By PPH Foundation

A woman can lose a dangerous amount of blood in minutes after giving birth. Yet in many maternity units around the world, including in low-resource settings, healthcare teams have traditionally been trained to respond one step at a time: identify the bleeding, administer a treatment, wait to see whether it works, then move to the next intervention if necessary. The problem is that postpartum haemorrhage does not wait. Every delay allows bleeding to continue, increasing the risk of shock, organ failure, hysterectomy, and death.

A growing body of evidence is now reshaping this approach. Instead of treating postpartum haemorrhage sequentially, global maternal health experts are urging healthcare providers to act immediately using a bundled package of interventions known as E-MOTIVE. The approach, championed by the World Health Organization, the International Federation of Gynecology and Obstetrics, and the International Confederation of Midwives, is proving that faster, coordinated action can dramatically reduce severe bleeding and save lives (WHO, 2023; Williams et al., Nature Medicine, 2024).

The E-MOTIVE approach begins with the “E”, early detection of postpartum haemorrhage using a calibrated blood collection drape. Rather than relying on visual estimates, which frequently underestimate blood loss, the drape allows healthcare providers to measure bleeding objectively and identify haemorrhage sooner. Once blood loss reaches the trigger threshold, the MOTIVE treatment bundle is activated immediately.

The first letter, “M”, stands for uterine Massage. Following childbirth, the uterus is expected to contract firmly to compress blood vessels that supplied the placenta. When the uterus fails to contract effectively, a condition known as uterine atony, severe bleeding can occur. Uterine massage stimulates contractions and is often the first physical intervention used to control haemorrhage.

“O” stands for Oxytocics. These medicines, including oxytocin and other uterotonics, strengthen uterine contractions and are among the most effective treatments for postpartum haemorrhage caused by uterine atony. FIGO identifies uterotonics as a cornerstone of postpartum haemorrhage management and recommends that facilities ensure their availability and timely administration (FIGO, 2022).

“T” represents Tranexamic Acid, commonly known as TXA. This medicine helps prevent the breakdown of blood clots, allowing the body to stabilise bleeding more effectively. Evidence from the WOMAN Trial demonstrated that early administration of tranexamic acid significantly reduces deaths due to bleeding when given promptly after haemorrhage begins (WOMAN Trial Collaborators, The Lancet, 2017). Because of this evidence, WHO recommends that TXA be administered as early as possible and within three hours of birth when postpartum haemorrhage is diagnosed.

“I” stands for Intravenous Fluids. As blood loss increases, women are at risk of circulatory collapse. Rapid fluid replacement helps maintain blood pressure, preserve organ perfusion, and stabilise the patient while definitive treatment continues. Intravenous access also allows additional medications and blood products to be administered when needed.

The final letters, “E”, stand for Examination and Escalation. Healthcare providers must quickly identify the underlying cause of bleeding, whether it is uterine atony, retained placental tissue, genital tract trauma, or a clotting disorder. If first-line interventions fail, escalation may include advanced procedures, blood transfusion, surgical management, or referral to higher levels of care. The objective is to ensure that treatment progresses rapidly rather than waiting for deterioration.

What makes E-MOTIVE revolutionary is not simply the interventions themselves. None of the components are entirely new. The innovation lies in delivering them together and immediately once haemorrhage is detected.

For decades, many facilities employed a stepwise response in which treatments were introduced sequentially. However, researchers found that these delays often allowed bleeding to worsen before effective control measures were fully implemented. The landmark E-MOTIVE trial, involving more than 210,000 women across Kenya, Nigeria, South Africa, and Tanzania, demonstrated that early detection combined with bundled first-response treatment reduced severe postpartum haemorrhage by approximately 60 percent compared with usual care (The New England Journal of Medicine, 2023; Williams et al., Nature Medicine, 2024). Subsequent analyses have also shown the approach to be cost-effective for health systems, strengthening the case for wider adoption (Williams et al., Nature Medicine, 2024).

A 2025 analysis published in The Lancet Global Health further reinforced these findings, reporting that earlier diagnosis and bundled treatment substantially improved outcomes by ensuring that haemorrhage was recognised and treated during the critical early period after childbirth when rapid intervention matters most (Gallos et al., The Lancet Global Health, 2025).

According to Dr Kireki Omanwa, a Co-Lead of the End PPH Initiative, the greatest value of E-MOTIVE lies in its ability to eliminate dangerous delays.

“Postpartum haemorrhage can become life-threatening within a very short time. The E-MOTIVE bundle recognises that every minute matters. Instead of waiting to see whether one intervention works before introducing another, healthcare teams act decisively using proven treatments at the earliest signs of excessive bleeding. This shift from delayed response to immediate action has the potential to save thousands of mothers’ lives, particularly in settings where resources are limited and referral pathways may take time.”

The International Federation of Gynecology and Obstetrics has endorsed the universal adoption of E-MOTIVE elements and advocates for a systematic bundle approach that emphasises readiness, recognition, response, and reporting (FIGO, 2022). Similarly, WHO and ICM have highlighted the importance of combining objective blood loss measurement with rapid bundled treatment to improve maternal outcomes and accelerate progress toward reducing preventable maternal deaths.

For countries working to reduce maternal mortality, the message is becoming increasingly clear. The future of postpartum haemorrhage care may not depend on discovering new medicines, but on ensuring that existing lifesaving interventions are delivered together, promptly, and consistently. E-MOTIVE demonstrates that when health workers recognise bleeding early and respond as a coordinated team, mothers have a far greater chance of surviving one of childbirth’s most dangerous emergencies.

Sources

1. Gallos ID, Williams EV, Devall AJ, et al. When are postpartum haemorrhages diagnosed? A nested observational study within the E-MOTIVE cluster-randomised trial. The Lancet Global Health. 2025;13(11).
2. Williams EV, Goranitis I, Oppong R, et al. A cost-effectiveness analysis of early detection and bundled treatment of postpartum hemorrhage alongside the E-MOTIVE trial. Nature Medicine. 2024;30(8):2343-2348.
3. Coomarasamy A, Gallos ID, Devall AJ, et al. E-MOTIVE Trial. The New England Journal of Medicine. 2023.
4. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with postpartum haemorrhage. The Lancet. 2017;389(10084):2105-2116.
5. World Health Organization. Lifesaving solution dramatically reduces severe bleeding after childbirth. Geneva: WHO; 2023.
6. International Federation of Gynecology and Obstetrics. Uterine Atony and Uterotonics in Postpartum Haemorrhage: FIGO Statement. London: FIGO; 2022.
7. Image by DC Studio on Magnific</a>