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Life-threatening bleeding after childbirth, known as postpartum haemorrhage (PPH), remains one of the leading causes of maternal deaths worldwide. Providing emergency care and quick intervention during PPH is vital to save a woman’s life. However, access to emergency healthcare facilities that can provide this care is often a major barrier in many countries -disparities are rife in urban and rural areas.   

The World Health Organization’s year-long campaign h highlights the urgency to address access to maternal health amid stagnated progress towards reducing maternal deaths.  

In this expert comment, Dr Aduragbemi Banke-Thomas, Co-Director of MARCH, discusses his research on geographical inequalities in obstetric emergencies. Dr Amy Brenner shares her insights as Principal Investigator of the I’M WOMAN Trial and how the trial teams across Nigeria, Pakistan and Tanzania are working on a solution.  

What are some of the biggest barriers pregnant women face in accessing emergency care? 

Dr Aduragbemi Banke-Thomas: 

For many women, it is access to timely, high-quality care. The WHO reports that low- and middle-income countries (LMICs) and it is women in these countries that are most likely to die from a PPH. By the time a woman is bleeding, she's already in an emergency and should be receiving urgent care and interventions.  

However, for diverse reasons, emergency obstetric care is not always available or accessible, especially for pregnant women living in rural, hard-to-reach communities and densely populated urban environments. 

In urban settings, the time it takes to reach a hospital can be impacted by traffic congestion, lack of public transport, poor road infrastructure and access to a vehicle. Women in rural areas may travel long distances, might only have access to local community hospitals, which may be ill-equipped to provide the care they need, or need to wait for referral or transport options to a more specialised hospital. 

In the case of Nigeria, and many other LMICs, ambulances exist in some areas but not the entire country. Often, women are relying on a relative or neighbour to drive them to hospital or a bystander to help them and sometimes they have to pay a lot of money to travel.   
 
in collaboration with Google Health, we assessed the travel time to emergency obstetric care facilities across 15 of the most populous cities in Nigeria.  

Our study found that the time that a woman needed to travel to reach an emergency facility varied with traffic congestion. In addition, the choice of facilities some women could travel to was also limited by time – some women could not reach more than one emergency obstetric care facility within an hour.  
 
We found that the WHO’s two-hour benchmark for a pregnant woman needing emergency care is way too generous for pregnant women who face emergencies. As per our , in Nigeria, journeys greater than 30 minutes of travel following referral resulted in a significantly higher chance of maternal deaths. 

During an emergency, timely access to emergency obstetric care and skilled health workers can Pregnant women experiencing an obstetric emergency need to find and reach a capable health facility in time to be able to get access to this care. 

Dr Amy Brenner: 

Travelling to a capable health facility is the guaranteed way in which a pregnant woman can get care. However, sometimes travelling to care might be impossible or be delayed. In such instances, care needs to start where the emergency occurred at first. If one were to treat an obstetric emergency as a road traffic accident – the emergency response would start at the scene of the accident.   

There are many cases where women giving birth at home start bleeding or are taken to the local clinic to be given some misoprostol – a drug used to induce labour as well as treat PPH – and the women continues to bleed.   

In this instance, women are triaged to the next place and when they arrive there, the hospital may be out of stock of interventions for PPH, including tranexamic acid (TXA) – a life-saving drug used to reduce severe bleeding. 

From our data, we know that women who bleed badly can bleed to death in a matter of minutes. Two hours is far too long a distance to travel to access emergency treatment. If it takes that long to reach a facility and a woman has a severe PPH, the chances of survival are extremely low. 
 
 
The solution: intramuscular administration of a life-saving drug 

Dr Amy Brenner:
 
is working on one solution that could break down these barriers to accessing emergency obstetric care. The I’M WOMAN Trial team is a global clinical trial working across Nigeria, Pakistan and Tanzania. We are looking at whether giving TXA before childbirth, and into a muscle (IM), rather than a vein (IV), can reduce postpartum bleeding and improve outcomes for women. 
 
°®ÍþÄÌapp access to emergency obstetric care and hospital facilities, such as surgery, can save lives. But for women who are unable to quickly access such services, we need to bring life-saving interventions into the community.  

If we show that IM TXA is as effective as the current IV mode of administration, it will offer an opportunity to be able to treat an obstetric emergency almost immediately, wherever it happens.  

Injecting TXA into a muscle, rather than slowly through a vein, which requires a skilled healthcare worker to fit a cannula, could mean the drug could be delivered outside a hospital setting. This would be hugely beneficial in bringing TXA to the community and treating women with PPH at the time of the emergency onset, before they reach a hospital.  
 
It would change the game for women everywhere – reducing the need to travel to a skilled healthcare worker or hospital facility. It could also reduce the need for blood transfusions, and surgeries like hysterectomy. 
 
Since 2017, the WHO recommends using TXA to treat PPH, but not enough doctors are using it. Therefore, raising awareness of TXA and following the in hospitals can allow women to get the care they need in an emergency. By tackling the access, availability and affordability of life-saving treatments, including TXA, women can get the right care, at the right time and the world could get back on track to meet Sustainable Development Goal 3.1 of the  
 

Further information

Dr Aduragbemi Banke-Thomas is Associate Professor of Maternal and Newborn Health and the Co-Director of the MARCH Centre. His research focuses on maternal health, especially as it relates to women living in Africa, and particularly vulnerable women such as refugees and black and ethnic minorities living in North America and Europe. Specifically, his research has explored issues on and strategies to optimise cost and cost-effectiveness, geographical access, and quality of maternal and newborn health care for these women. 

Dr Amy Brenner is Principal Investigator of the at LSHTM and Project Lead of the project (tranexamic acid access for all mothers with bleeding after childbirth) funded by Unitaid. The I’M WOMAN Trial is part of the TRANSFORM project. Amy’s current research focuses on expanding equitable access to TXA and finding alternate routes to giving it, specifically for postpartum haemorrhage.