Clinical care processes for early postpartum haemorrhage detection: a nested observational study 2 within the E-MOTIVE trial

Kristie-Marie Mammoliti^1*Fernando Althabe²Christina Easter³James Martin³Adam Devall¹Adeosun Love Funmi⁴Rahmatu Yusuf⁴Abubakar Fatima⁴Arigbede Ololade Christiana⁴JimKelly Mugambi⁵Polycarp Oyoo⁵Masumbuko Sambusa⁶Akwinata Banda⁶Fawzia Samuels⁷Sara Willemse⁷Sibongile Doris Khambule⁸Hilal Mukhtar Shu'aib⁴Aminu Ado Wakili⁴Jenipher Okore⁵Ard Mwampashi⁶Mandisa Singata-Madliki⁹Edna Arends⁷Elani Muller⁹Hadiza Galadanci⁴Zahida Qureshi⁵Fadhlun Alwy Al-Beity⁶Sue Fawcus⁷Neil Moran^10,11George Gwako⁵Alfred Osoti⁵Ioannis Gallos²Arri Coomarasamy¹

• ¹College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
• ²Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
• ³Institute for Applied Health Research, University of Birmingham, Birmingham, United Kingdom, Birmingham, United Kingdom
• ⁴African Center of Excellence for Population Health and Policy, College of Health Sciences, Bayero University, Kano, Nigeria, Kano, Nigeria
• ⁵Department of Obstetrics and Gynecology, University of Nairobi, Nairobi, Kenya, Nairobi, Kenya
• ⁶Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, Dar es Salaam, Tanzania
• ⁷Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Cape Town, Cape Town, Western Cape, South Africa
• ⁸Effective Care Research Unit, University of the Witwatersrand, Johannesburg, South Africa ,and Walter Sisulu University ,Mthatha,South Africa, Johannesburg, South Africa
• ⁹Effective Care Research Unit, University of the Witwatersrand, Johannesburg, South Africa, Johannesburg, South Africa
• ¹⁰KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa, Pietermaritzburg, South Africa
• ¹¹Department of Obstetrics and Gynaecology, Nelson Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa, Durban, South Africa

Postpartum haemorrhage (PPH) is the leading cause of maternal mortality, particularly in low-and-middle-income countries. The E-MOTIVE trial demonstrated a 60% reduction in severe PPH and related complications with the E-MOTIVE intervention compared to usual care. We examined patterns of clinical care during the initial postpartum hours—specifically, frequency of postpartum maternal assessments, PPH diagnostic methods, and blood loss thresholds used—and how these practices related to variations in PPH detection and outcomes in E-MOTIVE intervention hospitals compared to usual care hospitals. MethodsThis prospective observational study, nested within the E-MOTIVE trial, involved passive, direct observations of healthcare workers providing postpartum care to women and managing PPH across 78 hospitals in Nigeria, Kenya, Tanzania, and South Africa. We conducted a descriptive analysis of the frequency and timing of postpartum maternal assessments, diagnostic methods and blood loss thresholds used to detect PPH, comparing clinical practices between E-MOTIVE care and usual care. Results Between June and December 2022, the study included 2,578 women at E-MOTIVE care hospitals and 2,834 at usual care hospitals. At E-MOTIVE hospitals, 88% (n/N) of women received at least one postpartum maternal assessment, 71% (n/N) at least two, 57% (n/N) at least three, and 48% (n/N) four, with assessments conducted earlier and more frequently than at usual care hospitals. Objective blood loss quantification improved detection, with the most common method and blood loss threshold at E-MOTIVE hospitals being ≥300 mL plus at least one abnormal clinical sign, used in 47% (n/N) of PPHs. Postpartum haemorrhage was detected earlier and more frequently at E-MOTIVE hospitals: 76% (n/N) within 30 minutes, 97% (n/N) within 60 minutes, and 100% (n/N) within 90 minutes (median: 17 minutes; IQR 11-30), compared to 54%, 79%, 96% respectively, and 100% within 134 minutes in usual care (median: 26 minutes; IQR 13-56). Discussion Frequent, timely postpartum assessments and objective blood loss thresholds of ≥300 mL and ≥500 mL enhanced early PPH detection. The first 90 minutes postpartum has been identified as a critical window for early detection, termed the 'Golden 90 minutes for PPH detection.' Incorporating these insights into clinical training and recommendations can improve maternal outcomes related to PPH.