Africa: The Groundbreaking Solution to Stop More Women Dying of Postpartum Haemorrhage

Midwives educated to international standards, who are licensed, regulated, fully integrated into health systems and working in interprofessional teams can help avoid about two thirds of all maternal and newborn deaths. © UNFPA Kenya
12 May 2023
interview

Postpartum haemorrhage (PPH) affects about 14 million women each year and claims the lives of around 70 000 women annually - mostly in low and middle-income countries - the equivalent to 1 death every 6 minutes. PPH is defined as the loss of more than 500ml of blood within 24 hours after birth, it is the leading cause of maternal mortality worldwide.

Delays in the detection or treatment of postpartum haemorrhage can result in complications or death.

A new solution, known as E-MOTIVE, could provide a major breakthrough in reducing deaths from childbirth-related bleeding, according to a landmark study published by researchers from the World Health Organization (WHO) and the University of Birmingham.

The study, which involved over 200 000 women in Tanzania, South Africa, Nigeria and Kenya found that measuring blood loss and bundling it with WHO-recommended treatments, rather than offering them sequentially, resulted in dramatic improvements for women. The recommended E-MOTIVE package includes early and accurate detection of PPH using a blood-collection drape, which can help provide objective, accurate, and early diagnosis of postpartum haemorrhage, WHO reports.

Professor and Director Africa Center of Excellence for Population health and Policy, Bayero University Kano, Nigeria, as well as study co-author Hadiza Galadanci spoke with allafrica's Sethi Ncube.

What is a blood-collection drape?

It is a simple innovation that you can use, like a plastic, that you can put underneath the buttocks of the mother when she's delivering, after delivery of the baby any blood that comes will get into a pouch, so that you can calculate how blood the mother loses after delivering. It's a device that we can use to dictate the amount of blood that a woman loses after delivery of the baby. Before this, what we do is usually we estimate, we just look at the blood on the bed. We look at the blood is on the cloth of the woman. We look at the blood that is on the floor and then we can now say it is 200ml, it is 300ml, it is 1000ml, it is 2000ml, just by looking and estimating. This has shown that our estimations are wrong, because we underestimate and therefore we don't start treatment on time. But this device will tell you exactly the amount of blood loss and therefore you will know when to start treatment.

There is a small tether that you can tie to the woman's your body immediately after delivery. And once she stops bleeding, you will remove it. So for the E-MOTIVE trial, we keep it for about one to two hours, if the woman stops bleeding after one hour we can remove it, but if she continues to bleed we keep it till two hours after delivery.

How can a woman who's just delivered differentiate between normal bleeding and PPH to get quicker treatment?

So a woman can actually know when she's bleeding heavily because in a normal delivery, a woman can lose as little as 100ml of blood, she can lose 200ml or 300ml, but by the time she gets to 300ml it shows that something is getting wrong because she should stop bleeding before that 300ml, by the time she gets to 500ml it really shows there is something wrong and treatment needs to be done. So what we did in this trial was that once it gets to 500ml, we treat but even when it gets to 300ml and the woman is showing signs that she is not doing well in terms of her pulse or blood pressure or she's sweating, then we know that there's a problem and we start treatment.

If a woman delivers in a health facility - which we're advocating for, that every woman should deliver in a health facility - the nurses or the midwives or the doctors taking care of the delivery know when something is wrong. Once she gets to 300ml they will have to start managing or to start monitoring her blood pressure and her pulse, if it's showing that there is a problem that is - change in pulse, change in blood pressure, change in respiration - treatment must commence immediately even at 300ml.

If there is no change at 300 ml they can wait until it's 500ml, once it's 500ml whether there is any change or there is no change the healthcare provider has to initiate treatment at 500ml because postpartum haemorrhage is diagnosed at 500 ml or any blood loss that has an associated change in the vitals or the clinical state of the woman.

How does E-MOTIVE contribute to the WHO's lifesaving solution for reducing severe bleeding after childbirth?

The intervention actually addresses three aspects that have been shown to actually increase the risk of women dying from postpartum haemorrhage, the first is that postpartum haemorrhage is not diagnosed early. We don't pick it up early, because we estimate the blood loss and data has shown that up to 50% times of detection rate of postpartum haemorrhage is missed at 500 ml, you can miss up to 50% which means that somebody has lost up to 500ml but your method 50% of the time, even when it gets to 1000ml still healthcare providers miss it, because they're not detecting it early. So E-MOTIVE, the E there is early detection.

Now the other thing is that it's also been shown that when you give the treatments sequentially and it doesn't work, this sequential treatment further reduces the chance of the woman having all the treatment at the same time, so with E-MOTIVE we do a bundle approach. We do the massage, we give the oxytocin, we give the IV fluids, we give the tranexamic acid - all at the same time - within 15 minutes so that we can achieve the stoppage of that bleeding.

Now the last E in E-MOTIVE - it's been shown that if these interventions do not work, you need to escalate, you need to go to the next level. And the next level is that you might need to put anti-shop garment, you might need to use a balloon, you might need to take the patient to the theatre. So there is need for you to know that there is something else you can do if this intervention doesn't work. So that's what E-MOTIVE is all about. Now we showed that we reduced the outcome of severe postpartum haemorrhage by 60% with this intervention. This shows that if you use this intervention of E-MOTIVE, you can reduce the postpartum haemorrhage by 60%. And we know that postpartum haemorrhage is one of the commonest causes of maternal mortality, it accounts for almost a quarter of all maternal deaths globally. And in some countries, in fact, more than a quarter. So if you're able to do this intervention, it means we're contributing to the life saving interventions that WHO has been advocating for.

What has the reception been to this lifesaving solution to PPH?

Everybody is eager to learn more about E-MOTIVE because ... we have demonstrated a 60% reduction in severe postpartum haemorrhage. Everybody, healthcare providers, researchers is wanting to know more about E-MOTIVE. We have shown it is effective, when you see we have to implement it, ....we have to make sure that it works. It worked in 4 countries during our research, in Nigeria, South Africa, Kenya and Tanzania. So we have to make sure that we implement it in other countries that have this high burden and in fact not only in low middle income countries, even in high income countries. There's been interest from researchers, from donors from government officials, from international organizations, to really know more about E-MOTIVE so that it can be implemented in countries where it is really required so that we can see a reduction is severe postpartum haemorrhage and therefore a reduction in maternal mortality.

In fact, not only severe postpartum haemorrhage was reduced in our finding, even the normal postpartum haemorrhage, which is 500ml loss reduced in our intervention side and detection increased in our intervention side. Once you're able to detect it, you reduce the time, the delay that occurs in a woman getting access to treatment, you reduce that time by early detection and then you increase the rate of women responding by giving all the intervention at once in a bundle approach.

So when can we expect it because maybe in countries like South Africa?

The process is not that simple - we have published in high impact journal, New England Journal of Medicine. I think the next thing is that there is a need for WHO to look at this evidence and see how they can update their recommendations because governments need guidance. Once we have a guideline, a global guideline, then countries can now come back home and change or update their own national guidelines. And then of course, we will need to get the health system strengthened so that we can get this E-MOTIVE implemented. We need the drapes, there will be many innovations to the drape, there will be people that will develop more drapes, we need to have more drapes in our countries and make sure that they are available in our health facilities.

We need to train our healthcare workers to really be able to give the intervention and of course we need to support also our health care providers. The good thing about the E-MOTIVE is that we're able to show also some part of implementation strategies.
What do you do if you really want to implement E-MOTIVE?
1. you have to do training -
2. you have to provide what we call the PPH trolley, where you have all the things that are required to provide this intervention.
Also, you will need to have audit and feedback because you will need to support the system with data and make sure that you can go back and give us feedback and make the system work. And then of course, you also need champions that will really ensure that this intervention is carried out in our various health facilities.

What feedback or experiences have healthcare professionals shared about using E-MOTIVE in their practice?

Healthcare workers are so happy with the intervention because - 1. they see it works, they can see that they no longer have women losing so much blood and them running around looking for blood transfusion, looking for theatre. 2. the labour ward gets even cleaner, because all the blood gets into our drape, and therefore even the cleaners at the labour ward are happy with the E-MOTIVE.

Midwives don't have to estimate blood loss, they can actually see the amount of blood loss and they know when to start treatment. So they don't have to think, do I start treatment? Do I wait and see whether she'll get better? They have an objective way of knowing when to start this treatment. When we finished the research all the hospitals where we worked, 80 hospitals across the four countries, they wanted more drapes and they want to continue the intervention, they don't want to stop.

E-MOTIVE has given us a breakthrough that we probably should look at other conditions in obstetrics, other complications and see whether we can use the same approach that we have used in E-MOTIVE.

How expensive will it be adopting this solution?

The only increase in the normal way we treat is the drape and really, the drape should not be beyond access to our woman. If our governments can procure the drape and if there is more demand and the cost of the drape will even go down. Many other industry and innovators can actually produce different types of drapes and bring down its cost. I think it's something that can be achievable. But we need commitment from our donors, we need commitment from international organizations, we need commitment from even our innovators and our industry and most importantly, we need commitment from our governments.

Are you working on any ongoing research to further enhance the effectiveness of the E-MOTIVE?

We just finished taking data on E-MOTIVE. So, I'm sure now that we're done with this, we'll look at the research agenda and ... see how we can further bring evidence as far as reducing the burden and death associated with postpartum haemorrhage.

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