When are postpartum haemorrhages diagnosed? A nested observational study within the E-MOTIVE cluster-randomised trial

Area of Science:

• Obstetrics and Gynecology
• Global Health
• Clinical Trials

Background:

• Current primary postpartum hemorrhage (PPH) definitions may miss early diagnoses due to limited data on timing.
• Understanding PPH diagnosis timing and methods is crucial for effective strategies.
• The E-MOTIVE trial demonstrated a 60% reduction in PPH adverse outcomes with an early diagnosis and bundled treatment approach.

Purpose of the Study:

• To compare the timing of PPH diagnosis after vaginal birth across four African countries.
• To analyze the diagnostic methods used for PPH within the E-MOTIVE trial intervention.
• To evaluate the impact of different diagnostic thresholds on PPH diagnosis timing.

Main Methods:

• Direct observations of healthcare workers in 39 hospitals across Nigeria, Kenya, Tanzania, and South Africa.
• Observations conducted from vaginal birth up to 2 hours postpartum.
• Analysis of clinical judgment and objective blood loss thresholds (300 mL with clinical signs or 500 mL) for PPH diagnosis.

Main Results:

• Median time to PPH diagnosis was 15 min (Nigeria, Tanzania), 17 min (Kenya), and 30 min (South Africa).
• Diagnosis within 30 min ranged from 58% (South Africa) to 86% (Tanzania).
• Nigeria, Kenya, and Tanzania predominantly used a 300 mL threshold with clinical signs, while South Africa used 500 mL.

Conclusions:

• Using a 300 mL threshold with clinical signs led to earlier PPH diagnosis (15-17 min median) compared to a 500 mL threshold (30 min median).
• Earlier diagnosis facilitates timely intervention for postpartum bleeding.
• All PPH cases were diagnosed within 90 minutes, irrespective of the threshold used.