Cheap, effective, and absent: a policy and guideline analysis of emergency medical services response to postpartum hemorrhage in low- and lower-middle-income countries

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Obstetric emergencies constitute approximately 1% of emergency medical services (EMS) calls in high-income countries but 15%-25% in many low-and lower-middle-income countries (LLMICs).This analysis examined how policies and guidelines conceptualize EMS roles in postpartum hemorrhage (PPH) management within LLMICs.Four documents were purposively reviewed: the World Health Organization (WHO) consolidated PPH guidelines, the 2022 International Federation of Gynecology and Obstetrics recommendations on PPH management, the WHO Prehospital Clinical Protocols, and the Emergency Medicine Kenya Foundation EMS Clinical Protocols 2025.Using the Walt and Gilson Policy Triangle framework, guidelines were analyzed across context, content, actors, and process.This enabled a structured comparison of responsibilities at the prehospital-facility interface rather than a direct equivalence assessment.Findings were synthesized to assess alignment between recommendations and LLMIC EMS realities, while recognizing regional heterogeneity.Gaps appear to reflect structural and policy barriers to translating evidence into EMS practice more than limitations in evidence.Elements of established PPH care bundles, including the E-MOTIVE bundle, have emerging or indirect evidence supporting feasibility for trained non-physician EMS providers.Four priorities were identified: EMS-specific training, reform of historical and legislative constraints on non-physician practice, development of an EMS-validated PPH care bundle, and greater representation of LLMIC-based EMS experts in guideline development.