“Hospitals can’t improve maternal health unless they know what is happening”: Sir Sabaratnam Arulkumaran on preventing maternal deaths

As global health leaders across Africa renewed commitments in July to prevent deaths from postpartum haemorrhage, the UK was also confronting its own failings in maternity care.

Sir Sabaratnam Arulkumaran, known to many as Arul, has spent decades working to improve maternal health, from practising obstetrics in large maternity units to advising the UK government on maternity services, as well as shaping international guidelines on treatments for postpartum haemorrhage (PPH).

As a former President of the International Federation of Gynecology and Obstetrics (FIGO), Sir Sabaratnam has long argued that improving maternal health requires more than clinical expertise.

“Health systems need to measure what is happening, act on the evidence, and work with the communities they serve,” he says.

In this interview, he discusses what he learned from improving maternity services at Northwick Park Hospital in the early 2000s after it was revealed that maternal deaths at the hospital was more than six times the national average. He also shares his experience of guiding community health workers, and how birth spacing and access to contraception can help prevent maternal deaths in the long term.

You have worked in maternity care as an obstetrician and advisor to UK Government, to influencing global maternal health practice at FIGO. Where did your interest in maternal health begin?

I was practising clinical gynaecology and obstetrics in large maternity units, including in Singapore, where one unit had around 25,000 deliveries a year. But when I joined the FIGO Executive Committee in 1992, I recognised that I could do much more than hospital-based practice.

I was involved with FIGO for more than two decades, first as treasurer and later as secretary, president-elect and president. When I came to the UK in 1997 and joined Nottingham University, and later St George’s in 2001, my interest in maternal health continued.

In what capacity did you advise the Health Secretary to improve maternal health in England?

In the early 2000s, there were 10 maternal deaths over three years at Northwick Park Hospital – several times the national average.

The Secretary of Health asked me to help reorganise the services. It was about a month before the general election, and the Healthcare Commission was considering putting the hospital into special measures. There was a possibility that the hospital could be closed, which would have left thousands of women without a place to give birth. Something had to be done.

I went there with a group of obstetricians and midwives and introduced what I called clinical governance. We made sure there were enough doctors and midwives, that guidelines were implemented, and that audits were carried out to see whether practice was following those guidelines.

We also introduced regular teaching and training, as well as a risk and complaints register so that problems could be investigated.

We brought in heads of midwifery from four different hospitals to help with these functions and then submitted a report. Over the following 18 months, there was not a single maternal death.

What did that experience teach you about improving maternity care?

The basic principle is measurement. Science is measurement, and practice is based on science.

If you don’t measure what you do, you won’t know what the best way is to advance care. All the trials we do are part of this measurement: we do something, we measure it, we show a benefit, and then we say: please adopt it.

We wanted to measure what was happening on the ground, so we introduced a maternity dashboard. We recorded, on a monthly basis, what was happening in the hospital. This included total deliveries, operations, admissions to intensive care for mothers and babies, deaths, complaints, risk incidents and so on.

If something was within the national average, it was green. If it was higher, it was amber, and if it was extremely high, it was red. When something was red, it went straight to the clinical and hospital director so that they could investigate what had happened and act immediately.

Why is measurement so important?

Hospitals can’t improve unless they know what is happening.

You need to know what is happening at the grassroots level, where the woman is actually receiving treatment. Sometimes people think something is happening at a higher level, but when you go into the labour ward, it may not be happening there. 
The challenge is to monitor and measure.

How does this differ in low- and middle-income countries?

A woman who gives birth in the UK might survive postpartum haemorrhage. In a sub-Saharan African country, she might not.

In low- and middle-income countries, more than 50% of women are anaemic, so they can succumb to postpartum haemorrhage very quickly.

When health systems are not organised, it can look like a deficit in midwives or not enough consultants to attend births, with large numbers of deliveries and only a few people available to provide care.

Then there is access to medication. If the medication needed is not available, including tranexamic acid (TXA), that creates another problem. In some countries, TXA is available for clinical trials but is not necessarily available routinely afterwards.

There needs to be a monitoring mechanism to see whether women are being given TXA in time, how many women receive it compared with those who do not, and how this relates to morbidity and mortality.

You have described this as a “maternity ecosystem”. What does that mean?

The ecosystem includes the hospital on one side, the community on the other, and the transport and funding mechanisms connecting them.

India has addressed this quite well in some states. Deliveries in health facilities have increased substantially, and arrangements have been made with private facilities to provide care, with the government paying the facilities.

There are also transport arrangements. A pregnant woman can get into a taxi and have the fare reimbursed by the government.

The improvement in maternal mortality in India has been substantial. It demonstrates what can happen when the maternity ecosystem is improved as a whole – reducing delays in transport and treatment and ensuring that appropriate medication is available.

You have also worked on postpartum contraception. What is the connection between contraception and postpartum haemorrhage?

As an adult, on average, we have about five grams of elemental iron in the body. Every pregnancy takes around 500 milligrams with the foetus, so you lose about one tenth of your iron.

If a woman becomes pregnant repeatedly without enough time to replenish those stores, she can become anaemic. If she is already anaemic and then has a postpartum haemorrhage, she is much more vulnerable. That is why birth spacing is important.

During my time at FIGO, we introduced postpartum contraception by inserting an intrauterine device (IUD) soon after the baby was delivered, within 48 hours. It is a long-term, reversible method of contraception. If a woman wants another baby in two or three years, it can simply be removed.

This gives her an opportunity to build up her haemoglobin and iron reserves, thereby reducing morbidity and mortality associated with postpartum haemorrhage.

We worked in six countries – Kenya, Tanzania, Bangladesh, Nepal, India and Sri Lanka – to make postpartum contraception using reversible methods part of national policies.

Giving iron and treating infections, including bacterial and helminthic infections and malaria, are also important aspects of managing anaemia, alongside treating abnormal uterine bleeding.