Why are Postpartum Haemorrhage Deaths Still a Global Health Crisis?
14 June 2010 – Dhaka, Bangladesh – A mom and her new born baby at the Maternal & Child Health Training Institute for medically needy in Dhaka: Maternal mortality ratio remains a very serious concern in Asia and the Pacific – especially in South and South-West Asia, which has one third of the world’s maternal deaths. Only 5% of births in Nepal and 19% in India were attended by skilled personnel in 2006. (UNESCAP 2009)

Postpartum haemorrhage (PPH), a blood loss of 500 ml or more within 24 hours of birth, is the leading cause of maternal mortality worldwide, according to the World Health Organization. Around 14 million women die a year, said Metin Gülmezoğlu, executive director of the Concept Foundation. Yet, PPH is mainly preventable. Some 99% of PPH deaths have been eliminated in high-income countries, and 99% occur in low- and middle-income countries – specifically in sub-Saharan Africa and South Asia.

Why do we have these deaths in 2023, and what can be done to prevent them?

This was the topic of a recent Geneva Graduate Institute/Global Health Centre event: “Dying for Life: Are Mothers Still a Global Health Priority?” The November 27 event was moderated by Claire Somerville, director of the Geneva Graduate Institute’s Gender Centre.

Gülmezoğlu said that there is a general lack of research and development around new solutions for PPH, in addition to a challenge of being able to implement the results of those studies that do happen in lower-income countries where women may be giving birth outside of hospitals or other traditional healthcare facilities. According to Gülmezoğlu, countries sometimes do not have up-to-date guidelines nor sufficient political support to fund them. Other times, the challenges are related to pharmaceuticals around adequate supply chain systems and quality issues.

Postpartum Haemorrhage: The role of gender inequality

There is also a question of whether the situation would be different if it were men, not women, who were dying from PPH. Gülmezoğlu said that “the issues of maternal health, contraception and safe abortion are rarely just issues of health or clinical care. They have very strong relations with access to health care, inequalities, and specifically gender inequality.”

“I suppose if this had been an issue that impacted men more broadly, or more directly, that it might be prioritised differently,” said Shirin Heidari, a senior researcher in the Gender Centre of the Geneva Graduate Institute and Founder and director of GENDRO. She said that while there is no way to prove that the situation would be different if this were a male versus a female issue, “there are indications that that would be the case. You wouldn’t speculate looking back at the history of medicine, research, and broader health agenda. We have seen a trend that issues that are related to women’s health and women’s rights have often slid down in the global health priority agenda.”

She quoted Prof Mahmoud Fathalla, who passed away earlier this year: “Women are not dying because of untreatable diseases. They are dying because societies have yet to make the decision that their lives are worth saving.”

However, Heidari noted that in more recent decades, women’s rights and health have gained more significant and broader attention.

PPH roadmap aims to fast-track progress toward Sustainable Development Goal target 3.1

To that end, the WHO recently completed a roadmap to combat postpartum hemorrhage between 2023 and 2030. More than 130 stakeholders developed the roadmap, which includes four strategic areas: research, guidelines, implementation and advocacy, explained Femi Oladapo, head of the Maternal and Perinatal Health Unit in the WHO’s Department of Sexual and Reproductive Health and Research, who also spoke at the event.

Specifically, the roadmap aims to fast-track progress toward Sustainable Development Goal target 3.1: To reduce the global maternal mortality ratio to less than 70 per 100,000 live births.

The WHO stated that the roadmap is designed for key figures in public health and all parties involved in the broader maternal and child health ecosystem. This includes the global community, funding entities, researchers, innovators, industry representatives, professional associations, guideline developers, health ministries, and, importantly, the general public, focusing on women.

“Postpartum haemorrhage is something everybody wants to do something about. So, it wasn’t really difficult finding the audience and attracting people around the table,” Oladapo said. He said that the team followed the traditional WHO process of engaging stakeholders, prioritising issues, and building consensus to make the roadmap. The WHO developed an 18-person steering committee that was geographically- and gender-balanced, as well as included people with expertise from various sectors: innovators, NGOs, advocates and more.

“We made sure that everybody’s voice who needed to be there was around the table from the start,” Oladapo said. In addition, surveys, work groups and virtual meetings culminated in a three-and-a-half-day in-person event in March in Dubai.

“Even after the summit, we continue to engage regularly,” Oladapo added, noting that the roadmap does not belong to the WHO but is a roadmap that was done for all key stakeholders and that holds multiple people and entities accountable.

“We set up an accountability platform where you can see all of these key activities or milestones from now to 2030,” Oladapo described. “There is a call to action in the last chapter of the roadmap that calls on different stakeholders” – women, women’s groups, civil society organisations, professional associations, the research community and the government. “There’s something for everybody to do, and there’s a separate chapter on calls to action, on what each group should do to ensure that the goals of their roadmap are realised.”

Mamtesh, 24, has just given birth to a healthy daughter. Nearly three years ago, Mamtesh suffered antepartum haemorrhaging during her first pregnancy and her son passed away shortly after birth. This pregnancy and delivery, which took place in a government hospital, had no complications. She is happy with the hospital and the normal delivery.

‘Ministries of health have a central role to play’

Oladapo also stressed that politics plays a crucial role in ensuring the roadmap’s success and women’s health in general. He said it is also funded in countries where maternal health is prioritised, and health outcomes improve.

“Ministries of health have a central role to play,” Oladapo stressed. “So, in the development of the roadmap, we brought [representatives] around the table” from around 20 ministries of health.

These ministries are critical, for example, in ensuring research is funded and in building the infrastructure to allow for innovations. Moreover, sometimes, there is a disconnect between global evidence-based recommendations and what people are doing on the ground, and the ministries can play a central role in terms of the adoption and adaption of these recommendations, as well as ensuring that staff – at least at the hospital level – are adequately trained.

“In Nigeria, there are no user fees for maternal health, and maternal mortality has plummeted,” according to Oladapo. “In other places, where you have to pay for every little thing, women continue to die. So this is all within the hands of the ministry.”

Image Credits: UN Photo/Kibae Park/Flickr, Children's Investment Fund/Flickr .

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