Childbirth is still dangerous. While welcoming their granddaughter, the two founders of the Gates Foundation focused on maternal and child health. Improvements in maternal and child survival over the past few decades were one of the most visible areas of global progress, but since 2015 they have stalled, and have even worsened in some countries as a result of the pandemic.
"Even in the smoothest circumstances, childbirth comes with great physical and psychological exertion." The birth of her eldest daughter reminded Melinda Franky Gates of her own experience – the entire labor lasted 14 hours, leaving me so exhausted that I could barely walk. And in the worst case, childbirth can be fatal.
In her Goalkeeper report, released September 12, Melinda cited a troubling set of data: a mother dies every two minutes from complications in childbirth, an estimated 5 million children die before their fifth birthday each year, and 74% of child deaths occur in their first year of life.
While improvements have stalled, a particular phenomenon is that advances in technology have allowed researchers to learn more about maternal and child health, and problems are starting to become easier to solve. "Unfortunately, however, these solutions do not reach mothers and children who need it most. This situation needs to be changed. Melinda said.
It is also said that making innovation land in the present is more urgent than innovation itself. The Gates Foundation believes that low-cost innovations could save an additional 2 million lives by 2030 if widely used in low- and middle-income countries.
On August 5, 2023, in a village in Papua New Guinea's Central Province, Liu Zhenqiu, deputy captain of the 12th batch of Chinese medical teams assisting Papua New Guinea and deputy chief physician of the neonatal department, auscultated a local baby. Since 2002, China has sent 12 batches of medical teams to Papua New Guinea, making positive contributions to improving the medical and health level of Papua New Guinea and promoting friendship between China and Papua New Guinea. Xinhua News Agency (Photo courtesy of the 12th batch of Chinese medical teams assisting Papua New Guinea)
New technologies and inequality
In this report, Melinda French Gates mainly writes about departments related to maternal health, and Bill Gates pays more attention to infant health. The common intersection of both is the use of low-cost technology to solve the problem of small incisions that cause maternal and infant death.
The report focuses primarily on maternal mortality due to postpartum haemorrhage. Postpartum haemorrhage is the leading cause of maternal death, accounting for about 70,000 deaths each year, and survivors may also face the long-term effects of complications, the report said. Postpartum haemorrhage is when blood is lost in more than 500 milliliters within 24 hours of delivery, and it is difficult for health workers to tell how much blood loss is considered excessive blood loss. A study in African countries found that about half of women who experienced postpartum haemorrhage were never diagnosed and therefore never treated accordingly.
The report describes a low-cost technique for "diagnostic difficulties", namely a V-shaped plastic collection bag that can be hung next to the delivery bed to visualize the amount of bleeding collected, so that doctors can promptly apply measures such as uterine massage, uterotonics, hemostatic acid, intravenous fluids and vaginal examinations. The study found that among the 200,000 women enrolled in the study, health workers using V-shaped collection bags and following the new E-MOTIVE guidelines were able to reduce cases of severe bleeding by 60%.
Equally important is preventing PPH, which is reported to be anaemia, or severe iron deficiency anaemia, which affects up to 37% of pregnant women globally. In some parts of South Asia, the figure is as high as 80 per cent. The traditional way to cope with anaemia is to take iron supplements, but oral medications may cause discomfort and require 180 days of admission. This is a big challenge for accessibility and adherence.
In response to this problem, Nigerian academics are studying a single 15-minute intravenous iron injection. Not only can it replenish a woman's iron stores during pregnancy and even after pregnancy, but it can also be used to quickly and effectively treat cases of severe anaemia.
Similar new technologies may also improve the environment for babies. Bill Gates says that over the past decade, the field of child health has evolved faster and more rapidly than expected. If researchers continue to develop new methods and health workers can make these innovations available to every mother and child in need, doctors can ensure that babies survive the most critical first days of life.
"Death is a ripple effect," the report said, adding that a baby who died of pneumonia was likely to be born prematurely or malnourished. Treating pneumonia alone does not guarantee the survival of the child, and we should try to prevent the formation of the first link in the causal chain, that is, to solve malnutrition.
The report talks about the impact of the flora in the human digestive tract. The field of child health used to think that breast milk was only food for newborns, but now it has been found that the natural bacteria in the baby's intestine also feed on it. The most common of these bacteria is Bifidobacteria, which breaks down specific sugars in breast milk and converts them into nutrients. Without these probiotics, it is useless to feed your baby more, and it is difficult for their digestive system to absorb these nutrients. That's why doctors now recommend giving babies — especially premature or stunted babies — probiotic supplements containing bifidobacteria.
Another recent finding suggests that the new timing of providing supplements can be advanced from after childbirth to the uterine period. According to the report, the medical community used to believe that malnutrition could not be treated until a child was 6 months old and started eating. But new research has found that the microbiomes of babies and mothers are interconnected. If a pregnant woman is rich in bifidobacteria, these probiotics can be passed from the mother's digestive tract to the child's digestive tract. In this way, babies are already born with a healthy intestine.
"Low-cost innovations could prevent millions of stillbirths and infant deaths in low- and middle-income countries." The report re-emphasizes.
On May 31, in the infant care training room of Shenyang Institute of Technology, students from the College of Preschool Education conducted infant care training. Photo by Xinhua News Agency reporter Yang Qing
Reshaping maternal and child health systems
In addition to promoting the application of new technologies, it is also crucial to build a strong execution system. "More innovations will emerge in the future as researchers learn more about how AI can be used to improve maternal health. Of course, these breakthroughs alone will not solve all problems," Melinda said, adding that countries need to continue to recruit, train and pay health workers equally – especially midwives; Countries should also build more resilient health care systems.
At a concurrent seminar, Jiang Hong, a professor at Fudan University's School of Public Health, presented China's model for reducing maternal mortality. The data shows that from 1991 to 2021, China's maternal mortality rate decreased significantly in both urban and rural areas, as well as infant mortality and under-five mortality rates. Jiang Hong said that this is related to decades of evidence-based decision-making and project implementation.
The data shows that from 1991 to 2021, there was a significant decline in infant and maternal mortality in China.
How to provide quality services to remote and backward areas? Jiang Hong gave the example of the Guangxi Zhuang Autonomous Region transforming the role of a traditional midwife in rural areas. At that time, about half of Guangxi's 109 counties were poor counties, and the maternal mortality rate was relatively high, exceeding the national average at that time.
According to reports, in the 90s of the 20th century, the most important cause of maternal deaths, nearly 60%, was postpartum hemorrhage. Bleeding is very related to the quality of medical services and the rationality of the health service system. One internationally recommended approach is to ensure that specialized antenatal health care providers are available to each pregnant woman during childbirth and that skilled service providers can link to the health system. In the event of an emergency, pregnant women can be transferred to a system that provides quality-assured obstetric services.
At that time, Jiang said, there were many traditional birth attendants in remote rural areas who provided such services, but they were independent of the health system, and most of them received informal training, lacking relevant skills and transportation channels. At the same time, it is impossible to build a health post with the capacity to deliver babies in every village, and only by sending pregnant women to hospitals for delivery can every pregnant woman have access to professional midwifery services.
Jiang Hong said that in the context of the hospital birth policy, local policymakers began to consider how to change the historical role of rural birth attendants and let her take on new functions. They are familiar with the local cultural environment, every family and household in the village, and after appropriate capacity improvement, they can serve as village-level maternal and child health care personnel, as links between families and health systems and medical institutions, and promote the timely use of obstetrics, including prenatal, intrapartum and postnatal health services.
"First of all, traditional family birth attendants are provided with relatively formal training, and then they must be able to obtain certificates through examinations and gradually transform into village-level maternal and child health workers. Since it is difficult to abolish all traditional birth attendants in remote areas, some are still retained, which is a gradual process of policy transformation. For those traditional birth attendants who still have no way to obtain a certificate after examination and training, some traditional birth attendants with a relatively low level of education may be cancelled directly. She said.
The training of maternal and child health workers at the village level has been accompanied by changes in the health system. Jiang Hong introduced that in order to solve the problem of transshipment in mountain villages, once pregnant women send ambulances to pick them up in remote mountainous areas where there is a road under the mountain, the village will set up a stretcher team; Because there are many local ethnic minorities and do not like white colors, the hospital experimented with changes, turning the bed quilt and mattress to pink, weakening the feeling of the hospital.
According to reports, after a change in functions, the number of traditional birth attendants fell from 130,000 before the start of the project in 1997 to less than 2,000 in 2006, and by the time the project was conducted in 2013, it was "basically gone". This also indirectly affected the hospital delivery rate, which was 46% in 1998 and approached 100% in 2013; The maternal mortality rate has dropped significantly from 86 per 1,000 in 2013 to 14 per 100,000.
Looking back on this history, Jiang Hong also talked about the problems that still exist in China's maternal and child health. For example, the level of maternal mortality in the vast western region is still high, there are many pastures in the area, it is difficult to track and follow up the management of maternal health care, and many complications and problems that should have been detected by timely use of maternal health services and timely prenatal physical examinations will be delayed until very late. At the same time, how to improve the accuracy of health information and improve the health literacy of residents themselves is also an important problem that is still facing at present.
"Innovative solutions to further improve maternal and child health are urgently needed." "These are probably areas where we can go further and actively work on," she said. ”
This echoes the report's call that these lives can only be saved if all mothers and babies have access to high-quality health care and the innovations mentioned in the report.
"To do this, we need policy change, political will, and more investment in women's health and health workers, including midwives. We need to listen to women and ensure they have a say in their own health. Above all, we need a shared commitment that we can no longer accept that mothers and babies die for preventable causes in any corner of the world. Melinda French Gates and Bill Gates wrote in the report.
Written by: Nandu reporter Song Chenghan from Beijing