INTRODUCTION

In an attempt to reignite the reduction in maternal deaths that has stalled since 2015,¹ WHO has recently published a postpartum haemorrhage (PPH) roadmap following wide consultation.² The roadmap seeks to reduce mortality through progress in four areas: research, standards, advocacy and implementation. But some have argued that global maternal deaths are primarily a result of poverty and global inequity, and that there will be little improvement until that fundamental problem is addressed. So how much can really be achieved, and are there practical interventions that can be made despite limited resources?

2 CAUSES OF MATERNAL DEATHS

Although rates of clinical PPH are much higher in high-resource settings and are increasing with time, death from PPH is closely associated with poverty, both on an individual and health system level. As a result, of the estimated 80 000 PPH deaths annually, nearly 90% occur in countries with low- and low/middle socio-demographic indexes.³ India, Pakistan, DRC, Ethiopia and Nigeria together have nearly 30 000 haemorrhage deaths annually, accounting for 37% of the global total. The same inequity is seen within countries as well, with maternal deaths occurring largely within the poorest in the society.⁴

The classic PPH is an atonic bleed after a spontaneous vaginal birth but most of these women can be relatively easily cured with uterotonics and so account for few deaths where healthcare is provided. Confidential enquiries show how PPH deaths come largely from two groups, representing the well-recognised split of ‘too little, too late’ and ‘too much, too soon’.^{5, 6} The former group comprises those who frequently give birth outside of the health system for reasons of distrust, poverty, ignorance or lack of transport. They are typically anaemic, malnourished and have infectious disease comorbidities. They present in a moribund state after tortuous journeys with untreated atonic uterus, ruptured uterus, genital tears or retained placenta, and the local health system cannot rescue them. Tragically, sometimes this group includes some women who have given birth in facilities and who have relatively minor, easily treatable complications, but whose care has been delayed and inadequate. Death results from delays, a lack of adequately trained staff, and shortages of blood, drugs and consumables.⁷ The latter group is those whose PPHs occur after current or prior intervention: those undergoing emergency caesarean sections (CSs) or who have placenta praevia/accreta or rupture following previous CSs. With intervention rates spiralling worldwide in an attempt to protect mothers and babies, this is becoming a critical group worldwide.

3 IMPLEMENTATION PRIORITIES

What can be done to address this terrible toll? Without doubt, the long-term solution is country-wide economic growth, unhindered by conflict, with free services provided for those who are do not have the means to obtain them privately. Economic growth allows governments to lift the poorest out of poverty and to improve their provision of maternal healthcare, education and transport. All countries who currently enjoy low maternal mortality rates (e.g. Sweden, UK, Poland) have used this method to progress through the process of obstetric transition,⁸ thereby reducing their MMR from the levels seen in much of sub-Saharan Africa today. But this is not easy, and neither is it in the hands of health workers. And so, as politicians work to eradicate world poverty and uplift services, there is a need to identify high-impact interventions that provide the very best care for the available money. They also need to be able to reach the women who need them most.

Given these broad principles, there are five broad areas that are likely to provide the best value for money in PPH care and that would make a real change.

1. High-quality intrapartum care by midwives supported by doctors. Care during labour and birth is the front-line of the battle against PPH. In some settings, this is primarily the role of doctors. But not only is this unnecessary for healthy women having normal births, repeated studies have shown that scaling up midwifery is a cost-effective way of reducing maternal and perinatal mortality.⁹ It also has the effect of reducing intervention rates which themselve cause PPH. However, a midwifery-led system requires an extensive support system around it. Well-trained medical staff are critical to deal with high-risk women and complications of labour, and to provide interventions when necessary. Their clinical skills are needed to identify correctly those women who need a caesarean and then carry it out rapidly and safely, as well safely assisting vaginal births with forceps or ventouse. Ongoing multi-disciplinary training of this maternity team in emergency obstetric care is required along with clear-sighted, compassionate leadership to teach and conduct ongoing audit and review. Managers are needed to ensure that staff, medicines and consumables are readily available when needed. This all needs to be wrapped in respectful care for staff and pregnant women as, without it, women (and staff) will stay away.
2. Antenatal anaemia treatment. Antenatal anaemia is very common worldwide and is one of the mechanisms by which PPH mortality is linked to poverty. Anaemia not only makes atonic PPH more likely, it also makes women more vulnerable to death when bleeding does occur. Thankfully, the detection and treatment of anaemia in antenatal clinics is a low-cost midwifery intervention and should be a priority if PPH deaths are to be prevented. Ongoing studies are comparing the relative efficacy of oral and intravenous iron.
3. PPH management. For many years, the focus of PPH research has been on the optimal way to prevent PPH. Repeated studies have shown the importance of atonic uterus as a cause of PPH and that oxytocin (usually given intramuscularly, but as an intravenous infusion in high-risk cases) is highly effective at reducing PPH rates.¹⁰ The use of prophylactic tranexamic acid (TXA) for high-risk women may also prove to be an important strategy. However, much attention has turned now to PPH treatment. The E-MOTIVE study demonstrated that routine, real-time measurement of blood loss, and the provision of a bundle of care (uterine massage, oxytocic, TXA, i.v. infusion, and examination) before blood loss reaches 500 ml (or 300 ml in high-risk cases) not only reduced blood loss but PPH deaths as well.¹¹ The investigators found that many women with excessive blood loss remained untreated and the use of a routine blood loss collection drape improved treatment rates. Although the study was conducted in four sub-Saharan African countries, the study has implications for births in all settings, and the search is on for the production of low-cost, reusable, environmentally friendly blood loss measurement techniques. Ongoing studies will identify the optimal initial oxytocic to be used, and whether TXA can be given intramuscularly. In those with refractory PPH, external uterine compression and intrauterine devices (balloons of various types, suction or packing with gauze) are widely used, although both their absolute and relative efficacy are unknown. For those with surgical and placental causes of PPH, skilled surgery is needed to repair tears and ruptures, and to remove adherent placentas. At district hospitals, generalist doctors must be taught the relatively simple surgical skills needed to manage refractory PPH short of hysterectomy: uterine compression sutures, uterine artery ligation, and uterine tourniquet. All can be done prior to referral to higher level hospital if required.
4. Health systems. In the countries where most maternal deaths occur, healthcare workers work against the odds to provide safer services for women. But fully staffed primary and secondary health services free at the point of use are rare, and there is often inadequate emergency transport between levels of care. Weak governance structures mean that the already precarious rural government health systems are often further depleted by corruption, disrespectful care and staff non-attendance, with women needing to provide bribes to obtain even basic care. This burden disproportionately affects the poorest and leads to their reluctance to attend health centres. It also results in long delays in obtaining effective emergency care as women seek money, functioning health units, and taxi drivers willing to transport bleeding or dying women in their vehicles. Strengthening fragile health systems will take increased funding along with powerful national leadership. Funding is necessary to ensure that all health centres and hospitals are functioning effectively and that there are secure and effective supply chains for vital medication and consumables. Community transport systems are a priority, along with anti-shock garments to keep women alive during transfer. But there are also local, low-cost actions that can make a real difference. Community mobilisation through women’s groups can empower women, leading to mutual support, improved emergency transport and care-seeking behaviour. Improved local management is needed so that staff themselves receive respectful care, continuous professional development and appropriate pay. The use of WhatsApp (or its local equivalent) is proving very useful to disseminate quality improvement (QI) messages, request and receive advice, and to arrange transfers between facilities. It also assists when it comes to achieving rapid maternal and perinatal death review, a process that aids staff to self-reflect while the case is still fresh in their minds. Simple, facility-based QI projects using QI journals can also help build a staff community and provide them with a sense of pride in their work.
5. Blood transfusion. Although expensive and logistically complex to achieve, the provision of safe blood for transfusion is so important for saving women’s lives that it enters the list of critical interventions. In many low-income settings, the arrival of un-booked women in shock from PPH is a common occurrence, and although atonic uterus may respond to uterotonics and tamponade, many have retained placenta or uterine rupture and require immediate surgery. Taking these women to theatre when shocked, hypovolaemic and with coagulation abnormalities carries a very high mortality and preoperative blood transfusion is transformative. To achieve this, central and tertiary hospitals need well-organised blood banks with cross-matched blood and blood components (fresh frozen plasma, platelets and fibrinogen). All district hospitals need functional fridges with backup generators to store O Neg and group-specific blood for emergency transfusion. Freeze-dried plasma (that can be reconstituted with sterile water) is a new, accessible form of clotting factor, as it can be stored unrefrigerated for 2 years.

Over the last decades, many researchers have sought the ‘magic bullet’, a single intervention that will solve the problem of maternal mortality from PPH. Sadly, however, there are no simple fixes as PPH deaths largely result from system failures that are not easily solved. PPH death rates can be viewed as a marker of an effective healthcare system, testing not only the accessibility and function of rural maternity services, but also their ability to escalate care rapidly in cases of emergency so that women receive timely high-level surgical and anaesthetic interventions. The WHO PPH Roadmap provides a robust way forward to achieve this with its four pillars of advocacy, implementation, research and standard setting. But of these, implementation is key. Academics have been justifiably criticised for spending too much time focusing on trying to find new solutions, while forgetting the lessons of history that saw massive reductions in PPH deaths in western countries 100 years ago despite relatively primitive levels of care.¹² We may argue about the optimal components of the intervention, but we should keep in mind the saying that ‘the best is the enemy of the good’. We cannot wait until we are sure what ‘perfect care’ looks like before we start making changes. The PPH Roadmap may set the agenda up to 2030, but the implementation of packages to improve PPH care must start now.