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A breakthrough for maternal health

A cost-effective intervention for postpartum haemorrhage is reducing maternal death worldwide by 60%.

26 November 2024

Professor Arri Coomarasamy and his team are changing how the world is treating postpartum haemorrhage.

For millions of women worldwide, childbirth still carries life-threatening risks. Every two minutes in 2020, a woman died in pregnancy or labour, amounting to a global death toll of around 287,000 women that year. Most of those deaths occurred in low and middle-income (LMIC) countries. Most could have been prevented. 

Researchers at the University of Birmingham, in collaboration with the World Health Organization (WHO) and universities across the world, have conducted the largest-ever trial on postpartum haemorrhage, assessing a set of clinical interventions and tools targeting PPH.

A breakthrough solution for postpartum haemorrhage

Postpartum haemorrhage (PPH), or excessive bleeding after childbirth, is the leading cause of maternal mortality, killing around 70,000 women annually, despite being largely preventable. University of Birmingham researchers have developed a game-changing new solution, known as E-MOTIVE, which reduced severe bleeding by 60% and reduced deaths by 27% in a major trial.

Time is of the essence when responding to postpartum bleeding, so interventions that eliminate delays in diagnosis or treatment should make a massive difference.

Professor Arri Coomarasamy, Professor of Gynaecology and Reproductive Medicine

The intervention — developed in partnership with the WHO and trialled on over 200,000 women in four countries — combines a simple early-diagnosis tool with a “bundle” of effective treatments, to identify and stop bleeding.

“Time is of the essence when responding to postpartum bleeding, so interventions that eliminate delays in diagnosis or treatment should make a massive difference,” says Professor Arri Coomarasamy, who led the trial and is the Co-Director of the University of Birmingham’s WHO Collaborating Centre on Global Women’s Health.

One challenge is that PPH is often detected too late, in part because healthcare professionals rely on visual estimations of blood loss for their diagnosis. Inaccuracies in those subjective judgements result in up to 50% of haemorrhages being missed, according to studies.

To tackle that problem, the E-MOTIVE programme uses a simple funnel-shaped plastic sheet called a ‘drape’, which is placed under a woman to collect and measure lost blood. At a cost of around $1-2, it gives medical professionals a clear and early indication of when a mother is approaching the 500ml of blood loss that signals a significant haemorrhage — allowing staff to intervene earlier.

Professor Coomarasamy delivering a training session to practitioners in Kenya.

Professor Coomarasamy delivers a training session to practitioners in Kenya.

A second challenge is that when medical professionals do identify PPH, they typically respond “sequentially”, with a series of interventions. If one fails, they implement another. “The problem with this sequential approach is that if the woman is bleeding, you are losing time. It is the time that kills her,” says Professor Coomarasamy.

The E-MOTIVE study found that “bundling” together WHO-recommended treatments, rather than offering them one-by-one, resulted in dramatic improvements in outcomes. Under the intervention, patients were treated simultaneously with a uterine massage, medicines to contract the womb and stop bleeding, and intravenous fluid. Health practitioners were also trained to identify when a case needs escalating to advanced care, including surgery.

The trial, conducted between 2021 and 2023, with grant support from the Bill and Melinda Gates Foundation, was the largest ever conducted on PPH treatment. The 80 participating hospitals in Nigeria, Tanzania, Kenya and South Africa were surveyed for seven months as they implemented their usual treatments. Half were then randomly allocated to receive the E-MOTIVE intervention, while the other half continued their standard care.

The results were dramatic:

28 women died in the group receiving standard care, compared to 17 in the group receiving the E-MOTIVE package. Severe bleeding — defined more than a litre of blood loss after birth — fell by a 60% in the trial group. This resulted in a lower mortality and a substantial reduction in blood transfusions — an important outcome in low-income countries where blood is scarce.

“We were looking for a 25% reduction in severe bleeding; we would’ve been happy with that,” says Professor Coomarasamy. “To get almost 60% reduction was truly phenomenal.”

The trial has been greeted as a breakthrough by international health and development organisations. Since its findings were published in July 2023, the WHO has convened a group to draft its first official guidelines on bundled PPH care. In September, the Bill and Melinda Gates Foundation published a report which highlighted bundled PPH interventions as one of seven key strategies to advance progress on the UN Sustainable Development Goals on maternal and child mortality. It stated that bundled treatments could be provided for less than $1 per package — making them cheap enough to scale in low-income countries.

Many local hospitals already have the capacity to implement the E-MOTIVE interventions. Every component of the intervention can be performed by midwives, meaning that it can be applied in regions where doctors are scarce. The trial used existing local procurement pathways, sourcing medicines from local hospitals. The drapes are currently manufactured in India, posing some supply constraints. However, “lots of companies are gearing up for mass production. That’s a challenge that’s being addressed,” says Professor Coomarasamy. “The countries where we did the trial have been trailblazers,” he argues. Many others could soon follow.

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Featured staff

  • Professor Arri Coomarasamy

    Professor of Gynaecology and Reproductive Medicine

    Staff profile for Professor Arri Coomarasamy, Professor of Gynaecology and Reproductive Medicine at the Department of Metabolism and Systems Science, and Director of the Tommy's National Centre for Miscarriage Research.

    Phone: +44(0)121 371 8202 PA to Professor Coomarasamy
    Email:

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