Maternal Health - Q3 - Sep 2019 by Mediaplanet UK&IE

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DR ANSHU BANERJEE - WHO Women experience abuse and a lack of respectful and compassionate care during childbirth. » p2

DR DAGHNI RAJASINGAM - RCOG Most maternal deaths are entirely avoidable. » p6

SHANNON HADER - UNAIDS Without human rights and gender equality... we are only going to get so far. » p7

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The lives of women and children depend on quality healthcare It is estimated that high quality health systems could prevent one million newborn deaths and half of maternal deaths per year. In addition, women often report experiencing a lack of respectful and compassionate care which decreases their confidence in the health system. DR ANSHU BANERJEE Director, World Health Organization (WHO), Department of Maternal, Newborn, Child and Adolescent Health

ccess to healthcare is vital but quality of care is also i mp or t a nt i n re duc i n g mortality and morbidity, says Dr Allisyn Moran, scientist at the World Health Organization (WHO). WHO is strengthening its focus on improving the quality of healthcare, to promote healthy pregnancies and births as well as positive exper iences of preg nanc y and childbirth. This will result in fewer deaths, improved health and better long-term outcomes. There a re s ever a l e s s ent i a l elements to promote quality of care including adequate infrastructure, health worker availability and competence,

2.6 million babies are stillborn, and 2.5 million newborns die annually.

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e qu ipment a nd s uppl ie s, a nd Quality Equity and Dignity Network accountability. For example, it is includes three common components estimated that one in for improving respectful care five births globally and the experience of care takes place in during pregnancy and less developed childbirth: Access to services has countries increased, resulting (L DC s), 1: Every woman in almost 80% of live and that, and her family births occurring with each year, are provided with the assistance of skilled 17 million emotional support health personnel in women that is sensitive the latest period 2012in these to their needs and 2017 globally (this was, c o u nt r i e s strengthens the however, only over 50% in g i ve b i r t h woman’s capabilsub-Saharan Africa). in health ity, such as allowing cent res w it h women to choose to have inadequate water, a companion during labour sanitation and hygiene. and childbirth. Equally, there is a projected shortage “There is evidence that allowing of 18 million healthcare workers women to choose to have a by 2030, which includes health companion during labour and personnel crucial to providing childbirth can improve outcomes maternal healthcare services. for both the woman and the baby. Furthermore, there is a need However, there are challenges to improve clinical care and for implementation, especially in reduce harmful interventions, low-resource settings.” as well as the necessity of harBarriers include facilities that nessing patient, family and limit privacy and contribute to community engagement and labour ward overcrowding, diffiempowerment. culties in maintaining hygiene Respectful and compassionate standards, limited knowledge of the care are an essential element of benefits of labour companionship quality of care. For example, the and negative attitudes.

DR ALLISYN MORAN Scientist, World Health Organization (WHO), Department of Maternal, Newborn, Child and Adolescent Health

More than 300,000 mothers die around the time of childbirth.

Dr Anshu Banerjee notes, “All these improvements should be part of the commitments made towards Universal Health Coverage, which should also guarantee that, in order to leave no one behind, these services are affordable for all and do not lead to catastrophic health payments for anyone.” WRITTEN BY: LINDA WHITNEY

2: Women and newborns receive care with respect and preservation of their dignity. "It is not uncommon to hear of physical or verbal abuse, where women are shouted at or slapped by healthcare professionals." 3: Communication with women and their families is effective and responds to their needs and preferences. All women and their families should receive information about their care and have effective interactions with staff as well as coordinated care, with clear, accurate information exchange between relevant health and social care professionals.

Globally, maternal mortality has declined by 38% since 2000.

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Women helping women: How maternity healthcare in Afghanistan is changing While maternal and infant mortality rates in Afghanistan may be dropping, the often-confusing figures still highlight that further work needs to be done to tackle the societal issues these women face.

‘Taboo’ to seek medical help With thousands of families displaced by conflict, traditional roles of local women acting as midwives are no longer being fulfilled. Trust in the medical community has been eroded, many fear vaccinations and health professionals due to a lack of information. This distrust prevails, and it can often make the concept of seeking medical help taboo. International aid bodies have worked to tackle some © PROVED BY MUSLIM HANDS issues, but the involvement of NGOs in Afghanistan is declining, and the issues are so wide-ranging that progress is slow. In 2011, one clinic, run by the charity Muslim Hands, came up with a unique solut ion. They bega n training local women as community health workers, reaching out to mothers and pregnant women in their own homes. The only requirements were that

o understand the high maternal mortality rate in Afghanistan, it is important to first understand the living situation of many women. In Kabul, there are only two maternity hospitals. Due to geographical and cultural obstacles, many women find it hard to travel to facilities, so often go without pre and post-natal care.

Trust in the medical community itself has been eroded, and many fear vaccinations and health professionals due to a lack of information.” workers must be women who lived in the community and had a secondary school education. Now, women who cannot attend the clinic still have access to basic medical care, advice and support. The health workers are also instrumental in identifying cases where women need more advanced medical interventions. Training local women in healthcare Dr Abrahim K hairandesh says: “We realised that we needed to provide an alternative way of caring for these women and believe our community health workers are the way forward. They bridge the gap between primary care services while also providing a low-cost

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DR ABRAHIM KHAIRANDESH Regional Partnerships Manager, Muslim Hands means to identify high-risk cases.” Despite initially being mistrusted, community workers are now sought out for advice and are the first port of call for a pregnant or new mother. “I have heard stories of dogs being set on our community health workers and doors slammed shut but, after a few visits, the door eventually opens. “These women are now welcomed and seen as guests of honour. That has only come with years of hard work and integration.” With the notion of: ‘leave no one behind’ and the importance of maternal health in shaping the future of all societies, Dr Khairandesh calls upon everyone to extend their support. “We have a saying in Afghanistan that, with one hand a mother rocks the cradle, and with the other she rocks the world.”

Maternal health rights accessible for all Muslim Hands also run a maternal health clinic in Somalia, but want to reach even more women in conflict affected, fragile states where multiple barriers to accessing maternal healthcare continue to have a devastating impact on their health, wellbeing and basic rights.

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WRITTEN BY: GINA CLARKE Read more at muslimhands.org.uk /motherkind

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What you need to know about pre-eclampsia Pre-eclampsia and eclampsia can have serious implications. Not every pregnant woman displaying symptoms will have the condition — but close monitoring is vital.

re-eclampsia has long been a leading cause of maternal mor ta l it y i n preg na nt women around the world — and it still is, says Dr Manu Vatish, Clinical Consultant in Obstetrics and Clinical Research in Maternal Medical Disorders, Oxford University Hospital. “Globally, approximately 80,000 women a year die from pre-eclampsia or eclampsia, which is also implicated in the deaths of around half a million babies,” says Dr Vatish. The highest burden affects people in lower- to middle-income countries. “In the UK, one woman in a million will die from the disease; while in South Africa, it remains a major cause of maternal mortality,” explains Dr Vatish. Other factors also increase the risk of developing pre-eclampsia: for example, if you have HIV, or autoimmune disease or chronic kidney disease.

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Short- and long-term health effects of pre-eclampsia Pre-eclampsia and eclampsia occur when the placenta does not work properly. Complications of the condition may include stroke, damage to other organs or placental failure (which can result in a low birth weight for the baby, or even stillbirth). To prevent these complications, doctors will look out for warning signs of pre-eclampsia in pregnant women. The symptoms include high blood pressure, protein in the urine, headaches, dizziness, rapid weight gain and abdominal pain. It is important to catch pre-eclampsia early, before it can become eclampsia. “At that point the mother can start to have seizures, which makes adverse outcomes for the mother and her unborn child much higher,” explains Dr Vatish. Pre-eclampsia is also thought

DR MANU VATISH Clinical Consultant, Obstetrics & Clinical Research in Maternal Medical Disorders, Oxford University Hospital

The only treatment is to deliver the baby, which is a very easy decision to make if the mother is in week near her due date. It’s less easy if she is at week 25.” to cause long-term health effects, including a lifetime increased risk of cardiovascular disease for mother and baby. The only treatment is to deliver the baby Unfortunately, the only treatment is to deliver the baby, which is a very easy decision to make if the mother is near her due date. It is less easy if she is at week 25 of pregnancy. “Then, doctors have to balance things, trying to eke out as much time as possible for the baby while not letting the mum get sick,” says Dr Vatish.

Testing is crucial to identify those who might be at risk so that their condition can be managed quickly and effectively. This isn't easy, because many pregnant women can display the symptoms and not have pre-eclampsia. Plus, notes Dr Vatish, the traditional tools used to diagnose pre-eclampsia do not successfully pinpoint who will go on to develop the disease. Only 30% of women presenting with symptoms and signs suspicious of pre-eclampsia, will actually have the disease. New, more accurate test helps with diagnosis The shape of diagnosis may be about to change, however, because a new test is available, which can tell who is at risk of developing pre-eclampsia in the next week with a much greater degree of accuracy (99.3%). It work s by me a s u r i n g t wo

biomarkers in the placenta: Soluble Flt-1 (sFLT-1) and placental growth factor (PLGF). “The sFLT-1 molecule binds the PlGF, causing blood vessels to not work as well as they should,” says Dr Vatish. “So, anyone who is going to get pre-eclampsia will have much higher levels of sFLT-1 and lower levels of PLGF.” The discovery of these biomarkers also opens up possible avenues for treatment. Pinpointing pre-eclampsia with greater accuracy means that more women presenting with suspected symptoms can be sent home with a clean bill of health, focusing medical attention on the women who may really need it. This is particularly positive news for developing countries, or countries with high populations. WRITTEN BY: TONY GREENWAY MEDIAPLANET

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How a simple blood test can improve pregnancy care? Preeclampsia — a potentially serious condition that affects women in pregnancy — is difficult to diagnose. Thankfully, a new test is better able to predict who might develop it.

e live in a world where women outnumber men, yet statistics show that women's medical needs are continually underestimated and often go unmet. Perhaps this is because many women are too busy focusing on the health and happiness of others — sometimes at the expense of themselves — to notice the scale of the problem. Take the tragedy of maternal deaths. Many of these are preventable because the healthcare solutions to prevent or manage complications in pregnancy are well-known.

Even so, there are approximately 830 deaths every day from preventable causes related to pregnancy and childbirth,1 with 80% including complications from severe bleeding, infections (mostly after childbirth), unsafe abortions and high blood pressure during pregnancy.2 Why early detection of preeclampsia is crucial Preeclampsia is a condition that usually affects women in the second half of their pregnancy. This, along with other hypertensive disorders

INTERVIEW WITH:

SOPHIA CHAO Vice President, Women’s Health, Roche Diagnostics

There are approximately 830 deaths every day from preventable causes related to pregnancy and childbirth.” of pregnancy, is one of the leading causes of fetal and maternal morbidity and mortality, accounting for 10–15% of all maternal deaths.3 Naturally, early detection and effective care can vastly reduce the number of preeclampsia-related fatalities. The problem is that preeclampsia symptoms — such as high blood pressure and swollen feet, ankles and hands — can be mistaken for the normal effects of pregnancy, making it difficult to diagnose. To further complicate matters, standard preeclampsia diagnosis is limited and involves detecting high blood pressure after 20 weeks and protein in the urine. Unfortunately, these two indicators are poor predictors of who will develop adverse outcomes and who will go on to have normal pregnancies. This is an issue because 80% of pregnant women with signs of

preeclampsia won't develop the condition4 — but are unnecessarily hospitalised in case they do. Clearly, when it comes to preeclampsia diagnostics, there's a need for a more innovative solution. The beneﬁts of an innovative new preeclampsia testing using biomarkers sFlt-1 and PlGF Thankfully, one has been found. A novel preeclampsia test has been developed that measures two proteins found in the mother’s blood, making it possible to predict with greater certainty which women with suspected preeclampsia will and will not develop the condition. In fact, a recent study published in the New England Journal of Medicine, shows the test predicts which women will not develop preeclampsia in the next week with more than 99% confidence.5 This is good news for patients, because women who are unlikely to develop preeclampsia are saved the stress of close monitoring and the disruption of a hospital stay. Sophia Chao notes: “This innovation in preeclampsia testing using biomarker tests ultimately ensured that those who needed a high level of care received it, while others would be able to return home safely.” It ’s also good for clin icians, because doctors can send healthy women home safely and focus patient management on women who are more likely to need it. And, ultimately, there’s a cost-saving for the healthcare system. By using the new biomarker testing in clinical practice, the hospitalisation of women suspected of having preeclampsia could be reduced by 50%, leading to cost savings of £344

per patient.6 Annual UK savings are projected to be £24 million. It's just one example of how an increase in medical knowledge, coupled with advances in science, data, analytics and digital technology, promise a transformational shift in the approach to diagnostics and healthcare, making it more evidence-based and personalised. WRITTEN BY: TONY GREENWAY Roche Diagnostics is focused on a holistic view of conditions and diseases specific to women with over 50 diagnostic products from fertility, pregnancy to female cancers and bone health.” Sophia Chao reflects: “The vision is to improve outcomes for women through the journey of their lives by addressing their unique unmet medical needs. We are committed to providing an extensive women’s health portfolio and ground-breaking medical value diagnostic solutions that advance medical practice and to make them accessible to women across the world.

Read more at diagnostics.roche.com

1: 1 WHO 2016 Maternal mortality fact sheet 2: WHO 2016 Maternal mortality fact sheet 3: Berg, C. J., Mackay, A. P., Qin, C., and Callaghan, W. M. (2009).Overview of maternal morbidity during hospitalization for labor and delivery in the United States: 1993-1997 and 2001-2005. Obstet.Gynecol. 113, 1075-1081. 4: Klein, E., Schlembach, D., Ramoni, A., et al. (2016). Influence of the sFlt-1/PIGF ratio on clinical decision-making in women with suspected preeclampsia. Plos ONE 11(5): e0156013. doi:10.1371/journal.pone.0156013. 5: Zeisler, H., Llurba, E., Chantraine, F. et al. (2016). Predictive Value of the sFlt-1: PlGF Ratio in Women with Suspected Preeclampsia. N Engl J Med. 374, 13-22. 6: Vatish, M., Strunz-McKendry, T., Hund, M., Allegranaz, D., Wolf, C., Smare, C. (2016). sFIt/PIGF ratio test for pre-eclampsia: an economic assessment for the UK. Ultrasound in Obstet Gynecol. 48(6):765-771

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Maternal mortality and morbidity - a global issue Medicine has made giant leaps over the past 100 years, with the birth of penicillin, the contraceptive pill and vaccines, but maternal mortality rates are still devastatingly high.

very day, around 830 women die from preventable causes lin ked to preg nancy and childbirth, with 99% of those deaths occurring in developing countries. The majority of these deaths could be prevented with timely healthcare, trained workforce, appropriate medical supplies and adequate sanitation, but these basic needs are still not widely accessible. Where are maternal deaths occurring? The maternal mortality rate is significantly higher in developing countries, with 239 maternal deaths in 100,000 live births compared to 12 in 100,000 in developed countries. Sub-Saharan A frica accounts for around 66% of the number of maternal deaths globally. Sierra Leone has the highest estimated lifetime risk with approximately one in 17 women losing their lives during pregnancy, childbirth or in the post-partum period. Why are the ﬁgures so high? The figures remain high for reasons

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including lack of access to medical care, lack of funding and a dearth of information for women. Many of these are sadly common in developing countries and especially prevalent for women in rural areas, w ith medical care often unaffordable and/or only accessible by covering significant distance. Poverty, both on an individual and societal level, leads to higher maternal mortality. This lack of k nowledge, and lack of access to information, can contribute to improper sanitation, which increases the risk of disease. Women lack information on what to expect and poor medical supplies mean screening is not available as easily as in developed countries. There are also low numbers of skilled healthcare workers in a number of regions. What are the causes of maternal mortality? The m a i n c au se s of m ater n a l mortality include severe bleeding, i n fec t ion s, pre - ecla mpsia a nd eclampsia and complications from

A woman’s risk of maternal death over her lifetime is 1 in 4,900 in developed countries, compared to 1 in 180 in developing countries.” delivering unsafe abortions. These are all issues that can be mitigated to ensure a safe pregnancy and birth but, unfortunately, the facilities necessary are not available for many women. A lack of education on pregnancy and the birthing process also contributes to adverse outcomes, with some unable to recognise concerning symptoms. How do we reduce the number of maternal deaths? Most maternal deaths are entirely avoidable. Access to antenatal care in pregnancy, special care during childbirth and support after childbirth significantly improve health outcomes for women and their babies. O ne t a r g e t u nde r t he U N ’s Sustainable Development Goal 3 is to

DR DAGHNI RAJASINGAM Consultant Obstetrician, Royal College of Obstetricians and Gynaecologists reduce the global maternal mortality ratio to less than 70 per 100,000 births – with no country having a maternal mortality rate of more than twice the average worldwide. As part of the Global Strategy and goal of Ending Preventable Maternal M o r t a l it y, t h e Wo r l d H e a l t h Orga n i zat ion is work i ng w it h partners to address the barriers. Funding is key and international aid is essential in lowering these numbers, but there are also cost-effective options available with little infrastructure required at a local level. One such example is the RCOG global health programme in South Africa and Tanzania, called Leading Safe Choices. The programme is focused on workforce training to enable over 60,000 women to receive postpartum family planning counselling and contraception after birth. In total, 744 healthcare professionals in 20 facilities were trained, with a focus on long-acting, reversible methods made available to women for free. This is important because women in developing countries tend to have

more pregnancies and, as a result, their lifetime risk of death due to pregnancy is higher. A woman’s risk of maternal death over her lifetime is 1 in 4,900 in developed countries, compared to 1 in 180 in developing countries. It is also essential women have control over their fertility to enable them to plan when to have a family, and ensure births are spaced out to improve health outcomes. The RCOG has made maternal health worldwide a key priority – the health of a nation depends on the health of women and girls. We will continue to advocate for the very best in women’s health.

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Stalling HIV progress is a wake-up call to the world Progress in stopping new HIV infections among children has stagnated, missing global targets set for 2018. Countries have to look at why this is happening if 2020 targets are to be met.

he news is concerning. In July, the Joint United Nations Programme on HIV/AIDS (UNAIDS) published its Start Free Stay Free AIDS Free report, focusing on 23 countries with high numbers of children, adolescents and young women living with HIV (21 countries in Africa, plus India and Indonesia). It revealed that progress in stopping new HIV infections among children has stagnated, missing global targets set for 2018 by a wide margin. “We've made tremendous progress in this area since 2010, but we're far off the mark and, in the last three years, numbers have plateaued,” says Shannon Hader, Deputy Executive Director of Programme at UNAIDS. “Overall, Eastern and Southern Africa have been doing well, making more gains than West and Central Africa, where progress has stagnated at very low levels.” It's a wake-up call if the world is to

meet its 2020 targets, which include reducing the annual number of children newly infected with HIV to fewer than 20,000.

Women may be scared to tell their husbands and families that they have HIV.”

Structural barriers to HIV services The report notes that: “In some settings, as many as 30% of all new infections in children can be attributed to their mothers acquiring HIV during pregnancy and breastfeeding.” Un for t u nately, t here i sn't a universal solution to this problem. “In some countries, babies are being infected because HIV positive women aren't accessing preventative mother-to-child transmission services during pregnancy or breast-feeding,” says Hader. “That might be because there are structural barriers such as user fees — or it might be because of quality issues. We know that women will be dissuaded from going to a clinic if

they feel it won't be clean, respectful and welcoming.” In other countries, HIV positive women are better able to access these services, says Hader. “The trouble is, after they receive starter treatment, they fall out of care either during pregnancy or after delivery. So, what's happening there?” Overcoming stigma and discrimination One answer could be that they are worried about experiencing stigma and discrimination. “Women may be scared to tell their husbands and families that they have HIV,” says Hader. “Going back to the clinic and keeping your medicine secret is a

SHANNON HADER Deputy Executive Director of Programme, UNAIDS

really stressful thing to do when you're pregnant or breast-feeding.” Programmes therefore need t o e n s u re t h at t he s e wome n want to return to clinics and feel empowered to do so, with support from community health workers and 'mentor mothers'. After delivery, it's crucial that women continue with treatment, and that babies continue to get follow-ups. “The problem is, going back and forth to a clinic and staying on medicines might be overwhelming for a new mum,” says Hader. “Or she might feel that, because her baby's first test was negative, she doesn't need to worry about it anymore.” Again, community support is vital. Protecting those at risk of HIV Plus, there's the issue of predicting which women could be newly infected with HIV. “That's a whole

different problem — and hard to do,” says Hader. “Countries have to find out who the most at risk might be and make sure they have access to intensive HIV prevention services to keep them and their babies safe.” So, is Hader's feeling that maternal rights are being denied in some countries? “You'd have to look at that country by country,” she says. “But I will say this: without human rights, gender equity and anti-discrimination policies, we are only going to get so far with our response to HIV.” WRITTEN BY TONY GREENWAY