A plastic sheet with a pouch could be a 'game changer' for maternal mortality

It's a startling statistic. Every year, 70,000 women around the world basically bleed to death after childbirth. That averages out to nearly 200 deaths a day and makes postpartum hemorrhage a leading cause of maternal deaths.

Now a new study points to a surprisingly simple and inexpensive solution: Basically, if the woman lies on a plastic sheet with a small transparent pouch at the other end to collect the blood, the medical team has an immediate sense of how much danger she's in and can take swift action.

The cost of the sheet-with-a-pouch: Between $1-2.

A more precise measurement of blood loss with a 'drape'

The study, carried out in 80 hospitals across four African countries, used a simple device called a "drape" to collect and measure the amount of blood from women who have just given birth. The device, combined with a bundle of treatment options recommended by the World Health Organization, reduced the number of women experiencing severe bleeding by 60%. The study also found a reduction in maternal deaths from bleeding.

This intervention "is really a game changer in preventing maternal deaths," says Deekshita Ramanarayanan, a program associate with the Wilson's Center's Maternal Health Initiative, who wasn't involved in the new study. "Over a quarter of maternal deaths can be attributed to postpartum hemorrhage," she adds.

Postpartum hemorrhage is defined as bleeding more than 500 milliliters (a bit more than 2 cups) within 24 hours of giving birth. It happens to an estimated 14 million women every year. Yet about half of the cases go undetected.

The reason so many cases are missed is because health-care providers use an inexact approach to gauge how much blood a new mother has lost, says Dr. Arri Coomarasamy, a gynecologist at the University of Birmingham and an author of the new study, which was supported by a grant from the Bill and Melinda Gates Foundation, a funder of NPR and this blog.

"The usual practice is to visually estimate how much blood a woman has lost after childbirth," he says. "The health-care provider would look under the woman, look at the linen and make a judgment as to whether she's lost too much blood or not. We know that that is very imprecise."

So he and an international team of researchers used a "blood collection drape that systematically collects blood after childbirth," he says. The drape has ML levels marked on the pouch where the blood is held.

"It's basically like a shower curtain" that does not absorb the blood but rather enables it to flow into the pouch, says Sheila Davis, a nurse practitioner for decades and now CEO at Partners in Health, which helps many low- and middle-income countries improve maternal health outcomes.

One end of the drape is placed under a woman who has just delivered vaginally; the other end tapers into the collection pouch that hangs down from her bed.

"Any blood that is lost after childbirth, after the delivery of placenta, all of that goes into the drape," says Coomarasamy.

"Then we are able to see how much blood is coming out and that allows us to make a call as to whether she is bleeding too much."

The drape gives providers a quick and more precise estimate of blood loss, allowing them to act right away.

For the study, the researchers trained hospital providers in the intervention group to treat women with a set of treatments recommended by the World Health Organization. The treatments include massaging the uterus to help it contract, which would stop the bleeding, and administering the drug Oxytocin, which also helps the uterus contract, and the drug Tranexamic acid, which promotes clotting. Other treatments include IV fluids, which replace lost fluids from bleeding, and a physical exam to check for sources of bleeding.

WHO recommends bundling these treatments, "which means that all the effective treatments need to be given at once in somebody who was bleeding," explains Coomarasamy. "So there isn't any time lost."

The providers in the control group of hospitals provided care as usual, which normally involves using one of the treatments at a time, then trying another ... and another.

"The problem is the ticking of time, and it is the ticking of time that kills somebody who is bleeding," says Coomarasamy.

The "bundled care" approach used in the study cuts down the time it takes to address the problem.

There were a total of 12 deaths due by bleeding in the treatment group versus 18 in the control group.

The idea of testing the drape in a clinical trial came about when Coomarasamy and his colleagues looked at how different countries were improving detection of postpartum hemorrhage.

"The drape turned out to be the most used option and the most acceptable option," says Coomarasmy. "Vietnam has been using drapes for many years," he says. "Some parts of India and some parts in California are now using it routinely."

"What I thought was important [about the study] was it wasn't looking for one silver bullet," says Davis at Partners in Health. "I think oftentimes people look for one silver bullet to solve problems and life is not like that."

The fact that the solutions were tested out in "real-life settings in busy secondary hospitals [which can't provide specialized care]," was also promising, she adds.

With the drapes costing as little as $1 they're a "cost-effective solution" for reducing maternal deaths in middle and low-income countries, says Ramanarayanan.

She is particularly hopeful that this intervention can help prevent adolescent maternal deaths — the leading cause of death for girls aged 15-19 worldwide.

"Adolescent pregnancies carry a much higher risk of postpartum hemorrhage, primarily because teenage girls' uteruses are not fully developed to sustain a pregnancy in a healthy way," says Ramanarayanan. "Having effective treatments like this can be really, really influential in preventing maternal death in adolescence."