According to global estimates, there were 295,000 maternal deaths in 2017—35 percent less than the estimated 451,000 maternal deaths in 2000. However, this still falls short of sustainable development goal 3.1, which seeks to reduce global maternal mortality to 70 per 100,000 live births by the year 2030.
Postpartum hemorrhage (PPH) remains the leading cause of maternal mortality; however, this burden is not equally shared. Ninety-four percent of all maternal deaths occur in low- and middle-income countries and over a third of those deaths are due to PPH.
In Kenya, the government prioritized maternal health and set a concrete goal to reduce maternal morbidity and mortality in line with achieving sustainable development goal 3.1. One way of achieving this goal is by improving availability of, access to, and utilization of quality and affordable maternal health care in the country.
For several years, PATH has been working with cross-sector partners, including the Kenya Ministry of Health, to address PPH deaths through inclusive problem solving. One key solution shows promise.
Effective, context-appropriate solutions
Effective uterotonics—drug formulations that help prevent and treat postpartum hemorrhage—are a critical part of reducing PPH and maternal mortality. However, oxytocin, the primary uterotonic for preventing and treating postpartum hemorrhage, must be stored between 2-8°C to maintain its effectiveness.
This is a challenge in many health facilities in Kenya, where consistent electricity supply and access to reliable refrigerators are often not available.
When oxytocin is unavailable, or its quality cannot be guaranteed because it wasn’t kept cold, the World Health Organization (WHO) recommends the use of other uterotonics for example, heat-stable carbetocin (HSC).
The process of identifying and developing this game-changing solution began more than a decade ago.
From 2012 to 2014, PATH worked with Merck for Mothers to identify technologies with potential to save the lives of women during pregnancy and childbirth in low-resource settings. This unique collaboration evaluated more than 30 promising technologies that address the two leading causes of maternal mortality—post-partum hemorrhage and preeclampsia.
PATH compared these technologies across multiple parameters, such as commercialization potential, user and stakeholder acceptability, and time to impact. Merck applied the findings and recommendations to build an investment strategy for accelerating a short list of promising maternal health technologies, including a heat-stable uterotonic.
Based on the context of challenges across nine counties in Kenya where PATH supports maternal health work, the government prioritized introducing heat-stable carbetocin (HSC) as the primary solution. This decision was based on costs, availability, quality assurance, and product design.
HSC is a long-acting uterotonic, which, as the name suggests, doesn’t require cold chain transport or storage. It has been shown to maintain stability over a period of 36 months at 30°C and 75 percent relative humidity. Its effectiveness is comparable to oxytocin and it can only be used to prevent PPH.
Evidence-driven, people-centered innovation
In January 2020, PATH’s Living Labs partnered with the Kenya Ministry of Health to better understand the barriers to and opportunities for managing and preventing postpartum hemorrhage in the country. This work was funded in part by MSD for Mothers.
Using human-centered design (HCD) methods, PATH engaged key stakeholders—many of them nurses and midwives—across nine counties and elevated their voices in the planning and prioritization process.
“We are committed to reducing maternal deaths and morbidity, and to do that, we need to design appropriate solutions for the diversity of health settings across the country,” said Brian Taliesin, Global Director, Living Labs.
“By working with health care workers, we are able to truly understand the challenges, and prioritize solutions that are more likely to work in practice.”
The Living Labs team conducted individual interviews, workshops, group discussions, facility visits, and surveys with more than 300 nurses, midwives, county health directors, and national stakeholders who shared memorable postpartum hemorrhage cases, experience with treatment methods, and overall challenges with PPH management at their facilities.
“We spent close to 14 months engaging with health care workers and policymakers in deep discussion around topics that they are clearly passionate and knowledgeable about,” explained Wilkister Musau, Design and Innovation Specialist with the Living Labs.
“As a result, we had insights, nuanced information, and useful feedback that we could then put to use.”
The HCD activities helped inform a roadmap for increasing skills and confidence among health care providers; improving planning and timely procurement and distribution of essential supplies; and identifying and introducing uterotonics—such as HSC—aligned with the WHO recommendations.
Community- and country-focused priorities
The Ministry of Health is currently reviewing the cost effectiveness data, collected by PATH, and has approved the national roadmap. The Smiles for Mothers consortium has taken up the priorities identified by the health workers and are supporting the implementation of the roadmap with the Ministry of Health.
Kenya is now preparing for more widespread rollout of HSC, along with training and education around good practices for procurement, planning, storage, diagnosis, and treatment.
HSC is now seen as a crucial part of a suite of maternal medicines used collectively to reduce the risk of death from PPH in low- and medium-income countries. And its use is gaining traction. HSC has been approved for use in India, South Sudan, Sierra Leone, and Tanzania.
“Health care workers understand more about the challenges and opportunities that exist in their context. Our work as innovators is to develop and prioritize solutions that best fit their needs, as detailed in the national roadmap.”— Sue Wairimu, Design and Innovation Lead, Living Labs