Birth, Beds And Bacteria: Supporting Maternity Services in Low-Income Countries

Thursday, 07 April 2016

Professor Wendy Graham, Professor of Obstetrics & Epidemiology, University of Aberdeen.

Medico-Chirurgical Hall at 7.00 pm (preceded by a finger buffet from 6.00 pm)

Professor Wendy Graham recently became Emeritus Professor of Obstetrics and Epidemiology at the University of Aberdeen, and also holds an Honorary Professorship at the London School of Hygiene and Tropical Medicine. She trained at Sheffield and then Oxford University, and has specialist interests in the prevention of obstetric mortality – working collaboratively in over 25 low-income countries over the last 30 years.
Professor Graham’s current work includes quality improvement of maternity services, prevention of healthcare-associated infections, and maternal death surveillance. She remains research active in her Emeritus role, and is the P.I. for a new MRC-funded study on improving hand-hygiene on maternity units. She is the Chief Scientific Adviser for The Soapbox Collaborative – an Aberdeen-based charitable trust devoted to reducing infections at delivery in low-income countries.  Professor Graham continues to serve as an adviser for many international organisations and initiatives, including the World Health Organization and the Wellcome Trust, and to work with research groups, NGOs and health facilities primarily in Bangladesh, Ethiopia, Gambia, India and Tanzania. She is also the lead for an initiative at the University of Aberdeen to strengthen learning on global health among medical students.


The President welcomed the company to the meeting. He reported on the success of the recent James Petrie Memorial Lecture given by Professor Gordon McInnes from Glasgow before an audience of around 200 during the RCPE Annual Symposium in Aberdeen on 30th March.

He then reported on a visit to the Society’s premises last month by representatives of the Seven Incorporated Trades; the visitors enjoyed a short presentation followed by an opportunity to look around the artefacts which had been presented and labelled by Dr Hilary Hinton, Librarian. The Society has been invited to look for an opportunity for a reciprocal visit, perhaps during next year’s President’s programme.

The audience were reminded of forthcoming Heritage Group annual event (14th April) on local involvement in the development and provision of medicine in remote locations, including in relation to the offshore oil industry. Encouragement to participate (as audience or performer) in the Famous for Five Minutes charity event on 14th May was also repeated.

Next the company was informed of the David Millar Award, introduced in 2015 and to be awarded annually to a General Practitioner making a substantial contribution to palliative care; the award is named for our former President by Macmillan Cancer Support for whom he was the first GP adviser. The inaugural winner was Dr Debbie Harvey, from Sefton on Merseyside.

The President then outlined our recent discussions with the University of Aberdeen who are taking forward plans to create a undergraduate teaching and postgraduate learning hub with state-of-the-art IT facilities in the Society’s Hall during the coming summer. The Society has sought and been given reassurances from the University that developments will be sensitive to the heritage of the Society and ambience of the premises. Temporary relocation of meetings may be necessary while works are ongoing.

Dr John Scott then read an obituary notice on his former colleague and a former Society member, Dr Sisir Roy, who had worked in Geriatrics in Aberdeen as a Senior Trainee and Consultant 1968-1992, being an influential Service Lead in the latter 10 years prior to retirement to Suffolk.

The President then invited Professor Wendy Graham, to give the evening’s lecture. Professor Graham had come from the London School of Hygiene and Tropical Medicine to lead development, as Professor of Obstetric Epidemiology, of the Dugald Baird Centre for Research on Women’s Health. Professor Graham has recently moved back to a post at the LSH&TM but continues collaborative work with colleagues in Aberdeen.

She explained that her talk "Birth, Beds & Bacteria: Supporting Maternity Services in Low-Income Countries” could perhaps have been labelled ‘Back to Basics’ as she reviewed for us her experience and research from less affluent nations around the world which have repeatedly led to the conclusion that addressing relatively unsophisticated principles of simple hygiene in maternity units is likely to yield greatest benefits.

Of 140 million births worldwide per year, some 5 million result in stillbirth or early neonatal death, and there is also a substantial toll of maternal mortality. The great majority of adverse outcomes are in low-income countries with perhaps 85+% of maternal deaths being preventable and much of infant and maternal mortality due to infection. Strategically there has been encouragement to focus perinatal care on institutions but without, necessarily, ensuring development and resources for such establishments to cope with the burgeoning numbers progressively attending in the hope of improving outcomes. Indeed, overcrowding dilutes care and increases risks of cross-infection.

In considering why so many services are struggling to provide better outcomes in the 21st century leads to the inevitable conclusion that water, sanitation, soap and hygiene are central and recurring issues in need of improvement. Professor Graham was particularly keen to address the problems associated with poor standards of cleaning in many institutions – with lack of staff, education, equipment and supplies all contributing. The wrong kind of mop used inefficiently and with lack of clean water supplies may result in so-called cleaning operations simply spreading infections and risk of contagion.

Historical references were made to the work of Aberdeen Doctor, Alexander Gordon who had written a treatise on puerperal infection in the 18th century, and to the situation in Glasgow Maternity Hospital at the beginning of last century where the well-to-do, by opting for inpatient confinements were mistaken in their belief that they were buying better care – since the hospital had a fourfold increase in perinatal mortality than for home confinements. Sadly, it is the persisting prevalence of long-recognised risks that afflict maternity practice in low-income countries to this day.

The work of the Soap Box Collaborative (SBC) was described. It is a charity which Professor Graham and colleagues established in Aberdeen in 2012 that aims to combine both research into problems and implementation of solutions in maternity care in poorer parts of the world. Many countries have sought assistance and a series of photographs from some very primitive, filthy and poorly provided for facilities were shown which Professor Graham described as “pathetic for the 21st Century”.

The audience heard of intermittent water supplies – delivered by solar powered pumps, and so therefore only on bright days, of counterfeit, low-price and negligible efficacy cleaning solutions, of filthy mops – perhaps made from cheap garments of clothing and thus of perfect materials for promoting colonisation by pathogenic micro-organisms.

Poor record keeping systems largely preclude any opportunities to count, understand and learn from the ongoing problems. The depressing culture of repeated failure in supplies, water, electricity, etc., add a further dimension of hopelessness among staff and hence a self-fulfilling apathy towards achieving improvement.

Assessment of facilities undertaken by SBC repeatedly and frustratingly show that the basic essentials keep being forgotten – especially in relation to cleanliness. However, the charity has implemented several projects and initiatives which can make localised but very valuable contributions to improving things.

An example from Ethiopia showed how a maternity hospital had been fitted out with battery-operated taps but no provision of replacement batteries or system of maintenance that would ensure these were fitted. A team from NHSG maintenance department had been out to replace the washing facilities to avoid the need for batteries.

Lack of soap and examination gloves in the Gambia has been recognised as an infection risk which no amount of teaching about hand hygiene can overcome while supplies remain inadequate or non-existent. Soap Box initially supplied cheap kits of essential supplies to expectant mothers and this has now developed into a system of preparation and provision of very low cost, locally assembled kits of such materials that can be made affordable to those in need.

In conclusion, Professor Graham reminded us that little can count a lot, that simple things are regularly forgotten or ignored and that while strategies to ‘change the world’ are regularly overwhelmed by politics and bureaucracy, focussed and pragmatic action can regularly make a big difference in improving peripartum care and outcomes.

An enthusiastic question and answer session followed after which the President thanked Professor Graham for her lecture and the meeting was adjourned.

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