Published in The Lancet Global Health, the research, part of the large-scale E-MOTIVE cluster-randomised trial, analysed more than 2,500 births across 39 hospitals in Nigeria, Kenya, Tanzania, and South Africa. The study assessed when and how PPH is diagnosed and compared clinical approaches across different national contexts.
Understanding the Global Challenge
Postpartum haemorrhage remains the leading cause of maternal mortality worldwide, responsible for around 70,000 preventable deaths each year, according to the World Health Organization (WHO). The majority of these deaths occur in low- and middle-income countries, where delays in recognising and treating excessive bleeding are common.
Traditionally, PPH has been defined as blood loss of 500 millilitres or more within 24 hours of birth. However, evidence has long suggested that the most severe bleeding and maternal deaths occur within the first one to two hours after delivery. The new study challenges the adequacy of this traditional threshold and timing, providing real-world data to inform global re-evaluation of PPH definitions.
Explainer video
Professor Arri Coomarasamy explains in more detail in this video
Findings from the E-MOTIVE Study
The nested observational study found that women in settings using a lower diagnostic threshold of 300 mL combined with at least one abnormal clinical sign, such as rapid pulse, low blood pressure, or heavy continuous bleeding, were diagnosed substantially faster than those in hospitals applying the standard 500 mL threshold.
Median time to diagnosis was 15–17 minutes in Nigeria, Kenya, and Tanzania, compared with 30 minutes in South Africa, where the higher threshold predominated. Across all sites, every case of postpartum haemorrhage requiring an intervention was diagnosed within 90 minutes of birth, underscoring the importance of this early critical window for response.
This approach builds on the E-MOTIVE trial’s use of a calibrated obstetric drape to objectively measure blood loss, alongside a treatment bundle known as MOTIVE (uterine massage, oxytocics, intravenous fluids, and genital tract examination). Implementing this early detection and response system led to a 60% reduction in severe PPH, surgical interventions, or maternal deaths compared with standard care.
Towards an Evidence-Based Redefinition of PPH
The study’s authors note that relying solely on a fixed blood loss volume may underestimate risk, especially among women with pre-existing anaemia or other clinical vulnerabilities. For such women, even a moderate loss of blood can be life-threatening. The data therefore support context-specific diagnostic thresholds that integrate both objective measurement and clinical assessment.
The findings also contribute to ongoing WHO efforts to reappraise the definition and management of postpartum haemorrhage, encouraging policies that prioritise earlier detection and intervention; particularly in resource-limited settings.
“By focusing on the timing and method of diagnosis, this research provides actionable evidence that can directly inform global guidelines,” said the study’s lead author, Dr Kristie-Marie Mammoliti of the University of Birmingham.
“Our results highlight that earlier recognition and treatment of postpartum bleeding can save lives and reduce complications.” Implications for Practice and Policy The authors argue that the first 90 minutes after birth should be recognised as a critical window for identifying and managing PPH. Training health-care workers to use both objective blood loss measurement and clinical judgement can substantially improve response times and outcomes. These insights are particularly relevant for low-resource health systems, where delays in identifying postpartum bleeding are often linked to higher maternal mortality. The study also emphasises that implementation success depends on well-trained midwives, consistent use of calibrated tools, and supportive clinical environments that empower early intervention.
A Step Forward for Global Maternal Health
This research provides robust, multi-country evidence that earlier recognition of postpartum haemorrhage, using 300 mL thresholds combined with clinical signs, can prevent deterioration, reduce the need for emergency surgery, and improve survival. It offers a scientific foundation for global health agencies seeking to update definitions and protocols that have remained largely unchanged for decades.
The work forms part of a broader global effort led by the E-MOTIVE team, the World Health Organization, and partners including Ammalife, to improve maternal care through innovation, implementation research, and equitable collaboration.
E-Motive video
Publication
Click here to read the full publication in The Lancet Global
For media enquiries
Rob Phillips, Communications Manager at the Nuffield Department of Women’s & Reproductive Health, University of Oxford, rob.phillips@wrh.ox.ac.uk