What if four Boeing 737s crashed every day?

Why our approach to solving maternal mortality needs to change.

The number of women who die due to pregnancy-related deaths yearly is equivalent to 1460 fully loaded Boeing 737s crashing into the earth, with no survivors.

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x 1 460

An Introduction to Maternal Mortality

To kick off the obvious, let’s define maternal mortality.

Maternal mortality is any death within 42 days of pregnancy termination. “Pregnancy termination” could refer to aborting, miscarrying or giving birth.

There is also “maternal morbidity” which is severe injury due to pregnancy. I won’t be writing about it here.

Everyday >830 women die

That’s one woman per every dot below.

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830+ deaths/day

Annually, there are >300 000 deaths

What’s worse is that these numbers are likely underreported. This figure could be 30% higher. But, let’s just keep this ballpark.

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300 000 deaths/year… also, HOLY SHIT.

If the world had the maternal healthcare system of Finland, there would be 98.6% fewer maternal deaths

There are roughly 140M births/year. The Finish Maternal Mortality Ratio (MMR) is 3 deaths per 100 000 live births. That brings us to ~4,200 deaths annually.

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Deaths if the world had the MMR of Finland
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Deaths if the world had the MMR of the EU

This is a reduction we can make today.

By no means is this an “easy” problem to solve, but it’s also not impossible. Countries like Australia, France, Norway and most of the developed world are living examples that we can reduce maternal mortality.

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Modern Day Hospital

99% of deaths are in the developing world.

This isn’t a biological issue, it’s an access-to-infrastructure issue.

  • Women are dying where there isn’t medication.
  • Women are dying where facilities lack electricity and running water.
  • Women are dying in places where they don’t have proper roads to reach hospitals.
  • Women are not dying because they give birth. They’re dying because they give birth in unsafe circumstances.
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Women in poor, rural communities sometimes give birth in huts.

This is what it looks like to give birth in the most dangerous hospitals:

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Parts of the global healthcare system are trapped in the 1800s.

In the 1800s, Sweden was a poor country with its population spread out all over the place.

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A farm in 19th century Sweden
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Birthing teamwork

During this time, Sweden’s MMR was 830 deaths/ 100,000 live births

The Swedish health commission realized that 400 out of 651 dying women could be saved with skilled midwives. So, they built a program to certify and distribute midwives so that each home birth was attended.

  • Using sterile gowns & birthing clothing
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Today, there are places in the world that perform worse than Sweden 200 years ago.

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Giving birth in rural Africa | Source
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Giving birth in rural Africa | Source
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Giving birth in rural Africa | Source

Sweden’s healthcare system was trapped in the 1800s because it *was* the 1800s. There was very little choice. But now it’s 2020 — countries shouldn’t be trapped in the 1800s.

Sweden had to create the “wheel” of maternal healthcare. Now, we don’t have to re-invent it.

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Source

What are the causes of Maternal Mortality?

There’s two aspects of maternal mortality:

  1. The systematic (non-medical) side

Medical Causes

We need to start by understanding the process of birth and after birth. (No, afterbirth isn’t a form of re-incarnation).

The Basics of Pregnancy

Once women get pregnant, their bodies adapt to grow a human in there for approximately 40 weeks.

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Placenta (red), umbilical cord (red & blue cord)

Let’s talk about giving birth

There are 3 stages to labour

  1. Delivery of baby
  2. Afterbirth
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Phases of labour | Source
  1. Hypertension
  2. Abortion
  3. Sepsis (the body’s response to infection)
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Here’s a breakdown of the causes of Maternal Mortality | Data Source

Hemorrhaging

After delivering her child, a 17-year-old mother from South Sudan holds her baby in her family home. An hour later, she still has not delivered her placenta. Her skin starts to get very pale, she’s having trouble thinking clearly, and she feels a moistness where she’s sitting.

In Medical lingo, PPH is the loss of >500mL of blood within the first 24 hours after labour

PPH is an obstetric emergency (health problems that are life-threatening for pregnant women and their babies).

There are 4 root causes of PPH.

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Here’s the breakdown of PPH root causes | Data Source

Uterine Atony

Imagine doing pushups for 30 hours straight, then being asked to do 1000 squats.

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The famous uterus 🤗
  • Large Baby size
  • Prolonged labour
  • Rapid Labour
  • Induced labour (drugs are used to speed up labour, which weakens the uterine wall)

Trauma

Trauma to the uterus is any damage to the birth canal. When the birth canal is damaged, the placenta will have trouble exiting.

  • Mishappen pelvic muscles
  • Fetus’ shoulder lodged in mother’s pelvis during labour (Shoulder dystocia)
  • Abnormal fetus position

Tissue Attachment

This is when the placenta either:

  • detaches from the uterine wall but does not exit the body

Thrombin

Coagulopathy is a blood-clotting condition where blood clots can’t form. Therefore, A small bleed can turn into a continuous bleed.

Hypertension

There’s a woman in a rural village planning to give birth to her 7th child.

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Unsafe Abortions

Children are expensive. Especially in parts of the world where people are living in extreme poverty.

  • Relying on unregulated “medicine” or “herbal treatments”
  • Herbal preparations into the vagina or cervix
  • Placing a foreign body such as a twig, coat hanger, or chicken bone into the uterus
  • Inappropriate medication into the vagina or rectum
  • Jumping from the top of stairs or a roof
  • Inflicting blunt trauma to the abdomen
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Nearly half of all abortions are unsafe in developing countries | Source

Infection

Infection: in the 19th century, 50% of mothers died because of sepsis. Then we learned to wash our hands. Remember Sweden?

Systematic & Non-medical Causes

Before we start going into the laundry list of infrastructural downfalls, we need to understand the healthcare system’s structure and style in countries where MMR is highest.

Structure of Maternal Healthcare

Giving birth with no one present (NOP)

  1. Female Autonomy (finance, property ownership, decision making) was statistically significant to NOP birth rates)
  2. Culture & Tradition (e.g., “hospitals are for weak women”)
  • 8.9% had no training at all.
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Source
  • ‘Skilled’ workers often aren’t sufficiently ‘skilled’ (they don’t update their skills, and health workers work jobs they’re not trained for)
  • Facilities lack basics. Like cotton pads, electricity and running water.
  • There’s no ambulance service. If PHC has a case that they need to send to a more equipped facility, it’s often next-to-impossible to transfer.
  • Male doctors are an issue for maternal health. Husbands won’t give permission for their wife/wives (non-monogamous relationships are common). Women feel uncomfortable going to another man.

Long story short: PHCs lack adequate staff and adequate equipment.

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Example of PHC | Nasarawa, Nigeria
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Single room four-bed space serving as male, female and children’s Ward at the Bosso PHC | Source
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Umuokanne Health Centre | Source
  • C-sections
  • IV fluids & medications
  • Access to drugs that need to be refrigerated (sometimes)
  • C-section = around $262 USD (This has massive ranges)
  • Monthly income for a low-income family= $348 (By the way, across Nigeria, women have 5–7 children on average. Families are large).
  • Equipment. (This issue stems from lack-of-funding).
  • Poor drug-management supply chains; drugs are often out of stock, and if they are in stock, counterfeit.
  • Inadequate blood-banking systems.
  • This bullet list has the potential to be longer than your quarantine grocery list (I know 🤯😥)
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The curtains are for privacy
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Often, these foam beds are years old. They are soaked with former women’s body fluids.
  • TBAs (untrained birth attendants)
  • SBAs (ex. midwives, nurses, etc)
  • At primary healthcare centres
  • At secondary healthcare centres

3 Delay Model

It’s a simple framework used to describe the delays women experience in reaching the care they need.

Delay #1: Why do women not seek care?

There are 4 main reasons we’ve uncovered:

  1. Tradition + Stigma (ex. women who give birth at home are “stronger”)
  2. Ignorance (low education & literacy rates, lack of sex-ed)
  3. Lack of Autonomy (women don’t have power over decisions)
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A woman getting educated on maternal health. These are the type of interventions that help women seek care.

Delay #2: Why can’t women reach care?

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  1. Distance
  2. No access to transport nor an ambulance
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Not to mention, the quality of general hospitals differs DRAMATICALLY. This is a general hospital in Vermont.
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Road in rural Jigawa (80-90% of the population lives in rural areas). If it rains, roads will generally be blocked/inaccessible.
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Compared to a maintained road in rural Vermont.

Delay #3: Why is care inadequate?

(graphic visualization)

  1. Low Staff, unskilled staff
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TBA helping give birth in a birthing hut.

It’s the poorest that are dying the most.

Money is the prime cause of death

Ultimately, these issues in one way or another stem into one thing. Poverty. People are poor. The hospitals are poor. There isn’t enough money to help the system flourish.

Something is wrong.

My team and I are currently building EMM. Our goal is to help tackle maternal mortality, starting with postpartum hemorrhages (PPH) in Northern Nigeria.

A Deeper Take on Postpartum Hemorrhages.

(Note, the research here directly reflects Northwestern Nigeria, but in general, the information is applicable to countries with high MMR, typically in the developing world).

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PPH

Why are women dying?

No recognition or slow recognition.

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Blood mat
  • Stop the bleeding with few resources
  • Provide proper emergency obstetric care without training

What solutions exist for PPH?

I will mostly cover health intervention directed towards PPH in this section. There are also other solutions like raising awareness and setting guidelines which could lead to PPH mortality decreases indirectly. I’ll focus on direct solutions.

  • Cons: can (ironically) cause trauma and more bleeding; needs a trained professional to operate
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Manual Removal of Placenta (Source)
  • Cons: needs a trained professional to operate
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Source
  • Cons: trained professional needed
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Source & Research Paper
  • Cons: needs a hospital facility, needs to be refrigerated, needs to be administered by trained staff
  • Cons: cultural barrier because it can double as an abortion pill
  • Cons: injectable; needs a professional to administer
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Uterine Butterfly

What are their downfalls?

In parts of the world women don’t give birth at hospitals, nor with trained staff. Many of the PPH solutions require trained health workers or midwives, and hospital environments (e.g., to administer IV liquids).

  1. Train many many skilled workers and midwives

We can start solving this: there’s a gap in scaling Misoprostol & raising PPH awareness

Note: I will be releasing a more detailed run-down of Misoprostol in a few weeks. Follow my medium page to get notified when I do.

Misoprostol

This is a drug that induces uterine contractions such that it helps remove the placenta. It “induces labour.”

And, the pill is cheap to manufacture (just a matter of cents), does not require trained staff (it’s an oral pill), and can be stored at room temperature.

✅Cheap

Awareness

In Northern Nigeria, the literacy rate is about 22% for women, and 51% for men. People aren’t educated.

  • Culturally, western medicine may be looked down up. Drugs can interfere with the birthing process.

Key Takeaways

  • If the entire world had the healthcare system of the countries with the lowest maternal mortality rate (MMR) 96–98% fewer women would die annually.
  • 66% of the problem is in Subsaharan Africa, which is also the region where MMR rates are declining the slowest.
  • Parts of the world have worse healthcare systems than developed countries systems in the 1800s.
  • Maternal mortality is not a medical problem. It’s a systematic problem.
  • The 4 medical causes of maternal mortality are hemorrhages, hypertension, unsafe abortion and infections; with hemorrhages taking the most lives.
  • There are 5 structures of maternal healthcare in developing countries: NOP, Traditional Birth Attendants, Skilled BAs, Primary Health Centres, General Hospitals.
  • The systematic challenges with this problem are poverty, distance to care, female decision making (autonomy), health worker training, staffing, health centre funding, lack of utilities (electricity + water) and cultural stigmas.
  • The solutions we’re using to solve postpartum hemorrhaging usually need trained staff, and adequately equipped hospitals. In Nigeria (and other developing countries), there’s staff shortage & few high-quality hospitals which make most solutions unusable.
  • There’s a gap in scaling Misoprostol; a drug that saves 80% of its users. It requires no staff and no hospitals.
  • High MMR correlates to low literacy and education. A part of this issue is distributing resources (such as staff and equipment), but a huge part is facilitating cultural change. There are stigmas around “western medicine” and “giving birth with medical assistance” which prohibit communities from using life-saving interventions.

Let’s build a world where pregnancy isn’t a death sentence.

Questions? Email isabella [at] endmaternalmortality [dot] com.

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Daughters get married off, so it is common for 15-year-olds to get pregnant| Source
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<20% of Nigeria’s health centers are functional
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“This is the place where she delivered before” (Giving birth in Ethiopia) | Source
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Girls are more likely to die during childbirth in South Sudan than they are to complete secondary education.
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Women laying on the floor in labour because of a lack of beds | Source
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Hemorrhaging after birth| Source
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1 in 8 women in Sierra Leone will die during childbirth, compared to 1 in 4000 in other countries | Source
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Transport conditions are rarely sufficient
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Nearly every family here loses one child before the age of five, usually through dehydration. They have five, six children and no time or money to take care of them” The world’s busiest maternity ward (Manilla) | Source
This is a 5-hour video of a woman walking to get antenatal care. It’s powerful in showing us the reality of pregnant women around the world.

If you’re here, chances are you’re very curious and/or passionate. Here are some documentary recommendations:

17 yo building better maternal healthcare in developing countries.

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