University of Birmingham

For millions of women worldwide, childbirth still carries life-threatening risks. Every two minutes in 2020, a woman died in pregnancy or labour, amounting to a global death toll of around 287,000 women that year. Most of those deaths occurred in low and middle-income (LMIC) countries. Most could have been prevented. 

Researchers at the University of Birmingham are developing lifesaving interventions for two major causes of maternal mortality: postpartum haemorrhage (PPH) and unsafe caesarean sections. Their solutions could radically improve women’s chances of surviving childbirth in the LMICs, saving thousands of lives annually.

A breakthrough solution for postpartum haemorrhage

Postpartum haemorrhage (PPH), or excessive bleeding after childbirth, is the leading cause of maternal mortality, killing around 70,000 women annually, despite being largely preventable. University of Birmingham researchers have developed a game-changing new solution, known as E-MOTIVE, which reduced severe bleeding by 60% and reduced deaths by 27% in a major trial. 

The intervention — developed in partnership with the World Health Organization (WHO) and trialled on over 200,000 women in four countries — combines a simple early-diagnosis tool with a “bundle” of effective treatments, to identify and stop bleeding.

“Time is of the essence when responding to postpartum bleeding, so interventions that eliminate delays in diagnosis or treatment should make a massive difference,” says Professor Arri Coomarasamy, who led the trial and is the Co-Director of the University of Birmingham’s WHO Collaborating Centre on Global Women’s Health.

One challenge is that PPH is often detected too late, in part because healthcare professionals rely on visual estimations of blood loss for their diagnosis. Inaccuracies in those subjective judgements result in up to 50% of haemorrhages being missed, according to studies.

To tackle that problem, the E-MOTIVE programme uses a simple funnel-shaped plastic sheet called a ‘drape’, which is placed under a woman to collect and measure lost blood. At a cost of around $1-2, it gives medical professionals a clear and early indication of when a mother is approaching the 500ml of blood loss that signals a significant haemorrhage — allowing staff to intervene earlier.  

A second challenge is that when medical professionals do identify PPH, they typically respond “sequentially”, with a series of interventions. If one fails, they implement another. “The problem with this sequential approach is that if the woman is bleeding, you are losing time. It is the time that kills her,” says Professor Coomarasamy.

The E-MOTIVE study found that “bundling” together WHO-recommended treatments, rather than offering them one-by-one, resulted in dramatic improvements in outcomes. Under the intervention, patients were treated simultaneously with a uterine massage, medicines to contract the womb and stop bleeding, and intravenous fluid. Health practitioners were also trained to identify when a case needs escalating to advanced care, including surgery. 

The trial, conducted between 2021 and 2023, with grant support from the Bill and Melinda Gates Foundation, was the largest ever conducted on PPH treatment. The 80 participating hospitals in Nigeria, Tanzania, Kenya and South Africa were surveyed for seven months as they implemented their usual treatments. Half were then randomly allocated to receive the E-MOTIVE intervention, while the other half continued their standard care. 

The trial has been greeted as a breakthrough by international health and development organisations. Since its findings were published in July 2023, the WHO has convened a group to draft its first official guidelines on bundled PPH care. In September, the Bill and Melinda Gates Foundation published a report which highlighted bundled PPH interventions as one of seven key strategies to advance progress on the UN Sustainable Development Goals on maternal and child mortality. It stated that bundled treatments could be provided for less than $1 per package — making them cheap enough to scale in low-income countries. 

Many local hospitals already have the capacity to implement the E-MOTIVE interventions. Every component of the intervention can be performed by midwives, meaning that it can be applied in regions where doctors are scarce. The trial used existing local procurement pathways, sourcing medicines from local hospitals. The drapes are currently manufactured in India, posing some supply constraints. However, “lots of companies are gearing up for mass production. That’s a challenge that’s being addressed,” says Professor Coomarasamy.  “The countries where we did the trial have been trailblazers,” he argues. Many others could soon follow. 

Preventing caesarean section deaths

Caesarean sections represent a second and growing cause of maternal mortality. While they are integral to safe emergency obstetric care, they are also linked to high maternal and perinatal deaths in LMICs. Mothers giving birth by caesarean section in these geographies are 100 times more likely to die than those in the developed world.

University of Birmingham researchers are leading a new initiative to change that. The five-year project, known as C-Safe, will be trialled in India and Tanzania from April 2024. “This will be the largest implementation research that’s ever been done to improve the safety of caesarean sections,” says Professor Shakila Thangaratinam, Co-Director of the WHO Collaborating Centre for Global Women’s Health.

It is a growing concern that caesarean section rates have risen higher than is medically necessary, increasing the mortality risk for mothers and babies. “There was a point where caesarean section rates were very low in low- and middle-income countries. But with maternal health now being a priority, the resources are available in most parts of the world,” explains Professor Thangaratinam.

Three factors are now driving unnecessarily high uptake, she argues. First, healthcare professionals are adopting increasingly defensive practices, offering elective caesarean sections in a bid to guard against complications and medico-legal risks. Second, assisted vaginal deliveries are declining globally, with fewer health professionals trained to use effective interventions such as a vacuum. Third, many women are poorly advised on the risks associated with caesarean sections. “Doing a caesarean section is seen as the answer to any potential problem,” she says.

Yet unsafe and unnecessary caesarean sections are linked to PPH, sepsis and anaesthetic complications, as well as an increased rate of uterine ruptures in subsequent pregnancies. Studies show that up to 8% of babies born by caesarean section die, mostly from delays and inappropriate decision-making. Current surgical safety initiatives are either not specific to caesarean sections, or focus on preventing a single complication, rather than several.

The C-Safe programme aims to tackle these problems by ensuring that caesarean sections are done for the right reasons and conducted safely. It promotes the appropriate use of caesarean sections by requiring health professionals to accurately report on their decision-making. It will also deter unnecessary procedures by facilitating safe vaginal deliveries. At the same time, it will make operations safer by implementing much-needed standards for caesarean sections.

The intervention — developed in partnership with the WHO and Jhpiego, a global surgery foundation — will be trialled at eight hospitals, with plans to scale-up in its two target countries. To support implementation, researchers have worked closely with local policymakers, and are offering training for health workers, and education for women and communities. “It has to work within the existing health system. We can’t just parachute in and parachute out,” says Professor Thangaratinam.

To this end, C-Safe’s core programme can be adjusted to meet local needs. Tanzania and India, for instance, face different challenges. Tanzania has a shortage of obstetricians and anaesthetists. Its caesarean sections are often conducted by clinical officers, with few safety protocols in place. By comparison, India is well-resourced, but its practitioners face a culture of blame and medico-legal concerns, which results in risk aversion and a higher rate of elective caesarean sections.

“We chose two different health systems for the trial, because if it works in these systems, it is much easier for others to operationalise,” Professor Thangaratinam explains. By tailoring the C-Safe programme to their needs, nations should be able to ensure that even after the trial concludes, its protocols remain embedded within their health systems — making childbirth safer for millions of women.