Five steps, fast: This plastic sheet and pouch can stop thousands of women from dying after giving birth

14 May 2023

Researchers have found a way to drastically reduce the incidence of fatal bleeding after childbirth by 60%, according to a study presented at the International Maternal Newborn Health Conference in Cape Town last week.

Losing half a litre of blood or more after giving birth is one of the biggest reasons new mothers die in South Africa (after HIV).

New research conducted in hospitals here and Tanzania, Kenya and Nigeria shows that life-threatening blood loss after giving birth can drop by 60%. The results were presented at the International Maternal Newborn Health Conference in Cape Town last week.

It’s a three-part plan that uses slightly tweaked versions of tools and treatment rules that are already common in South Africa’s public hospitals.

Scientists have found that a plastic sheet with a funnel-like pouch attached to the bottom edge can, along with a few other steps, cut life-threatening bleeding after vaginal births in hospitals by 60%. This is according to a study presented at the International Maternal Newborn Health Conference held in Cape Town from 8-11 May 2023. The research was also published in the New England Medical Journal.

The piece of plastic, which researchers call a “drape”, is slid in underneath the patient and tied around her waist after she’s given birth. It collects blood in a pouch that hangs off the bottom end of the hospital bed — and it costs less than R30.

In South Africa, one of the most common causes of women dying as a result of pregnancy is excessive bleeding. If someone loses more than half a litre of blood in the first 24 hours after giving birth vaginally, it is called postpartum haemorrhage.

Often people die because health workers don’t notice soon enough how much blood the new mother has lost, the study’s authors explained in a press release.

But their simple, three-part solution could prevent 22,000 people from bleeding to death from childbirth each year, according to estimates shared at the conference.

The study was conducted in 78 hospitals across South Africa, Kenya, Nigeria and Tanzania between August 2021 and the end of 2022, with 14 of the hospitals being in South Africa. Facilities could only be part of the study if they handled between 1,000 and 5,000 vaginal births each year.

Sue Fawcus, a gynaecology professor at the University of Cape Town who led the local arm of the study, says South Africa could easily roll out this monitoring method at state hospitals.

The first step is to set up the “drape”. Drapes have previously been tested as well, for instance, in India, but in this study, using a pouch with markings to show how much blood somebody has lost meant a health worker could act before it’s too late.

If a nurse or midwife sees that the new mother has lost 300ml of blood in the first hour after having given birth — so, 200ml before postpartum haemorrhage sets in — they can start the second part of the solution.

This is to check whether the patient’s blood pressure or heart rate is also dropping.

If so, step three kicks in. A health worker should then do five things the World Health Organisation (WHO) says to help to stop dangerous bleeding after childbirth.

These include: giving the patient a minute-long uterus massage (or a massage until the uterus contracts); administering a medicine that causes contractions (which, in turn, cuts blood supply to the uterus and slows bleeding) or giving the patient a drug used to stop heavy bleeding, putting them on a drip; and finally, checking for blood clots or tears in or around the person’s vagina.

Step three has to happen within 15 minutes of somebody losing 300ml of blood, the researchers explained at the conference — and the actions have to occur in order, one after the other.

This differs from how follow-up care after childbirth usually goes, as a nurse or a midwife would wait a while before doing the next thing on the list to see if their actions have made any difference.

The more quickly health workers step in when someone starts to bleed, the better the patient’s chance of surviving, explained Arri Coomarasamy, co-author of the study and professor of gynaecology at the University of Birmingham at a media briefing.

The study’s results could lead to a change in the WHO’s recommendations, but it might take a few months for the global health body to consider the new evidence, said Olufemi Oladapo, who heads up the WHO team looking at birthing mothers’ health.

South Africa’s maternity treatment guidelines already include the WHO’s list of five things to do in dealing with postpartum haemorrhage, although doctors and midwives usually do them one by one and wait a while between steps. This also meant that the medicines needed for the study were already in stock at state pharmacies.

How did the study work?

It was a randomised control trial, which researchers say is the best way to see how well a medicine or action works because the investigators try hard to eliminate any factors that may skew the results.

They do this by splitting the study participants into two groups, which have the same characteristics. But the treatment being investigated is given only to one group.

In this after-birth bleeding study, it was the hospital that was assigned to either of the groups, rather than patients. Hospitals included in the treatment group all got drapes with volume markings to use during vaginal births. Maternity-ward staff were also trained on how to do the five actions in the WHO’s recommended list.

The “placebo” group — that is, the hospitals that did not offer the treatment being investigated — used drapes without volume markings, and midwives or nurses didn’t get any training on following the list of WHO actions. Other than this, patients at these facilities got the usual care that birthing women could expect at that hospital.

How well did the three-part plan work?

The volume-marked drapes and doing the list of five things to stop bleeding as one set saved lives, the research shows, because it helped health workers to catch instances of dangerous blood loss early. This meant that they could do something to help in time.

In the hospitals where the new plan was followed, excessive bleeding was noticed in time in 90% of the patients, whereas it was picked up soon enough only in half of the patients in hospitals where the usual approach was still followed.

The success comes down to the volume markings taking the guesswork out of knowing how much blood a patient has lost, explains Coomarasamy, and this is why health workers could respond fast enough.

What does this mean for South Africa?

The marked drapes used in the trial were made in India and cost just R26 each, the authors explained at the conference. Fawcus says they are considering approaching the health department to investigate local suppliers and making the trial’s interventions part of South Africa’s national guidelines for maternal health.

Until then, the 14 hospitals here that took part in the study will keep getting drapes with volume markings for another year. DM/MC

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

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Maverick Citizen

How did the study work?

How well did the three-part plan work?

What does this mean for South Africa?