Lessons for Future Implementation of the E-MOTIVE Bundle

Lancet Glob Health; 2025 Feb;13(2):e187-e188. doi: 10.1016/S2214-109X(25)00001-4

A bundled care approach for the management of postpartum haemorrhage following vaginal delivery has been shown to reduce adverse maternal outcomes due to postpartum haemorrhage. This bundle, also known as the E-MOTIVE intervention, is comprised of the use of a calibrated blood collection drape to facilitate early detection of postpartum haemorrhage and the timely delivery of a standardised set of evidence-based interventions given within 15 min of detection of postpartum haemorrhage to control bleeding. These actions are supported by implementation strategies to help strengthen health systems and promote practice changes among providers. In 2023, WHO issued new recommendations in support of the performance of the E-MOTIVE bundle in hospitals settings. WHO's guidelines recognise the importance of implementation strategies to embed new care processes into clinical practice, and the need to address limitations in resources and staffing that could impede the introduction of a complex intervention.

In this issue of The Lancet Global Health, Meghan Bohren and colleagues provide insights on which factors and implementation strategies supported the successful performance of the E-MOTIVE intervention in hospitals in four African countries and contributed to the positive clinical findings. They report a high level of compliance (ie, fidelity) in the use of the calibrated drape for postpartum haemorrhage detection and the performance of all bundle components in quick succession to manage postpartum haemorrhage. Access to all necessary supplies and medicines was crucial for the bundle's successful implementation. With the exception of the calibrated drapes, which were purchased and given to the study sites, hospital staff were responsible for procuring and stocking or restocking all other supplies needed to implement this bundle. Survey results confirmed that these supplies were mostly available. Frequent monitoring of supplies to facilitate the smooth running of the study probably contributed to good restocking practices and reliable access. Whether these facilities will face supply shortages outside of the study is unknown. Given the drape's importance as part of the intervention, it will also be important to know how the availability of drapes will be sustained in the future.

An important consideration for future scale-up of the E-MOTIVE bundle is the quantity and quality of the health-care workforce that is required to ensure its safe and effective implementation. The analysis of delivery observation data by Bohren and colleagues confirmed that hired research midwives at sites in Nigeria and Tanzania would often perform components of the bundle, as opposed to hospital staff (including midwives, student midwives, and nurses) who were also trained to implement the bundle. The authors postulate that the research midwives, who were primarily hired to have a supportive role in the study, likely became involved in implementing the bundle due to staffing shortages and their moral obligation to assist in emergencies. This finding highlights the need for further information on the staffing requirements for implementing the E-MOTIVE bundle. Unsurprisingly, research on other care bundles has shown that improvements in the patient-to-nurse ratio are associated with better clinical outcomes. Therefore, additional guidance on staffing minimums would be beneficial for all initiatives that aim to improve maternal outcomes and the quality of care in hospitals in low-to-middle-income countries.

This paper also shares important findings on the challenges with performing routine clinical assessments after birth, which are supported in guidelines on postpartum monitoring. Providers were trained to monitor blood pressure and pulse, evaluate uterine tone, and observe for excessive bleeding every 15 min in the first hour postpartum to facilitate early diagnosis of postpartum haemorrhage. Delivery observations confirmed that the first assessment was performed routinely; however, there was fidelity drift with subsequent assessments at later intervals. Poor compliance with postpartum monitoring is well documented in other studies and often attributed to insufficient staffing and equipment shortages. Additional research is needed to understand the potential effect of missed assessments on the effectiveness of the E-MOTIVE bundle, if any. Timely care depends on good routine monitoring; however, there are still unanswered questions about the optimal frequency for measuring vital signs postpartum and observing for early obstetric warning signs.

The results presented by Bohren and colleagues deepen our understanding of the performance of the E-MOTIVE bundle components and which factors and implementation strategies helped to support their implementation. Effective postpartum haemorrhage care evidently requires many resources for training and supporting staff, in addition to equipping them with the necessary supplies to implement a care bundle. The next priority will be to introduce and implement the E-MOTIVE bundle in other settings, outside the context of a clinical study, and identify what factors and strategies are necessary for it to be successful and sustainable.