Effectiveness of zipline’s drones’ delivery service in improving postpartum hemorrhage (PPH) management and reducing its related mortality and morbidity: A retrospective cross-sectional survey in Rwanda

Effectiveness of zipline’s drones’ delivery service in improving postpartum hemorrhage (PPH) management and reducing its related mortality and morbidity: A retrospective cross-sectional survey in Rwanda | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effectiveness of zipline’s drones’ delivery service in improving postpartum hemorrhage (PPH) management and reducing its related mortality and morbidity: A retrospective cross-sectional survey in Rwanda Nsengiyumva Richard¹, Nduwayezu Richard², Kagame Alexis², Uhawenimana Thierry Claudien¹, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8454583/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background In sub-Saharan Africa, maternal deaths from postpartum hemorrhage (PPH) often result from delayed access to blood products and emergency medicines. To address last-mile delivery challenges, Rwanda launched the Zipline drone delivery project in 2016. This study evaluated the effectiveness of Zipline’s drone service in improving PPH management and reducing related mortality and morbidity. Methods A retrospective cross-sectional design was used to collect data from maternity registries, patient files, and healthcare providers in 13 rural hospitals served by Zipline drones between May and October 2023. Purposive sampling identified the study population. Data were compared across two timeframes: 12 months before and 12 months after Zipline’s implementation. Results Following Zipline’s introduction, maternal deaths from PPH decreased by 46%, with an 11.5-fold reduction in the likelihood of death. Survival rates rose by 21.4%, transfers for PPH dropped by 61%, and average hospitalization duration declined by 40%, from five to three days. PPH-related morbidity fell by 51%, with a 14.6-fold decrease in likelihood. Over 60% of healthcare providers reported that Zipline drones improved PPH management and contributed to reduced maternal mortality. Conclusion Within one year, Zipline drones significantly reduced maternal mortality and PPH complications, demonstrating their potential to address obstetric emergencies. Expanding drone technology to all health facilities and developing larger drones as airborne ambulances could further reduce delays caused by poor infrastructure and long distances, ultimately improving maternal healthcare outcomes. Effectiveness zipline’s drones postpartum hemorrhage (PPH) management reducing mortality and morbidity Rwanda Figures Figure 1 Figure 2 Figure 3 Background Postpartum hemorrhage (PPH) is a leading global cause of maternal mortality. Globally, more than 14 million women suffer from PPH and its associated complications annually and it causes between 44,000 to 86,000 deaths annually worldwide.( 1 ). Evidence show that PPH accounts for 25–43% of maternal deaths in underdeveloped countries and is the primary cause of death during pregnancy in those countries ( 2 ). In sub-Saharan Africa, 26% of maternal deaths from hemorrhage are attributed to delayed access to blood products and emergency medicines ( 3 ), ( 12 ). Rwanda have already made great progress in combating postpartum deaths. It decreased its maternal mortality rate from “1,160 deaths per 100,000 live births in 2000 to 260 in 2019( 4 ). However, postpartum hemorrhage is still the first cause of maternal death is postpartum hemorrhage and it contributes to nearly a quarter of maternal deaths ( 5 ). In Rwanda, 80% of the population lives in rural areas and the healthcare system faces significant maternal health challenges that have been exacerbated by geographical barriers and limited access to essential services( 6 ). High rates of maternal mortality persist and particularly rural areas suffer the most due to poor transportation infrastructure, which complicates access to healthcare facilities. These challenges exacerbate maternal mortality due to PPH, including complex medical supply chains, limited availability and timely access to blood and essential medicines used in PPH management plus supply expiration, fluctuating hospital demands, and difficult to navigate rural terrain causing delays in PPH related emergency care( 7 ). To ensure fast and convenient access to lifesaving and essential health products, and to overcome healthcare challenges caused by last-mile delivery issues, Rwanda launched the Zipline drone delivery project in 2016( 8 ). This initiative employs unmanned aerial vehicles (UAVs) or autonomous drones specifically designed to transport blood products and critical medicines, especially those used in emergency obstetric care, to remote and hard-to-reach health facilities( 8 ).The deployment of this cutting-edge technology offers a promising solution to the challenges faced in obstetric and maternal healthcare. By improving the delivery speed and reliability of vital medical supplies, it has the potential to significantly enhance healthcare outcomes in these underserved areas( 9 ).Before Zipline’s intervention, healthcare workers in Rwanda relied on refrigerated trucks transporting blood over challenging terrain, often causing substantial delays( 10 ) As of June 2022, Zipline had delivered over 105,000 units of blood to 410 facilities across 27 districts in Rwanda, significantly improving the availability and delivery speed of life-saving supplies ( 11 ). Notably, Zipline’s deliveries primarily support maternity care, transporting blood and essential medications such as oxytocin, tranexamic acid, misoprostol, magnesium sulfate, intravenous fluids, and antibiotics essential for managing PPH. For example, in 2023 alone, Zipline delivered 28,754 units of blood, mostly to women in critical conditions during childbirth, with an average delivery time of 42 minutes from order placement ( 12 ). Despite Rwanda’s recent efforts to introduce various innovations, including high-tech solutions in healthcare delivery to improve health outcomes and overall quality of care, there remains a lack of studies and empirical evidence on the impact of these innovations on patient outcomes. In particular, due to limited data on the effect of drone technology on maternal health in Rwanda, this study aimed to evaluate the effectiveness of Zipline’s drone delivery service in enhancing postpartum hemorrhage management and reducing PPH-related mortality and morbidity. This study will help in advancing evidence-based healthcare innovation for improved maternal health. METHODOLOGY Research Approach and Design This study employed a quantitative research approach utilizing a retrospective cross-sectional design. This design enabled the examination and comparison of postpartum hemorrhage (PPH) cases over two distinct 12-month periods before and after the inauguration of Zipline drone services at selected hospitals. By analyzing existing patient records retrospectively, the study aimed to objectively measure changes in morbidity and mortality related to PPH, while also gathering health care providers’ perceptions through structured surveys to provide comprehensive insights into the intervention’s impact. Study Setting, Population, and Sampling The research was conducted across 13 rural hospitals served by Zipline drones, strategically distributed across all four provinces of Rwanda: West, East, North, and South. The study population included all documented PPH cases within the 12 months preceding and the 12 months following the introduction of Zipline services. Additionally, maternity healthcare providers including midwives and doctors working in these hospitals were surveyed to assess their views on Zipline’s contribution to managing and improving outcomes of PPH. Only rural and remote health facilities were included to focus on areas most affected by logistical challenges, while urban settings such as Kigali city and higher-level referral hospitals, including university teaching hospitals, were excluded. Healthcare providers eligible to participate had to have at least one year of experience at their respective hospitals prior to Zipline’s arrival, excluding newcomers to ensure familiarity with pre- and post-intervention conditions. A purposive sampling method was used to select rural hospitals in each province. The total population sampling principle was applied to review all available PPH case files within the specified timeframe. For healthcare providers, any midwife or doctor meeting eligibility criteria and available during data collection who consented participated in the study. Data Collection Methods and Instruments Quantitative data regarding morbidity and mortality were extracted from patient files using a detailed checklist designed to capture critical indicators. Items on the checklist included total maternal deaths, the number of PPH diagnoses, deaths attributed to PPH, and related complications such as length of hospital stay, hypovolemic shock, cerebral anoxia, renal failure, anemia, puerperal sepsis, postpartum depression and psychosis, hypotension, coagulopathies, cardiac signs, and lactation issues. To enrich the clinical data, a structured questionnaire was administered to maternity healthcare providers to evaluate their perceptions of Zipline drones' effectiveness in PPH management. The questionnaire employed a straightforward “Yes” or “No” response format to gauge agreement or disagreement regarding Zipline’s contribution, facilitating easy quantification and analysis of healthcare providers’ attitudes and experiences related to this innovative delivery method. This mixed data collection approach ensured a robust understanding of both clinical outcomes and frontline perceptions. Data collection procedure After obtaining ethical approval from the University of Rwanda Institutional Review Board (UR/IRB) and formal permission from hospital administrations, the research team including researchers and assistants received thorough training on data collection tools and methods. Upon arrival at maternity departments, additional approval was sought from maternity matrons to access archived patient files. The team systematically reviewed postpartum hemorrhage (PPH) cases from two timeframes: 12 months before and 12 months after the introduction of Zipline drone services. In hospitals with electronic records, relevant data were extracted from maternal death and hospitalization registries within the Health Management Information System (HMIS). A structured checklist was used to consistently document morbidity and mortality data across all hospitals. All collected data were securely compiled and entered into a database for analysis. Additionally, quantitative data on healthcare providers’ perceptions were gathered through structured questionnaires. Prior to interviews, informed consent was obtained after clearly explaining the study’s purpose. Nurses and doctors were then surveyed, with their responses carefully recorded to assess the role of Zipline drones in improving PPH management and patient outcomes. Data Analysis, Reporting, and Bias Management Data analysis was performed using SPSS version 25, utilizing both descriptive and inferential statistical techniques. Descriptive statistics summarized the frequency and percentage distributions of maternal mortality and morbidity related to postpartum hemorrhage (PPH). For inferential analysis, a paired T-test was conducted to find out the difference in means of mortality, morbidity and length of hospitalization between before and after zipline drones introduction in settings. Additionally, bivariate regression analysis was used to assess and predict the effect of Zipline drone implementation on reducing PPH-related mortality and morbidity. The statistical significance was set at a p-value of less than 0.05 and a 95% confidence interval to ensure robustness of the results in To provide a balanced and accurate evaluation, potential confounding variables such as healthcare professionals’ expertise, staff-to-patient ratios, patients’ obstetric history, delivery methods, hospital infrastructure, and available medical equipment were carefully identified and controlled for during data processing and reporting. This comprehensive approach ensured that observed effects were attributable to Zipline drone services rather than extraneous factors. Moreover, triangulation was employed to minimize bias by cross-verifying quantitative findings from patient medical records with quantitative data from healthcare providers’ self-reported perceptions. This method enhanced the validity and completeness of the analysis, enabling a more nuanced understanding of Zipline's true impact on PPH management and outcomes, while preventing overestimation of its influence. Ethical considerations This study was conducted in strict accordance with ethical guidelines and received official approval from the University of Rwanda Institutional Review Board (UR/IRB), under approval number 133/CMHS IRB/2023. Prior to data collection, formal permission was also obtained from each participating hospital to ensure compliance with institutional policies and respect for the research environment. To protect the rights and privacy of healthcare providers participating in the study, anonymity was rigorously maintained by using coded identifiers instead of personal information. Participants were thoroughly informed about their rights, including voluntary participation, confidentiality, and the assurance that their responses would remain private throughout the research process. This approach fostered trust and ethical engagement between researchers and participants. Regarding patient records, particularly those related to Postpartum Hemorrhage (PPH), stringent confidentiality protocols were followed. Access to medical files was limited strictly to the research team members, with no unauthorized personnel allowed to view or handle sensitive information. Additionally, all patient data were anonymized by replacing names with unique codes, to ensure the protection of patient confidentiality and upholding the highest standards of ethical integrity throughout the study. RESULTS Patterns of PPH-related mortality and survival during the 12 months before and after the initiation of Zipline drones Figure 1. Distribution PPH-related mortality and survival during the 12 months before and after the initiation of Zipline drones Figure 1 illustrate the PPH related mortality &survival patterns 12 months before and after Zipline initiation. It shows that after the implementation of Zipline, maternal death due to postpartum hemorrhage (PPH) dropped from 147 to 79. Survival rates for PPH cases rose from 61.7% to 83.1%, with the mean number of cases surviving increasing from 722 to 891. Additionally, the total cases of PPH requiring transfer reduced from 113 to 44, and the average hospitalization duration for PPH cases shortened from 5 days to 3 days, highlighting the positive impact of Zipline's intervention in maternal healthcare. PPH deaths patterns per blood group in all hospitals Figure 2.Distribution of PPH deaths patterns per blood group in all hospitals The figure 2 illustrates a significant reduction in postpartum hemorrhage (PPH) deaths across all blood groups and Rh factors in 13 hospitals following the introduction of Zipline drones, with the total number of deaths decreasing from 147 to 79; the three blood groups that experienced the most substantial reductions in PPH deaths were AB- (from 29 to 6), O- (from 27 to 12), and A- (from 23 to 11), indicating that Zipline's intervention had a particularly strong impact on these rare blood groups. PPH deaths per hospital, Distance &time to nearest blood transfusion region center Figure 3. Distribution of PPH deaths per hospital, Distance &time to nearest blood transfusion region center Figure 3 illustrates the distribution of maternal deaths caused by postpartum hemorrhage (PPH) in relation to hospital distance from transfusion centers. Before the introduction of Zipline drones, hospitals located further from transfusion centers experienced significantly higher numbers of deaths compared to those closer to the centers. However, after the implementation of Zipline, a consistent reduction in PPH-related deaths was observed across all hospitals, irrespective of their distance. For instance, hospital H6, located 158 km away (a 400-minutes round trip), saw a decrease in deaths from 19 to 8. Similarly, hospital H2, situated just 24 km away, experienced a reduction in deaths from 6 to 4. These results demonstrate the positive impact of Zipline on reducing maternal deaths, regardless of the proximity of hospitals to transfusion centers. Distribution of PPH related morbidity 12 months before and 12 months after Zipline introduction at selected facilities Table 1: Distribution of PPH associated complication/morbidity 12 months before and after Zipline services at all health facilities 12 MONTHS BEFORE ZPL 12 MONTHS AFTER ZPL PPH associated complication/Morbidity Frequency(n), % Frequency(n), % Total case diagnosed with PPH 869(100) 970(100) PPH cases complicated with hypovolemic shock 207(23.8) 115(11.9) PPH cases complicated with Coma and other neurologic problems 85(9.8) 49(5.1) PPH cases complicated with renal problems 37(4.3) 13(1.3) PPH cases complicated with anemia 182(20.9) 109(11.2) PPH cases complicated with post-partum depression/other post-partum mental health disorders (anxiety, stress) 64(74) 30(3.1) PPH cases complicated with cardiac problems/cardiopathies 18(2.1) 11(1.1) PPH cases complicated with coagulopathies 27(3.1) 9(1.0) Breastfeeding issues 285(32.8) 98(10.1) Table 1 presented above illustrates the prevalence of various complications among mothers experiencing postpartum hemorrhage (PPH) before and after the implementation of zipline drone technology. After the implementation of the ZPL intervention, the total number of diagnosed postpartum hemorrhage (PPH) cases increased from 869 to 970. However, there was a significant reduction in the frequency of PPH-associated complications and morbidities. Hypovolemic shock cases decreased from 23.8% to 11.9%, coma and other neurological problems dropped from 9.8% to 5.1%, and renal problems fell from 4.3% to 1.3%. Anemia complications reduced from 20.9% to 11.2%, while postpartum depression and other mental health disorders declined sharply from 7.4% to 3.1%. Cardiac complications lessened from 2.1% to 1.1%, and coagulopathies decreased from 3.1% to 1.0%. Breastfeeding issues also showed substantial improvement, with cases declining from 32.8% to 10.1%. Health care providers’ perceptions on impact of zipline on PPH management and survival in maternity. HEALTH CARE PROVIDERS PERCEPTIONS/RESPONSES ON IMPACT OF ZIPLINE DRONES ON PPH MANAGEMENT&SURVIVAL Yes % No % There was delayed blood transfusion intervention before zipline 142 88.8 18 11.3 There is a time blood was completely missed blood during the resuscitation before zipline 136 85.0 24 15.0 Missed blood product led to transfer the PPH patient to another facility 127 79.4 33 20.6 Patient was transferred due to stock out of blood in the middle of patient resuscitation 98 61.3 62 38.8 PPH related complications were many before zipline 72 45.0 88 55.0 Chance of Surviving PPH was low before zipline 69 43.1 91 56.9 Chance of Surviving PPH increased after zipline 85 53.1 75 46.9 Rh negative patients could be transferred most of the time they are PPH candidates before Zipline 74 46.3 86 53.8 After Zipline I feel comfortable and less stressed while managing a PPH case with blood 153 95.6 7 4.4 Zipline helped reducing PPH mortality cases in our setting 88 55.0 72 45.0 We could wait for blood 1 hour or above waiting for blood before zipline 93 58.1 67 41.9 There is no difference between before &After Zipline regarding PPH management& Survival 54 33.8 106 66.3 Table 2: Health care providers’ perceptions on impact of zipline on PPH management and survival in maternity The findings presented in Table 2 highlight healthcare providers' views on the transformative role of Zipline drones in managing postpartum hemorrhage (PPH) and improving patient survival. Among the 160 staff surveyed, the majority (88.8%) responded that prior to the introduction of Zipline drones, delays in blood transfusions, 85%reported instances where blood was entirely unavailable during maternal resuscitation, and a great number (61.3%) pointed out stock-outs that led to the need for patient transfers to other facilities. More on that, over one quarter (45%) responded that before Zipline drones there was a high prevalence of PPH complications, while 43.1% indicated that survival rates for mothers with PPH were low. However, on the other side, over half of participants (53.1%) reported that after the introduction of Zipline drones’ technology there is increased survival rates and chances among women with PPH. Furthermore, 55% credited the Zipline project with reducing PPH-related mortality in their healthcare facilities. Furthermore, the majority (66.3%) of health care providers disagreed with the claim that there was no difference between pre- and post-Zipline scenarios, affirming the positive impact of the intervention on PPH management and outcomes. Relationship between Zipline Drones use and prevalence of PPH related morbidity and mortality at selected hospitals Comparison of mortality, morbidity, and hospitalization length before and after the Zipline drone project Table 3. Paired T-test Levene’Test t-test equality of Means Sig.(2-tailed) F t df Mortality (Pre vs Post ZPL drones) 18.24 3.15 969 0.002 3.10 867 Morbidity (Pre vs Post ZPL drones) 13.51 2.93 745 0.030 2.00 732 Hospitalization length (Pre vs Post ZPL drones) 11.23 0.81 180 0.021 0.50 164 The paired T-test was conducted to find out the difference in means of mortality, morbidity and length of hospitalization between before and after zipline drones introduction in settings. As shown in Table 3, there is a statistically significant differences in mortality, morbidity, and hospitalization length before and after the introduction of drones. Specifically, mortality rates significantly decreased one year after the implementation of zipline drones (t = 3.15, p = 0.002). Morbidity also showed a significant reduction following drone use (t = 2.90, p = 0.030). Additionally, hospitalization length was significantly shorter one year after the drones were introduced (t = 0.80, p = 0.021). These findings suggest that the use of drones is linked to meaningful improvements in these clinical outcomes. Regression analysis Table 4. Regression analysis Variable OR 95% CI p-value PPH Mortality 12 months before Zipline 11.05 < 0.000** 12 months after Zipline [10.81-14.03] PPH Morbidity 12 months before Zipline 14.68 [7.55-10.52] 0.048* 12 months after Zipline Notes: * Statistically significant at p<0.05; ** statistical significance level at p<0.001 A binary regression analysis was conducted to investigate the relationship between the usage of Zipline drones and the prevalence of postpartum hemorrhage (PPH)-related morbidity and mortality in selected hospitals. The analysis compared data from 12 months prior to the introduction of the drones with data from the 12 months following their implementation. As shown in Table 4, the period before the use of Zipline drones was significantly associated with higher odds of PPH-related mortality and morbidity. In contrast, the findings indicate a substantial reduction in these PPH outcomes after the drones were introduced. Specifically, PPH-associated mortality was markedly higher in the 12 months preceding the use of Zipline drones. Following their introduction, the likelihood of maternal death due to PPH decreased 11.5-fold across all studied hospitals (OR=11.05, 95% CI: 10.81–14.03, p < .001). Regarding morbidity, the analysis revealed that PPH-associated complications were also higher during the 12 months before the drones were introduced. A 14.6-fold reduction (OR=4.68, 95% CI: 7.55–10.52, p = 0.048) in the likelihood of PPH-related complications was observed across all 13 hospitals within the 12-month post-implementation period. Discussion Our study found that the introduction of Zipline's drone delivery system in healthcare has significantly improved the management of postpartum hemorrhage (PPH) and reduced adverse outcomes associated with the PPH. It was revealed that following the implementation of Zipline’s service, maternal deaths due to PPH decreased by 46%, the likelihood of maternal death decreased 11.5-fold, survival rates increased by 21.4%, transfers for PPH cases dropped by 61%, and the average length of hospitalization was reduced by 40%, from five days to three. Also, the PPH related morbidity dropped by average 51% while the likelihood of PPH associated morbidity reduced by 14.6-fold. More on that, majority of health care providers affirmed the introduction of Zipline drones helped them to manage correctly the PPH and perceived that project to have contributed to the reduction of maternal mortality associated with PPH. These findings underscore the transformative potential of drone-enabled logistics in maternal healthcare, particularly in resource-limited settings. Regarding the impact of Zipline drones on maternal mortality reduction, our results align with those of Jeon et al. ( 13 ), in Rwanda which found that Zipline's drone deliveries reduced in-hospital maternal mortality from PPH by over 50%.Also, our results extend findings from Ghana showing 56.4% fewer maternal deaths at drone-served facilities( 14 ). However, there is a notable lack of research and comparative data examining the effects of Zipline’s drones on PPH patient transfers and hospitalization duration. To date, this study is the only one available that has explored these specific aspects, underscoring the need for further research in this area. The greatest PPH management and outcomes improvements after Zipline drones use were noted particularly for patients requiring rare blood products and very distant hospital compared to transfusion center. As for rare blood products, the most pronounced improvements were observed in AB- (79% reduction), O- (56%), and A- (52%). These findings align with broader evidence on drone-enabled medical supply chains while highlighting unique advantages for managing scarce blood inventories. We also revealed the introduction of Zipline drones triggered significant advancements in managing postpartum hemorrhage (PPH) and improving patient outcomes at the study settings, particularly for cases requiring rare blood products and for hospitals situated far from transfusion centers. We realized that Zipline Drones use might have helped addressing the challenges of supplying rare blood types, with the most notable improvements observed in the availability of AB- blood (79% reduction in shortages), followed by O- (56% reduction) and A- (52% reduction). Such findings not only support existing evidence on the efficiency of drone-enabled medical supply chains but also underscore the unique capabilities of these technologies in optimizing the distribution and management of scarce blood inventories, ensuring life-saving interventions are readily accessible in critical situations. Concerning the distance and time from the transfusion center, we revealed that the introduction of Zipline's drones has profoundly reduced geographic disparities in postpartum hemorrhage (PPH) mortality, morbidities, hospitalization length. By providing swift and reliable transportation of blood products to hospitals, regardless of their distance from transfusion centers, the project triggered a remarkable PPH good management and outcomes across both close and the very remote hospitals. These findings may be supplemented with those of a previous research conducted in Rwanda, that revealed the overall average time for drone delivery was 49.6 minutes ( 15 ). This contrasts sharply with the pre-Zipline era, where higher rates of PPH-related deaths, complications, patient transfers, and delays in hospitalization were predominantly concentrated in remote areas as it was reported( 16 ). Thus, we may argue that the adoption of drone technology has therefore played a crucial role in addressing these challenges, ensuring equitable healthcare access and improving overall outcomes for PPH patients. Conclusion and recommendation The findings of our study underscore the transformative impact of introducing Zipline drones on maternal healthcare in selected hospitals. Within just one year of implementation, these drones have substantially reduced postpartum hemorrhage (PPH)-related maternal mortality and morbidity, reflecting an essential shift in the ability to respond to obstetric emergencies. Their ability to supply rare blood types and specialized blood products swiftly has improved the management of PPH cases significantly. Additionally, the utilization of Zipline drones has reduced the need for transferring PPH cases to other facilities and contributed to a shorter length of hospital stays for affected patients, ensuring timely and effective care. To build upon this progress, expanding the use of Zipline drones across all healthcare facilities could yield even greater improvements in maternal and neonatal health outcomes. By broadening the range of services provided especially in the management of obstetric and gynecological emergencies the drones have the potential to drive an exponential decline in maternal and neonatal morbidity and mortality. Their implementation could represent a pivotal advancement in closing healthcare gaps in remote and underserved areas. Furthermore, we propose a reimagining and redesign of Zipline drone technology to accommodate larger sizes and sturdier structures, enabling their use as airborne ambulances. This innovation could revolutionize emergency transportation, mitigating maternal and neonatal mortality caused by delays often attributed to damaged infrastructure or the challenges of reaching referral hospitals from remote areas. Such enhancements would provide a critical lifeline to patients requiring immediate care and significantly strengthen healthcare delivery systems. Limitation of the study Our results should be interpreted cautiously carefully, as it is not definitive that the decline in deaths can be solely attributed to the use of drones for blood transportation. While healthcare experts highlighted the significance of zipline in blood supply, the study did not consider other potential factors like hospital accreditation and various variables that could have contributed to the decrease in maternal mortality rates post-zipline implementation. Therefore, further research is recommended to accurately ascertain the specific impact of zipline services on reducing maternal deaths due to postpartum hemorrhage. In addition, this study was conducted in hospitals served by Zipline, comparing data from only 12 months before and after its initiation, which may limit the generalizability of the findings. While the results suggest a decline in maternal mortality and morbidity following Zipline drone deliveries, they should be interpreted cautiously, as other factors such as hospital accreditation, healthcare accessibility, and clinical practice improvements were not accounted for. Future studies with a longer follow-up period, ideally three to five years, and a broader scope of influencing variables are recommended to better assess the drones' true impact on maternal health outcomes. Abbreviations PPH Postpartum hemorrhage UAV Unmanned aerial vehicle HMIS Health Management Information System IRB Institutional Review Board ZPL Zipline Declarations Ethics approval and consent to participate Approved by University of Rwanda Institutional Review Board (133/CMHS IRB/2023). Informed consent obtained from providers; patient data anonymized. Availability of data and materials All data supporting the findings of this study are available within the paper and its Supplementary Information. Competing interests The authors declare no competing interests. Funding The study had no funding. Consent to Publish declaration The authors declare that they consent to the publication of this manuscript. No individual person’s data (such as medical records, images, or personal details) are included in this article. Therefore, specific consent to publish is not applicable. Authors' contributions RN: Conceptualization, methodology, data analysis, writing-original draft. RN, RN, AK, UTC, AU, BO, UA, HI, FU, NB, NA, HF, PK: Investigation, data collection, review/editing. All authors read and approved final manuscript. Acknowledgements This study is a result of efforts from many stakeholders and partners that collaborated with the Zipline Rwanda and University of Rwanda. Our research team wishes to extend thanks to all members, hospitals and individuals who strived and offered their efforts and inputs at various levels during this study. Finally, special thanks to all members of technical and research working groups from Zipline who contributed in the follow up of this study References UNICEF, UNFPA. Trends in maternal mortality estimates by WHO. World Bank Group and UNDESA/ Population Division; 2023. International Federation of Gynecology and Obstetrics. New WHO Postpartum Haemorrhage Roadmap – an essential tool to reduce maternal mortality between 2023 and 2030. 2023. Moyo E, Dzinamarira T, Moyo P, Murewanhema G, Ross A. Magnitude and Determinants of Postpartum Hemorrhage in Sub-Saharan Africa: A Systematic Review and Meta-Analysis. 2024. UNFPA.East and Southern Africa. A transformative journey to reach zero preventable maternal deaths in Rwanda. 2024. Bazirete O, Nzayirambaho M, Umubyeyi A, Uwimana MC, Evans M. Influencing factors for prevention of postpartum hemorrhage and early detection of childbearing women at risk in Northern Province of Rwanda: beneficiary and health worker perspectives. BMC Pregnancy Childbirth. 2020;20(1). Selden O, Rusingiza E, Balkrishnan R, Overview. Infrastructural Challenges, Barriers to Access, and Progress for Rwanda’s Healthcare System: A Review. ntegrative J Med Sci. 2025;12. Kpienbaareh D, Atuoye KN, Ngabonzima A, Bagambe PG, Rulisa S, Luginaah I, et al. Spatio-temporal disparities in maternal health service utilization in Rwanda: What next for SDGs? Soc Sci Med. 2019;226:164–75. GAVI.The vaccine Alliance. Rwanda launches world’s first national drone delivery service powered by Zipline. 2016. Allan-Matheson D. Unmanned Aerial Vehicles in Healthcare: Now and for the Future–investing into emerging technology for rapid vaccination delivery in Healthcare, Globally and especially in rural Africa. 2018. Gangwal A, Jain A, Mohanta S. Blood Delivery by Drones: A Case Study on Zipline. Int J Innov Res Sci Eng Technol. 2019;8:8760–6. Nisingizwe MP, Ndishimye P, Swaibu K, Nshimiyimana L, Karame PDV. Effect of unmanned aerial vehicle (drone) delivery on blood product delivery time and wastage in Rwanda: a retrospective, cross-sectional study and time series analysis. Lancet Glob Heal. 2022;1(10):4. Zipline-Rwanda. Preventing maternal deaths through faster blood delivery. 2024. Jeon HH, Lucarelli C, Mazarati JB, Ngabo D, Song H. Last-mile Delivery in Health Care: Drone Delivery for Blood Products in Rwanda. Available SSRN. 2022. Kremer P, Haruna F, Briegleb C, Amoah ME, Oteng KF, Boadi S. Tinkorang E. A mixed method impact assessment of the use of aerial logistics to improve maternal health and emergencies outcomes in the Ashanti Region of Ghana. BMC Health Serv Res. 2025;25(1):360. Nisingizwe MP, Ndishimye P, Swaibu K, Nshimiyimana L, Karame P, Dushimiyimana V. Effect of unmanned aerial vehicle (drone) delivery on blood product delivery time and wastage in Rwanda: a retrospective, cross-sectional study and time series analysis. Lancet Glob Health. 2022;10(4):e564–9. Tuyishime EMJP, Banguti RPNC, Cassidy A, Dylan L, Bould VCK. Improving Post-Delivery Complications and Quality of Birth Practice in District Hospitals in Rwanda. Public Heal Bull Rwanda. 2016. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 17 Feb, 2026 Reviewers agreed at journal 14 Feb, 2026 Reviewers agreed at journal 08 Feb, 2026 Reviewers invited by journal 05 Feb, 2026 Editor invited by journal 05 Jan, 2026 Editor assigned by journal 01 Jan, 2026 Submission checks completed at journal 01 Jan, 2026 First submitted to journal 26 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8454583","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":587898775,"identity":"eabe7623-4733-40a4-a632-adf90703bd59","order_by":0,"name":"Nsengiyumva Richard¹","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIiWNgGAWjYDACZgY2ECXHDyITCkjQYizZANJiQJw9YC2JGw6AKGK0mLczP3tc8MeGcfP51YkfHhgwyPOLHcCvReYwm7nxzLY0ZrMbbzdLAB1mOHN2An4tEsw8bNK8DYfZzG6c3QDSkmBwmxgtPH/+8xjPOLv5Bwla2A5IGPD3biPWFjYzad62ZAOJG7zbLBIMJIjwC//hZ0CH2dX395/dfPNHhY08vzQBLUiawSoliFUOAvwHSFE9CkbBKBgFIwkAANaEOrHiWmxZAAAAAElFTkSuQmCC","orcid":"","institution":"University of Rwanda","correspondingAuthor":true,"prefix":"","firstName":"Nsengiyumva","middleName":"","lastName":"Richard¹","suffix":""},{"id":587898776,"identity":"265338b7-2029-4a79-bf0a-b83ab474eda0","order_by":1,"name":"Nduwayezu Richard²","email":"","orcid":"","institution":"University of Rwanda","correspondingAuthor":false,"prefix":"","firstName":"Nduwayezu","middleName":"","lastName":"Richard²","suffix":""},{"id":587898777,"identity":"8d73d6c7-5a7b-456f-acd7-bf3c743a6d01","order_by":2,"name":"Kagame Alexis²","email":"","orcid":"","institution":"University of Rwanda","correspondingAuthor":false,"prefix":"","firstName":"Kagame","middleName":"","lastName":"Alexis²","suffix":""},{"id":587898778,"identity":"3351ee4f-249d-4aac-9be5-0ceda379a465","order_by":3,"name":"Uhawenimana Thierry Claudien¹","email":"","orcid":"","institution":"University of Rwanda","correspondingAuthor":false,"prefix":"","firstName":"Uhawenimana","middleName":"Thierry","lastName":"Claudien¹","suffix":""},{"id":587898780,"identity":"223d43b5-bf59-43b7-b44b-d148d0ba20df","order_by":4,"name":"UMUKUNZI Alice¹","email":"","orcid":"","institution":"University of Rwanda","correspondingAuthor":false,"prefix":"","firstName":"UMUKUNZI","middleName":"","lastName":"Alice¹","suffix":""},{"id":587898781,"identity":"f07be0b3-98fa-41a6-a4ff-f029f702581a","order_by":5,"name":"Bazirete Olive¹","email":"","orcid":"","institution":"University of Rwanda","correspondingAuthor":false,"prefix":"","firstName":"Bazirete","middleName":"","lastName":"Olive¹","suffix":""},{"id":587898782,"identity":"1445321a-54d5-4033-ac78-b2c80bdf2356","order_by":6,"name":"Uwineza Angelique³","email":"","orcid":"","institution":"Johns Hopkins Program for International Education in Gynecology and Obstetrics (Jhpiego)","correspondingAuthor":false,"prefix":"","firstName":"Uwineza","middleName":"","lastName":"Angelique³","suffix":""},{"id":587898783,"identity":"478b2bb8-6068-404b-82b3-9bcc4d117c66","order_by":7,"name":"Habimana Innocent⁴","email":"","orcid":"","institution":"World Health Organization, Rwanda Country Office","correspondingAuthor":false,"prefix":"","firstName":"Habimana","middleName":"","lastName":"Innocent⁴","suffix":""},{"id":587898784,"identity":"4c508fbb-fa0e-4b43-813d-362244754da2","order_by":8,"name":"Uwimana Francoise⁵","email":"","orcid":"","institution":"Kibagabaga Hospital","correspondingAuthor":false,"prefix":"","firstName":"Uwimana","middleName":"","lastName":"Francoise⁵","suffix":""},{"id":587898785,"identity":"630e8054-1ec4-471e-834d-61bd9904bad8","order_by":9,"name":"Ndimurukundo Bauduine¹","email":"","orcid":"","institution":"University of Rwanda","correspondingAuthor":false,"prefix":"","firstName":"Ndimurukundo","middleName":"","lastName":"Bauduine¹","suffix":""},{"id":587898788,"identity":"bc6f75cd-fd8f-4f9a-aacf-38e9fa19972d","order_by":10,"name":"Nshimiyimana Aboubakar²","email":"","orcid":"","institution":"University of Rwanda","correspondingAuthor":false,"prefix":"","firstName":"Nshimiyimana","middleName":"","lastName":"Aboubakar²","suffix":""},{"id":587898789,"identity":"98d88185-8af6-4fd2-8983-24a40c8e76f2","order_by":11,"name":"Haruna Florence⁶","email":"","orcid":"","institution":"Zipline, Global Health Impact and Fulfillment Operations","correspondingAuthor":false,"prefix":"","firstName":"Haruna","middleName":"","lastName":"Florence⁶","suffix":""},{"id":587898790,"identity":"23ce8ca5-45b4-41cc-b4b5-b8770045b6cf","order_by":12,"name":"Pedro Kremer⁶","email":"","orcid":"","institution":"Zipline, Global Health Impact and Fulfillment Operations","correspondingAuthor":false,"prefix":"","firstName":"Pedro","middleName":"","lastName":"Kremer⁶","suffix":""}],"badges":[],"createdAt":"2025-12-26 10:38:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8454583/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8454583/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102326404,"identity":"8d6f6b10-e3b5-460f-8dd1-0bb6035087b7","added_by":"auto","created_at":"2026-02-10 14:35:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":62243,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution PPH-related mortality and survival during the 12 months before and after the initiation of Zipline drones\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8454583/v1/d36e24419537806b1b69cf9b.png"},{"id":102326405,"identity":"5b55a565-6688-4434-bc4b-5e585915f5e1","added_by":"auto","created_at":"2026-02-10 14:35:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":23781,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of PPH deaths patterns per blood group in all hospitals\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8454583/v1/5fe7a71940575dd160f0f67e.png"},{"id":102326406,"identity":"9318bb86-4455-4202-a9c5-7487e6c7825d","added_by":"auto","created_at":"2026-02-10 14:35:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":34835,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of PPH deaths per hospital, Distance \u0026amp;time to nearest blood transfusion region center\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8454583/v1/348cb284890daa5399679f8f.png"},{"id":102326408,"identity":"a7407162-f328-43c8-a0cd-db3a15cdc609","added_by":"auto","created_at":"2026-02-10 14:35:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1233774,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8454583/v1/31e0abe7-9fdb-475f-a33a-6900cf528d26.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of zipline’s drones’ delivery service in improving postpartum hemorrhage (PPH) management and reducing its related mortality and morbidity: A retrospective cross-sectional survey in Rwanda","fulltext":[{"header":"Background","content":"\u003cp\u003ePostpartum hemorrhage (PPH) is a leading global cause of maternal mortality. Globally, more than 14\u0026nbsp;million women suffer from PPH and its associated complications annually and it causes between 44,000 to 86,000 deaths annually worldwide.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Evidence show that PPH accounts for 25\u0026ndash;43% of maternal deaths in underdeveloped countries and is the primary cause of death during pregnancy in those countries (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In sub-Saharan Africa, 26% of maternal deaths from hemorrhage are attributed to delayed access to blood products and emergency medicines (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Rwanda have already made great progress in combating postpartum deaths. It decreased its maternal mortality rate from \u0026ldquo;1,160 deaths per 100,000 live births in 2000 to 260 in 2019(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). However, postpartum hemorrhage is still the first cause of maternal death is postpartum hemorrhage and it contributes to nearly a quarter of maternal deaths (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Rwanda, 80% of the population lives in rural areas and the healthcare system faces significant maternal health challenges that have been exacerbated by geographical barriers and limited access to essential services(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). High rates of maternal mortality persist and particularly rural areas suffer the most due to poor transportation infrastructure, which complicates access to healthcare facilities. These challenges exacerbate maternal mortality due to PPH, including complex medical supply chains, limited availability and timely access to blood and essential medicines used in PPH management plus supply expiration, fluctuating hospital demands, and difficult to navigate rural terrain causing delays in PPH related emergency care(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo ensure fast and convenient access to lifesaving and essential health products, and to overcome healthcare challenges caused by last-mile delivery issues, Rwanda launched the Zipline drone delivery project in 2016(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). This initiative employs unmanned aerial vehicles (UAVs) or autonomous drones specifically designed to transport blood products and critical medicines, especially those used in emergency obstetric care, to remote and hard-to-reach health facilities(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).The deployment of this cutting-edge technology offers a promising solution to the challenges faced in obstetric and maternal healthcare. By improving the delivery speed and reliability of vital medical supplies, it has the potential to significantly enhance healthcare outcomes in these underserved areas(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).Before Zipline\u0026rsquo;s intervention, healthcare workers in Rwanda relied on refrigerated trucks transporting blood over challenging terrain, often causing substantial delays(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAs of June 2022, Zipline had delivered over 105,000 units of blood to 410 facilities across 27 districts in Rwanda, significantly improving the availability and delivery speed of life-saving supplies (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Notably, Zipline\u0026rsquo;s deliveries primarily support maternity care, transporting blood and essential medications such as oxytocin, tranexamic acid, misoprostol, magnesium sulfate, intravenous fluids, and antibiotics essential for managing PPH. For example, in 2023 alone, Zipline delivered 28,754 units of blood, mostly to women in critical conditions during childbirth, with an average delivery time of 42 minutes from order placement (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite Rwanda\u0026rsquo;s recent efforts to introduce various innovations, including high-tech solutions in healthcare delivery to improve health outcomes and overall quality of care, there remains a lack of studies and empirical evidence on the impact of these innovations on patient outcomes. In particular, due to limited data on the effect of drone technology on maternal health in Rwanda, this study aimed to evaluate the effectiveness of Zipline\u0026rsquo;s drone delivery service in enhancing postpartum hemorrhage management and reducing PPH-related mortality and morbidity. This study will help in advancing evidence-based healthcare innovation for improved maternal health.\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eResearch Approach and Design\u003c/h2\u003e \u003cp\u003eThis study employed a quantitative research approach utilizing a retrospective cross-sectional design. This design enabled the examination and comparison of postpartum hemorrhage (PPH) cases over two distinct 12-month periods before and after the inauguration of Zipline drone services at selected hospitals. By analyzing existing patient records retrospectively, the study aimed to objectively measure changes in morbidity and mortality related to PPH, while also gathering health care providers\u0026rsquo; perceptions through structured surveys to provide comprehensive insights into the intervention\u0026rsquo;s impact.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Setting, Population, and Sampling\u003c/h3\u003e\n\u003cp\u003eThe research was conducted across 13 rural hospitals served by Zipline drones, strategically distributed across all four provinces of Rwanda: West, East, North, and South. The study population included all documented PPH cases within the 12 months preceding and the 12 months following the introduction of Zipline services. Additionally, maternity healthcare providers including midwives and doctors working in these hospitals were surveyed to assess their views on Zipline\u0026rsquo;s contribution to managing and improving outcomes of PPH. Only rural and remote health facilities were included to focus on areas most affected by logistical challenges, while urban settings such as Kigali city and higher-level referral hospitals, including university teaching hospitals, were excluded. Healthcare providers eligible to participate had to have at least one year of experience at their respective hospitals prior to Zipline\u0026rsquo;s arrival, excluding newcomers to ensure familiarity with pre- and post-intervention conditions. A purposive sampling method was used to select rural hospitals in each province. The total population sampling principle was applied to review all available PPH case files within the specified timeframe. For healthcare providers, any midwife or doctor meeting eligibility criteria and available during data collection who consented participated in the study.\u003c/p\u003e\n\u003ch3\u003eData Collection Methods and Instruments\u003c/h3\u003e\n\u003cp\u003eQuantitative data regarding morbidity and mortality were extracted from patient files using a detailed checklist designed to capture critical indicators. Items on the checklist included total maternal deaths, the number of PPH diagnoses, deaths attributed to PPH, and related complications such as length of hospital stay, hypovolemic shock, cerebral anoxia, renal failure, anemia, puerperal sepsis, postpartum depression and psychosis, hypotension, coagulopathies, cardiac signs, and lactation issues. To enrich the clinical data, a structured questionnaire was administered to maternity healthcare providers to evaluate their perceptions of Zipline drones' effectiveness in PPH management. The questionnaire employed a straightforward \u0026ldquo;Yes\u0026rdquo; or \u0026ldquo;No\u0026rdquo; response format to gauge agreement or disagreement regarding Zipline\u0026rsquo;s contribution, facilitating easy quantification and analysis of healthcare providers\u0026rsquo; attitudes and experiences related to this innovative delivery method. This mixed data collection approach ensured a robust understanding of both clinical outcomes and frontline perceptions.\u003c/p\u003e\n\u003ch3\u003eData collection procedure\u003c/h3\u003e\n\u003cp\u003eAfter obtaining ethical approval from the University of Rwanda Institutional Review Board (UR/IRB) and formal permission from hospital administrations, the research team including researchers and assistants received thorough training on data collection tools and methods. Upon arrival at maternity departments, additional approval was sought from maternity matrons to access archived patient files.\u003c/p\u003e \u003cp\u003eThe team systematically reviewed postpartum hemorrhage (PPH) cases from two timeframes: 12 months before and 12 months after the introduction of Zipline drone services. In hospitals with electronic records, relevant data were extracted from maternal death and hospitalization registries within the Health Management Information System (HMIS). A structured checklist was used to consistently document morbidity and mortality data across all hospitals.\u003c/p\u003e \u003cp\u003eAll collected data were securely compiled and entered into a database for analysis. Additionally, quantitative data on healthcare providers\u0026rsquo; perceptions were gathered through structured questionnaires. Prior to interviews, informed consent was obtained after clearly explaining the study\u0026rsquo;s purpose. Nurses and doctors were then surveyed, with their responses carefully recorded to assess the role of Zipline drones in improving PPH management and patient outcomes.\u003c/p\u003e\n\u003ch3\u003eData Analysis, Reporting, and Bias Management\u003c/h3\u003e\n\u003cp\u003eData analysis was performed using SPSS version 25, utilizing both descriptive and inferential statistical techniques. Descriptive statistics summarized the frequency and percentage distributions of maternal mortality and morbidity related to postpartum hemorrhage (PPH). For inferential analysis, a paired T-test was conducted to find out the difference in means of mortality, morbidity and length of hospitalization between before and after zipline drones introduction in settings. Additionally, bivariate regression analysis was used to assess and predict the effect of Zipline drone implementation on reducing PPH-related mortality and morbidity. The statistical significance was set at a p-value of less than 0.05 and a 95% confidence interval to ensure robustness of the results in\u003c/p\u003e \u003cp\u003eTo provide a balanced and accurate evaluation, potential confounding variables such as healthcare professionals\u0026rsquo; expertise, staff-to-patient ratios, patients\u0026rsquo; obstetric history, delivery methods, hospital infrastructure, and available medical equipment were carefully identified and controlled for during data processing and reporting. This comprehensive approach ensured that observed effects were attributable to Zipline drone services rather than extraneous factors.\u003c/p\u003e \u003cp\u003eMoreover, triangulation was employed to minimize bias by cross-verifying quantitative findings from patient medical records with quantitative data from healthcare providers\u0026rsquo; self-reported perceptions. This method enhanced the validity and completeness of the analysis, enabling a more nuanced understanding of Zipline's true impact on PPH management and outcomes, while preventing overestimation of its influence.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003eThis study was conducted in strict accordance with ethical guidelines and received official approval from the University of Rwanda Institutional Review Board (UR/IRB), under approval number 133/CMHS IRB/2023. Prior to data collection, formal permission was also obtained from each participating hospital to ensure compliance with institutional policies and respect for the research environment.\u003c/p\u003e \u003cp\u003eTo protect the rights and privacy of healthcare providers participating in the study, anonymity was rigorously maintained by using coded identifiers instead of personal information. Participants were thoroughly informed about their rights, including voluntary participation, confidentiality, and the assurance that their responses would remain private throughout the research process. This approach fostered trust and ethical engagement between researchers and participants.\u003c/p\u003e \u003cp\u003eRegarding patient records, particularly those related to Postpartum Hemorrhage (PPH), stringent confidentiality protocols were followed. Access to medical files was limited strictly to the research team members, with no unauthorized personnel allowed to view or handle sensitive information. Additionally, all patient data were anonymized by replacing names with unique codes, to ensure the protection of patient confidentiality and upholding the highest standards of ethical integrity throughout the study.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003ePatterns of PPH-related mortality and survival during the 12 months before and after the initiation of Zipline drones\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 1. Distribution PPH-related mortality and survival during the 12 months before and after the initiation of Zipline drones\u003c/p\u003e\n\u003cp\u003eFigure 1 illustrate the PPH related mortality \u0026amp;survival patterns 12 months before and after Zipline initiation. It shows that after the implementation of Zipline, maternal death due to postpartum hemorrhage (PPH) dropped from 147 to 79. Survival rates for PPH cases rose from 61.7% to 83.1%, with the mean number of cases surviving increasing from 722 to 891. Additionally, the total cases of PPH requiring transfer reduced from 113 to 44, and the average hospitalization duration for PPH cases shortened from 5 days to 3 days, highlighting the positive impact of Zipline\u0026apos;s intervention in maternal healthcare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePPH deaths patterns per blood group in all hospitals\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 2.Distribution of PPH deaths patterns per blood group in all hospitals\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe figure 2 illustrates a significant reduction in postpartum hemorrhage (PPH) deaths across all blood groups and Rh factors in 13 hospitals following the introduction of Zipline drones, with the total number of deaths decreasing from 147 to 79; the three blood groups that experienced the most substantial reductions in PPH deaths were AB- (from 29 to 6), O- (from 27 to 12), and A- (from 23 to 11), indicating that Zipline\u0026apos;s intervention had a particularly strong impact on these rare blood groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePPH deaths per hospital, Distance \u0026amp;time to nearest blood transfusion region center\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 3. Distribution of PPH deaths per hospital, Distance \u0026amp;time to nearest blood transfusion region center\u003c/p\u003e\n\u003cp\u003eFigure 3 illustrates the distribution of maternal deaths caused by postpartum hemorrhage (PPH) in relation to hospital distance from transfusion centers. Before the introduction of Zipline drones, hospitals located further from transfusion centers experienced significantly higher numbers of deaths compared to those closer to the centers. However, after the implementation of Zipline, a consistent reduction in PPH-related deaths was observed across all hospitals, irrespective of their distance. For instance, hospital H6, located 158 km away (a 400-minutes round trip), saw a decrease in deaths from 19 to 8. Similarly, hospital H2, situated just 24 km away, experienced a reduction in deaths from 6 to 4. These results demonstrate the positive impact of Zipline on reducing maternal deaths, regardless of the proximity of hospitals to transfusion centers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDistribution of PPH related morbidity 12 months before and 12 months after Zipline introduction at selected facilities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1: Distribution of PPH associated complication/morbidity 12 months before and after Zipline services at all health facilities\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"678\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 378px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e12 MONTHS BEFORE ZPL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e12 MONTHS AFTER ZPL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 378px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePPH associated complication/Morbidity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eFrequency(n), %\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eFrequency(n), %\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 378px;\"\u003e\n \u003cp\u003eTotal case diagnosed with PPH \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 138px;\"\u003e\n \u003cp\u003e869(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 162px;\"\u003e\n \u003cp\u003e970(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 378px;\"\u003e\n \u003cp\u003ePPH cases complicated with hypovolemic shock\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 138px;\"\u003e\n \u003cp\u003e207(23.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 162px;\"\u003e\n \u003cp\u003e115(11.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 378px;\"\u003e\n \u003cp\u003ePPH cases complicated with Coma and other neurologic problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 138px;\"\u003e\n \u003cp\u003e85(9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 162px;\"\u003e\n \u003cp\u003e49(5.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 378px;\"\u003e\n \u003cp\u003ePPH cases complicated with renal problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 138px;\"\u003e\n \u003cp\u003e37(4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 162px;\"\u003e\n \u003cp\u003e13(1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 378px;\"\u003e\n \u003cp\u003ePPH cases complicated with anemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 138px;\"\u003e\n \u003cp\u003e182(20.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 162px;\"\u003e\n \u003cp\u003e109(11.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 378px;\"\u003e\n \u003cp\u003ePPH cases complicated with post-partum depression/other post-partum mental health disorders (anxiety, stress)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 138px;\"\u003e\n \u003cp\u003e64(74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 162px;\"\u003e\n \u003cp\u003e30(3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 378px;\"\u003e\n \u003cp\u003ePPH cases complicated with cardiac problems/cardiopathies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 138px;\"\u003e\n \u003cp\u003e18(2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 162px;\"\u003e\n \u003cp\u003e11(1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 378px;\"\u003e\n \u003cp\u003ePPH cases complicated with coagulopathies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 138px;\"\u003e\n \u003cp\u003e27(3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 162px;\"\u003e\n \u003cp\u003e9(1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 378px;\"\u003e\n \u003cp\u003eBreastfeeding issues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 138px;\"\u003e\n \u003cp\u003e285(32.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 162px;\"\u003e\n \u003cp\u003e98(10.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 1 presented above illustrates the prevalence of various complications among mothers experiencing postpartum hemorrhage (PPH) before and after the implementation of zipline drone technology. After the implementation of the ZPL intervention, the total number of diagnosed postpartum hemorrhage (PPH) cases increased from 869 to 970. However, there was a significant reduction in the frequency of PPH-associated complications and morbidities. Hypovolemic shock cases decreased from 23.8% to 11.9%, coma and other neurological problems dropped from 9.8% to 5.1%, and renal problems fell from 4.3% to 1.3%. Anemia complications reduced from 20.9% to 11.2%, while postpartum depression and other mental health disorders declined sharply from 7.4% to 3.1%. Cardiac complications lessened from 2.1% to 1.1%, and coagulopathies decreased from 3.1% to 1.0%. Breastfeeding issues also showed substantial improvement, with cases declining from 32.8% to 10.1%.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealth care providers\u0026rsquo; perceptions on impact of zipline on PPH management and survival in maternity.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"723\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 505px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHEALTH CARE PROVIDERS PERCEPTIONS/RESPONSES ON IMPACT OF ZIPLINE DRONES ON PPH MANAGEMENT\u0026amp;SURVIVAL\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 505px;\"\u003e\n \u003cp\u003eThere was delayed blood transfusion intervention before zipline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e88.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e11.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 505px;\"\u003e\n \u003cp\u003eThere is a time blood was completely missed blood during the resuscitation before zipline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e136\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e85.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e15.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 505px;\"\u003e\n \u003cp\u003eMissed blood product led to transfer the PPH patient to another facility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e127\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e79.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e20.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 505px;\"\u003e\n \u003cp\u003ePatient was transferred due to stock out of blood in the middle of patient resuscitation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e61.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e38.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 505px;\"\u003e\n \u003cp\u003ePPH related complications were many before zipline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e45.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e55.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 505px;\"\u003e\n \u003cp\u003eChance of Surviving PPH was low before zipline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e43.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e56.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 505px;\"\u003e\n \u003cp\u003eChance of Surviving PPH increased after zipline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e53.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e46.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 505px;\"\u003e\n \u003cp\u003eRh negative patients could be transferred most of the time they are PPH candidates before Zipline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e46.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e53.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 505px;\"\u003e\n \u003cp\u003eAfter Zipline I feel comfortable and less stressed while managing a PPH case with blood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e153\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e95.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 505px;\"\u003e\n \u003cp\u003eZipline helped reducing PPH mortality cases in our setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e55.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e45.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 505px;\"\u003e\n \u003cp\u003eWe could wait for blood 1 hour or above waiting for blood before zipline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e58.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e41.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 505px;\"\u003e\n \u003cp\u003eThere is no difference between before \u0026amp;After Zipline regarding PPH management\u0026amp; Survival\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e33.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e66.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 505px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Table 2: Health care providers\u0026rsquo; perceptions on impact of zipline on PPH management and survival in maternity\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings presented in Table 2 highlight healthcare providers\u0026apos; views on the transformative role of Zipline drones in managing postpartum hemorrhage (PPH) and improving patient survival. Among the 160 staff surveyed, the majority (88.8%) responded that prior to the introduction of Zipline drones, delays in blood transfusions, 85%reported instances where blood was entirely unavailable during maternal resuscitation, and a great number (61.3%) pointed out stock-outs that led to the need for patient transfers to other facilities. More on that, over one quarter (45%) responded that before Zipline drones there was a high prevalence of PPH complications, while 43.1% indicated that survival rates for mothers with PPH were low. However, on the other side, over half of participants (53.1%) reported that after the introduction of Zipline drones\u0026rsquo; technology there is increased survival rates and chances among women with PPH. Furthermore, 55% credited the Zipline project with reducing PPH-related mortality in their healthcare facilities. Furthermore, the majority (66.3%) of health care providers disagreed with the claim that there was no difference between pre- and post-Zipline scenarios, affirming the positive impact of the intervention on PPH management and outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRelationship between Zipline Drones use and prevalence of PPH related morbidity and mortality at selected hospitals\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of mortality, morbidity, and hospitalization length before and after the Zipline drone project\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 3. Paired T-test\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevene\u0026rsquo;Test\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et-test equality of Means\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSig.(2-tailed)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003edf\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMortality (Pre vs Post ZPL drones)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e18.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e3.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e969\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 192px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e3.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e867\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMorbidity (Pre vs Post ZPL drones)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e13.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e2.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e745\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 192px;\"\u003e\n \u003cp\u003e0.030\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e732\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospitalization length (Pre vs Post ZPL drones)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e11.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 192px;\"\u003e\n \u003cp\u003e0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e164\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe paired T-test was conducted to find out the difference in means of mortality, morbidity and length of hospitalization between before and after zipline drones introduction in settings. As shown in Table 3, there is a statistically significant differences in mortality, morbidity, and hospitalization length before and after the introduction of drones. Specifically, mortality rates significantly decreased one year after the implementation of zipline drones (t = 3.15, p = 0.002). Morbidity also showed a significant reduction following drone use (t = 2.90, p = 0.030). Additionally, hospitalization length was significantly shorter one year after the drones were introduced (t = 0.80, p = 0.021). These findings suggest that the use of drones is linked to meaningful improvements in these clinical outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRegression analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 4. Regression analysis\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"636\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; OR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 636px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePPH Mortality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 291px;\"\u003e\n \u003cp\u003e12 months before Zipline\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11.05 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u003c/strong\u003e0.000**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 291px;\"\u003e\n \u003cp\u003e12 months after Zipline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e[10.81-14.03]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 291px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePPH Morbidity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 291px;\"\u003e\n \u003cp\u003e12 months before Zipline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e14.68 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e[7.55-10.52]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e0.048*\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 291px;\"\u003e\n \u003cp\u003e12 months after Zipline\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 636px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 636px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eNotes: *\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eStatistically significant at p\u0026lt;0.05; ** statistical significance level at p\u0026lt;0.001\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 255px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 131px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eA binary regression analysis was conducted to investigate the relationship between the usage of Zipline drones and the prevalence of postpartum hemorrhage (PPH)-related morbidity and mortality in selected hospitals. The analysis compared data from 12 months prior to the introduction of the drones with data from the 12 months following their implementation. As shown in Table 4, the period before the use of Zipline drones was significantly associated with higher odds of PPH-related mortality and morbidity. In contrast, the findings indicate a substantial reduction in these PPH outcomes after the drones were introduced. Specifically, PPH-associated mortality was markedly higher in the 12 months preceding the use of Zipline drones. Following their introduction, the likelihood of maternal death due to PPH decreased 11.5-fold across all studied hospitals (OR=11.05, 95% CI: 10.81\u0026ndash;14.03, p \u0026lt; .001). Regarding morbidity, the analysis revealed that PPH-associated complications were also higher during the 12 months before the drones were introduced. A 14.6-fold reduction (OR=4.68, 95% CI: 7.55\u0026ndash;10.52, p = 0.048) in the likelihood of PPH-related complications was observed across all 13 hospitals within the 12-month post-implementation period.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study found that the introduction of Zipline's drone delivery system in healthcare has significantly improved the management of postpartum hemorrhage (PPH) and reduced adverse outcomes associated with the PPH. It was revealed that following the implementation of Zipline’s service, maternal deaths due to PPH decreased by 46%, the likelihood of maternal death decreased 11.5-fold, survival rates increased by 21.4%, transfers for PPH cases dropped by 61%, and the average length of hospitalization was reduced by 40%, from five days to three. Also, the PPH related morbidity dropped by average 51% while the likelihood of PPH associated morbidity reduced by 14.6-fold. More on that, majority of health care providers affirmed the introduction of Zipline drones helped them to manage correctly the PPH and perceived that project to have contributed to the reduction of maternal mortality associated with PPH. These findings underscore the transformative potential of drone-enabled logistics in maternal healthcare, particularly in resource-limited settings.\u003c/p\u003e \u003cp\u003eRegarding the impact of Zipline drones on maternal mortality reduction, our results align with those of Jeon et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), in Rwanda which found that Zipline's drone deliveries reduced in-hospital maternal mortality from PPH by over 50%.Also, our results extend findings from Ghana showing 56.4% fewer maternal deaths at drone-served facilities(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). However, there is a notable lack of research and comparative data examining the effects of Zipline’s drones on PPH patient transfers and hospitalization duration. To date, this study is the only one available that has explored these specific aspects, underscoring the need for further research in this area.\u003c/p\u003e \u003cp\u003eThe greatest PPH management and outcomes improvements after Zipline drones use were noted particularly for patients requiring rare blood products and very distant hospital compared to transfusion center. As for rare blood products, the most pronounced improvements were observed in AB- (79% reduction), O- (56%), and A- (52%). These findings align with broader evidence on drone-enabled medical supply chains while highlighting unique advantages for managing scarce blood inventories.\u003c/p\u003e \u003cp\u003eWe also revealed the introduction of Zipline drones triggered significant advancements in managing postpartum hemorrhage (PPH) and improving patient outcomes at the study settings, particularly for cases requiring rare blood products and for hospitals situated far from transfusion centers. We realized that Zipline Drones use might have helped addressing the challenges of supplying rare blood types, with the most notable improvements observed in the availability of AB- blood (79% reduction in shortages), followed by O- (56% reduction) and A- (52% reduction). Such findings not only support existing evidence on the efficiency of drone-enabled medical supply chains but also underscore the unique capabilities of these technologies in optimizing the distribution and management of scarce blood inventories, ensuring life-saving interventions are readily accessible in critical situations. Concerning the distance and time from the transfusion center, we revealed that the introduction of Zipline's drones has profoundly reduced geographic disparities in postpartum hemorrhage (PPH) mortality, morbidities, hospitalization length. By providing swift and reliable transportation of blood products to hospitals, regardless of their distance from transfusion centers, the project triggered a remarkable PPH good management and outcomes across both close and the very remote hospitals. These findings may be supplemented with those of a previous research conducted in Rwanda, that revealed the overall average time for drone delivery was 49.6 minutes (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This contrasts sharply with the pre-Zipline era, where higher rates of PPH-related deaths, complications, patient transfers, and delays in hospitalization were predominantly concentrated in remote areas as it was reported(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Thus, we may argue that the adoption of drone technology has therefore played a crucial role in addressing these challenges, ensuring equitable healthcare access and improving overall outcomes for PPH patients.\u003c/p\u003e "},{"header":"Conclusion and recommendation","content":"\u003cp\u003eThe findings of our study underscore the transformative impact of introducing Zipline drones on maternal healthcare in selected hospitals. Within just one year of implementation, these drones have substantially reduced postpartum hemorrhage (PPH)-related maternal mortality and morbidity, reflecting an essential shift in the ability to respond to obstetric emergencies. Their ability to supply rare blood types and specialized blood products swiftly has improved the management of PPH cases significantly. Additionally, the utilization of Zipline drones has reduced the need for transferring PPH cases to other facilities and contributed to a shorter length of hospital stays for affected patients, ensuring timely and effective care.\u003c/p\u003e\u003cp\u003eTo build upon this progress, expanding the use of Zipline drones across all healthcare facilities could yield even greater improvements in maternal and neonatal health outcomes. By broadening the range of services provided especially in the management of obstetric and gynecological emergencies the drones have the potential to drive an exponential decline in maternal and neonatal morbidity and mortality. Their implementation could represent a pivotal advancement in closing healthcare gaps in remote and underserved areas.\u003c/p\u003e\u003cp\u003eFurthermore, we propose a reimagining and redesign of Zipline drone technology to accommodate larger sizes and sturdier structures, enabling their use as airborne ambulances. This innovation could revolutionize emergency transportation, mitigating maternal and neonatal mortality caused by delays often attributed to damaged infrastructure or the challenges of reaching referral hospitals from remote areas. Such enhancements would provide a critical lifeline to patients requiring immediate care and significantly strengthen healthcare delivery systems.\u003c/p\u003e\u003ch2\u003eLimitation of the study\u003c/h2\u003e\u003cp\u003eOur results should be interpreted cautiously carefully, as it is not definitive that the decline in deaths can be solely attributed to the use of drones for blood transportation. While healthcare experts highlighted the significance of zipline in blood supply, the study did not consider other potential factors like hospital accreditation and various variables that could have contributed to the decrease in maternal mortality rates post-zipline implementation. Therefore, further research is recommended to accurately ascertain the specific impact of zipline services on reducing maternal deaths due to postpartum hemorrhage. In addition, this study was conducted in hospitals served by Zipline, comparing data from only 12 months before and after its initiation, which may limit the generalizability of the findings. While the results suggest a decline in maternal mortality and morbidity following Zipline drone deliveries, they should be interpreted cautiously, as other factors such as hospital accreditation, healthcare accessibility, and clinical practice improvements were not accounted for. Future studies with a longer follow-up period, ideally three to five years, and a broader scope of influencing variables are recommended to better assess the drones' true impact on maternal health outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePPH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePostpartum hemorrhage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUAV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnmanned aerial vehicle\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHMIS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Management Information System\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIRB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInstitutional Review Board\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eZPL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eZipline\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproved by University of Rwanda Institutional Review Board (133/CMHS IRB/2023). Informed consent obtained from providers; patient data anonymized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data supporting the findings of this study are available within the paper and its Supplementary Information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003cbr\u003e\u003c/strong\u003eThe study had no funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they consent to the publication of this manuscript. No individual person\u0026rsquo;s data (such as medical records, images, or personal details) are included in this article. Therefore, specific consent to publish is not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRN: Conceptualization, methodology, data analysis, writing-original draft. RN, RN, AK, UTC, AU, BO, UA, HI, FU, NB, NA, HF, PK: Investigation, data collection, review/editing. All authors read and approved final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003cbr\u003e\u003c/strong\u003eThis study is a result of efforts from many stakeholders and partners that collaborated with the Zipline Rwanda and University of Rwanda. Our research team wishes to extend thanks to all members, hospitals and individuals who strived and offered their efforts and inputs at various levels during this study. Finally, special thanks to all members of technical and research working groups from Zipline who contributed in the follow up of this study\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUNICEF, UNFPA. Trends in maternal mortality estimates by WHO. World Bank Group and UNDESA/ Population Division; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInternational Federation of Gynecology and Obstetrics. New WHO Postpartum Haemorrhage Roadmap \u0026ndash; an essential tool to reduce maternal mortality between 2023 and 2030. 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoyo E, Dzinamarira T, Moyo P, Murewanhema G, Ross A. Magnitude and Determinants of Postpartum Hemorrhage in Sub-Saharan Africa: A Systematic Review and Meta-Analysis. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNFPA.East and Southern Africa. A transformative journey to reach zero preventable maternal deaths in Rwanda. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBazirete O, Nzayirambaho M, Umubyeyi A, Uwimana MC, Evans M. Influencing factors for prevention of postpartum hemorrhage and early detection of childbearing women at risk in Northern Province of Rwanda: beneficiary and health worker perspectives. BMC Pregnancy Childbirth. 2020;20(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSelden O, Rusingiza E, Balkrishnan R, Overview. Infrastructural Challenges, Barriers to Access, and Progress for Rwanda\u0026rsquo;s Healthcare System: A Review. ntegrative J Med Sci. 2025;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKpienbaareh D, Atuoye KN, Ngabonzima A, Bagambe PG, Rulisa S, Luginaah I, et al. Spatio-temporal disparities in maternal health service utilization in Rwanda: What next for SDGs? Soc Sci Med. 2019;226:164\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGAVI.The vaccine Alliance. Rwanda launches world\u0026rsquo;s first national drone delivery service powered by Zipline. 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllan-Matheson D. Unmanned Aerial Vehicles in Healthcare: Now and for the Future\u0026ndash;investing into emerging technology for rapid vaccination delivery in Healthcare, Globally and especially in rural Africa. 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGangwal A, Jain A, Mohanta S. Blood Delivery by Drones: A Case Study on Zipline. Int J Innov Res Sci Eng Technol. 2019;8:8760\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNisingizwe MP, Ndishimye P, Swaibu K, Nshimiyimana L, Karame PDV. Effect of unmanned aerial vehicle (drone) delivery on blood product delivery time and wastage in Rwanda: a retrospective, cross-sectional study and time series analysis. Lancet Glob Heal. 2022;1(10):4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZipline-Rwanda. Preventing maternal deaths through faster blood delivery. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJeon HH, Lucarelli C, Mazarati JB, Ngabo D, Song H. Last-mile Delivery in Health Care: Drone Delivery for Blood Products in Rwanda. Available SSRN. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKremer P, Haruna F, Briegleb C, Amoah ME, Oteng KF, Boadi S. Tinkorang E. A mixed method impact assessment of the use of aerial logistics to improve maternal health and emergencies outcomes in the Ashanti Region of Ghana. BMC Health Serv Res. 2025;25(1):360.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNisingizwe MP, Ndishimye P, Swaibu K, Nshimiyimana L, Karame P, Dushimiyimana V. Effect of unmanned aerial vehicle (drone) delivery on blood product delivery time and wastage in Rwanda: a retrospective, cross-sectional study and time series analysis. Lancet Glob Health. 2022;10(4):e564\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTuyishime EMJP, Banguti RPNC, Cassidy A, Dylan L, Bould VCK. Improving Post-Delivery Complications and Quality of Birth Practice in District Hospitals in Rwanda. Public Heal Bull Rwanda. 2016.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Effectiveness, zipline’s drones, postpartum hemorrhage (PPH), management, reducing mortality and morbidity, Rwanda","lastPublishedDoi":"10.21203/rs.3.rs-8454583/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8454583/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn sub-Saharan Africa, maternal deaths from postpartum hemorrhage (PPH) often result from delayed access to blood products and emergency medicines. To address last-mile delivery challenges, Rwanda launched the Zipline drone delivery project in 2016. This study evaluated the effectiveness of Zipline\u0026rsquo;s drone service in improving PPH management and reducing related mortality and morbidity.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective cross-sectional design was used to collect data from maternity registries, patient files, and healthcare providers in 13 rural hospitals served by Zipline drones between May and October 2023. Purposive sampling identified the study population. Data were compared across two timeframes: 12 months before and 12 months after Zipline\u0026rsquo;s implementation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFollowing Zipline\u0026rsquo;s introduction, maternal deaths from PPH decreased by 46%, with an 11.5-fold reduction in the likelihood of death. Survival rates rose by 21.4%, transfers for PPH dropped by 61%, and average hospitalization duration declined by 40%, from five to three days. PPH-related morbidity fell by 51%, with a 14.6-fold decrease in likelihood. Over 60% of healthcare providers reported that Zipline drones improved PPH management and contributed to reduced maternal mortality.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWithin one year, Zipline drones significantly reduced maternal mortality and PPH complications, demonstrating their potential to address obstetric emergencies. Expanding drone technology to all health facilities and developing larger drones as airborne ambulances could further reduce delays caused by poor infrastructure and long distances, ultimately improving maternal healthcare outcomes.\u003c/p\u003e","manuscriptTitle":"Effectiveness of zipline’s drones’ delivery service in improving postpartum hemorrhage (PPH) management and reducing its related mortality and morbidity: A retrospective cross-sectional survey in Rwanda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-10 14:35:25","doi":"10.21203/rs.3.rs-8454583/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-17T17:06:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"131212251643090587243486555702335633812","date":"2026-02-14T07:32:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"302254950671674510716293974952539040636","date":"2026-02-09T02:05:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-05T12:51:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-05T17:56:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-02T01:03:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-02T01:02:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-12-26T10:29:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"04483350-7f53-426b-91c5-03d61f453a8a","owner":[],"postedDate":"February 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-10T14:35:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-10 14:35:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8454583","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8454583","identity":"rs-8454583","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}