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

• Transport for referrals from community and between facilities should be included in the protocols, together with provision of health workers who can provide ongoing care for women with PPH during the transfer. Transport should be arranged by the health facility, where possible, avoiding out-of-pocket expenses.
• Referral protocols should clearly define when escalation is needed, who initiates the referral, what stabilization measures must be provided before transfer, and what communication should take place between referring and receiving facilities.
• Protocols should be aligned with local health system capacities and include realistic timelines and contingency plans in case of delays or service unavailability.
• To ensure continuity of care, referral protocols should include mechanisms for documentation and handover, including clinical information, treatment provided and any complications encountered.
• Referral systems should be integrated into emergency preparedness planning and supported by training and regular simulation exercises involving both sending and receiving teams.
• Community-level awareness of referral pathways and emergency transport availability should be promoted so that women and families understand when and how to seek higher-level care.
• Facilities should monitor and audit the timeliness and outcomes of referrals to identify bottlenecks, improve coordination and strengthen the quality and responsiveness of the referral system.
• Where feasible, protocols should consider the use of telecommunication tools (e.g. phone applications such as WhatsApp, mobile phones, radios) to coordinate emergency referrals and provide remote support during transfer.