Dar es Salaam, Tanzania — "Did you know hundreds of thousands of women die in childbirth every year? Dr Anita Zaidi is determined to change that."
Dr. Zaidi champions the cause of equal rights for women across the world. As the president of the Bill & Melinda Gates Foundation's Gender Equality Division, she spearheads the foundation's initiatives to dismantle obstacles that hold women and girls back. Under her leadership, Dr. Zaidi works relentlessly to transform and empower the lives of women and girls across Africa and South Asia, through self-determination, wellness, and economic prospects.
The report by the World Health Organization (WHO) paints a concerning picture of global maternal health. Despite some progress between 2000 and 2015, maternal mortality rates have either stagnated or even increased in recent years, with a woman dying from pregnancy or childbirth roughly every two minutes. WHO warns that without significant progress towards global targets for reducing maternal mortality, over one million more women could lose their lives by 2030.
The report highlights that these tragedies are concentrated in the poorest regions and conflict zones. Sub-Saharan Africa, for example, bears the brunt of the burden, accounting for about 70% of maternal deaths globally. In areas facing severe humanitarian crises, the situation is even more dire, with maternal mortality rates more than double the worldwide average.
The past two decades have witnessed a remarkable acceleration in scientific advancements, leading to significant strides in global health, especially for the most vulnerable populations.
However, a critical challenge remains - can we win the global race against preventable maternal deaths?
"The number of women dying in childbirth hasn't changed since 2015, with hundreds of thousands of deaths annually," said Dr. Zaidi. She pointed out that the major cause of maternal death during childbirth is postpartum hemorrhage (excessive bleeding after childbirth).
"Early detection allows for timely intervention and could significantly reduce maternal mortality rates," she said.
The "drape" that saves lives
A large-scale study involving over 200,000 women across four countries investigated a new approach to postpartum hemorrhage (excessive bleeding after childbirth). The method involved using a simple and inexpensive tool called a drape to objectively measure blood loss. This innovative approach led to significant improvements for women, with a 60% reduction in severe bleeding and a decrease in maternal mortality.
"Postpartum hemorrhage (PPH) is the leading cause of death for women during childbirth," said Dr. Zaidi. "Tragically, many PPH cases go undiagnosed because healthcare workers struggle to gauge excessive blood loss."
"We now have a simple, low-cost way to identify when blood loss is dangerously excessive: a drape that looks like a V-shaped plastic bag," she said. Dr. Zaidi said that by simply "hanging this drape at the bedside", healthcare workers can effectively identify "dangerously high blood loss", potentially saving countless mothers' lives.
"This inexpensive approach, known as E-MOTIVE, was used in a study with over 200,000 women across multiple African countries, allowed for early detection of excessive blood loss in 20-30% of cases," she added. " Studies showed a dramatic 60% reduction in severe bleeding when healthcare providers intervened."
She stressed the importance of swift action in managing postpartum hemorrhage. She advocates for a bundled approach, where multiple interventions like IV fluids, uterine massage, and medications (oxytocin and salicylic acid) are administered, all crucial steps to prevent severe blood loss during childbirth.
"No woman needs to die for postpartum," she said.
Iron deficiency - a global threat to pregnant women and babies
Iron deficiency anemia is a significant concern during pregnancy, affecting an estimated 40% of expectant mothers worldwide. This condition can lead to serious complications for both mother and baby, including increased risk of maternal mortality, premature birth, low birth weight, and impaired baby development. WHO estimates a significant disparity between income levels, with anemia affecting over half of pregnant women in low- and middle-income countries (LMICs) compared to a fifth in high-income countries.
What causes this iron deficiency?
Iron deficiency occurs when the body's iron stores are depleted. This can happen due to blood loss (often from menstruation or previous pregnancies), or from inadequate dietary intake, particularly in individuals with limited consumption of red meat. Iron is essential for the production of hemoglobin, a protein in red blood cells responsible for transporting oxygen throughout the body. When iron levels are low, the body struggles to deliver sufficient oxygen, leading to various health complications. Pregnant women with iron deficiency are at increased risk for several problems, highlighting the critical importance of addressing this issue to ensure the well-being of both mother and child.
"Pregnant women in Africa often suffer from this condition, and while iron tablets are typically given, they're ineffective for treating existing anemia," she said.
Dr. Zaidi highlighted a promising solution, ferric carboxymaltose, an iron injection that can address anemia in just one dose, even if administered late in pregnancy. This single-dose injection, administered even as late as the third trimester, can effectively address anemia in most pregnant women, positively impacting both mother and baby.
Sub-Saharan Africa faces a significant burden of anemia in pregnant women, and Malawi is no exception. This low-income country in southern Africa presents numerous challenges for expectant mothers. A staggering 45% of pregnant women in Malawi grapple with iron deficiency anemia, a condition that can lead to serious health risks for both mother and baby, according to a Lancet study.
Dr. Zaidi explains the crucial link between iron deficiency and postpartum hemorrhage. She said "Iron deficiency leads to anemia and a lack of red blood cells. These red blood cells carry oxygen and without sufficient oxygen, the uterus cannot contract effectively after childbirth. This impaired contraction allows blood vessels to remain open, causing postpartum hemorrhage, the biggest cause of bleeding after birth."
While iron is crucial, Dr. Zaidi highlights that malnourished women often lack essential nutrients.
She points out the disparity between prenatal care in high-income countries (comprehensive prenatal vitamins) and developing countries (often limited to iron and folate). She stresses the benefits of complete prenatal vitamins, including a significant increase in newborn birth weight and improved maternal health.
How portable ultrasounds are saving lives
While obstetric ultrasound is a standard part of prenatal care in developed countries, access remains limited in sub-Saharan Africa despite some improvement. The high cost of ultrasound equipment often puts it out of reach for healthcare facilities in developing nations. This lack of resources translates to a lower quality of care for patients, particularly pregnant women. Furthermore, even if the equipment is available, trained sonographers are needed to operate it and interpret the results, creating another hurdle.
A staggering "nearly 300,000 women die from pregnancy-related complications" each year, according to the Gates Foundation. This tragic figure is further compounded by "more than 4 million newborns" who die shortly after birth. These preventable deaths disproportionately impact "low- and middle-income countries", often due to limited access to crucial technologies like ultrasounds.
"The lack of ultrasound machines at primary care facilities is a major concern," Dr. Zaidi explained. "This hinders early detection of potential problems during pregnancy and limits proper prenatal care."
"There's a new development that could be a game-changer," she enthused. "Affordable AI-Enabled Portable Ultrasound devices are emerging."
"These water bottle-sized tools connect to smartphones and can identify potential risks for mothers and babies, even in remote locations without on-site radiologists or obstetricians," according to Dr. Zaidi.
Dr. Zaidi sees promise in the portable ultrasound devices that connect to smartphones, requiring minimal training and utilizing artificial intelligence to interpret fetal images, allowing healthcare workers to assess the baby's health, viability, and gestational age. "They can make informed decisions about delivery, providing safe childbirth at the primary care center or referring to a higher-level facility for more complex cases. Kenya is at the forefront of adopting this technology, with the potential to be the first country to roll out AI-enabled ultrasounds," she said.
Dr. Zaidi believes Kenya and Rwanda's success can serve as a model for global implementation, including remote areas with limited access to specialized healthcare.
The Gates Foundation is also championing the development of affordable, wearable sensors for monitoring labor progress in any environment. These innovative tools empower doctors and midwives, especially in remote areas, to identify potential complications during childbirth. This vital data allows healthcare workers to make informed decisions and ultimately save more lives.
Preventing unintended pregnancies cuts maternal mortality
Dr. Zaidi shines a spotlight on family planning, a crucial yet often neglected aspect of women's health. She argues that "half of all pregnancies are unintended," highlighting the significant impact family planning can have. She even criticizes policymakers for neglecting this issue, saying they've "forgotten the importance of family planning and how much it's a powerful intervention for economic growth."
Despite a staggering 40% of pregnancies being unintended, advancements in readily available contraceptive options have stalled for decades. This lack of innovation is further compounded by the fact that nearly 40% of women in low- and middle-income countries who choose contraception abandon their chosen method within the first year, often citing dissatisfaction.
To address this gap in family planning options, Dr. Zaidi expresses optimism about a DMPA-SC, a hormonal birth control shot. This method offers a revolutionary approach: self-administration using a small, insulin-like needle. "The key advantage of DMPA-SC is that it empowers women to take control of their reproductive health," Dr. Zaidi explains.
The concept of self-care empowers individuals to take a more active role in their health, and for women, this shift can be particularly significant. Many women still grapple with the burden of managing sexual and reproductive health issues, often compounded by stigma.
Dr. Zaidi cites successful research on self-injection in several African countries, including Nigeria, Uganda, Malawi, and Kenya. These findings emphasize the potential of this method, particularly because it eliminates the need for frequent clinic visits. "Women only need one training session to learn how to self-administer the injection," she explains. "A single injection protects for three months. This eliminates the need for frequent clinic visits."
A mother's gut, a child's future
Dr. Zaidi emphasizes the need for a multifaceted approach to tackling malnutrition in Africa, particularly its link to maternal health. She points out, "Most child malnutrition develops because the mother is malnourished."
A staggering 149 million children under 5 were estimated to be stunted, according to a 2022 WHO report. Undernutrition, a major threat to child health, claims the lives of nearly half of all children under five globally. This issue disproportionately affects low- and middle-income countries, leaving a lasting and devastating impact on individuals, families, communities, and entire nations, across developmental, economic, social, and medical aspects.
A growing body of research suggests that the gut microbiome may hold the key to ending malnutrition. A mother's overall health and nutritional status during pregnancy are crucial because she transfers a significant portion of her gut microbiome to her developing baby. Undernourished pregnant women face a multitude of risks, including higher chances of obstructed labor and complications during or after childbirth. Poor maternal nutrition also affects fetal development, leading to low birth weight and increased susceptibility to illness in newborns.
She delves deeper, exploring the scientific underpinnings of gut inflammation and its contribution to childhood malnutrition. She introduces the concept of the microbiome, the complex community of microorganisms living in the gut, as a crucial factor affecting malnutrition. A mother's gut health can directly impact the development of her baby's microbiome, potentially leading to gut inflammation in the child and hindering their ability to absorb nutrients effectively.
"A healthy microbiome is essential for proper nutrient absorption," she said. "So, with our partners, we are developing Multiple Micronutrient Supplements (MMS) to help mothers and babies improve their microbiome, grow healthier, and fend off disease."
Prebiotics are substances that act as food for the good bacteria in the gut.
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"We are trying to see if you can incorporate the prebiotics that the bugs like...to quieten down the inflammation, make your gut healthy, and absorb more of the nutrients in your body," she explains. "By promoting the growth of good bacteria and potentially reducing gut inflammation, prebiotics could be a powerful tool to improve nutrient absorption and combat malnutrition, particularly in children born to malnourished mothers."
Dr. Zaidi's optimism is fueled by encouraging data from Bangladesh, where a prebiotic product developed by the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDRD) has shown positive results in improving growth and development in both mothers and children. However, she emphasizes the crucial need for further research in Africa to confirm its effectiveness in the continent's specific context. "Now we are trying to see, is it the same in Africa? Do we see the same results?" she inquires.
The Gates Foundation is also working on a new generation of microbiome-enhanced Ready-to-Use Therapeutic Foods (RUTFs) that are effective at helping children regain weight, and better at preventing relapses into malnutrition.
In addition, they're also supporting the development of Capscan, a revolutionary pill-sized device. This non-invasive tool offers a quick and painless way to analyze a person's unique gut microbiome, providing insights into previously undetectable microbial activity. Capscan has the potential to significantly accelerate research in this field, paving the way for exciting discoveries and treatments related to the gut microbiome and its role in childhood health.
Why women's health matters
Dr. Zaidi highlighted two key areas for improvement: ensuring better access to existing beneficial tools and fostering innovation for entirely new solutions.
"There are existing tools that could significantly benefit women's health but are not readily available or accessible to them," she said. "They could make life so much better for millions and millions of women around the world if implemented effectively."
The second area Dr. Zaidi identifies is the "complete lack of tools for certain women's health issues. The problems are significant, but there are no existing solutions."
"Here, innovation is key," she said.
Dr. Zaidi commends the Gates Foundation's efforts to develop tools for women's health though there is a problem with funding. A mere "1%" is currently dedicated to researching women's health issues. In response to this concerning statistic, she pointed out the launch of the Women's Global Health Alliance, a new initiative aiming to raise awareness about this critical funding gap.
Dr. Zaidi sees a revolution brewing in women's health. "Historically, healthcare has been a one-size-fits-all approach, neglecting the unique biological and gender-based needs of women," she said.
"This lack of research," according to Dr. Zaidi, "creates a treasure trove of opportunities for breakthroughs in women's health."
Dr. Zaidi stresses the need to approach women's health problems through focused research that emphasizes sex and gender differences in health. She explains, "There are so many opportunities because this field has hardly been touched upon before in terms of what concerns or matters pertain more or differently for women compared to men."
