Background
Delays in identifying and treating postpartum haemorrhage can result in serious maternal morbidity and mortality. In Africa, objective measurement of blood using a calibrated blood-collection drape (to diagnose postpartum haemorrhage) and use of the E-MOTIVE treatment bundle (comprising early detection of postpartum haemorrhage, massage of uterus, oxytocics, tranexamic acid, intravenous fluids, and examination and escalation of care) improved the consistency and speed of response to postpartum haemorrhage. The aim of this study was to evaluate the implementation and effectiveness of the E-MOTIVE intervention in a south Asian setting.
Methods
A prospective pre–post intervention study was conducted at eight secondary-level care hospitals in the Sindh and Punjab provinces of Pakistan. Hospitals were included if they were geographically and administratively distinct from each other, had between 1000 and 5000 vaginal births annually, and provided comprehensive obstetric care with the ability to perform surgery for postpartum haemorrhage, if needed. Usual care was observed at all participating hospitals for 6 months (from Sept 28, 2022 to March 30, 2023); next, a 2-month transition period took place for training and set-up of the E-MOTIVE intervention (Oct 10, 2023 to Dec 10, 2023); then, the E-MOTIVE intervention was implemented for 3 months (Dec 11, 2023 to March 10, 2024). The E-MOTIVE intervention consisted of a calibrated blood collection drape for early detection of postpartum haemorrhage (E) and a bundle of first-response treatments (MOTIVE) comprising uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, examination, and escalation. The primary composite outcome comprised severe postpartum haemorrhage (≥1000 mL blood loss), laparotomy for bleeding, or death from bleeding. Implementation outcomes were the postpartum haemorrhage detection rate and bundle use rate. Blood loss was measured by collecting and weighing drapes. The study retained the same primary clinical and implementation outcomes as the main trial (NCT04341662).
Findings
18 hospitals were assessed for eligibility, ten were excluded for not meeting the inclusion criteria (four with fewer than 1000 births per year, three with no operating theatre available, one with bundle treatment already implemented, one with more than 5000 births per year, and one with a security hazard), and eight hospitals in the Punjab and Sindh provinces of Pakistan were deemed eligible for inclusion and participated in the study. 5089 women were included in the E-MOTIVE group and 9033 women were included in the usual care group. The median age of women in the E-MOTIVE group was 30 years (IQR 26–32) and in the usual care group was 30 years (IQR 25–30). The primary composite outcome of severe postpartum haemorrhage (blood loss of ≥1000 mL), laparotomy for bleeding, or maternal death from bleeding occurred in less than 0·1% of women in the E-MOTIVE group (two of 5089) versus 2·0% (183 of 9033) in the usual care group (risk ratio 0·03 [95% CI 0·01–0·13]; p=0·0015). Postpartum haemorrhage detection was 100·0% (109 of 109) in the E-MOTIVE group versus 50·9% (534 of 1050) in the usual care group (rate ratio 1·99 [95% CI 1·01–3·92]), and bundle use was 100% (109 of 109) in the E-MOTIVE group versus 40·7% (428 of 1050) in the usual care group (rate ratio 2·50 [95% CI 1·19–5·26]).
Interpretation
Implementation of the E-MOTIVE intervention in Pakistan was associated with improvements in clinical outcomes and increased rates of postpartum haemorrhage detection and treatment bundle use. The E-MOTIVE intervention could be generalisable to south Asian settings.
