04 · Evidence · The E-MOTIVE Trial

First response bundle (MOTIVE)

60% reduction in severe outcomes.

The E-MOTIVE trial

All drugs and techniques listed here have long been part of established guidelines. E-MOTIVE focused on the importance of timing and combination: This was examined across 80 secondary hospitals in Kenya, Nigeria, South Africa, and Tanzania, involving 210,132 women having vaginal births. [1]

Why the E-MOTIVE bundle

E-MOTIVE was designed and evaluated as an integrated intervention for the early detection and treatment of postpartum haemorrhage. The “E” component centres on early detection through routine use of a calibrated blood-collection drape, allowing blood loss to be measured objectively and predefined treatment thresholds to be recognised promptly.

Once PPH is identified, the MOTIVE treatment bundle is initiated without delay: uterine Massage, Oxytocic drugs, Tranexamic acid, IntraVenous fluids, Vaginal/genital tract Examination, and escalation of care where required.

E-MOTIVE

▪ Observations (cumulative blood loss volume, blood flow, uterine tone) every 15 minutes documented on the blood loss monitoring chart

▪ Blood pressure and pulse carried out at least once in the 1st hour postpartum and documented on the blood loss monitoring chart

E · Early detection of postpartum haemorrhage

E

Early detection of postpartum haemorrhage

▼

Trigger criteria

1) Clinical judgment
2) Blood loss 300 mL or more plus one abnormal observation
3) Blood loss 500 mL or more

Massage of uterus

M

Massage
of uterus

Oxytocic drug

O

Oxytocic
drug

Tranexamic acid

T

Tranexamic
acid

IV fluids

IV

IV fluids

Examination of the genital tract

E

Examination of
the genital tract
+ Escalation

▼

Treatment for
Refractory PPH

Massage until uterus has contracted or for one minute

10 IU IV Oxytocin slow injection (>2 mins) or diluted in 200–500 mL crystalloid over 10 minutes plus a maintenance dose of 20 IU IV oxytocin diluted in 1000 mL saline over 4 hours (± misoprostol)

Tranexamic acid 1 g IV injection or diluted in 200 mL crystalloid over 10 minutes

IV fluids should be given if clinically indicated and may require a 2nd IV access

Ensure bladder is empty, evacuate clots, check for genital tract tears with an internal Examination and check placenta for completeness

Implementation strategies (ACTT)

Audit newsletters: sharing with all staff monthly detection and bundle use rates along with numbers of PPH, severe PPH, blood transfusion, laparotomy and death from PPH; feedback given at monthly departmental meetings.

Champions: Midwife and doctor to oversee change, troubleshoot, give feedback on audit newsletters, connect with other champions through chats, meetings and websites for sharing knowledge and lessons learnt.

Trolley and/or carry case: including all medicines and devices required for the treatment of PPH; restocked after every use; and a stocking checklist completed at the start of every shift.

Training: on-site, simulation-based, and peer-assisted training of 90 minutes facilitated by the use of provider guides, flipcharts and job aids displayed in labour wards.

When the trigger fires, five components arrive at once: massage, oxytocics, tranexamic acid, intravenous fluids and examination. Below, the E-MOTIVE trial results: detection rose from 51.1 to 93.1 percent, bundle delivery from 19.4 to 91.2 percent, and severe outcomes fell from 4.3 to 1.6 percent.

The cost of E-MOTIVE

An economic evaluation conducted alongside the trial showed that the E-MOTIVE intervention was cost-effective [3]. The adjusted cost difference was US$0.30 per patient (95% CI −2.31 to 2.78), with an estimated US$11.83 per case of severe PPH prevented, and US$113.91 per disability-adjusted life-year (DALY) averted.

When the willingness-to-pay threshold surpasses roughly US$1,500 per DALY averted, the probability of cost-effectiveness exceeds 80% [3]. Since costs and thresholds vary between countries, ministries should combine this evidence with local budget-impact analysis.

The economic analysis dispels the assumption that better outcomes necessarily entail higher costs beyond what the system can afford.

Does E-MOTIVE apply effectively in real-world settings?

E-MOTIVE's effectiveness has remained consistent outside trial settings. In Pakistan, a before-and-after study at eight hospitals assessed E-MOTIVE under routine conditions. The outcome of severe PPH, laparotomy for bleeding, or death from bleeding fell from 20 cases per 1,000 births with usual care to fewer than 1 per 1,000 with the E-MOTIVE intervention, a 97% reduction in risk. PPH detection improved from half of all cases to every case, and first-response bundle use from 4 in 10 women to all women. [4].

The overall evidence includes one large trial across four African countries, an implementation study in Pakistan.

01 National guidelines

The status of national postpartum haemorrhage guidelines, country by country.

02 Activities

Activities at local and national level to train, implement and scale up E-MOTIVE.

03 Engagement

Initiatives and efforts taken up by national or local government and ministerial bodies to implement E-MOTIVE.

04 Training

E-MOTIVE training activity across implementing countries.

05 Manufacturers

Manufacturers producing the calibrated blood-collection drapes used in E-MOTIVE.

In practice · Same woman. Same blood loss. Different outcomes.

Usual care

Blood loss is estimated visually and recorded as normal.

  • An hour on, the woman is pale and tachycardic; the blood loss is re-estimated at “maybe 600”.
  • A uterotonic is given.
  • Tranexamic acid is considered at the next review.

By the time the diagnosis is confirmed, the woman is experiencing severe PPH, and the response is escalation to theatre.

The E-MOTIVE pathway

The drape reads 520 mL at thirty minutes. Based on this measurement:

  • PPH is diagnosed, and the first-response bundle is initiated within fifteen minutes of diagnosis [6].
  • Uterine massage begins,
  • oxytocics,
  • tranexamic acid,
  • IV fluids are administered,
  • and the examination reveals a small vaginal tear, which is repaired in the room [5].
References

[1]  Gallos I, Devall A, Martin J, et al. Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage (E-MOTIVE). New England Journal of Medicine, 2023;389:11–21.

[2]  Coomarasamy A, Devall AJ, Bell S, et al. Diagnosis and treatment of postpartum haemorrhage: a race against time. The Lancet, 2026.

[3]  Williams I, et al. A cost-effectiveness analysis of early detection and bundled treatment of postpartum hemorrhage alongside the E-MOTIVE trial. Nature Medicine, 2024;30:2343–2348.

[4]  Devall AJ, Nausheen S, Muhammad S, et al. Early detection and bundled treatment of postpartum haemorrhage with the E-MOTIVE intervention: a prospective pre-post intervention study in Pakistan. The Lancet Obstetrics, Gynaecology & Women’s Health, 2025.

[5]  Mammoliti K-M, Martin J, Devall A, et al. Observation studies of bedside practice alongside the E-MOTIVE trial, including “When are postpartum haemorrhages detected?”, The Lancet Global Health (in press), with the trial’s mixed-methods process evaluation.

[6] WHO. Recommendations on the assessment of postpartum blood loss and use of a treatment bundle for postpartum haemorrhage, 2023.