When Is Postpartum Haemorrhage Treatment Initiated? A Nested Observational Study Within the E-MOTIVE Trial

Abstract

Objective: To compare the frequency and timing of postpartum haemorrhage (PPH) treatment initiation between hospitals implementing the MOTIVE treatment bundle (which consisted of uterine Massage, Oxytocic drugs, Tranexamic acid, IntraVenous fluids and Examination) and those following usual care.

Design: Nested prospective observational study.

Setting: Hospitals in Nigeria, Kenya, Tanzania and South Africa participating in the E-MOTIVE trial.

Population or sample: Healthcare workers treating PPH.

Methods: Between June and December 2022, we observed healthcare workers for 1-2 weeks in 39 E-MOTIVE and 39 usual care hospitals across Nigeria, Kenya, Tanzania, and South Africa managing vaginal birth and treating PPH. We descriptively compared the frequency and timing from PPH detection to treatment initiation of individual treatments and the MOTIVE bundle, between E-MOTIVE care and usual care.

Results: Among 2578 observations in E-MOTIVE care hospitals, 295 (11%) PPHs were treated, and among 2834 observations in usual care hospitals, 219 (8%) PPHs were treated. In E-MOTIVE care hospitals, 97% (286/295) of women with PPH received the MOTIVE bundle, compared to 36% (79/219) in usual care. Median initiation times for the first component were similar (0 vs. 1 min), but E-MOTIVE care hospitals achieved faster initiation of all components (13 min, IQR 6-18) compared to usual care (18 min, IQR 10-25). In total, 79% (233/295) of women in E-MOTIVE care had all components initiated within 20 min, compared to 22% (48/219) in usual care.

Conclusions: Timely and comprehensive management of PPH using the MOTIVE bundle, particularly initiating all components within 15-20 min, was commonly observed in the E-MOTIVE care hospitals. Scaling up E-MOTIVE care should emphasise timely bundle initiation to strengthen PPH treatment and improve maternal health outcomes in low-and-middle-income countries.

Keywords: MOTIVE bundle; PPH; PPH treatment; PPH treatment bundle; postpartum haemorrhage; sub‐Saharan Africa.

FIGURE 1

Consort diagram.

FIGURE 2

Elapsed time from postpartum haemorrhage detection to each treatment and MOTIVE bundle initiated. M = uterine massage, O = Oxytocics; T = tranexamic acid; IV = intravenous fluids; E = examination of the genital tract; First component of MOTIVE initiated * = Elapsed time from PPH detection to first treatment initiated when ALL MOTIVE components administered; All components of MOTIVE initiated ** = Elapsed time from first treatment initiated to last treatment initiated when all the MOTIVE bundle components administered; Excluded from boxplot are the following outliers in usual care: 2 for tranexamic acid initiated, 2 for last treatment initiated. The dotted lines represent the 15 min intervals until 60 min postpartum.