"I was running around hospitals trying to get blood. By the time I got back she was gone."
Dr. Olufemi Oladapo is haunted by the memory of the excited mother-to-be whom he couldn't save in Nigeria in his early career. After waiting six years to become pregnant, she died of postpartum hemorrhage. That's the leading cause of maternal death, responsible for 43,000 deaths a year.
To fight this tragedy, Dr. Oladapo, who's now a physician with the World Health Organization's Special Programme on human reproduction, co-authored a sweeping three-part series published today in the Lancet. characterizing the crisis and laying out how to solve it.
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The condition impacts some 27 million women each year. Some bleeding is normal after childbirth. But excessive bleeding — a postpartum hemorrhage — is incredibly dangerous.
"It can become a medical emergency very quickly," says Adam Devall, a professor of maternal health at the University of Oxford. A woman who has had an otherwise uncomplicated labor can deteriorate within minutes if the bleeding is not recognized and treated promptly.
And the women themselves are aware of how severe it is.
"Typically, the women say, 'I feel like I'm dying.' They actually sense it when they are bleeding too much," says Ioannis Gallos, who's with the World Health Organization's Maternal and Perinatal Health Unit. "If no one was to act on it, within 10 to 20 minutes, easily a woman can die."
That's why postpartum hemorrhage is considered, in Devall's words, "a race against time."
Calling the series a comprehensive compilation of all the evidence, former Jhpiego Chief Medical Officer Dr. Harshad Sanghvi praised the authors for "this tremendous effort" and considers the series "a significant call to action." Jhpiego is a nonprofit organization with a focus on women's and children's health.
Starting with a special drape
To treat these bleeds promptly, say the co-authors, it's essential to measure the blood loss rather than merely eyeballing it — which can miss the hemorrhages about half the time. Devall says a simple plastic drape placed beneath the woman can work wonders.
"The blood then collects into this specially designed drape, which has calibrated lines on it," says Devall. "These lines allow midwives and doctors to easily see the amount of blood loss after the birth."
There are multiple interventions: uterine massage to encourage contractions, medication, IV fluids.
The researchers conducted a massive trial across Nigeria, Kenya, Tanzania and South Africa involving more than 200,000 women. They tested this approach — of early detection with a drape, clear criteria for treatment and the subsequent set of simultaneous interventions … and the results were unmistakable.
"We saw a massive decrease in severe bleeding," says Devall.
A survival gap
The study also points up a tremendous difference between survival rates in wealthy and lower resource countries.
"The rate of postpartum hemorrhage is not any different between high-income countries and low-income countries," says Oladapo. "What is different is what is given when these conditions are identified."
The report finds the mortality rate from postpartum hemorrhage can be more than 200 times less in well-resourced countries like the United States compared to under-resourced countries such as Afghanistan, Vietnam or Nigeria, where Oladapo treated that patient years ago.
The drug oxytocin can stem the bleeding but it does require refrigeration – a challenge in lower resource countries.
The report also calls for pit-crew-like simulation-based training for the whole care team.
The research team says the goal now is to get medical professionals and health workers to adopt their recommendations.
It's an idea that appeals to Doreen Kainyu Kaura. She's a professor of midwifery at the University of the Western Cape in South Africa who wasn't involved in the research effort. She says the conclusions align with what she's experienced in the delivery room.
"It will be a fantastic approach to ensure that we have these lifesaving interventions that reach women at the right place, at the right time," says Kaura.
"Women should not be dying from PPH [postpartum hemorrhage] in this day and age, given what we know," says Oladapo. "If we use what we have now, we will reduce more than 95% of the deaths."
And the economics favors interventions: "Postpartum hemorrhage as it is now is costing us more money than what we would have used to prevent it."
"If you invest even 5% of the cost of postpartum hemorrhage in preventing it," Dr. Oladapo concludes, "you're going to not just save lives but also save money."
Dr. Sanghvi shares his optimism, "This is the decade in which we can probably reach the goal of eliminating postpartum hemorrhage as the leading cause of maternal death. I think it is within our reach."
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