Germaine Greer wrote that ‘[c]hildbirth has been transformed from an awesome personal and social event into a medical phenomenon’ (Greer, 1984: 19). But given that around 830 women die every day from preventable causes related to pregnancy and childbirth, and that 99% of all maternal deaths occur in developing countries (World Health Organization, 2017), it is also clear that medicine has a role to play in addressing these bleak statistics. Indeed, Hadi (2017) notes that sexual and reproductive health has been identified by Amnesty International as an important human rights issue. In particular, postpartum haemorrhage (PPH) is the leading cause of maternal mortality in Africa and Asia, accounting for almost half of the total number of deaths in these regions, and an estimated 25% of global maternal mortality (Snelgrove, 2009).
Li et al (2017) noted that the anti-fibrinolytic agent tranexamic acid (TA) could exert its haemostatic effect by inhibiting the activation of plasminogen to plasmin; that TA's safe and effective use in reducing haemorrhage and transfusion requirements during various elective surgeries has been demonstrated; and that TA has been shown to reduce blood loss during, for example, hysterectomy. The authors suggested that intravenous TA for patients undergoing caesarean section was effective and safe, but that further studies with larger samples were needed to confirm this.
It was therefore gratifying to learn in April 2017 of a high quality, randomised, double-blind, placebo-controlled trial of TA in around 20 000 women, selected from 193 hospitals in 21 countries, who were aged 16 years and older with a clinical diagnosis of PPH following a vaginal birth or caesarean section (WOMAN Trial Collaborators, 2017). Results showed not only that deaths from PPH were reduced by 19% when TA was given intravenously—with no adverse effects—but that maternal mortality was reduced by 31% when TA was administered within 3 hours of birth.
While the authors recommended that TA should be given as soon as possible after the onset of bleeding, they acknowledged that the intravenous administration of TA in low- and middle-income countries, where many PPH deaths occur indomestic settings, is not always feasible. However, the results should lead to further research into non-intravenous modes of TA administration.
An editorial in The Lancet is clear, however, that the study's findings should serve as an impetus ‘to accelerate, not diminish, global action for maternal, child, and adolescent health’. This concern over a possible reduction in global action partly stems from its view that ‘Antonio Guterres, UN Secretary-General, […] has shown little serious interest in health since his appointment. If this indifference continues it will be an important setback for women's and children's health’ (The Lancet, 2017).
But as Hadi (2017) explains, sexual and reproductive health in low- and middle-income countries has only attracted global attention as a means of improving health outcomes in the past 24 years. The comparatively low level of sexual and reproductive health uptake is a contributing factor to the ‘high level of maternal mortality and morbidity, sexually transmitted infections, unintended and multi-pregnancies and gender-based violence’ (Hadi, 2017: 67). On the other hand, there is no denying the significant impact of 24 years of global efforts in many countries.
The life-saving possibilities of promptly administered TA during PPH are undeniable and welcome. However, in the context of our global cultures and traditions, different perspectives of birth abound. While reducing maternal mortality in low- and middle-income countries will require international collaboration, it will also require sensitivity to the cultural and practical realities of birth around the world.