Lilia Sebouai Global Health Security Reporter

Every two minutes, a woman dies from complications related to pregnancy or childbirth.

In 2023, there were 260,000 maternal deaths worldwide – over 700 a day – the vast majority of them in the developing world.

Three complications – pre-eclampsia, post-partum haemorrhage and sepsis – are responsible for most maternal deaths.

Yet all three are easily preventable, and are usually only fatal when the complications are recognised when it is already too late.

To tackle this, British researchers have developed a series of low-cost innovations aimed at preventing avoidable maternal deaths in some of the world’s poorest countries.

From a blood pressure monitor that can help doctors identify threats before symptoms show, to a device that accurately measures blood loss during childbirth and AI-powered ultrasound tools that make detailed scans possible in remote communities, these inventions are already saving thousands of lives.

So how do they work? And why are they now attracting attention far beyond the developing world, including within the NHS?

E-MOTIVE

When a woman begins to haemorrhage after giving birth, the warning signs are not always obvious. She may still be talking, sitting upright and appear stable even as her condition deteriorates.

Delay in detection is the main reason that postpartum haemorrhage (PPH) – defined as the loss of more than 500 ml of blood within 24 hours after birth – kills so many.

Around 27 million women experience it each year and an estimated 43,000 die as a result – roughly one death every 12 minutes.

To tackle the problem, Professor Arri Coomarasamy, professor of gynaecology and reproductive medicine at the University of Birmingham, and his colleagues, developed a package of medical interventions designed to identify dangerous bleeding earlier.

At the centre of the approach is a simple device: a funnel-shaped plastic sheet marked with measurements that is placed beneath a woman immediately after birth.

For decades, figuring out how much blood had been lost after childbirth (triggered when the uterus is too slow to contract after delivery) was largely guesswork. Midwives and doctors would visually assess blood-soaked sheets and clothing before estimating how much blood a woman had lost.

But that lack of precision put women in danger.

“Some will lose blood slowly and others will lose blood very quickly… by the time they were diagnosed, the problem was so advanced that it’s very difficult to solve it,” said Prof Coomarasamy.

This plastic sheet, called a drape, has taken the guesswork out of identifying threatening cases of postpartum haemorrhage. But the real innovation is arguably what comes next.

Once excessive bleeding is detected, health workers are trained to deliver a set of interventions known as the E-MOTIVE bundle, an acronym for the treatment.

It includes: early detection of PPH using the blood collection drape, massage of the uterus, oxytocin to help the uterus contract, tranexamic acid to promote blood clotting, intravenous fluids and verify the source of bleeding and escalate to urgent care if it continues.

Previously, these treatments were often given one at a time, with clinicians waiting to see whether each intervention worked before moving on to the next.

Additional delays in treatment could prove fatal. If left untreated, the sudden drop in blood pressure caused by postpartum haemorrhage can deprive vital organs of oxygen blood flow, causing shock, multi-organ failure and death. In severe cases, a woman can bleed to death within 10 to 20 minutes.

The E-MOTIVE system is already proving to be effective.

In 2023, a major randomised trial involving more than 200,000 women across four African countries, found that measuring blood loss using the drape and administering the six other interventions reduced cases of severe bleeding or death after birth by 60 per cent.

The findings, published in the New England Journal of Medicine, quickly prompted a World Health Organization (WHO) recommendation, and around 30 countries have since adopted the approach.

While women in the developing world are much more likely to die from postpartum haemorrhage than women in high-income countries, the risk of suffering the condition is similar wherever a woman gives birth.

NHS England now recommends the use of blood-loss drapes for instrumental deliveries – when forceps or a vacuum device are used to assist birth. Cost remains the main barrier to their wider adoption across all vaginal deliveries, according to Prof Coomarasamy.

For him, however, the bigger question is why postpartum haemorrhage has remained the leading cause of maternal death worldwide when the tools to prevent many of those deaths already exist.

“I think it is to do with women’s health and postpartum haemorrhage not being a sufficient priority in many societies,” he said. “It’s a grave injustice, because these women don’t need to die.”

CRADLE

At first glance the CRADLE Vital Signs Alert device resembles a standard blood pressure monitor, with a cuff that goes round the upper-arm and a small screen for the readings.

But look closer and you can see how it has been designed to work in the most basic health clinics, where trained medical staff, electricity and even clean water might be in short supply.

The device charges through a standard micro-USB port – the same one used for mobile phones. A single charge can deliver up to 20,000 readings.

A shock-absorbing casing and robust pressure sensor allow it to stay calibrated even after being dropped repeatedly. The electronics are sealed to protect against dust, sand, humidity and extreme heat.

Importantly for low-resource settings, the device has been designed for use by healthcare workers with limited specialist training.

Rather than requiring users to interpret complex cardiovascular measurements, it translates vital signs into a simple traffic-light warning system: green, amber or red.

Alongside blood pressure, the device automatically calculates the Shock Index – a clinical measure, first created in 1967 by Swiss surgeons, that divides heart rate by systolic blood pressure to detect early signs of shock before obvious symptoms appear.

All this matters because blood pressure alone can be misleading in identifying pregnancy-related risks.

As blood volume increases, the body can compensate for significant blood loss or infection while readings still appear deceptively normal. By the time blood pressure drops, a patient may already be critically unwell.

Dr Katie Kuhrt, a women and children’s health researcher at King’s College London, where the device was invented, said: “One woman might be able to lose 500ml of blood and be totally fine, but the woman next to me might be near death if she lost 500ml. If we use the shock index, we can actually measure what that amount of blood loss is doing to that specific woman”.

The CRADLE device has now been deployed in around 50 countries across Africa, Asia and South America. The impact has already been substantial.

More than 500,000 pregnancies across low- and middle-income countries, including regions of Africa, South Asia and the Caribbean, were monitored as part of the CRADLE-3 trial, one of the largest evaluations of a maternal early-warning device ever undertaken.

A subsequent analysis of the trial, published in The Lancet Global Health in 2021, highlighted the device’s ability to prompt earlier intervention before complications became life-threatening.

Researchers found that the introduction of the CRADLE device and its traffic-light alert system was associated with an 80 per cent reduction in emergency hysterectomies. a procedure often used as a marker of severe, unmanageable postpartum haemorrhage.

Secondary analyses also found that hospital referrals for obstetric bleeding nearly halved, suggesting that more cases were being identified and managed at local level before escalating into emergencies requiring transfer.

The WHO has since revised its definition of postpartum haemorrhage.

Rather than focusing solely on the volume of blood lost, the updated guidance puts greater emphasis on how a woman’s body responds to bleeding, a change designed to trigger earlier treatment.

Some of the most striking results came from Sierra Leone, which at the time had one of the highest maternal mortality rates in the world. Researchers reported a 60 per cent reduction in maternal deaths following the introduction of the device.

Despite growing demand, wider rollout remains a challenge. The monitor is deliberately designed to be inexpensive – costing around $2 to manufacture and about $20 for the end user – but that affordability has left little commercial incentive for companies to manufacture and distribute it at scale.

“If people realised just how common mothers dying was, and how easy it is to reverse it, I think they would do something about it,” said Prof Andy Shennan, professor of obstetrics and head of women and children’s health at King’s College London, who led the CRADLE team.

“Compared to many other difficult problems in the world, this is a simple, reversible one”.

AI ultrasound scans

For many women in the world’s poorest countries, just knowing whether you’re pregnant or not can take months.

As a result, many women receive little or no antenatal care, leaving potentially serious complications undetected until labour or delivery, or until a medical emergency develops.

In Britain, women are typically offered their first antenatal appointment at around eight to 10 weeks of pregnancy, followed by regular check-ups and ultrasound scans throughout.

In many low-income countries, however, access to ultrasound remains extremely limited. Scanners are expensive, specialist sonographers are in short supply, and some women must travel for days to reach the nearest clinic capable of performing a scan.

Yet ultrasound is one of the most important tools in modern maternity care. It can identify high-risk pregnancies, estimate a baby’s gestational age, detect abnormal foetal growth and help spot life-threatening conditions such as pre-eclampsia before symptoms appear.

To bridge this gap, researchers have developed handheld ultrasound probes that connect directly to a smartphone or tablet and are a fraction of the cost of traditional, bulky hospital machines.

The hardware is impressive, and the scanners are already being used around the world, including in Africa.

But the integration of AI could be about to make them even more powerful.

Researchers at King’s College London are testing artificial intelligence systems that can guide users through scans, interpret images in real time and flag potential abnormalities without the need for a specialist sonographer.

Last year, the team conducted a first-of-its-kind randomised controlled trial of AI-assisted foetal anomaly screening. The technology reduced the length of 20-week scans by more than 40 per cent, making examinations almost twice as fast as standard practice without compromising accuracy.

Rather than requiring sonographers to stop repeatedly to capture, measure and save images, the AI performs many of these tasks automatically in the background.

The ultimate goal is earlier detection. By making scans faster, more consistent and less dependent on specialist expertise, researchers hope the technology will identify serious abnormalities, including congenital heart defects, sooner.

But Dr Beardmore-Gray, a clinical lecturer in obstetrics and gynaecology at King’s College London’s Health Partners, said that technology is only part of the answer.

Scaling up will require not just devices, but training, electricity, procurement and long-term maintenance.

“Hard-won gains in women’s health have stalled, and in some cases reversed, over the past 5 years, due to shifting political priorities and extreme funding cuts,” she said.

“Technology alone is not a ‘silver-bullet’, but part of a wide-ranging toolkit of interventions that will only work if implemented holistically and sustainably. Political will, funding, resources, and functioning supply chains are needed to support long-lasting change”.

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