NUR 495 Module 3 Global Health Project on Postpartum Hemorrhage Example

Measuring the Blood to Save the Mother: Postpartum Hemorrhage and the E-MOTIVE Approach in Four African Countries

Student Name

Edson College of Nursing and Health Innovation, Arizona State University

NUR 495: Public and Global Health in Nursing

Instructor Name

Month Day, Year

Measuring the Blood to Save the Mother: Postpartum Hemorrhage and the E-MOTIVE Approach in Four African Countries

The Global Health Problem

Heavy bleeding after birth ranks among the top killers of mothers around the world, and the burden falls overwhelmingly on poorer countries. In my labor and delivery unit in Phoenix, a hemorrhage triggers a team, a cart of medications, blood products and an operating room down the hall. In many hospitals in sub-Saharan Africa, the same emergency unfolds with fewer staff, limited blood supply and long distances to surgical care. Two problems make it deadlier. First, blood loss is usually estimated by eye, which consistently underestimates it, so hemorrhage is recognized late. Second, even when it is recognized, the effective treatments may be given one at a time, with delays between them.

The Intervention: E-MOTIVE

The E-MOTIVE trial tested a response to both problems. It was an international cluster-randomized trial in 80 secondary-level hospitals in Kenya, Nigeria, South Africa and Tanzania, involving 210,132 patients who had vaginal births (Gallos et al., 2023). Intervention hospitals used a calibrated blood-collection drape placed under the woman after birth, which shows blood loss in milliliters so that hemorrhage can be diagnosed objectively and early. Once hemorrhage was detected, staff delivered a bundle of first-response treatments together rather than in sequence: uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, examination and escalation of care. The bundle was supported by an implementation strategy that included training, local champions and audit with feedback. Control hospitals provided usual care.

The primary outcome was a composite of severe postpartum hemorrhage with blood loss of at least 1,000 milliliters, laparotomy for bleeding, or maternal death from bleeding. It occurred in 1.6% of patients in the intervention hospitals and 4.3% in the usual-care hospitals, a risk ratio of 0.40 (Gallos et al., 2023). In plain terms, the combined approach was associated with about a 60% lower risk of the worst outcomes of bleeding.

How It Worked in Practice

A trial result means little if the intervention cannot be delivered. A mixed-methods process evaluation in the four countries observed 2,578 births and conducted surveys and interviews with health workers (Bohren et al., 2025). Use of the calibrated drape was nearly universal in observed births, and health workers found it acceptable, although they reported that some women were less comfortable with it. Fidelity to delivering the treatment bundle was high, and in about two thirds of observed hemorrhages the final treatment began within 15 minutes of diagnosis. These findings matter because they show that a simple tool and a clear sequence can be adopted in busy, resource-limited hospitals when implementation is supported.

Barriers and Equity

Several barriers remain. Drapes and medications must be reliably supplied, which depends on procurement systems that are often fragile. Staff turnover means training must be repeated. Women who give birth at home or in small clinics without skilled attendants do not benefit from a hospital-based intervention, and these are often the poorest women. Equity, a core value of public health, therefore requires pairing interventions like E-MOTIVE with efforts to bring more births into facilities with trained staff and to improve referral and transport. The broader maternal health picture also includes long-term injuries from obstructed labor, such as obstetric fistula, which a recent meta-analysis found most prevalent in the African region (Shu et al., 2026), a reminder that access to emergency obstetric care prevents more than one kind of harm.

Cost and Scale

Global health interventions must be affordable at scale. The E-MOTIVE components are inexpensive compared with the cost of a hemorrhage that progresses: a calibrated drape, standard uterotonic drugs, tranexamic acid and intravenous fluids are already on most essential medicines lists. The larger costs are training, supervision and supply chains. Because the trial was conducted in 80 ordinary secondary-level hospitals rather than specialized centers, its results are more likely to carry over to similar hospitals elsewhere (Gallos et al., 2023). The process evaluation also showed that research midwives sometimes took part in clinical care during the trial (Bohren et al., 2025), so scale-up will need to replace that support with local staff. A national ministry adopting the approach would need to budget for drapes as a recurring supply, include the bundle in pre-service midwifery education, and track hemorrhage outcomes through routine data systems.

Ethical Considerations

Global health work raises ethical questions about who decides and who benefits. The women affected by postpartum hemorrhage in these countries have little voice in research priorities, and interventions developed with outside funding can fade when funding ends. The trial's design, involving hospitals across four countries with local investigators, and its focus on a tool simple enough to be sustained, address some of these concerns. Respect for women also means attention to their comfort and dignity: the process evaluation noted that some women were less accepting of the drape than health workers were (Bohren et al., 2025), which calls for explanation and consent at the time of birth.

The Role of Nurses and Midwives

In most of the hospitals in the trial, midwives and nurses attend births and are the first to see a hemorrhage. E-MOTIVE puts measurement and a standard response directly in their hands, rather than waiting for a physician to judge blood loss. Global health nursing includes this kind of task-sharing and the training, supplies and support that make it safe. Our course reading on public health in a globalizing world emphasizes that nurses contribute to global health through practice, education, research and policy (Stanhope & Lancaster, 2024).

Lessons for My Practice

Two lessons apply in Phoenix. First, measured blood loss is more accurate than estimated blood loss, and many U.S. hospitals now use quantitative methods; our unit could audit how consistently we do. Second, bundled responses work better than step-by-step escalation, which supports our hemorrhage cart and drills. More broadly, the project showed me that a low-cost tool, a clear protocol and an implementation strategy can save lives on a large scale, which is the essence of public health.

Presentation Plan

The presentation for classmates will use six slides: the problem, the two causes of delay, the E-MOTIVE intervention, the results, implementation and barriers, and lessons for nurses, with one discussion question about measurement in their own units.

References

Bohren, M. A., Miller, S., Mammoliti, K. M., Galadanci, H., Fawcus, S., Moran, N., Hofmeyr, G. J., Qureshi, Z., Alwy Al-Beity, F., Forbes, G., Akter, S., Osoti, A., Gwako, G., Melo Santos, T., Evans, C., Wakili, A. A., Bakari, M., Takai, I. U., ... Gallos, I. (2025). Early detection and a treatment bundle strategy for postpartum haemorrhage: A mixed-methods process evaluation. The Lancet Global Health, 13(2), e329-e344. https://doi.org/10.1016/S2214-109X(24)00454-6

Gallos, I., Devall, A., Martin, J., Middleton, L., Beeson, L., Galadanci, H., Alwy Al-Beity, F., Qureshi, Z., Hofmeyr, G. J., Moran, N., Fawcus, S., Sheikh, L., Gwako, G., Osoti, A., Aswat, A., Mammoliti, K.-M., Sindhu, K. N., Podesek, M., Horn, I., ... Coomarasamy, A. (2023). Randomized trial of early detection and treatment of postpartum hemorrhage. New England Journal of Medicine, 389(1), 11-21. https://doi.org/10.1056/NEJMoa2303966

Shu, Y., Xu, M., Li, B., & Cao, H. (2026). Prevalence of obstetric fistula: A systematic review and meta-analysis of available evidence from 38 countries. Irish Journal of Medical Science. Advance online publication. https://doi.org/10.1007/s11845-026-04572-z

Stanhope, M., & Lancaster, J. (2024). Public health nursing: Population-centered health care in the community (11th ed.). Elsevier.