Bleeding and sepsis at childbirth are a danger to mothers: Sierra Leone study shows a simple screening tool can detect risk in time

“Severe bleeding after birth (postpartum haemorrhage) is the leading cause of maternal mortality globally. It causes approximately 70,000 deaths annually . About 80% occur in Africa and South Asia. A recently published World Health Organization analysis shows postpartum haemorrhage accounts for 28% of maternal deaths in sub-Saharan Africa, compared to 14% in northern Europe. Another leading cause of maternal mortality globally is pregnancy-related infections. The body’s natural response to infection sometimes causes injury to its own tissues and organs during pregnancy, childbirth, post-abortion or the postpartum period. This life-threatening condition is known as maternal sepsis. A 2024 global maternal sepsis study involving 2,466 women across 43 countries reported the highest proportion of infection-related serious maternal outcomes in low and middle-income countries. These included maternal death or severe, life-threatening illness. Of the six world regions studied, serious outcomes were highest in Africa at 19.5%. Most of these deaths are associated with delayed or missed diagnoses and subsequent timing of interventions. Early identification, based on prompt detection of abnormal vital signs such as heart rate and blood pressure, is crucial to prevent maternal deaths from postpartum haemorrhage and maternal sepsis. This is problematic in resource-constrained healthcare systems in many low- and middle-income settings, including sub-Saharan Africa. Read more: Maternal and child healthcare isn’t reaching everyone in urban sub-Saharan Africa We are on a team of maternal health researchers – obstetricians, physicians and midwives – with a vision to save mothers and babies through capacity research, innovation and building maternity systems. Our focus is on developing local leadership and international collaborative learning. Our most recent prospective study in Sierra Leone examined the experimental use of a simple tool – known as Shock Index – to monitor changes in the ratio of heart rate and blood pressure in response to blood loss or sepsis. Originally developed to identify shock in non-pregnant surgical and major trauma patients, it is emerging as a critical tool in maternity care. It is particularly valuable in low- and middle-income settings where sophisticated monitoring equipment is scarce, but the burden of maternal mortality is highest. Our findings showed that Shock Index can predict serious outcomes and enabled stratification of risks, including maternal death. Landmark study in Sierra Leone Sierra Leone has one of the highest maternal mortality ratios globally. Most preventable maternal deaths result from haemorrhage, hypertension or sepsis. Yet many facilities do not have the basic tools for vital sign monitoring. Early identification of maternal complications is a cornerstone of effective maternity care. Our team developed the CRADLE vital signs alert intervention as a simple, low-cost, point-of-care technology to identify these complications. It combines an accurate, semi-automated blood pressure and pulse device with an embedded traffic-light warning system. Previous evaluations showed that the technology improved detection, referral and health worker confidence, with potential to reduce morbidity and mortality. However, evidence on effectiveness at scale, and integration into routine systems in low-resource settings, remains sparse. Read more: Pregnant Nigerian women need faster access to hospitals – technology helped us calculate travel times Our Sierra Leone study evaluated whether national scale-up of this intervention could reduce adverse maternal and perinatal outcomes and be sustainably integrated into routine care. The study was carried out in three maternity hospitals in Sierra Leone among 495 women with bleeding and 855 women at risk of maternal sepsis. We found that Shock Index can predict serious outcomes and establish levels of risk. For example, a woman with Shock Index of at least 1.7 (very abnormal) had a 10-fold greater risk of maternal death compared to women with Shock Index 0.9 to 1.7 (abnormal). Importantly, Shock Index requires no specialised equipment. It is a practical, cheap solution, enabling triage of patients in resource-limited environments. This is particularly valuable where sophisticated monitoring equipment is scarce. History of the Shock Index and women’s health Early identification and timely intervention is key to saving lives in maternity, particularly in bleeding and sepsis. This is because the heart rate rises long before the woman appears to be sick. Falling blood pressure, too, may only be noticed too late. Relying on heart rate or blood pressure alone may lead to life threatening delays. Early retrospective studies from Nigeria , Egypt and the UK in pregnant women with bleeding and suspected sepsis showed that combining blood pressure and heart rate in a ratio – the Shock Index – enabled impending shock to be identified earlier. The Shock Index was incorporated into the CRADLE vital signs alert device to alert the users to abnormal readings. The research found that if Shock Index was greater than 1.7 (red light), there was a high risk of a serious maternal outcome. The woman might need a large blood transfusion or a hysterectomy. On the other hand a Shock Index less than 0.9 (green light) indicated that the woman was at low risk. Expanding applications Beyond bleeding and sepsis, researchers are exploring additional uses for Shock Index, including: Antenatal anaemia screening. An unpublished study in Karnataka, India, found abnormal Shock Index was strongly associated with severe maternal anaemia. This could be used to identify women at risk of related complications like postpartum haemorrhage, preterm birth and foetal growth restriction. Malaria detection . Work in Bidibidi refugee settlement, Uganda, showed Shock Index can help identify patients with malaria. Read more: Africa’s hidden stillbirth crisis: new report exposes major policy and data gaps Future steps The research team is now conducting qualitative work to understand how best to integrate CRADLE vital sign alert and Shock Index into existing early warning scores and management pathways. The end goal is to embed Shock Index into routine maternity care, ensuring timely, life-saving interventions for women most at risk. Our research has showcased the impact of the CRADLE vital sign alert. Furthermore the Shock Index is now incorporated in the new World Health Organization integrated Postpartum Haemorrhage Guideline . In addition, the WHO is recommending a postpartum haemorrhage treatment trolley, including the CRADLE vital sign alert. Our team is developing an updated CRADLE device which will display the Shock Index number to users, and store multiple readings. This will be useful in the care of the sickest patients where serial readings are required in quick succession to monitor response to emergency, life-saving treatments. The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.

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