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

Background:
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. This nested observational study explored clinical care practices between the time of vaginal birth and the removal of the obstetric drape. Specifically, we assessed the frequency of postpartum maternal assessments, including blood pressure, pulse, uterine tone, vaginal blood flow, and cumulative blood loss assessment—unique to the intervention. We also evaluated diagnostic methods, and blood loss thresholds used for PPH, and how these practices may have contributed to differences in PPH diagnosis and outcomes between E-MOTIVE intervention hospitals and usual care hospitals.

Methods:
This 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 diagnose 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% (2,272/2,578) of women received at least one postpartum maternal assessment, 71% (1,825/2,578) at least two, 57% (1,479/2,578) at least three, and 48% (1,234/2,578) four, with assessments conducted earlier and more frequently than at usual care hospitals. Objective blood loss quantification improved diagnosis, 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% (140/295) of PPHs. Postpartum haemorrhage was diagnosed earlier and more frequently at E-MOTIVE hospitals: 76% (223/295) within 30 min, 97% (287/295) within 60 min, and 100% 295/295) within 90 min (median: 17 min; IQR 11–30), compared to 54% (119/219), 79% (173/219), 96% (210/219) respectively, and 100% within 134 min in usual care (median: 26 min; IQR 13–56).

Discussion:
Frequent and timely postpartum maternal assessments, along with objective blood loss thresholds of with at least one abnormal clinical sign and ≥500 mL may enhance early PPH diagnosis. The first 90 min postpartum has been identified as a critical window for early diagnosis, termed the “Golden 90 min for PPH diagnosis.” Incorporating these insights into clinical training and guidelines may support improved maternal outcomes related to PPH.