E-MOTIVE Trial

The E-MOTIVE trial is the Early detection of Postpartum Haemorrhage and treatment using the WHO MOTIVE 'first response' bundle: a cluster randomised trial with health economic analysis and mixed methods evaluation 

EMOTIVE logo

Postpartum haemorrhage (PPH), defined as a blood loss of more than 500 ml, is the leading cause of maternal death worldwide and a major concern in low-resource countries.

Early detection and treatment of PPH with a bundle of interventions used for PPH management (the WHO MOTIVE 'first response' treatment bundle) are thought to improve critical clinical maternal outcomes.

 

Trial Design

E-MOTIVE is a multi-country, parallel cluster randomised trial with a baseline control phase, along with mixed-methods and health economic evaluations.

Eighty secondary level health facilities will take part in the trial. Initially, all health facilities will enter an 11-month baseline period in which they will be following usual care. After this, we will randomise 40 of the 80 health facilities to the E-MOTIVE intervention for 11 months, allowing two months for transition. The other 40 health facilities will continue to follow usual care as per the baseline period for the entire trial duration (2 years). The proposed sample size for data collection will be 337,920 women.

Aims of the Study

This study has the following aims:

1. Evaluate the implementation of the E-MOTIVE intervention compared with usual care on clinical, implementation and resource use outcomes.

2. Assess the cost-effectiveness of the E-MOTIVE intervention compared with usual care from a public healthcare system perspective.

3. Develop, optimise and manualise an implementation strategy, with parallel process evaluation alongside the trial, ready for scaling-up of the E-MOTIVE intervention if found to be effective.

Our purpose is to integrate the evidence into WHO guidance for programmatic implementation of the E-MOTIVE intervention, if found to be effective, for global impact.

Setting

This trial will be conducted across 80 secondary level health facilities, across 5 low-and-middle-income countries (LMICs): Kenya, Tanzania, Nigeria, South Africa and Sri Lanka.

Target Population

The research participants for this study will be the healthcare providers attending vaginal births in the study facilities. 

The recipients of the intervention will be women who have given birth vaginally and are at risk of PPH.

Intervention

The E-MOTIVE intervention, which targets the healthcare providers consists of 3 elements:

1. A strategy for early detection of PPH, which allows triggering of the ‘first response’ treatment bundle

2. A ‘first response’ bundle called “MOTIVE”, based on the WHO guideline recommendations and consisting of uterine Massage, Oxytocic drugs, Tranexamic acid, IV fluids and Examination & Escalation

3. An implementation strategy, focusing on simulation-based training, peer-assisted learning, local E-MOTIVE champions, feedback of actionable data to providers, calibrated drape with action line, and MOTIVE emergency kits.

A diagram of the E-MOTIVE intervention is shown below:

EMOTIVE diagram

Measurement of outcomes

Below are the primary and secondary outcomes for the E-MOTIVE trial:

Primary outcome (a composite of 3 clinical outcomes):

  1. Primary severe PPH defined as blood loss ≥1000 ml following a vaginal birth in the facility 
  2. Postpartum laparotomy for bleeding until discharge from the health facility* 
  3. Postpartum maternal death from bleeding until discharge from the health facility*

If any of the components occur, this will be deemed as positive for the primary outcome.   

Secondary clinical outcomes

The secondary clinical outcomes (where we expect to see a reduction if E-MOTIVE is effective) are based on the Core Outcome Set for PPH treatment, and are the following:

  1. Laparotomy postpartum until discharge from the health facility*;
  2. Laparotomy with compression sutures postpartum until discharge from the health facility*;
  3. Laparotomy with arterial ligation postpartum until discharge from the health facility*;
  4. Hysterectomy postpartum until discharge from the health facility*;
  5. Hysterectomy postpartum  for bleeding until discharge from the health facility*;
  6. All cause maternal mortality postpartum until discharge from the health facility*;
  7. Blood loss (measured in ml);
  8. Primary PPH defined as blood loss ≥500 ml;
  9. Duration of hospitalisation postpartum;
  10. Duration of ICU hospitalisation postpartum;
  11. Transfers to higher-level facility postpartum until discharge from the health facility;
  12. All cause neonatal mortality postpartum until discharge from the health facility*;
  13. Use of Non-pneumatic anti-shock garment (NASG) postpartum;
  14. Use of uterine balloon tamponade postpartum;
  15. Blood transfusion postpartum until discharge from the health facility*;
  16. Blood transfusion for postpartum haemorrhage until discharge from the health facility*;
  17. Intensive Care Unit (ICU) admissions postpartum until discharge from the health facility*;

Combined clinical and quality of care exploratory outcomes where we may observe an increase or a reduction if E-MOTIVE is effective

*In cases where a woman is transferred to another facility postpartum, discharge from the health facility relates to the facility the woman is transferred to  

Secondary implementation outcomes

The key secondary implementation outcomes are 1) postpartum haemorrhage detection rate (defined as recording of diagnosis of PPH by birth attendant) and 2) compliance with the MOTIVE bundle. Compliance with the MOTIVE bundle is defined as adherence with three core elements of the bundle: administration of oxytocic drugs, TXA and IV fluids. If all three core elements are administered, this will be deemed positive for bundle compliance. If any of the three core elements are not administered then this will be deemed negative for bundle compliance. It is hypothesised that the causal mechanism underpinning the intervention is that it will increase the rate at which PPH is diagnosed; and that an increase in awareness of women suffering from PPH will subsequently lead to an increase in uptake in the interventions to prevent PPH from progressing to severe consequences. This will ultimately lead to a reduction in the proportion of women suffering adverse outcomes from PPH. 

The secondary implementation outcomes are:

  1. Detection of PPH by the healthcare provider (with the following denominator: women diagnosed to have postpartum haemorrhage objectively measured as ≥500 ml blood loss detected by blood collection drape);
  2. Bundle compliance (with the following denominators: women diagnosed to have postpartum haemorrhage or excessive bleeding by healthcare provider; and women diagnosed to have postpartum haemorrhage objectively measured as ≥500 ml blood loss detected by blood collection drape).
  3. Uterine massage;
  4. Oxytocin use;
  5. Misoprostol use;
  6. TXA use;
  7. Intravenous fluids use;
  8. Examination of the genital tract;
  9. Number of women receiving any treatment uterotonic;
  10. Number of women requiring additional treatment interventions (not responding to the MOTIVE bundle).

Implementation outcomes will be reported with three denominators: the total study population; women diagnosed to have postpartum haemorrhage or excessive bleeding by healthcare provider; and women diagnosed to have postpartum haemorrhage objectively measured as ≥500 ml blood loss detected by weighing the blood collection drape.

The data are routinely collected as part of normal clinical practice and women will not be approached for additional trial-specific data or follow up at any point.

 

 

Training videos

Data entry for a new patient (for site teams): 

 

 

Editing a new record (for site teams): 

Cases of postpartum laparotomy and maternal death: 

Completing the Monthly Facility Form (for site teams):

Creating a data query (for hub teams): 

Answering a data query (for site teams):

Completion of data checks (for hub teams):

Monthly calibration of the baby weighing scales:

Using the blood collection drapes: 

More information...

Chief Investigator: Professor Arri Coomarasamy

Sponsor: University of Birmingham

Sponsor Ref: RG_19-231

Clinicaltrials.gov No.: NCT04341662

This study is funded by the Bill & Melinda Gates Foundation.

Current protocol: E-MOTIVE trial protocol v2.0