A few hours after almost bleeding out, Husaina Balarabe was calmly unaware that her life was in danger.
She cuddled her newborn, a lush-cheeked boy she named Aabid, and showed him to her sisters from her bed in a noisy delivery room at a hospital in Kano, a city in northern Nigeria.
Ms. Balarabe, a 26-year-old optometrist, had suffered postpartum hemorrhage, a side effect of childbirth that is the leading cause of maternal death worldwide.
She didn’t die because her midwife used a low-cost, low-tech intervention that was developed here and in other maternity wards in some of Africa’s poorest places, and is now saving lives across the continent.
The device was a thin piece of green plastic the size of a cookie sheet with a pocket on the end, called a maternal field. It was under Mrs. Balarabe during her delivery, and the pouch hung at the end of the bed. The midwife who caught baby Aabid saw blood flowing into the bag and quickly reaching and exceeding the danger level – 300 milliliters (or 10 ounces), indicated by a mark on the bag.
The nurse quickly grabbed a cart parked in the middle of the crowded maternity ward, called for help and got to work. From the cart, she took a syringe of oxytocin and injected it intravenously to contract Ms. Balarabe’s uterus. She added a dose of tranexamic acid to promote clotting. She massaged Ms Balarabe’s abdomen, encouraging more uterine contractions, while another nurse gave her intravenous fluids to restore her blood volume. The bleeding slowed down and after a few minutes it stopped completely.
Everything happened so quickly and smoothly that the new mother had no idea there was cause for alarm.
One in 10 women who give birth experience postpartum hemorrhage, and at least 70,000 women die from it each year. Almost all of these women live in low-income countries; More women die in childbirth in Nigeria than in any other country.
Maternal mortality is one of the most concerning global health issues because, until recently, key solutions required trained health workers to identify women at risk and intervene quickly when a childbirth suddenly becomes unsafe. But there is no cheap, easy way to train midwives and obstetricians, or convince them to stay in underserved rural areas when they could earn more in cities or other countries.
Postpartum hemorrhage occurs after the birth of a baby, when the placenta separates from the mother’s body, leaving hundreds of blood vessels open and pumping blood. During normal childbirth, the uterus contracts rapidly and the pressure closes these vessels. But if this contraction does not occur or occurs too slowly, or if pieces of placenta remain behind, blood flows nonstop and the woman can die in as little as 10 minutes.
Some bleeding is normal during childbirth. The reason many women die is that it is surprisingly difficult to tell if a person is losing too much blood. Research has shown that even midwives and doctors who have delivered hundreds of babies routinely underestimate the amount of blood a woman loses.
“The amount of blood on the couch, on the floor, on the cushions, on my clothes, on his clothes, is it 300 or 500 or 1000 milliliters?” asked Dr Hadiza Galadanci, professor of obstetrics and gynecology at Bayero University in Kano, who oversaw Nigerian research into the use of the field. “Often we don’t realize how much blood a woman has lost because we’re doing a visual assessment and it’s very, very subjective.”
By the time those giving birth decide it is time to act, it is often too late.
The curtain is now unfurled across Nigeria. But it was only the first part of the intervention that saved Ms. Balarabe. Then came the series of treatments after the bag became dangerously full of blood. None of these steps are new, but a few years ago, researchers tested what happened when they were all done at once — massage, oxytocin, tranexamic acid, IV fluids — and quickly. They found that, combined with draping, these interventions reduced deaths from postpartum hemorrhage in hospitals by about two-thirds.
Previously, health workers had been trained to respond by first trying a massage and then waiting 20 minutes to see if the bleeding stopped. If it didn’t, they tried medication and waited another 20 hours.
When all procedures are done together, in what is called a “package,” bleeding stops quickly in most women. “It’s like turning off a faucet,” Dr. Galadanci said.
If it doesn’t stop, the final step is escalation: getting the woman into an operating room or transferring her to a facility staffed by people who can stop the bleeding surgically.
“We have not had a single death due to postpartum hemorrhage since we started this operation,” said Binta Garba, who has been the head nurse of the labor ward at Aminu Kano Teaching Hospital for seven years.
Eight or nine times a week, one of her nurses spots a bag of blood exceeding the 300 milliliter mark and shouts, “Bring the bag!” The person closest to the cart rolls it to the bedside. “Everyone helps, and in a short time the bleeding stops,” Ms. Garba said.
When Dr. Galadanci was recruited to participate in this research five years ago, she was skeptical: How could a flimsy plastic sheet and a small procedural change in treatment save women’s lives? The research convinced her, and she launched a campaign to persuade Nigeria’s health minister to make it the national standard of care.
Now, pairs of midwife trainers are visiting labor rooms across the country to demonstrate the scope and package. Often they are met with the same skepticism.
“I thought, we already give oxytocin and tranexamic acid, women are still dying – you’re wasting my time telling me about something we’re already doing,” Kursiyya Shuaibu, one of the trainers, said of the first time she heard about the new procedure. Then she used it and saved a woman’s life. “When you put it together, it’s magical!”
Postpartum hemorrhage also occurs in high-income countries, but women are much less likely to die. They typically benefit from one-on-one care from a midwife or nurse, as well as electronic monitoring of vital signs that can quickly detect a problem, and a blood supply for transfusion is readily available.
Nigeria experiences high rates of serious postpartum hemorrhage due to weak primary care. Sixty percent of women are anemic and access to birth control is limited. In the North, the average woman has seven children and the risk of hemorrhage increases with each pregnancy.
A quarter of Nigerian women never receive antenatal care during pregnancy; less than half manage four visits. There is a critical shortage of health professionals across the system, from midwives who can screen for high-risk pregnancies to obstetricians who can deliver them safely.
Dr. Galadanci talks faster, walks faster, and bristles with impatience at the thought of improving the care women receive. She believes that the solutions to these fundamental problems must be just as simple.
“Draping is not about AI, it’s quite the opposite: it’s a simple, simple intervention that can solve our problems,” she said. “You don’t need a surgeon to come and save a woman. Or to teach you how to do a technique with something you have to buy overseas. No. You just need a calibrated plastic drape, and you have your medicine. And it’s done.”
Of course, curtains can only do so much: critical levels of understaffing still put women at risk. Recently, in the afternoon at the maternity ward of the teaching hospital – the best public hospital in Kano – a woman lost 600 milliliters of blood before anyone intervened. Another woman’s sheet wasn’t checked for nearly 45 minutes after her baby was born.
The fields used for research in Nigeria were imported from India and cost about $3 each. This is more than the national health budget could allow.
Dr. Muhammad Ali Pate, Minister of Health, wants Nigeria to provide more of what it needs. So Dr. Galadanci and his team contacted a family-owned plastic manufacturer in Kano that made plates, forks and containers for products like vegetable oil. Dr. Galadanci showed the chief engineer a field: could they make this?
The company made a prototype, but it was clear that any large production would require custom-made machines, which it would have to import from Taiwan. The Gates Foundation, which had helped fund early research, was eager to expand its use and offered a $600,000 grant. (The foundation also supported companies in Kenya and South Africa, where the field was tested, to manufacture it.)
In exchange, Systs Engineering agreed to sell the fields to the National Health System for 70 cents each. Since then, the war in Iran has driven up the price of raw materials, so much so that today curtains cost 80 cents. The company manufactures them for all of Nigeria and has started exporting to some neighboring countries.
Dr. Galadanci now moved on to the next problem: the field and pack work well in hospitals, but 60 percent of Nigerian women give birth at home. Her research team is testing a kit for community health workers who attend home births. It has an absorbent mat, and when it fills to the corners, it’s a sign that a woman can’t lose any more blood and needs to be taken to the hospital. The kit also contains the drug misoprostol, which causes the uterus to contract, helping to stop bleeding long enough for the woman to seek medical attention.
However, hospitals are under pressure. Recently, one morning at a maternity ward in central Kano, seven women gave birth in the space of a few hours. The sole obstetrician, Dr. Halima Ibrahim, had three urgent cases waiting for C-sections, and a single midwife supervised the delivery room. A woman moaned through the contractions of her 11th delivery, while in the corner, two student nurses used a telephone flashlight to sew up another woman’s episiotomy.
But the sheet helps. “We used to lose a woman every month: you end up with the baby in your arms and the mother is gone,” Dr Ibrahim said. “No more.”
Gn world
