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The Rwandan example

 In terms of reducing stillbirths, however, certain countries are ahead of the curve. One country at the forefront, and setting the example, is Rwanda.

Rwanda has reduced stillbirths the fastest of all of the African countries, cutting these types of death by , due to increased coverage of care and more midwives.

The presence of a skilled attendant during childbirth in Rwanda increased from 31% to 69% from 2000 to 2010, a  shows.

This rise in midwives has been complemented by the addition of 45,000 community health workers, 15,000 of whom are specifically tasked to encourage ante-natal care and take a woman in labour to a health facility.

As a result there has been improved registration of women coming earlier on in pregnancy. Commonly in other parts of Africa, such as Uganda, the median time for a woman to come in for antenatal care is in the third trimester. In Rwanda, it’s now early in the second trimester.

In addition,  during their pregnancy, the recommended number of visits stipulated by the WHO until very recently.

Sophie Akimpaye is one of the people behind the success. As the Head Nurse at the Mushishiro Health Centre in the Muganga District in Rwanda, a centre that has won awards for mobilising expectant mothers through community health workers, she has played a vital role in bringing women in for care during pregnancy within her district

Mothers who attended the previous WHO–recommended four antenatal checks themselves were rewarded with gifts to encourage others.

Sister Sophie, 44, is one of three nurse-trained nuns at the 30-bed centre, which is run by the church diocese. She works with one other senior nurse, four midwives and six assistant nurses in lush green farming country, where the heavy rains produce deep red mud matching the red corrugated iron rooftops.

Part of the reason why more of her patients are increasingly engaged with health facilities is because of a new Government insurance system, Mutuelles de Santé, that is based on earnings. This means people are not worried about not being able to pay. The system includes pre-and post-natal care and more than 

“Before the Mutuelles de Santé, we maybe only saw 50% of the population,” said Sister Sophie.

“I feel very happy because every patient who comes here is happy. If the case is too severe, we will take them to the district hospital by ambulance.”

The community health workers also use a text-based system that tells them when pregnant women should be seen at the health centre and reminds them when labour is a couple of weeks away, and what to do when contractions start. It also enables them to send ‘red-alert’ texts back in case of complications such as bleeding when they visit pregnant women.

The health centre is 55 km from the district hospital and three km from the main road making their antenatal achievements even more significant.

But now a new challenges awaits them.

In 2016,  were updated to state that women should be seen at a clinic eight times, with five of those in the last trimester.

Dr Ӧzge Tunçalp , a WHO Scientist in the Maternal and Perinatal Health & Preventing Unsafe Abortion section, says the pregnant women should have their first contact in the first 12 weeks’ gestation, another two at week 20 and 26, then five contacts at 30, 34, 36, 38 and 40 weeks’ where the risks are higher.

While this will be easier to implement in certain countries than others, Dr Tunçalp believes Rwanda will be able to handle it. “Rwanda is an example where they had the political will and the will to implement and that combination really worked.” She said. “As a smaller country, they have the advantage of being able to really scale up certain interventions very fast and really be able to implement these things.”

Other countries, however, may fare less well, but Prof Lawn is determined to make their road as smooth as possible.

Over the next five years, Prof Lawn, who is also director of the School’s  and her team aim to find more, and better data, on stillbirth causes and risk, how to reduce deaths through certain programmes, and create measures to be able to track the coverage of those programmes.

Her team will be working in Tanzania, Bangladesh and Nepal to observe an estimated 15,000 births, to collect data on the simplest possible measures of the care provided that can then be used more widely, to prevent babies dying.

Some of the interventions her team will be testing during and post-labour will be the use of resuscitation, antibiotics, ante-natal corticosteroids for preterm labour to help develop the babies’ lungs, and oxytocics to prevent haemorrhaging and the management of infections – none of which are routinely measured.

“If we look at the learning from the MDGs, the things that progressed the fastest weren’t just the things that had the most money, they also had good data for driving programme change,” says Prof Lawn. She says immunisation, ARV therapy for AIDS and the use of bed nets for malaria are three good examples where data on those interventions has been used to drive both coverage and the quality of care.

“In maternal and newborn health, it is known how many women give birth, but we have no idea how many, say, have (interventions) to prevent bleeding, or how many newborns are treated for serious infections” she said. “If we don’t have coverage statistics we have no idea how well we are doing. And we don’t have the measures of quality measures. it’s like driving a car with a blindfold”

Knowing what works to scale up

Another team at the School working towards improving maternal and child care in low and middle-income countries, are the  project, led by Professor Joanna Schellenberg, Professor of Epidemiology and International Health, and funded by the Bill & Melinda Gates Foundation. Her team is working as a measurement, learning and evaluation partner to groups funded by the Foundation in north east Nigeria, Ethiopia, and both West Bengal and Uttar Pradesh in India where there are particularly high maternal, newborn and child death rates.

Importantly, the IDEAS team are measuring the effectiveness of something that is greatly needed, but extremely difficult to achieve: behaviour change. They’re measuring whether changes in behaviour that improve newborn health are actually happening, such as a mother giving birth in hospital and immediately breastfeeding.

“In the past, some groups have been focused on spending large resources to measure survival every five years, two years, one year, but what’s important is tracking whether the things that would lead to better survival have changed,” said Prof Schellenberg.

Can we prevent women dying after childbirth?

The project began in 2010 and since then the team has carried out a series of large, representative household and linked health facility surveys, to measure interventions such as whether women give birth in healthcare settings, but also whether those facilities are providing the appropriate standard of care.

One key finding to date is that in Ethiopia, there has been a dramatic shift towards women giving birth in health facilities. IDEAS surveys showed a rise from 15% women in 2012 to 43% in 2015, an increase of 28 percentage points which is unusual. She puts this success down to an ‘enabling environment’ assisted by Government leadership and buy-in, Gates’ funding, and a number of other factors.

While that is very positive, according to Professor Joanna Schellenberg, it’s important that the health facility has not only a skilled birth attendant, but also the ability to carry out live-saving actions.

“One of the principal killers of women in childbirth is haemorrhage,” she explains. “Just giving birth in a health facility isn’t going to change anything unless that health facility can provide things like blood transfusion in a woman who’s potentially bleeding to death, or potentially use a preventive approach to manage the third stage of labour.”

 (PPH) – defined as the loss of 500 ml or more of blood in the first 24 hours of giving birth — can be prevented using prophylactic uterotonics, which contract the uterus and seal blood vessels. Results from IDEAS surveys show that their use rose from 11% in 2012 to 35% in 2015.

To her, success means that the findings are used to change what people do on the ground. “It means that the Gates’ Foundation would be using our results in their decisions. To some extent this is already happening.”

New uses for old drugs

Haleema Shakur, Co-Director of the Clinical Trials Unit at the School, is also tackling the issue of postpartum haemorrhage, by trialling a new treatment called  (TXA), which showed great promise in earlier trials.

TXA, a blood-clot stabiliser or antifibrinolytic, was first discovered by Japanese researchers in the 1950s — husband and wife team 

“The dream for the wife was to find a treatment that could help with stopping women bleeding to death, but she really couldn’t convince the obstetricians in Japan to actually follow through and do the research that was needed,” said Ms Shakur, Associate Professor at the Faculty of Epidemiology and Population Health.

Since then, doctors have tested TXA in surgical situations and in 2004 a review showed the compound reduced the need for blood transfusions by as much as a third.

Ms Shakur and colleague Professor Ian Roberts used this evidence to study bleeding following trauma injuries such as car crashes and shootings in Nigeria, known as the  trial, and found that the drug again reduced bleeding by a third — if given in the first hour.

“If you have a woman in front of you in a hospital bleeding, and if you can reduce her chances of dying, that’s worthwhile”

Ms Haleema Shakur, Associate Professor and CTU Co-Director at the London School of Hygiene & Tropical Medicine

But the game-changer came thanks to staff at the hospitals in Nigeria. They repeatedly asked Ms Shakur and her team why they weren’t looking at young women who were commonly being admitted as emergencies having almost bled to death after giving birth at home.

Ms Shakur learned that every year about  develop this severe bleeding after childbirth globally; about 1% of them will die, within an average of 2-4 hours from the start of bleeding.

This realisation soon led to the  – the largest trial on TXA to date – in 2010 which recruited 20,600 women in 193 hospitals in 21 countries to investigate whether TXA use could reduce death and hysterectomy during childbirth.

The results, due to be published early next year, are being awaited keenly as incidence of PPH is increasing globally, even in countries like the UK, where the rate is currently 5%. In Nigeria it is double that.

It’s not going to be a magic bullet entirely, because there isn’t one single thing you can do to cure this, and it’s not addressing all the other issues faced by women.” said Ms Shakur.

“But if you have a woman in front of you in a hospital bleeding, and if you can reduce her chances of dying, that’s worthwhile.”

Making enough time for care

The need for care, however, does not end after a successful childbirth. There are many more stages of care after this point. For example, there is great variability worldwide in the length of stay for a mother in a health facility.

 by Oona Campbell, Professor of Epidemiology and Reproductive Health at the School, found that the mean stay after women give birth to a single baby ranged from 0.5 days in Egypt, to 6.2 days in Ukraine. In Africa, Zambia had the shortest average stay (1.1) compared with 2.6 for Benin.

The problem is that women may be pressured to leave too early because of the need for beds, however, Prof Campbell adds that longer stays do not necessarily mean better care. She warns that women may be kept in hospitals until bills for care are paid, rather than them actually receiving additional services.

Prof Campbell now plans to look at why these variations occur.

“The moment of childbirth and the few hours afterwards are probably the highest risk period, but risk continues in the first couple of days of life,” she said. “You want those women who are having problems that have taken all that trouble to come in to health facilities, that those problems are detected.”

Another factor is making sure mothers are confident when they leave the comforts of the hospital.

“You’d want them to get help establishing breast feeding and making sure that they’re confident and comfortable looking after their babies,” said Prof Campbell.

This confidence is vital given this may be many young women’s first experience of health services. She concludes: “If they’re treated really poorly, what do we expect from them in the future in terms of coming back for care for their children or other health issues? It’s a critical period of transition.”

The recent series, led by Prof Campbell, showed how too many women experience one of two extremes: where they either receive care that is not timely or sufficient, or they receive too much care, too soon. The latter is marked by over-medicalisation and excessive use of unnecessary interventions in healthcare services. Meanwhile, some women receive no care at all.

The series called for a five point agenda for change to improve this situation, the first of which was quite straightforward: good quality care for every woman, every newborn, everywhere.

In her work Prof Campbell has seen many births in the UK and other rich countries and believes the commonality between them all is good care, whether things go wrong or not. “Sometimes it looks like an amazing process where even if things go wrong, women are treated really well, kindly, and are supported and you think, ‘Wow.’ I want that for every woman.”

The need for such aftercare is exemplified by Prof Lawn’s tale of her own birth in Uganda, half a century ago.

Her mother had experienced an unusually short stay in hospital, despite having had an emergency caesarean. She had been sent home the day after the procedure, and the birth of her first child, on a mattress laid on the back of a Land Rover.

Once home, she suffered a potentially fatal post-delivery complication of sepsis, blood poisoning, but thankfully survived.

She went on to have two more children in Uganda but Prof Lawn’s father had made sure her mother’s next two pregnancies were less traumatic. “My father packed my mother off to a maternity waiting home in the capital Kampala about five weeks before the due date,” she remembered. “Even then, she had a post-partum haemorrhage due to a retained placenta during the last delivery.”

Her case demonstrates that whoever you are, wherever you are, and whoever is shouting for you, childbirth comes with high risk, but these risks can be reduced with the right resources and attitudes.

“My mum is a remarkable woman,” said Prof Lawn . “She survived – and I also survived – because people had a norm that we should survive.”

Now the goal is to make that the norm in every clinic – in every country.

Title and cover image:© Save the Children