The issue of maternal and newborn mortality is one close to my heart. I tragically lost one of my twin babies during childbirth, and then had to fight for the survival of the other. In fact, I am an example of both what can go wrong when there is a delay and of the success of modern medicine. Even though I was an educated and informed woman, I was unable to save the life of my second twin daughter due to the infrastructural deficiencies in Nigeria’s healthcare system at the time. I had to wait to find an anesthetist for an emergency C-section – a delay that cost me my daughter’s life. It is however thanks to modern medicine that I was lucky to survive with one healthy child. This mission for improving maternal health is what has brought me here today and is why I am so passionate about finding interventions, such as tranexamic acid, which can save the lives of mothers.
In the developed world, death during childbirth is rare – in fact the average maternal mortality ratio in OECD countries is just 11 deaths per every 100,000 births. Sadly, this is not the case everywhere. Although in Europe, maternal mortality is a near-negligible figure, in Sub-Saharan Africa, the risk of maternal mortality remains painstakingly high. In Nigeria, for example, the country of my birth, a woman incurs a 1 in 23 risk of dying during child birth in her lifetime. In Chad, with the highest maternal mortality ratios in the world, this figure is closer to 1 in 17. It is countries such as these that can benefit the most from tranexamic acid.
Tranexamic acid works by clotting a woman’s blood, reducing the risk of death by PPH by a third. A drug as cheap and effective as tranexamic acid therefore provides a rare opportunity for continental divides to converge – by preventing a third of PPH deaths worldwide (of which a shocking 99% are from Sub-Saharan Africa), we are a significant step closer to fair and equal maternal care around the world. The trial results speak for themselves. Over 20,000 women were enrolled in this trial, which took place in 21 diverse geographical settings, including countries with some of the highest mortality rates and absolute numbers of maternal deaths globally1. I thank the trial organisers for including such a diverse cross section of countries. As I mentioned before, maternal mortality affects those in developing countries the most and to have the trial focused in countries such as my own is incredibly important.
The administration of the drug can be the importance between life and death; as we have heard this evening, when administered to women experiencing postpartum haemorrhage (or PPH) (which affects around 6% of births) the drug can lower the amount of blood lost by mothers, and was shown to reduce maternal deaths from PPH by a 30%. What’s more, the drug is already readily available, and costs just $3 per injection.
Clearly, if administered across Africa, the health outcomes would be immense and would lead to lives of thousands of women across Africa being saved.
But this will not be easily achieved and we can expect challenges along the way.
Firstly, funding. The drug has been shown to be inexpensive and excellent value for money. However given the competitive health funding agenda in Nigeria and across Africa it is becoming increasingly difficult to secure funds for interventions, especially where Ministries of Health have funding constraints and other health demands. To combat this, we need to look elsewhere and to form strategic partnerships to secure funding sources.
We also need to consider how women access the drug and how it is administered. In my country Nigeria, many women give birth at home or in poorly equipped and under resourced medical facilities. Investigators acknowledge that most maternal deaths occur in low-resource settings, either at home or in poorly resources health facilities where intravenous administration may not be available. I believe that by commissioning further study into the administration of this drug we can investigate whether there are viable alternatives that can be used in rural and remote settings. Another option is strengthening healthcare facilities in these communities. I have seen first-hand the impact of strengthening these facilities, allowing women who would often have to travel for miles to access maternal healthcare to give birth.
These are challenges which cannot be addressed without a coordinated response involving global organisations, country governments, the academic community and those on the ground. We need to issue a call to action, urging on those responsible to fund the drug and distribute it to those who need it most.
Finally, education for expectant and new mothers and midwifes. We need to ensure that all midwives are educated to a high standard, are aware of warning signs during pregnancy and can recognise when the situation needs to be escalated. Education is the first vital step in this process. My foundation provides ante- and post-natal education programmes to help prepare mothers for birth, give them confidence to go through labour, and to care for their babies. The programme provides a range of information and topics include; preparation for birth, labour, coping with pain, care of the newborn, and breastfeeding.
We also need to train midwives and upskill health workers. My foundation, the Wellbeing Foundation Africa has introduced an Emergency Obstetrics and Newborn Care Skills and Drills programme. Objectives of the project include improving the quality of emergency obstetric newborn care and supporting pre-service midwifery institutions to improve components of the curriculum. Scaling up initiatives like these has the potential to make a massive impact in terms of competency and delivery of vital maternal care. Similarly, We have also focused on education for expectant mothers with the introduction of Mamacare classes, providing antenatal classes covering a range of topics and issues.
It is vital that we coordinate the responses of actors – NGOs, health academics and researchers must synchronise their efforts for maximum effect. By putting pressure on governments, we can work towards collaboration with global organisations to put together a coordinated case for funding the drug. We then need to work together to ensure the drug is distributed to those who most need it. I am especially heartened to see the recently released WHO recommendations, which call for early use of the drug within three hours of both and administration of the drug being considered as start of the standard PPH treatment package. Such high-level recommendations add to the strength of our argument for the use of the drug and we must utilize these findings.
Immediate and widespread distribution of tranexamic acid is undoubtedly a step in the right direction but this needs to be met with a greater commitment from governments to boosting maternal health outcomes. Just $3 can save the life of a woman – a mother. We are also bound by a global commitment to reducing maternal mortality; outlined in SDG 3, the goal is to reduce maternal mortality rates to 70 per 100,000 live births by 2030. Maternal deaths not only signify a waste of life, but serve to massively and negatively impact the lives of their infants and communities, and remain a constant, and impenetrable barrier to development. Investing in better maternal health therefore serves as both a means and an end, to be prioritised accordingly.
When I established my foundation over 25 years ago, the outlook for maternal care in Nigeria, and beyond, looked bleak. Since then, Nigeria’s maternal mortality ratio has nearly halved. Although this achievement is commendable, it can only go so far in addressing the inadequacies in maternal care in Nigeria and in Africa. Progress has been made, but there remains much work to be done.
It is my hope that the ground-breaking tranexamic acid will mark a new era in maternal care around the globe, and that its positive impact can be matched, through heightened investment and commitment to the cause. The drug provides hope to thousands of women and their families – now we must follow through.
Toyin Saraki, who is the Founder Director of the Wellbeing Foundation Africa and Global Goodwill Ambassador for the International Confederation of Midwives, gave this speech at the London School of Hygiene & Tropical Medicine.
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