E-MOTIVE: A new process for managing birth-related bleeding

 

By: Dr. Azuka Ezeike, MBBS, FWACS (Obstetrics and Gynaecology), MSc (Public Health), Freelance Medical Writer. Medical review by The DLHA Team

The E-MOTIVE care bundle is a set of evidence-based interventions, which applied collectively lead to early diagnosis and effective treatment of postpartum haemorrhage

 

 

Highlights

• Haemorrhage, especially postpartum haemorrhage, is a leading cause of maternal deaths in Africa

• High rates of maternal mortality persist in African countries despite being largely preventable.

• Postpartum haemorrhage involves excessive bleeding post-delivery, often due to failure of contraction of the womb (uterus), retained placenta, or lacerations.

• Late diagnosis and delayed treatment due to inaccurate blood loss estimation contribute to high mortality rates.

• The E-MOTIVE Care Bundle involves early detection using calibrated drapes, uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, and examination/management of bleeding sources.

• The WHO 2023 Guidelines emphasize objective blood loss assessment and a standardized, timely treatment approach using the E-MOTIVE bundle.

• Implementation requires coordinated efforts from national health systems and stakeholders to ensure drug availability, availability of trained health workers, and infrastructure support.

 

Introduction

In Western societies, birth-related bleeding also known as postpartum haemorrhage (PPH) is largely preventable and manageable, but mortality remains high in African countries. Globally the maternal mortality ratio is 223 per 100,000 live births and this falls short of the projected 70 per 100,000 live births by 2030. [1] Sub-Saharan Africa and Asia contribute to 85% of the global maternal mortality. [2] In, Africa haemorrhage of any kind causes the most maternal deaths and PPH is responsible for approximately 60% of maternal deaths in developing countries [3] 

Postpartum haemorrhage is excessive bleeding after delivery in excess of 500mls after vaginal delivery and 1000mls after caesarean delivery.  It usually occurs within 24 hours of delivery.  PPH usually results majorly from uterine atony (lack of contraction of the womb after delivery). It can also result from retained placenta, tears (lacerations) in the birth tract and problems with blood clotting.

Efforts have been made to reduce the deaths from PPH in Africa but this has not yielded any significant dividend as the statistics are still dismal.  Central to the challenge is the delay in the diagnosis of PPH, which ultimately leads to a delay in treatment. 

Over time, guidelines have been provided by the World Health Organization (WHO) and other regulatory bodies for the prevention of PPH and these have been updated periodically. Despite the guidelines, deaths due to PPH continue unabated in Low and Middle Income Countries (LMIC). This has been identified to be due to the challenge of late detection and late initiation of treatment.  Late detection occurs due to inaccurate estimation of blood loss using the visual method of estimation.  

To stem the tide of PPH, the WHO in December 2023 released a new guideline on the assessment of postpartum blood loss and the use of a treatment bundle - The E-MOTIVE for the management of postpartum haemorrhage. [2] 

E-MOTIVE is the acronym for a set of evidence-based interventions that when applied collectively lead to early diagnosis and treatment of postpartum haemorrhage. [3]

This report aims to explain what the E-MOTIVE Care bundle is and how women can benefit from its use to manage postpartum bleeing during childbirth.  

 

The E-MOTIVE Treatment/Care Bundle

Overview

A care bundle is a complex set of interventions consisting of about three to five straightforward evidence-based practices that, when performed collectively and reliably, improve the processes of care and patient outcomes.

The E-MOTIVE is the acronym for a new PPH care bundle developed based on the WHO 2012 and 2017 recommendations on the treatment of PPH.  It was ratified following a WHO technical consultation meeting of the Guideline Development Group (GDG). [2] It is a ‘first response’ intervention in PPH management.

The acronym stands for:

• E - Early detection of PPH using a calibrated drape.

This is followed rapidly by (in no particular order):

• M - Massage of the uterus (womb)
• O - Administration of an  Oxytocic ( a drug that makes the womb contract)
• T - Administration of Tranexamic acid (a drug that prevents bleeding by encouraging the formation of clots)
• IV - Administration of Intravenous fluids (drip)
• E - Examination for, identifying and managing the source of bleeding, and Escalation to more advanced care, if bleeding  persists

 

Background on the Integration of E-MOTIVE in WHO’s 2023 Recommendations for PPH Management

The use of the E-MOTIVE treatment bundle in the management of PPH has been incorporated into the new WHO guidelines on PPH management. [2}

In the context of poor diagnosis of PPH, delayed treatment, and inconsistent use of recommended interventions, WHO convened a group of over 130 stakeholders for the first Global Summit on Postpartum Haemorrhage (PPH Summit) in March 2023. [1]

To assess the opinion of health workers on the E-MOTIVE bundle, in 2022 a study was conducted on 45 health workers in nine health facilities in Nigeria, Kenya and South Africa.  The aim was to identify the barriers and enablers of PPH management. The study participants were a mix of doctors, midwives, nurses and administrators in maternity hospitals in these countries. [4]

Following the results of this initial study, another research was conducted on 210,123 participants. These were women in labour in 80 secondary-level hospitals in Nigeria, Kenya, South Africa and Tanzania.[3, 4] The results published in May 2023 showed the use of the E-MOTIVE bundle led to more than 60% reduction in severe PPH, surgery and death from PPH. 

The main difference between the 2023 guideline and the 2012 and 2017 guidelines is that while these interventions are administered as separate interventions in the old guidelines, in the new guideline they are administered together (as a bundle)

The 2023 guidelines have two key recommendations:

1. Routine objective assessment of postpartum blood loss with a calibrated drape to improve the detection and treatment of PPH.

2. Standardised and timely treatment approach to PPH management through objective assessment of blood loss and use of a treatment bundle.

Additional considerations include:

• The recommendation is basically for vaginal delivery

• The individual interventions should be used for caesarean section as applicable

• The interventions should ideally be initiated within 15 minutes of diagnosis of PPH.

• Where a woman continues to bleed after receiving all interventions within the PPH treatment bundle, there should be a prompt referral to a higher-level healthcare facility or a senior clinical provider capable of providing further management.

 

Potential barriers to the implementation of the E-MOTIVE bundle

• The drape may limit the patient’s movement or confine the woman to the recumbent position

• Unavailability of some of the drugs especially tranexamic acid.

• Difficulty in maintaining the cold chain (temperature of between 2-8 degrees centigrade) needed to preserve oxytocin in the rural centres due to the absence of stable electricity.

• The cost of the drapes may limit supply to health facilities

• Some hospitals may not have the bed type needed for the drapes

• Health workers may lack knowledge on how to use the bundle

• Challenges with the assignment of specific roles to different cadres of health workers on the implementation of the bundle.

 

Implementation of the E-MOTIVE package

To effectively implement the recommendations, a burden is placed on national health systems and other stakeholders to;

• Update national policies and guidelines to comply with the recommendations

• Engage with relevant parties

• Apply the recommendation in a way that takes into account the demands of the health system and the intended users in the community

• Train and give supportive supervision to competent health staff

• Provide the enabling ground for the guidelines to be implemented by educating and assisting trained healthcare professionals in changing their mindset

• Create internal, current clinical protocols for the management of PPH

• Choose E-MOTIVE champions on-site who will lead, inspire, and assist others

• Have an emergency E-MOTIVE cart or kit available in all medical facilities

• Involve regional professional associations and educational institutions to provide an inclusive and participatory approach

• Make sure that the medical institutions have an adequate supply of high-quality medications and supplies for the care bundle, which includes tranexamic acid, oxytocin, calibrated drapes, and intravenous fluids

• Control the logistics and procurement procedures to guarantee that only high-quality drugs - especially uterotonics - are purchased

• Make sure that non-reusable parts, such as the calibrated drapes, are disposed of safely

• Make sure that decision-making is shared by educating women and carers ahead of time on the new PPH preventive and management strategies as well as their rights to select the type of care they want

• Provide enough personnel to allow for the coordinated execution of the bundle

• Describe the precise responsibilities that each health worker cadre will have when putting the bundle into practice

• Establish a reliable and user-friendly data management system to monitor the processes at the health facilities

• Ensure periodic audits of the implementation of the bundle to identify the strengths and weaknesses.

 

Conclusion

Death from postpartum haemorrhage is a tragedy for an individual, her family, the community and the nation. The E-MOTIVE bundle for the management of PPH was developed on the premise that women are entitled to sexual and reproductive health rights and access to evidence-based care.

Africa faces the biggest burden of postpartum haemorrhage mortality, thus health personnel must be updated and trained on how to implement the E-MOTIVE bundle.  The implementation of the care bundle comes at a financial cost. As a result, African countries’ health budgets should be improved, including funding for maternal care. It is also critical to train and deploy midwives, nurses, medical officers, obstetricians and gynaecologists, surgeons and anesthesiologists, and other maternal health care professionals on the implementation of the bundle.

 

References

1. World Health Organization. A roadmap to combat postpartum haemorrhage between 2023 and 2030 [Internet]. 2023 October 11. [Cited 2024 Jun 21]. Available from here.

2. World Health Organization. WHO recommendations on the assessment of postpartum blood loss and use of a treatment bundle for postpartum haemorrhage [Internet]. 2023 December 21. [Cited 2024 Jun 21]. Available from here.  

3. Gallos I, Devall A, Martin J, Middleton L, Beeson L, Galadanci H, et al. Randomized trial of early detection and treatment of postpartum hemorrhage. N Engl J Med. 2023 Jul 6;389(1):11–21. doi: 10.1056/NEJMoa2303966. Available from here.  

4. Forbes G, Akter S, Miller S, Galadanci H, Qureshi Z, Fawcus S, et al. Factors influencing postpartum haemorrhage detection and management and the implementation of a new postpartum haemorrhage care bundle (E-motive) in Kenya, Nigeria, and South Africa. Implementation Science [Internet]. 2023 Jan 11 [cited 2024 Jun 21];18(1):1. Available from: doi: 10.1186/s13012-022-01253-0. Available from here.

 

Related:

CARBETOCIN: An Essential Drug for Preventing Postpartum Haemorrhage

Why African women die more from birth-related bleeding

 

 

Published: September 3, 2024

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