- Every day around the world, 800 people die as a result
of complications related to pregnancy and childbirth.
I know that is a sad and startling way to start a video
but the truth is it's a startling and sad reality.
By the time I finish this intro
it will have happened again,
and by the time you get to the end of this video
at least five more lives will have been lost
but it doesn't have to be this way.
Over the past several decades
medicine and our understanding
of what causes maternal deaths and more importantly
how to prevent them has expanded dramatically.
At this point,
preventing maternal mortality is more about access
and action than it is knowledge or understanding.
As part of their sustainable development goals,
in 2015, the United Nations made maternal mortality
a key indicator.
As part of their targets under this goal
they aim to reduce global maternal mortality rates
from 150 and 100,000 live births
to less than 70 and 100,000 live births by 2030.
But who is keeping them accountable
with regards to this goal?
I've partnered with the Bill and Melinda Gates Foundation,
not only for this video but also for me to travel
from New Zealand all the way to New York City later
this week to attend their Goalkeepers Conference.
I am humbled and honored to be tasked
with not only attending and learning, but also sharing
with you the information that I gather
and also the information from their 2023 Goalkeepers report
on maternal and neonatal health around the world.
(gentle music)
In 2015, the United Nations adopted a set
of 17 sustainable development goals
which are meant to make the world a healthier,
more equitable and more sustainable place by 2030.
The goals range from ensuring access
to clean energy, to making more sustainable cities
and to good health and wellbeing
which is the third of the goals
and most important to what we are discussing here today.
Goalkeepers is exactly what it sounds like.
An initiative started by the Bill
and Melinda Gates Foundation meant to oversee
and keep track of progress on these goals.
That includes both an annual report
on one of the key indicators as well
as a conference focused on the topic for that year.
That leads me to this year's report
which I mentioned is all about maternal and neonatal health
and I wanted to talk about it
because it's obviously incredibly important,
but also because we are not on track
in any way to meet the goals set forth
by the United Nations in 2015.
Maternal and neonatal mortality rates are both higher
than they should be
and intricately involved with one another.
I have a couple of charts that I'll show you
from the 2023 Goalkeepers report.
The first one is neonatal mortality rates around the world
and this is tracked in deaths per 1000 live births.
You can see that this number is declining, which is great.
We want to see it on the decline,
but if you look over to the right hand side of this graph
you will see that it is nowhere near being on track to be
at the point that the United Nations SDG goals had put it
at as a target.
The second graph I wanna show you is
maternal mortality rates, which unfortunately is no better
and possibly significantly worse.
As you can see in the early 2000s,
we made great progress
in reducing maternal mortality rates around the world.
However, since the introduction of the goals in 2015
we really haven't seen a lot
of downward movement of maternal mortality rates.
It seems to have pretty well plateaued, and if you look
over to the right-side of this graph
that means we are nowhere near being on track to meet
the 2030 goals set forth by the United Nations.
We also know based on extensive publications on this topic
that in high-income countries like the United States
people of color including but not limited
to black and indigenous women and AFAB people die
at rates that are significantly higher,
sometimes up to three to five times higher
than their white counterparts even when you control
for education and socioeconomic status.
So what do we do?
We know what causes these deaths
and we know in large part how to prevent them
but knowledge means nothing if it doesn't end
up putting tools into the hands of the people who need them.
In the 2023 Goalkeepers report utilizing change makers
who are doing amazing things around the world
they have compiled a list of low cost innovations
which have the potential to save thousands
of lives and move us closer to those 2030 goals.
Most of the interventions that we're going to talk
about today are low-cost innovations
that are easily transportable.
That could make a massive difference
especially in low and middle-income countries
where maternal mortality rates are the highest
and small changes could have major impacts.
Obstetric hemorrhage kills almost 70,000 people
every single year making it the number one cause
of pregnancy related death around the world.
That is 27% of everyone who dies related
to their pregnancy is killed by massive bleeding.
If that bleeding occurs
around the time of delivery just after delivery,
this is called a postpartum hemorrhage, and that is defined
as losing half a liter or more so 500 milliliters
or more of blood loss after delivery.
We know that early intervention is the key
to preventing people
from having severe morbidity meaning bad outcomes
or mortality, meaning death related to obstetric hemorrhage
but you can't intervene early
unless you recognize early that it is happening.
Dr. Hadiza Galadanci is an OB-GYN in Africa
who along with a team of researchers,
looked into deaths related
to obstetric hemorrhage in Africa and found that up to 50%
of all of these people who died from obstetric hemorrhage
in their study were not even diagnosed
as having a postpartum hemorrhage.
This means that half of the people that they looked at
didn't even have the opportunity to get treated to prevent
or stop their hemorrhage
because it wasn't even recognized when it was happening.
Getting something as simple
as a calibrated obstetric drape that includes
a visual representation of how much blood loss has occurred
into the hands of birth workers
in these areas could be an incredibly important first step
to reducing the rate
of maternal mortality from obstetric hemorrhage.
Of course, this is just a first step
because in order to prevent bad outcomes from hemorrhage
you not only have to be able to recognize it
but also to treat it when you do recognize it
and that's where something called
a postpartum hemorrhage bundle comes in.
Now, traditionally, we have used what I'm going to talk
about in this bundle in a kind of sequential order
meaning you use the first intervention.
If that doesn't work, there's still bleeding.
You move on to the second one.
But what Dr. Hadiza Galadanci's team has found is
that employing all
of these five postpartum hemorrhage bundles together
at the same time or in close proximity
to each other rather than only moving
to the next one if the first one doesn't work
is much more effective in reducing bad outcomes
and deaths related to obstetric hemorrhage.
The five things included in the bundle that they talk
about in the 2023 Goalkeepers report are fundal massage
which is rubbing the top of the uterus
or the uterine fundus to help it contract down.
That is helpful
for an obstetric hemorrhage that is caused by acne
or the uterus being too relaxed and not contracted enough.
The second one is a medication called tranexamic acid.
This can be given either orally
or by IV and helps reduce bleeding.
This is used not only
in obstetric hemorrhage but actually found its footing
for treatment of major bleeding, kind of in the trauma
and surgical community where it was largely used
for major like motor vehicle accidents, gunshot wounds
things like that, and we have in the past probably
decade really started using it a lot in obstetrics
and it is incredibly helpful for obstetric hemorrhage.
The third one is a group
of medications that help the uterus contract down
and there's a whole lot of different medications included
in that one that a lot of you're probably familiar with
which is oxytocin and several others as well.
The fourth one is IV fluids
so helping to increase the vascular volume
of somebody who is bleeding is very helpful
when they're having severe bleeding.
And the fifth one is an examination of the genital tract.
That's because some amount
of obstetric hemorrhage is related to vaginal
or cervical lacerations, which are needing to be sewn
and none of the medications or tools
in this toolkit will help if it is caused
from a laceration except maybe the tranexamic acid.
But the best thing you can do if that is the cause
is to put stitches in it and stop the bleeding that way.
So Dr. Galadanci and her team did a trial
with over 200,000 women included, and what they found was,
when these five interventions were employed
at the same time, rather than only using one
if the one before it didn't work, there was a 60% reduction
in the amount of severe bleeding that they saw.
This is a massive number
and something that is fairly easy to employ
if the birth workers have the tools they need to recognize
that a hemorrhage is happening and treat it
with these relatively low cost and fairly easy to transport
and access medications and tools.
Something that I think is really important is not
just figuring out how do we diagnose
and treat obstetric hemorrhage
but how can we actually prevent it
or reduce how catastrophic the effects are
from it before we even have the event occur?
And one of the things that the 2023 Goalkeepers report talks
about is anemia.
Now, anemia is extremely common
in pregnancy for a whole variety of reasons
but iron deficiency anemia in pregnancy is really common.
Probably over a third of people
during pregnancy will have some level of anemia
and that number is as high in some places
like South Asia as 80%, so this is incredibly pervasive.
Now, in places like high-income countries,
most of the time we tell people to take iron tablets
and that will help improve their anemia.
Unfortunately, this requires about 180 days
of really consistently using the iron tablets to make much
of a difference in your levels of iron.
Unfortunately, accessing enough iron tablets
and being able to consistently take them
on a regimen that you need to for the amount
of days that you need to is incredibly difficult
or if not impossible for a large percentage
of people who have severe anemia
in low and middle-income countries and developing nations.
So what can we do about that?
Well, let me introduce you
to Nigerian OB-GYN, Dr. Bosede Afolabi
who is working so hard to make IV iron more accessible.
IV iron can be administered over the course
of about 15 minutes to people with severe iron deficiency
during pregnancy and make a massive impact on iron levels
and anemia leading up to the time of delivery.
It's a fairly stable medication.
It's administered over the course of only about 15 minutes
and just that one dose can make a massive impact
on somebody's iron levels
and hemoglobin levels going into delivery
which means if you do have an obstetric hemorrhage
you are more likely to tolerate that blood loss
without a major bad outcome
and you are less likely to die from it.
One in ten pregnancy related deaths
around the world is caused by sepsis.
Sepsis is an infection where bacteria gets
into the the blood
and causes a system-wide inflammatory response
that is life-threatening and can be incredibly
quick to cause someone to go from fairly healthy
to extremely ill.
In pregnancy and related to birth.
Most of the time sepsis
like this is going to be caused by an infection that happens
in the uterus either during the pregnancy chorioamnioitis
or after delivery called endometritis, but it can be caused
by pretty well anything including a urinary tract infection
and any other type of infection that you can think of.
A recent research trial
in Sub-Saharan Africa was done giving women who went
into labor a dose of a medication called azithromycin.
Now, this is a relatively common
and fairly inexpensive antibiotic that can be taken orally
and is safe to use during pregnancy.
What the researchers in this trial found is
that the women who took that azithromycin at the onset
of labor ended up showing a one-third decrease in the number
of sepsis cases that they saw in that patient population.
That is a big number, but it's even bigger when you think
about the fact that I just told you
that one in ten pregnancy related deaths
around the world is related to sepsis.
So if we could decrease sepsis by a third
that would make a massive impact
not only on maternal mortality,
but also on the morbidity or bad outcomes
where people don't die
but they have a serious complication related to that.
I can't fit it all in here
and I wanted to focus on kind of the highlights
which are what's related specifically
to my field of medicine and reducing maternal mortality.
But an equally important objective
of the sustainable development goals is to reduce neonatal
and early childhood mortality
and the 2023 Goalkeepers report does touch on this as well.
They talk about things like access to corticosteroids
for expected preterm delivery, as well as adequate nutrition
and prevention of pneumonia in young children.
I don't have time to go into all of that here
so I will link the Goalkeepers 2023 report down below
if you're interested in reading through that.
If there's one takeaway I want you to have from this video
and the 2023 Goalkeepers report and my involvement with them
in general, it is that we can reduce maternal
and neonatal mortality rates around the world.
We can get on track to meet the 2030 United Nations goal
of reducing maternal and neonatal mortality
to the targets that they set, but this is not going
to happen in the absence of us learning how that happens
and also working to make an effort to get these tools
into the hands of the people who need them.
Follow me on Instagram if you want to tag along
for the Goalkeepers Conference and hear from some
of these amazing change makers from around the world
who are committed to the goals that I talked about
in this video.
I'll be sharing what I learn, what can be done,
what is still needing to be done
and most importantly, I think how you and I can advocate
for the people with the power to invest their time
and money into reducing preventable deaths
from moms and babies around the world.