Below are the primary and secondary outcomes for the E-MOTIVE trial:
Primary outcome (a composite of 3 clinical outcomes):
- Primary severe PPH defined as blood loss ≥1000 ml following a vaginal birth in the facility measured up to 2 hours postpartum
- Postpartum laparotomy for bleeding until discharge from the health facility*
- 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:
- Laparotomy postpartum until discharge from the health facility*;
- Laparotomy with compression sutures postpartum until discharge from the health facility*;
- Laparotomy with arterial ligation postpartum until discharge from the health facility*;
- Hysterectomy postpartum until discharge from the health facility*;
- Hysterectomy postpartum for bleeding until discharge from the health facility*;
- All cause maternal mortality postpartum until discharge from the health facility*;
- Blood loss (measured in ml) up to 24 hours postpartum;
- Primary PPH defined as blood loss ≥500 ml up to 24 hours postpartum†;
- Duration of hospitalisation postpartum;
- Duration of ICU hospitalisation postpartum until discharge from the health facility*;
- Transfers to higher-level facility postpartum until discharge from the health facility;
- All cause neonatal mortality postpartum until discharge from the health facility*;
- Use of Non-pneumatic anti-shock garment (NASG) postpartum†;
- Use of uterine balloon tamponade postpartum until discharge from the health facility†*;
- Blood transfusion postpartum until discharge from the health facility†*;
- Blood transfusion for postpartum haemorrhage until discharge from the health facility†*;
- 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:
- 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);
- 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).
- Uterine massage;
- Oxytocin use;
- Misoprostol use;
- TXA use;
- Intravenous fluids use;
- Examination of the genital tract;
- Number of women receiving any treatment uterotonic;
- 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.