevent PPH where possible, recognise it early, initiate first-line response, stabilise the patient, document care appropriately, counsel on postpartum family planning where relevant, and ensure timely referral to the appropriate higher-level facility. Strengthening these competencies is therefore a practical and proportionate investment in reducing avoidable delays and improving continuity of care.

Punjab has already benefited from recent government and partner-supported EmONC investments, including training of approximately 3,081 providers in BEmONC and CEmONC-related areas during 2024–25. This TA is designed to complement, not duplicate, those investments.

2. Goals and Objectives

Goal: To strengthen the capacity of frontline healthcare providers at MNHCs to prevent, recognize, initiate first-line response to postpartum haemorrhage, and to improve timely referral and follow-up, thereby contributing to preventing maternal morbidity and mortality across Punjab.

Objectives

1. Improve MNHC Health Managers’ and LHVs/Midwives’ knowledge and understanding of PPH prevention, early recognition, risk factors, danger signs, AMTSL, uterotonic use, first-line response and postpartum family planning counselling/linkages.
2. Strengthen hands-on skills in AMTSL, objective blood loss management, uterotonic administration, uterine massage, initial stabilisation, emergency communication and timely escalation/referral.
3. Improve MNHC preparedness for PPH through use of minimum readiness standards, essential commodity checks, referral pathway mapping, documentation tools and linkage with higher-level facilities and emergency transport.
4. Embed the adapted PPH/PPFP training package and reporting/follow-up mechanisms within existing H&PD/MNCH systems, including the LMS, to support refresher training and future government-led scale-up.

3. Target Participants and Scale

The training will target two priority cadres at Punjab’s 2,500 Maryam Nawaz Health Clinics:

• Health Managers: Facility-level medical officers responsible for clinic operations, service delivery oversight, commodity readiness, staff coordination and referral decision-making. Their participation will help ensure that PPH readiness, documentation and referral protocols are understood and applied at facility level.
• LHVs/Midwives/Nurse Midwives: Frontline maternal health providers responsible for antenatal, intrapartum and postnatal care at MNHCs. They are most likely to be present when PPH occurs or is first recognised and will therefore be the primary clinical focus of the competency-based training.

The TA will focus on MNHCs/BHUs only, in line with H&PD’s request. RHCs, THQs, DHQs and tertiary facilities will be engaged as referral partners, not as primary training targets, unless H&PD later expands the scope. Before rollout, E4H/DU and H&PD/PIU will verify facility lists, participant nominations and existing EmONC/PPH-trained providers/trainers to avoid duplication and make use of available government and partner-trained capacity.

The proposed training programme will cover all 41 districts of Punjab, reaching approximately 2,500 Maryam Nawaz Health Clinics (MNHCs)/BHUs and training around 5,000 participants, comprising one Health Manager and one LHV, Midwife, or Nurse Midwife from each facility. Training will be delivered in 25–30 participant batches, resulting in an estimated 170–200 batches (approximately 4–5 batches per district, depending on the number of facilities).

The programme will utilise the existing pool of PPH/EmONC-trained master trainers, with approximately two trainers per district, who will receive a regional orientation/refresher through three orientation batches before rollout. Each training will be delivered as a one-day, competency-based course, with implementation expected over four to five months using a cluster-based approach. Trainings will be conducted at government training venues, including DHDCs, nursing schools, and DHQ/THQ training facilities.

4. Methodology and Approach

The training will be a one-day, competency-based module focused on the practical role of MNHC Health Managers and LHVs/Midwives in preventing, recognising and initiating first-line response to PPH. It will be skills-oriented and aligned with the MNHC scope of care, with emphasis on AMTSL, early detection, objective blood loss recognition, uterotonic use, initial stabilisation, emergency communication, documentation, referral and postpartum family planning counselling/linkages.

The training will complement, not replace, existing EmONC/BEmONC/CEmONC training supported by government and partners. Previously trained providers and trainers will be mapped during microplanning to avoid duplication and to identify existing trainers/resource persons for rollout.

4.1 Training Methods

The one-day module will combine short technical inputs with practical demonstrations, skills practice and scenario-based exercises. Methods will include:

• Short contextualised presentations on PPH prevention, early detection and first-line response.
• Demonstration and supervised practice of AMTSL, uterotonic preparation/administration, uterine massage and initial stabilisation.
• Case scenarios and role plays on emergency communication, referral decision-making, patient/family communication and documentation.
• Skills drills using available models/equipment, including PPH emergency response and referral simulation.
• Facility readiness self-assessment using a standardised PPH Readiness Checklist.
• Pre/post knowledge assessment and basic competency checklists to measure learning gains.
• Brief orientation on postpartum family planning counselling/linkages and referral for PPIUCD where services are available and authorised.
• Training material will be digitised to ensure it is LMS-ready for continuity and refresher trainings.

Each practical session will use small-group facilitation where feasible, so that participants receive demonstration, supervised practice and feedback. Trainer/resource persons will be drawn, as far as possible, from existing government and partner-trained PPH/EmONC trainer pools, with clinical validation through H&PD/PIU and relevant obstetric/midwifery expertise.

4.2 Indicative One-Day Training Agenda

The final agenda will be confirmed after finalisation of module and technical review by H&PD/PIU and clinical experts. An indicative structure is below:

The indicative one-day training agenda will cover participant registration and pre-assessment, followed by an overview of the burden of postpartum haemorrhage (PPH) and the role of Maryam Nawaz Health Clinics (MNHCs). Technical sessions will include understanding PPH, prevention strategies, early detection and first-line management, and emergency response and escalation. Participants will also receive training on referral pathways and documentation, facility readiness for PPH management, and the integration of postpartum family planning (PPFP) into routine maternal care. The programme will conclude with hands-on skills practice and simulation exercises, followed by a post-assessment, participant feedback, and closing session.

4.3 Module Adaptation and Training Materials

The training package will be adapted from existing approved materials rather than developed from scratch, including the 2025 WHO/FIGO/ICM Consolidated Guidelines for the Prevention, Diagnosis and Treatment of Postpartum Haemorrhage, E-MOTIVE, SOGP, national protocols, and UNICEF/UNFPA-supported EmONC materials The package will include:

• A concise facilitator guide for the one-day module.
• Participant handouts covering key PPH prevention, detection, first-line response and referral steps.
• Laminated PPH quick-response job aid for MNHC delivery areas.
• PPH Facility Readiness Checklist for Health Managers.
• Referral and documentation templates aligned with existing MNHC/HMIS processes.
• Pre/post-test and basic skills assessment tools.
• • Digital resources for upload to the existing digital systems (LMS), including approved videos/job aids where available.

The final adapted package will be reviewed and endorsed by H&PD/PIU before rollout. WHO, UNICEF, UNFPA, SOGP/MAP or other technical partners may be consulted in a streamlined manner where required, without creating a parallel validation process.

5. Implementation Strategy

5.1 Training Rollout

The training will be delivered through a phased, district-based rollout using existing government training infrastructure and trainer capacity. All 41 districts will be covered through a cluster/division-based approach, with parallel implementation where feasible to complete rollout within 4–5 months, subject to final participant lists and H&PD approval.

Each district will conduct batches of approximately 25–30 participants, with an estimated 170–200 batches province-wide. The final number of batches will be confirmed after verification of MNHC facility lists, participant nominations and previously trained providers. Scheduling will be staggered to minimise disruption to MNHC service delivery, and participant release will be formally authorised through the relevant CEO Health/District Health Authority.

Before rollout, H&PD/PIU and DU will jointly lead microplanning, including district-wise participant mapping, trainer identification, training calendars, venue selection, monitoring arrangements and coordination with district teams.

5.2 Master Trainers / Resource Pool

The TA will use and orient existing government and partner-trained PPH/EmONC trainers wherever possible, rather than creating a large new ToT structure. PIU has already shared an initial list of PPH-trained personnel/master trainers, which will be verified and expanded during microplanning.
A lean trainer/resource pool will be identified from existing capacity, including obstetricians/gynaecologists, trained EmONC/BEmONC/CEmONC resource persons, experienced nursing tutors, public health staff with training experience, and relevant district-level maternal health staff. As a planning assumption, approximately two trainers per district, with limited reserve capacity, will be identified, subject to verification of availability and suitability.
Instead of a full new Master Trainer Training, selected trainers will receive a one-day orientation/refresher on the standardised MNHC PPH/PPFP module to ensure consistent messaging, clinical accuracy, training quality, use of job aids, pre/post assessments and reporting requirements. This orientation may be delivered through three regional batches tentatively covering Lahore, Multan and Rawalpindi, subject to H&PD/PIU confirmation.
Limited Obs/Gyn technical input will support clinical validation and quality assurance of the orientation and rollout. Additional clinical expertise, including Shalimar Hospital/RCOG focal point support if facilitated by FCDO, may be engaged in a streamlined manner without creating a parallel technical process.

5.3 Training Venues

Training will be hosted in existing government facilities only. Suitable venues may include DHDCs, nursing schools, DHQ/THQ hospital training spaces or other public-sector facilities identified by district teams. Venue selection will prioritise accessibility, availability of training space, and suitability for small-group skills practice, simulation and demonstrations. No external/private venues will be hired unless specifically approved by H&PD and E4H as an exceptional case.

5.4 Coordination and Governance

A central coordination team, jointly managed by E4H and H&PD/PIU will be established to oversee planning, logistics, scheduling, monitoring, quality assurance and reporting (such as pre- and post-tests). The existing E4H-supported DU will comprise this team, with the Public Health Adviser leading the team.

Coordination and governance of the training programme will be led jointly by the **Health & Population Department (H&PD)/Programme Implementation Unit (PIU)** and the **E4H-supported Delivery Unit (DU)**, which will serve as the central coordination team under the leadership of the **Public Health Adviser**. The team will oversee overall planning, logistics, scheduling, quality assurance, monitoring, reporting, and training performance assessments. H&PD/PIU will provide overall strategic oversight, while the DU and E4H will support microplanning, adaptation of training materials, trainer orientation, monitoring and evaluation, and reporting. Clinical validation will be undertaken with support from obstetric and gynaecology experts as required, while district health authorities will lead implementation through nominated trainers. H&PD/PIU will also oversee certification, follow-up, and supportive supervision, with ongoing coordination and tracking support from the DU and E4H.

6. Facility Readiness, Referral and System Follow-up

The training will be linked to basic facility readiness and referral follow-up so that provider skills can be applied in practice. The TA will not procure commodities or create parallel systems; instead, it will use the training rollout to identify readiness gaps, strengthen referral clarity and support H&PD/PIU follow-up through existing MNHC mechanisms.

6.1 Facility readiness

As part of the training, each participating Health Manager will complete a standardised PPH Facility Readiness Checklist for their MNHC. The checklist will cover the minimum inputs required for timely PPH prevention, first-line response and referral. The minimum readiness package will be aligned with H&PD/PIU’s approved MNHC service package and relevant WHO/FIGO/ICM and national guidance. Indicative areas to be assessed include:

Readiness area Indicative items include:

• Medicines and supplies Uterotonics as per approved protocol, IV fluids/cannulas where within MNHC scope, TXA where authorised/available, clean delivery supplies
• Monitoring and equipment Blood pressure apparatus, basic emergency tray, blood loss recognition/measurement support where available
• Protocols and job aids PPH quick-response job aid, AMTSL/PPH protocol, referral criteria
• Referral preparedness Updated contact list for linked RHC/THQ/DHQ/tertiary facility and Rescue 1122/emergency transport
• PPFP/PPIUCD readiness PPFP counselling material, family planning commodities where available, IUCD/insertion supplies and infection prevention items where PPIUCD services are authorised/provided, and referral/linkage information where services are not available at MNHC level
• Documentation Referral form/register and HMIS/EMR reporting fields where available

The central coordination team (DU and Adviser) will compile checklist findings to generate a concise readiness summary for H&PD/PIU. This will help identify common gaps in commodities, protocols, documentation and referral preparedness for government follow-up. Any commodity gaps identified through the training will be reported to H&PD/PIU and relevant supply chain teams for action through existing systems.

6.2 Referral and emergency escalation

The training will reinforce district-specific referral pathways for PPH cases. The standard pathway will be confirmed during microplanning and is expected to include referral from MNHCs to the nearest appropriate RHC/MNH, THQ, DHQ or tertiary facility, depending on service availability and severity of the case.

Each participant will be oriented on when to refer, where to refer, how to stabilise, how to contact the receiving facility and/or Rescue 1122, how to document the referral, and how to record referral outcome/follow-up if needed. Referral guidance will be aligned with existing MNHC/HMIS/EMR documentation and with E4H’s concurrent work on referral management where relevant. The TA will not create a separate referral system but will support practical use of existing/refined forms, contact lists and reporting channels.

6.3 Follow-up through existing systems

Follow-up will be embedded within H&PD/PIU, DU and district systems. DU will support training tracking, compilation of readiness checklist findings, pre/post assessment data and referral-readiness issues. District teams and PIU will use this information to prioritise supportive supervision, resolve readiness gaps and reinforce referral linkage.

7. Monitoring, Evaluation and Supportive Supervision

The TA will use a proportionate monitoring approach focused on training coverage, competency acquisition, facility readiness, referral functionality, PPFP/PPIUCD counselling/linkages, and institutionalisation through existing systems. Monitoring will be led through DU in close collaboration with H&PD/PIU and district mechanisms, with support from E4H core team. A dedicated M&E STTA will not be required.

The TA will not claim a direct causal link between a one-day training and reductions in maternal mortality. Instead, it will track realistic and attributable changes in provider knowledge, practical skills, facility readiness, referral documentation and follow-up.

The programme will be supported by a results and monitoring framework to track implementation, training quality, and readiness for sustained service delivery. Key indicators will include **training coverage**, **knowledge and skills acquisition**, **facility readiness for PPH management**, **postpartum family planning (PPFP) and PPIUCD readiness and referral linkages**, **functionality of referral systems**, **routine service and data reporting**, **supportive supervision**, and the **institutionalisation of training materials** within government systems. Progress will be monitored through training registers, pre- and post-assessments, competency checklists, facility readiness assessments, referral documentation, HMIS/EMR and facility records, supervision reports, and evidence of integration into government learning platforms and future training plans.

7.2 Baseline and Follow-up

A simple baseline will be generated during training through pre-tests, skills checklists, facility readiness checklists and available facility-level service data. This will include, where available, current MNHC caseload information on deliveries, PPH cases, referrals, PPFP counselling and PPIUCD provision/referral. Follow-up will use existing DU and district supervision mechanisms to assess whether trained facilities are applying key practices, including AMTSL, early PPH recognition, first-line response, documentation, referral and PPFP counselling/linkage.

7.3 Supportive Supervision and Reporting

Supportive supervision will be embedded within existing H&PD/PIU and district systems. PIU/district teams will lead follow-up using standardised checklists, while DU will support tracking, consolidation of findings and reporting to H&PD.

At minimum, trained facilities should receive one structured follow-up contact within three months of training, prioritising facilities with low readiness scores, high delivery volume, weak referral linkages or remote location. Findings will be summarised for H&PD/PIU to support corrective action through routine supervision, supply chain, training and reporting channels.

A simple DU-managed tracker/dashboard will be used to monitor training coverage, pre/post results, readiness gaps, referral-readiness issues and follow-up actions. This will build on existing DU and MNHC/HMIS/LMS systems rather than creating a parallel reporting platform.

8. Sustainability and Institutionalisation

Sustainability will be built through existing H&PD, PIU, DU and MNHC systems rather than through a parallel training structure. The TA will focus on embedding the adapted PPH/PPFP module, job aids, readiness checklist, assessment tools and follow-up mechanisms into routine government platforms.

The main sustainability mechanisms will be:

• Integration into MNHC training systems: The adapted one-day PPH/PPFP module will be shared with H&PD/PIU for inclusion in MNHC in-service training, induction and refresher training plans.
• Use of existing trainer capacity: Existing government and partner-trained PPH/EmONC trainers will be identified, oriented and used for rollout where feasible. This will help retain training capacity within the system beyond E4H support.
• Digital learning and refresher access: Approved job aids, quick-reference materials, pre/post assessment tools and digital learning resources will be uploaded or retained within the PIU training repository to support future refresher training and self-directed learning.
• Routine follow-up through existing systems: DU, PIU and district teams will use readiness checklist findings, pre/post results, training trackers and supervision data to support follow-up through routine review, supervision and reporting channels.
• Alignment with emerging midwifery competency direction: The module will align with existing and emerging policy directions on midwives’ role in PPH prevention, early detection, first-line response and postpartum family planning counselling/linkages. Any formal notification, scope decision or HMIS/DHIS revision will remain government-led and will be supported through evidence generated by the TA where relevant.
• Laminated Cards and Checklist/Job Aids in facilities: These will be developed and distributed to all facilities where they will be displayed to ensure visibility and for ease of reference.
• Government-led scale-up pathway: By the end of the TA, H&PD/PIU will have an adapted module, trainer/resource pool, LMS-ready materials, readiness tools and implementation learning that can be used for refresher training, induction of new MNHC staff and potential expansion to other facilities if prioritised by government.

Position Title:

Period of Performance: (mid-July 2026 – December 2026 - 5 Months)

Reporting To: E4H Punjab Team Lead, in coordination with H&PD/PIU

Purpose:

To provide technical and clinical oversight for adaptation, validation, trainer orientation and quality assurance of the One-Day PPH Training Package, ensuring alignment with national and international evidence-based guidance and the MNHC scope of practice.

Key Responsibilities

• Review relevant national and international PPH resources and adapt existing materials to develop a one-day PPH training package—including the training module, facilitator guide, participant materials and job aids—ensuring alignment with national PPH guidelines, E-MOTIVE principles, and relevant WHO, International Federation of Gynecology and Obstetrics (FIGO) and International Confederation of Midwives (ICM) recommendations.
• Provide technical input on Active Management of the Third Stage of Labor (AMTSL), uterotonic use, early detection, first-line response, stabilisation and referral protocols relevant to MNHC providers.
• Support development and review of clinical skills checklists, case studies and simulation exercises.
• Facilitate trainer orientation/refresher workshops and provide clinical clarification as required.
• Conduct quality assurance reviews of training delivery and provide recommendations for improvement.
• Advise on clinical aspects of facility readiness tools and referral guidance.
• Provide technical support to H&PD/PIU and DU on emerging clinical issues relevant to the intervention.
• Review and endorse selected technical outputs and training reports as requested.

Deliverables

1. Clinically validated PPH training package and tools.
2. Facilitate trainer orientation workshops. 
3. Quality assurance observations and recommendations along with Brief technical reports and review notes.

Qualifications and Experience

• MBBS with FCPS/MS/MCPS (Obs & Gynae) or equivalent recognised postgraduate qualification.
• Minimum 10 years of relevant clinical experience in maternal and newborn health.
• Demonstrated experience in EmONC, PPH management and provider capacity building.
• Previous experience as a trainer or master trainer in maternal health programmes preferred.
• Strong understanding of Pakistan maternal health protocols and service delivery systems.

Level of Effort: 50 working days over the implementation period.

Duty Station: Punjab, with travel for training workshops and selected quality assurance visits as required.

Payment Method: Payments upon submission of Deliverable Reports to FCDO