The taps in the hospital were covered in plastic sheets, and staff on the maternity ward at Felege Hiwot referral hospital in northwestern Ethiopia had long written them off as useless. In their place were buckets of water, a poor replacement for doctors and nurses trying to keep the rate of infection down in one of the region’s busiest maternity units. Then Sam Tweed, a visiting medical student from Aberdeen University in Scotland, turned his attention away from the patients and went in search of a plumber. The plumber dismantled the pipes and found a surprisingly simple problem. The sensors on the taps, installed by an Italian NGO, were battery operated, and the batteries had died. They were replaced, and water once again splashed into the basins.
To Wendy Graham, world expert in obstetric epidemiology at the London School of Hygiene & Tropical Medicine, those taps symbolize so much in the fight to stop women dying in childbirth. “We’ve got to discuss the minutiae alongside the bigger picture,” says Graham.
In addition to her research at the London School, Graham runs the Soap Box Collaborative, which sent medical student Tweed to Ethiopia as part of its mission to improve water, sanitation and hygiene (WASH) in African and Asian maternity wards.
Graham’s obsession with cleanliness in hospitals is nothing new, but it takes on renewed urgency following the publication of a major study on maternal health by the Lancet, of which she is a key author. Launched at the United Nations General Assembly just over a week ago, the study comprises six papers that analyze decades of epidemiological data on pregnancy and childbirth, providing the most comprehensive picture yet of the global status of maternal health. The headline figure from the series, that the number of women dying from maternal causes has almost halved since 1990, was greeted with muted applause. While a 50 percent drop marks a significant improvement, it falls short of the target set by the U.N. in 2000 with the Millennium Development Goals, which aimed to see maternal deaths reduced by 75 percent by 2015.
To Graham, who says she is “outraged” that outcomes for women haven’t improved more in the 30 years she’s been working in maternal health, the failure of the global health community to further reduce maternal mortality is partly due to a lack of attention to detail.
“Sometimes, we’re talking about really basic things. We’re talking about a woman delivering a baby on a bed that is not covered in blood from the previous patient,” says Graham. “It’s no good talking about global targets without also addressing the nitty gritty.”
While the number of women giving birth in the presence of a skilled birth attendant rose from 57 percent to 74 percent between 1990 and 2013, the change did not always correlate with an improvement in patient safety.
“The big difference now from 10 years ago is women are going to facilities more, they are seeking out care,” says Graham. “But when you drill down into the quality of this care, it’s not good enough.”
While that could mean wards with no soap or running water, it also includes women arriving at facilities where staff are under-equipped to diagnose and deal with even the most basic obstetric emergencies. In other cases, the series reports women’s safety being compromised by over-medicalization and interventions that aren’t needed. Summarized by the authors as a problem of “too little too late or too much too soon,” the issue is identified as being a particular problem in low- to- middle-income countries, where a rise in women accessing medical facilities to give birth is also leading to a rise in unnecessary procedures.
For example, in rural Burkina Faso less than 1 percent of women have access to a Caesarean, putting their lives at risk when a serious problem arises. By contrast, in private clinics in the country’s capital Ouagadougou, the rate of Caesareans can be over 33 percent, which puts women who are capable of having natural births at unnecessary risk of complications, including a greater risk of infection, according to Graham.
The solution, she says, must be rooted in a more joined-up approach to maternal healthcare and a realization that maternity services are central to the well-being of an entire hospital.
“We need to hold decision makers to account. We’re dealing with mothers and babies here, and the quality is just not good enough,” she says. “It is outrageous when you look at the size of budgets how little is allocated to maternal health. The maternity unit is the nub of the health system and a marker of the functioning of the hospital as a whole.”
The Lancet series ends with a raft of recommendations to improve chances of meeting the U.N.’s 2030 Sustainable Development Goals, which include a provision to reduce the global maternal mortality ratio to less than 70 per 100,000 live births, and ensure universal access to sexual and reproductive healthcare. In 2015, the maternal mortality ratio was 239 per 100,000 live births in developing countries versus 12 per 100,000 live births in developed countries.
The recommendations include a renewed push to invest in the Global Financing Facility, set up to support country-led efforts to improve and invest in maternal healthcare. The report also highlights the need to address the fact that 53 million women around the world still give birth without a skilled attendant. Many of those women, says the report, are among the most vulnerable in society, including those living in conflict zones or affected by natural disasters, as well as refugees, adolescents and ethnic minorities.
Graham says there is also an urgent need to improve resilience within health systems so health professionals can adapt to moving circumstances like disease epidemics or diversifying health needs such as rising levels of heart disease and diabetes among women.
At a grassroots level, she says more work should be done with people who could hold the key to improving services and reducing infection rates in a hospital, including cleaners and plumbers, and not just those who are commonly seen as important to the overall outcome of a woman’s delivery.
“There are only so many people at the front line, and they all can play a role in WASH,” says Graham. “If a cleaner’s mop is spreading germs, then it could have just as big an impact.”