Why our approach to solving maternal mortality needs to change.

Isabella Grandic

Apr 30, 2020·25 min read

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.

That’s four airplanes crashing every day for an entire year.

That’s over 300 000 innocent people plummeting to death in a fiery metal aircraft, as their internal organs tear, their limbs separate from the body and bones shatter. Their organs may liquefy, their bodies could get smashed by plane parts or passengers may get hypothermic if they’re in water.

To make things worse, most of these “plane crashes” could have been entirely prevented. Whether that’s because the pilot was untrained, or that the plane had a mechanical bug.

That’s four airplanes crashing every day for an entire year, where 90+% could have been avoided with the right pilots and the right equipment.

If almost 1500 planes were crashing due to preventable reasons globally, we would investigate them in a heartbeat. We would prevent people from dying when they don’t need to.

But, we don’t have to imagine this tragedy. It’s already happening. But, it doesn’t involve planes, it involves giving birth.

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.

Maternal mortality is an example of the global injustice of women. Women are dying bringing life to the world because they do so in unfavourable conditions.

I’ve been told stories of women giving birth in barns, giving birth shackled to the bed in order to “stay calm,” and giving birth on the side of the road weak and alone.

For too many women, the “happiest day of their life” turns into a near-death experience, trauma or death.

Let’s visualize the statistics of maternal mortality.

Everyday >830 women die

That’s one woman per every dot below.

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.

That’s one woman for each tiny pixel. (Good luck zooming in, the dots are scaled so far down that they’ve lost most of their image quality).

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.

Even if the world had the healthcare system of the EU (8/100 000), there would be 11,200 deaths, which is still a 96.3% decrease.

Compare these figures to the 300,000 figure above. 🤯

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.

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 aren’t doctors.
• 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.

You get the point.

Globally, 66% of deaths are in Sub-saharan + 22% are in South Asia.

Nigeria has the most deaths globally; 1 in 5 maternal deaths happen there.

In 4.5 days, more women die in Nigeria than in 1 year in the US. And the US has 67% more people. (Note: pregnancies per woman are much higher in Nigeria than the US, so that is also a portion of the “issue.”)

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

These are usually the SAFEST locations in developing countries.

Ok. You see the figures. You see the pictures. You realize this is a crazy problem. So, why does this happen?

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.

People were living hand to mouth, on their farms, struggling to survive and make ends meet.

The last thing on the Swedish people’s minds was giving birth in sterile environments.

Women were baby-making factories that gave birth at home. Or in their barns. Sometimes out in the field.

There was no medicine, no hygiene, and most often, no skilled medical help.

Sometimes, women used untrained “midwives” to assist them. Other times, there was no one present.

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.

Then, they introduced aseptic practices (which was very ahead of the game, at the time). Birth Attendants started:

• Using sterile gloves, or even washing their hands
• Using sterile gowns & birthing clothing

It seems simple & obvious now, but Sweden pioneered hygienic birth. It was novel. Unheard of.

Back then, if your birth attendant didn’t wash their hands, it was “natural.” Today, in the 21st century it’s just unacceptable.

There’s a reason Sweden’s MMR graph looks like this:

Now Sweden is one of the safest places to give birth.

Today, there are places in the world that perform worse than Sweden 200 years ago.

• Sierra Leone: 1 360/100 000
• Chad: 856/100 000
• Central Africa Republic: 882/100 000

These are just national averages. Within countries, MMR ratios differ dramatically. Especially in areas that are more rural (and, therefore, less urbanized).

For example, Nigeria’s national MMR is 814/100 000. However, Northern Nigeria is less industrialized than its south, so its MMR can be ~1 000–1 600/ 100 000. Way higher than the national average. And, way worse than 19th century Sweden.

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.

Yet, there are still parts of the world where women give birth with unskilled professions and where people don’t wash their hands.

What are the causes of Maternal Mortality?

There’s two aspects of maternal mortality:

1. The medical side
2. The systematic (non-medical) side

Typically, a woman has a medical condition that is harmless if treated effectively.

But women die because we don’t effectively treat their medical outcome.

The lack of emergency response kills her.

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.

To “adapt” the female body grows another organ called the placenta. Yes, you read that right. The female body grows an entire human AND an organ at the same time.

The placenta is the passageway between mom and baby. It’s the baby’s digestive system, circulatory system, respiratory system, and really, all the systems! It keeps the baby alive.

It regulates all of this through its umbilical cord.

During pregnancy, the baby relies on the placenta to grow and develop.

When the baby is born, it shouldn’t need the placenta anymore. (I said “shouldn’t” because there are millions of babies that are born prematurely every year. These babies often spend time in the ICU or similar to try and stay alive).

Let’s talk about giving birth

There are 3 stages to labour

1. Early & Active Labour
2. Delivery of baby
3. Afterbirth

The first stage is about dilating (opening) the cervix. The cervix is the passageway from the womb to the world. The baby’s head pushes on the cervix, which causes it to dilate. It’s the longest phase.

The second stage is pushing the baby out.

The third stage is the removal of the placenta. It happens around 20 or so minutes after the woman delivers her baby.

Now let’s look at the data. Why are women dying? From the chart below we can see that there are four main (diagnosed) reasons:

1. Hemorrhaging (severe bleeding)
2. Hypertension
3. Abortion
4. Sepsis (the body’s response to infection)

There is also a large chunk of deaths with “other” causes. These can be direct or indirect causes of maternal death.

Direct “other” examples: obstructed labour, anesthesia-related complications, ectopic pregnancy (fetus implants in the Fallopian tubes, not the uterus), etc.

Indirect “other” examples: lack of iron (anemia), heart disease, Malaria, etc.

We can treat most of these “other” causes with high-quality care, proper diagnosis and trained medical staff.

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.

She sniffs the air, which has a faint scent of blood oxidizing.

She looks down and see a pile of blood on the cold, hard, floor where she gave birth. Her birth attendant, an untrained woman from the village says “it’s just natural.”

No one does anything. For several hours.

By the end of the night, the bleeding got worse and worse. It never stopped. She bled to death.

This isn’t an uncommon scenario.

Many women suffer from postpartum hemorrhages (PPH). PPH is severe bleeding after birth.

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.

Uterine Atony

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

That’s giving birth.

Women “do pushups” for hours and sometimes days to push their baby (or babies) out. After that, (naturally) they are exhausted. Their uterus is tired. They can’t even get the muscular strength to go pee (note: that is a side effect of labour, not pushups).

It takes months to recover from this workout.

The last thing that’s on anyone’s mind after doing pushups for 30 hours straight is doing 1000 squats. A whole new workout.

Why does doing ‘squats’ after an intensive workout suck? You’re tired. But most importantly, your muscles are tired.

Uterine atony is when the uterus is “tired’ after birth, such that is does no properly remove the placenta.

Uterine atony causes 70% of postpartum hemorrhages.

The uterus is the internal organ that houses the baby. It’s surrounded by muscle. This muscle “contracts” to push the baby & placenta out.

However, childbirth can be extremely exhausting for the uterus. After the baby is out, the uterus may be too weak to properly contract (to remove the placenta).

If the uterus can’t contract the placenta properly, the woman could have uncontrollable bleeding.

Giving birth to an 8-or-so pound object in it of itself is a demanding activity, but there are certain factors that increase the risk of uterine atony:

• Age: women >35 are more likely to get uterine atony, or women that are <18 (adolescent)
• 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.

Trauma happens for a few reasons:

• Baby >8lbs
• Mishappen pelvic muscles
• Fetus’ shoulder lodged in mother’s pelvis during labour (Shoulder dystocia)
• Abnormal fetus position

In any case, deliveries that are longer and/or more painful are more likely to be “traumatic” to the birth canal.

Tissue Attachment

This is when the placenta either:

• does not detach from the uterine wall
• 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.

Thrombin is an important enzyme in blood (specifically plasma) that helps form clots.

Hypertension

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

Most of her pregnancies were normal, but this one has been very difficult. She begins to go into labour; she has a birth attendant with her. She is giving birth at the house because someone needs to watch the kids.

Her head starts to spin; she’s very dizzy and weak. Her birth attend is getting worried. She won’t be able to push. Her blood pressure is rising.

30 hours into labour, the mother becomes very very weak and she starts seizing. Her birth attendant tries to arrange for transportation to the hospital, but it is too expensive. The woman falls out of her seizure into a comma. She never wakes up.

Hypertensive disorders are a group of high blood pressure disorders.

For pregnant women, pre-eclampsia is one of the most common (and most dangerous) disorders.

It’s correlated to an abnormal placenta. The placenta has “spiral arteries” which connect to the fetus. If these arteries are thinner, the fetus won’t have enough blood to develop properly.

If the placenta isn’t nourishing its child, it’ll release pro-inflammatory proteins. In short, these proteins narrow the blood vessels and makes the kidneys keep more salt.

This results in high blood pressure. With high blood pressure and restricted arteries, parts of the body will decline in function.

Pre-eclampsia can turn into eclampsia (seizures) if left untreated.

Many pregnant women with high blood pressure have healthy babies without serious problems, high blood pressure can be dangerous for both the mother and the fetus.

Unsafe Abortions

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

Some women simply cannot afford another pregnancy.

Because there’s low contraceptive use (that’s a whole other blog post), many women get pregnant and wish to terminate the pregnancy.

However, in many countries, it’s highly restricted, difficult, or plainly illegal to get an abortion. But that doesn’t stop women from getting them.

Women in countries with illegal (or difficult to reach) abortions still get them. They’re just not as safe (or safe at all).

Examples of unsafe abortions:

• Drinking toxic fluids such as turpentine, bleach, or drinkable concoctions mixed with livestock manure.
• 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

Infection

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

Today infections cause 10.7% — 15% of maternal deaths. But, we can reduce infection impact with good hygiene and antibiotics/antiseptics.

Some of the most common infections killing mothers are tuberculosis, pneumonia, group A streptococcus (GAS) and meningitis.

Now you know the 4 main “medical” reasons for maternal deaths: PPH, hypertension, unsafe abortions and infection. Let’s move onto understand why women don’t receive the care they need.

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)

In Nigeria, 1 in 5 births are NOP births. Uneducated, rural, poor, Muslim mothers delivering her 3rd (or higher in birth order) child were most likely to give birth with no one around.

There are 3 main reasons studies have found that NOP births happen:

1. Economic Insecurity
2. Female Autonomy (finance, property ownership, decision making) was statistically significant to NOP birth rates)
3. Culture & Tradition (e.g., “hospitals are for weak women”)

In any case, it’s not uncommon for women to give birth entirely alone.

Giving birth with traditional birth attendants (TBAs)

TBAs are people (usually elderly women) who assist the mother during childbirth. Initially, they acquire their skills by delivering babies through trial and error or through an apprenticeship to other TBAs. They typically do not have medical backgrounds or midwifery certifications.

• 60% of TBAs had no formal education
• 8.9% had no training at all.

They will provide mothers with antenatal, labour, and postpartum support via mystic/religious methods (herbs, plants, drinks, incantations).

TBAs see birth almost as a divine process. They consider their apprenticeships and general secondhand birthing experience as sufficient training.

Why are women using untrained workers to manage their pregnancies?

Finance. They are cheaper and allow payments to be done in instalments.

Lack of education. Sometimes TBAs are the only option women know about.

Culture. TBAs are more trusted in the community; their practice is seen as natural.

Convenience. TBAs come to homes. Hospitals and professional clinics are too far.

Giving birth with skilled birth attendants (SBAs)

SBAs are accredited health professionals, like midwives, doctors, or nurses. They have education and training needed to manage normal (uncomplicated) pregnancies, childbirth, and the immediate postnatal period. And, they’re trained in the identification, management, and referral of complications in women and newborns.

Primary healthcare centres (PHC)

Primary healthcare centres are the “rural” facilities that serve the community’s basic healthcare necessities. Very often they’re run by community health workers; sometimes they have nurses.

I’ve interviewed 30+ people from Nigeria, Uganda, DRC, Gambia and Kenya. The main things I’ve learned about PHC is:

• There’s massive understaffing (in healthcare in general)
• ‘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.

Attending secondary healthcare centres (general hospitals)

General hospitals (hopefully) have physicians and have more equipment to do difficult procedures. Maternally, this entails:

• Blood Transfusions (although the blood banking system can vary between countries, it’s not always reliable)
• C-sections
• IV fluids & medications
• Access to drugs that need to be refrigerated (sometimes)

There is a whole smackdown of issues that arise with general hospitals. The first & foremost one is expenses. Generally, where MMR is high, there is no UNC and healthcare costs are unbearable. (Remember, it’s the poorest that are dying the most).

Fees vary between hospitals, countries, states and counties, but let’s take an example of one clinic in Northern Nigeria.

• Vaginal birth = around $40 USD
• 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).

These prices don’t include drugs, blood transfusions or other treatments. Most often, families have to buy supplies from the pharmacy to use at the hospital. Because hospitals are out of stock. General hospitals are expensive (as they relate to monthly salaries), and prices are unpredictable.

I’ve heard countless stories about women passing up lifesaving surgeries because she couldn’t afford the expense. Or, paying for services and then living in the hospital for months afterwards as she is unable to pay the bill. The list gets heartbreakingly long of scenarios, struggles and stories.

From my conversations, the other issues are:

• Doctor salaries and retention. Many patients cannot pay back procedures. Many doctors need to take pay cuts. It’s not uncommon to have 15–20 labouring moms with 3 doctors supervising.
• 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 🤯😥)

Pictures speak louder than words. I was having a conversation with Amoura Zynga who runs Premature Babies and Mothers Fund, @PBM HEALTH (on Facebook).

She shared some startling photos from a government-funded (military) hospital in Kinshasa, the capital of the Democratic Republic of the Congo. It’s a city of almost 12M people.

It breaks my heart that women around the world are exposed to such circumstances. I would be uncomfortable letting my cat give birth here. 😰

So, to recap, the main types of birthing assistance is:

• NOPs (no one present)
• TBAs (untrained birth attendants)
• SBAs (ex. midwives, nurses, etc)

The types of facilities were women can give birth are:

• At home
• At primary healthcare centres
• At secondary healthcare centres

Research in maternal mortality often follows a framework called the 3 delay model. Let’s look at that next.

3 Delay Model

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

First Delay: the delay in seeking care.

Second Delay: the delay in reaching for care (i.e., transport).

Third Delay: the delay in receiving adequate care.

To solve maternal mortality, we need to address these delays so women can get the care they need when they need it.

Delay #1: Why do women not seek care?

There are 4 main reasons we’ve uncovered:

1. Financial (people don’t seek it because “they can’t afford it”)
2. Tradition + Stigma (ex. women who give birth at home are “stronger”)
3. Ignorance (low education & literacy rates, lack of sex-ed)
4. Lack of Autonomy (women don’t have power over decisions)

Through our research and conversations with people from 8+ African Countries, these causes have more or less remained the same.

Delay #2: Why can’t women reach care?

It boils down to 3 things:

1. Roads and Infrastructure
2. Distance
3. No access to transport nor an ambulance

More maternal deaths happen in rural and remote communities. Again, the poorest are dying the most. So, on top of their remoteness, they also have the least amount of resources.

Because staffing and funding are low, most general hospitals are in urban centres. These could be tens of kilometres away.

For example, Jigawa is a state in Nigeria about the size of Vermont, USA. It has 10 general hospitals for a population of 5.6M people. Vermont has 20 general hospitals for 600,000 people.

I want to highlight one last thing: there is no ambulance. No 911. No emergency service transport (at least not one that is properly functional). So, if a mother was hypertensive and seizing, there is no number she can call for help.

Delay #3: Why is care inadequate?

(graphic visualization)

I briefly touched on this throughout the article, but I can summarize it into two categories:

1. Lack of essential services (electricity, beds, water, antiseptic devices, etc)
2. Low Staff, unskilled staff

Without the right staff, equipment is useless because it won’t be used properly.

To improve the quality of care we need to either build equipment that unskilled staff can use or train more staff.

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.

But, with that, you’d think that throwing money at the solution will eradicate the issue.

We have spent 20 Billion dollars from 1990–2014 on reducing maternal mortality. However, the number of deaths in Northern Nigeria is on the rise.

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.

PPH is one of the leading factors of Maternal Death in the world. Let’s look at why.

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).

PPH is common, and in many parts of the world, it’s not a death sentence. But in too many it is.

Why are women dying?

No recognition or slow recognition.

Remember that most women give birth with untrained birth attendants. <10% of women in Northern Nigeria give birth at hospitals.

Even trained midwives lack proper training. 20% of Namibia’s midwives could reliably diagnose and manage postpartum hemorrhages.<40% of Namibia’s midwives correctly monitored women in labor

We don’t have proper tools to recognize & act. [Doctors + Midwifes] underestimate blood loss by 33–50% using visual estimation.

In the western world, we still normally diagnose PPH by measuring the weight of a soaked blood towel. It’s still not precise.

Blood may be disregarded as “natural.” Or, “unclean.” Women give birth on top of rivers to move the blood away. If birth attendants ignore the blood, we can never diagnose it.

Sometimes, we literally can’t see the blood. Home births and births at facilities can happen in the dark — or with limited lighting because of a lack of electricity. I don’t know about you, but I can barely brush my teeth in the dark. I’m not sure how TBAs and SBAs are able to deliver children safely in the dark.

The combination of not having the tools to measure, and not having proper training to understand the importance of recognizing PPH leads to a delay in care.

No materials or solutions quick enough

It can be difficult to:

• Find a blood donor and facility to administer the transfusion fast enough
• 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.

Manual removal of placenta: the health worker pulls out the placenta.

• Pros: inexpensive, effective
• Cons: can (ironically) cause trauma and more bleeding; needs a trained professional to operate

Fundal Massage: massage the top of the fundus to help contract the placenta. It works well, it just requires a trained worker to execute the process.

• Pros: inexpensive, effective
• Cons: needs a trained professional to operate

Uterine balloon tamponade: a balloon inserted into the uterus to stop any bleeding.

• Pros: inexpensive
• Cons: trained professional needed

Oxytocin: a hormone that helps kick-start contractions (which help push out the placenta). It’s administered as an intravenous (IV) infusion or intramuscular (IM) injection; meaning it normally is served in a hospital environment.

• Pros: low-cost, effective
• Cons: needs a hospital facility, needs to be refrigerated, needs to be administered by trained staff

Misoprostol: an oral drug that helps expel the placenta. It can also be used as an abortion pill.

• Pros: low-cost, effective
• Cons: cultural barrier because it can double as an abortion pill

Tranexamic acid (TXA): an antifibrinolytic agent that increases clotting. It is a common trauma drug used to stop bleeding.

• Pros: low-cost, effective
• Cons: injectable; needs a professional to administer

Other new technologies & devices: these are upcoming devices that are still getting tested. For example, PPH Butterfly, InPress Technologies and XStat™ Mini Sponge Dressing (MSD).

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).

The most optimal solution (that will make an immediate impact) is one that can be used at homes or in low-resource settings without trained health workers or midwives.

In the longterm, we need to:

1. Build proper healthcare infrastructure with adequate equipment
2. 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.”

This very process of removing the placenta is the same concept of abortion. In fact, abortion is the same concept of labour. It’s the “birthing” (or removal) of something from the uterus. In the case of abortion, that might be a fetus. In the case of PPH, that’s the placenta.

There are two types of Misoprostol: vaginal and oral.

Studies show that time and time again Misoprostol provides protection to ~80% of women from PPH.

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

✅Accessable

✅Easy to use

Why isn’t it everywhere?

❌Cultural barrier: when used in conjunction with mifepristone (another drug), Misoprostol is an abortion pill. Coincidentally, the countries with the highest MMR are also the countries where it’s more difficult to get abortions. The stigma of using an abortion pill to save 80% of PPH cases makes implementation harder.

❌Drug markets with counterfeit medicine. In many places, such as Nigeria, you can’t trust everything sold at pharmacies. There’s a drug management issue.

❌Poverty leads buyers to the black market where drugs are cheaper. This is also where drugs are dangerous and often sold in the wrong doses.

❌Lack of knowledge of its uses in PPH.

That brings me to the next “gap” in addressing hemorrhages: awareness.

Awareness

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

The last thing on the local government’s mind is educating its women (and men) on postpartum hemorrhaging.

Scaling Misoprostol isn’t even mostly a medical or distribution problem. We have a great solution, and it’s cheap. With the right partnerships, Misoprostol could be scaled quickly & cheaply.

There are stigmas holding it back:

• It is technically an abortion pill (however, to stop PPH, we administer Misoprostol after birth, so there’s no life to abort)
• Culturally, western medicine may be looked down up. Drugs can interfere with the birthing process.

We have a marketing problem.

My team’s first project at EMM is creatively scaling Misoprostol in Jigawa State, Nigeria. We’ll be launching the details soon. You can subscribe to public-facing updates here.

We’re doing this because we want to build a better world. Where women and girls are treated equally by the healthcare system. Where female voices are heard. Where women have autonomy.

There’s no reason why 4 Boeing 737s need to crash and burn every day. We can start preventing this, today.

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.

This isn’t a world we should live in. Not today, not ever.

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

• No Woman Should Die Giving Birth
• No Women No Cry
• World’s Most Dangerous Place to Give Birth
• Tackling Maternal Health Outcomes in Africa
• Maternal Mortality in Nigeria