Title: Stopping mothers dying from sepsis in Africa
Funder: Department of Health and Social Care

Abstract: I am a scientist and maternal and fetal medicine specialist, recently appointed as Professor of Global Maternal and Fetal Health at the University of Liverpool. I am based full-time in Malawi.My programme of work aims to reduce mortality and morbidity from maternal sepsis in Africa.Over the next 5 years I will undertake a broad programme of research, in 3 workstreams: Workstream 1: Understanding maternal infection in MalawiThere is the urgent need for better information on maternal infections and morbidity outcomes in Malawi. I will lead the development of a maternal infection and severe maternal outcome surveillance system, that will be piloted in Blantyre district, Malawi. We will also co-design clinician and public facing dashboards, to enable the surveillance data to be used for quality improvement. It is well recognised that care delays often contribute to adverse outcomes, and we will develop and pilot a novel geospatial location approach to explore these care delays and map infection and delay hotspots. We will link surveillance data to laboratory data to understand the aetiology of these infections and the antimicrobial resistance profiles. Workstream 2: Preventing infections; focussing on caesarean section and miscarriage surgeryInfection is 20 times more likely after caesarean birth. We will conduct a research priority setting exercise, following a modified James Lind Alliance approach, with a broad stakeholder group to prioritise 10 uncertainties in the prevention of infection after caesarean section. One of the priority topics will be selected for a pilot study in preparation for a full trial. The WHO has highlighted evidence based recommendations to reduce infections after caesarean section yet surveys of practice show these are not performed reliably. We will utilise a behavioural change perspective to co-design an intervention to improve compliance with these practices at caesarean section and miscarriage surgery. Workstream 3: Improving the management of maternal sepsis We will investigate if lactate measurement, available as a point-of-care test, has incremental benefit over conventional maternal vital sign assessment in the diagnosis of sepsis and identification of women at risk of severe morbidity and mortality.We will also aim to test at scale if a maternal sepsis bundle based approach (FAST-M) is clinically effective in reducing maternal infection related mortality and severe morbidity and if it is cost effective. A robust mixed methods implementation evaluation will also be conducted to understand the way the intervention functions in practice.These 3 workstreams will be accompanied by 2 cross cutting themes: Training and capacity building:We will support Malawian researchers and clinicians to develop their research careers and become the next generation of leading scientists. Communication with the public, practitioners and policy makers:We will throughout be communicating about the research we are doing with the public to raise the profile of women's health issues and the importance of maternal infections and sepsis.

Lay abstract: I am a doctor-scientist who is working in Malawi to reduce the number of women who die or are seriously harmed during childbirth. Around the world a woman dies in childbirth every 2 minutes. Nearly all these women are dying in poor countries. Recent estimates suggest that maternal infection and sepsis plays a part in up to half of all these death. 'Maternal sepsis' is a medical problem caused by infection during or after pregnancy. It occurs when the body's response to the infection become so serious that her organs start to fail and it is life threatening.It is important to be working on this problem in Malawi, as this remains one of the countries where the rates of mothers and their babies dying in childbirth is still far too high. Over the next 5 years I will study this problem from a number of approaches to help reduce this problem both for the benefit of women in Malawi and in other poor countries. Understanding maternal infection We will develop and introduce a computerised system to track all the infections that happen related to pregnancy, and work with patients and others to make sure the information is presented in a way to help improve care.One of the problems women often face is that they are delayed in their efforts to get care. We will use a system aided by detailed satellite maps to let women show us what happened during their journeys and understand where these delays happened.We will also identify which germs are causing the infections, and which antibiotics are effective.Preventing infections; focussing on caesarean section and miscarriage surgery It is ideal to prevent infections before they even happen and one of the major problems is infection after caesarean section surgery. We will work with patients and other health care workers to work through all the different ways we could try to tackle this problem and decide which are the most important questions. We will then pick one of these questions and run a small clinical trial, in preparation for a full trial.We know that there are already infection prevention practices that the World Health Organisation recommends, but that health care workers don't actually do in every woman. We will map out how we can act to change these behaviours so these key actions are done reliably. Improving the management of maternal infections and sepsis It is hard for health care workers to identify which women are most unwell with infections. At the moment we use simple measurements like the blood pressure. We will examine if the levels of lactic acid in the mother's blood, which can be checked on a small handheld machine, will work better.We already tested a programme that can improve the quality of care of women with sepsis during or after childbirth in 15 health facilities in Malawi. However, we need to show if it actually reduces the numbers of women who die or have serious problems and also if it is good value for money. This will be done through a larger trial. Whilst doing this work we will ensure that we are working to support Malawian researchers to develop their careers and become the next generation of leading scientists. We will also throughout be communicating about the research we are doing with the public to raise the profile of women's health issues and the importance of research in this area.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING;7.1 INDIVIDUAL CARE NEEDS
Health categories: INFECTION;INFLAMMATORY AND IMMUNE SYSTEM;REPRODUCTIVE HEALTH AND CHILDBIRTH