IMPLEMENTATION OUTCOMES AND EFFECTIVENESS OF E-MOTIVE POSTPARTUM HAEMORRHAGE TREATMENT IN NIGERIAN STANDARD CLINICAL SETTINGS.

Background: Nigeria  contributes the highest number of global maternal deaths, with PPH leading the the global causes of maternal mortality. The E-MOTIVE trial demonstrated the use of objective blood measurement and clinical bundle which reduced 60% of severe PPH and other related complications³. The trial results is followed by guideline changes at global and national levels.

Objectives:  This study aims to determine the implementation outcomes and effectiveness of E-MOTIVE bundle treatment for postpartum haemorrhage (PPH) in standard clinical settings in Nigerian health facilities. We assessed the usage of the bundle components and the effectiveness of the bundle treatment in standard clinical practice and compared the outcomes with the E-MOTIVE trial results.

Design and methods: The E-MOTIVE was a multi-country, parallel cluster randomised trial with a baseline control phase that studied over 200,000 women across 80 health facilities. 41 facilities came from Nigeria with 19 intervention, 19 control, and 3 adaptive sites.

All the facilities from Nigeria were used for this implementation. The control and adaptive sites were trained on the intervention at the onset. The E-MOTIVE bundle treatment (uterine Massage, Oxytocic, Tranexamic acid, IV fluids, Examination, and Escalation) and the use of calibrated drape for early detection of PPH were implemented in routine clinical settings in the facilities using the implementation strategies of training, PPH trolleys, and champions. Data summaries on bundle usage and PPH outcomes for all women having vaginal deliveries in those facilities were collected monthly from the sites. Implementation started in December 2023 through December 2024. The trends of the outcomes were analysed using Excel and R and presented graphically from the baseline period to implementation and compared with the trial results.

Results: Compliance with drape and bundle components usage during the implementation period was comparable to those from the E-MOTIVE trial (100% vs. 98% and 91% vs. 104%, respectively). The primary outcomes occurred in 1.5% of the women during the implementation as compared to 4.3% baseline in the control facilities and 1.6% in E-MOTIVE intervention arm, showing a significant reduction by 65% - showing that - similar results were achieved while implementing in routine clinical settings outside research trial. Other key secondary outcomes such as PPH, severe PPH and blood transfusion for PPH were found to be comparable to those achieved during the trial.

Conclusion: Early detection and bundle treatment for PPH has demonstrated a notable decrease in unfavourable maternal outcomes when implemented in standard clinical settings in Nigeria, with comparable and better trends than seen during the trial period. The intervention, if implemented and scaled up, can help to reduce adverse maternal outcomes associated with PPH in Nigeria.

Authors and references: Aminu A. Wakili¹, Hadiza Galadanci¹, Hilal Mukhtar Shuaib¹, Abubakar Sadiq Isa¹, Arri Coomarasamy², Adam Devall², Kulandaipalayam N. Sindhu², Leanne Beeson², Marcelina Podesek²

¹ Africa Centre of Excellence for Population Health and Policy (ACEPHAP), Bayero University Kano, Nigeria.

² Birmingham Clinical Trial Unit (BCTU), University of Birmingham, UK

³ Gallos I, Devall A, Martin J, Middleton L, Beeson L, Galadanci H et al. Randomized Trial of Early Detection and Treatment of Postpartum Haemorrhage. N Engl J Med. 2023 May 9. https://www.nejm.org/doi/full/10.1056/NEJMoa2303966