Every seven minutes, on average, a woman around the world dies from postpartum haemorrhage (PPH), or excessive bleeding during childbirth. It is the most common and dangerous complication of childbirth, affecting 24 million women and causing 70,000 deaths every year. It is treatable and can often be managed with medical care. However, this relies on access to quality health services, which are often lacking in lower-income countries. More than 85% of deaths from PPH happen in sub-Saharan Africa and South Asia.

To combat this, scientists at the University of Birmingham partnered with the World Health Organization and universities across the world to conduct a trial, the largest ever on postpartum haemorrhage, assessing a set of clinical interventions and tools targeting PPH. The trial, called E-MOTIVE, implemented three strategies targeting PPH: early and accurate detection, bundled treatment, and appropriate escalation. It delivered a higher-than-expected 60% reduction in adverse outcomes.

With this concern in mind, a bundled approach consists of trying various treatments simultaneously. If the healthcare provider sees that the amount of blood collecting in the drape is approaching 500ml, they can initiate treatments to contract the uterus and stop the bleeding. One way to do this is doing a uterine massage, where the healthcare provider rubs the abdomen to induce contraction. Another is oxytocic drugs, like oxytocin and misoprostol, that induce contraction. Contraction is more likely to occur when a combination of massage and drugs is tried. The third part of the bundle is tranexamic acid, a blood clotting drug that will reduce blood loss. This is complemented by an IV to replace the lost fluids. All of these steps are combined in the ‘MOTIVE’ bundle for PPH treatment.

The final element of the treatment bundle is appropriate escalation. Sometimes, despite accurate diagnosis and prompt treatment, haemorrhaging continues and a patient will need more advanced care. The E-MOTIVE interventions prepare medical providers to identify these cases quickly so that they can escalate the patient to urgent care. Healthcare providers examine the patient and escalate care appropriately, which can, for example, mean inserting a balloon into the uterus to stop the bleeding or taking the patient to surgery.

The E-MOTIVE trial was conducted between August 2021 and March 2023 in Nigeria, Tanzania. Kenya and South Africa, supported by a grant from the Bill and Melinda Gates Foundation. “We needed to show that our solutions actually help,” says Professor Coomarasamy, “and the way to do that is to do a proper clinical trial. So, we did the largest ever trial on postpartum haemorrhage treatment.” 

The 80 participating hospitals were surveyed for seven months as they implemented the usual treatments for postpartum haemorrhage. Then, half the hospitals were randomly allocated to receive the E-MOTIVE intervention, while the other half continued to perform standard care. Among the 200,000 women who gave birth vaginally across these hospitals throughout the trial, the researchers surveyed how many lost a litre or more of blood, required surgery, or lost their lives.

The trial was published in the New England Journal of Medicine and attracted high-profile attention, including from WHO Director General Tedros Adhanom Ghebreyesus, who rarely comments on an individual study.

With this degree of attention from international development and health organisations, scientists are hoping that the E-MOTIVE bundle will be rapidly scaled up and support women and healthcare providers in low-income countries across the world. While the WHO’s official guidelines and the work of the Bill and Melinda Gates Foundation will certainly help encourage uptake of the treatment, its affordability will help countries take the initiative on their own.

“The countries where we did the trial have been trailblazers,” says Professor Coomarasamy. The E-MOTIVE trial made use of existing procurement pathways and sourced the medicines from local stocks at hospitals, meaning that many hospitals already have the capacity needed to implement the treatment. While the supply of drapes may be an issue, it can be solved through innovation. “Lots of companies are gearing up for mass production,” says Professor Coomarasamy. “That’s a challenge that’s being addressed at the moment.”