MORE THAN BLOOD – Addressing Postpartum Haemorrhage

Postpartum haemorrhage (PPH) continues to be a major cause of death globally. In this article Rani Khanna, filmmaker, lecturer and doula, describes the making of the documentary More Than Blood, collaborating with the work of researchers and the medical team leading the E-MOTIVE programme.

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MORE THAN BLOOD – Addressing Postpartum Haemorrhage

Documentary directed by Rani Khanna

I have been making documentaries since 1995. In 2010 however, I decided to train with Michel Odent and Liliana Lemmers and become a birth doula.  Why? I am not completely sure. It was beyond any logical steps deriving from my filmmaking career.  What I do know is that it was connected to my own wonderful experiences of giving birth to my two children. It was an inner knowing that I could help support pregnant women to give birth.

In 2021, I successfully applied for the position of Creative Fellow in Filmmaking at the University of Birmingham in collaboration with the Institute of Metabolism and Systems Research and the Global Women’s Health Project in Birmingham. This position gave me the opportunity to combine my filmmaking skills and deep interest in worldwide practices and problems of birthing. More importantly, however, it allowed me to bring an important story to the public – the E-MOTIVE programme – a package of interventions aimed at saving mothers around the world from dying from post-partum haemorrhage (PPH) in childbirth. 

I had the honour of collaborating with Professor Arri Coomarasamy who is responsible for initiating the E-MOTIVE Project and implementing it in four African countries: Nigeria, Tanzania, Kenya and South Africa. 

Most of us in high-income countries who give birth or deliver babies do not ordinarily worry about the possibility of dying from PPH in childbirth, because everything is usually in place to prevent this from happening in a medical setting.  This is not the case in low-income countries, where every six minute a woman dies in childbirth. PPH is the leading cause of death.  

According to WHO, in 2017 approximately 295,000 women died during and following pregnancy and childbirth. Roughly two-thirds of these deaths occurred in sub-Saharan Africa. To bring this home, take the figures for 2017 that show Nigeria had 917 maternal deaths per 100,000 births, Tanzania had 524, Kenya had 342 and South Africa had 119. In comparison France had 8, the UK had 7 and Spain had 4. 

As a filmmaker I was asking myself many questions:

How can I make people care about an issue that doesn’t directly affect them?  

Why should we care about PPH here in the UK?  About women dying from PPH in Africa?

How can I tell both the medical narrative and the mothers’ narrative in an engaging, emotional, and realistic way, when I cannot travel to film anything due to the Covid-19 pandemic?  

How can I include the voices of the mothers who do not have access to zoom? 

How to show an African woman/mother that is representative of four different African countries? 

My starting point was to have in-depth discussions with Professor Arri and his wonderful team here in the UK and with the E-MOTIVE project leaders from each country. I began researching each country’s cultural background, belief systems, art, rituals and traditions around motherhood, birth, and death, as well as their political, medical, social situation.

It was fascinating to learn about the richness and complexities of each country, to talk via zoom to the remarkable women on the ground leading the E-MOTIVE trials, to discover what is problematic and challenging for pregnant women and their families, as well as the midwives and the medical staff.  Basically, there were too many problems, questions, and issues to contain in one short film. However, I definitely wanted to try and show the bigger picture; to at least give the viewer an understanding of why women were dying from PPH and what the E-MOTIVE project was offering to address this.

Due to the Covid pandemic travelling restrictions, I resorted to making a hybrid film: collaborating with a Russian animator, Riitta Hakkarainen, based in London and two women filmmakers, Wanjeri Gakuru based in Kenya and Sabrina Najib Zahor based in Tanzania. I also decided to include myself in the film given my experience as both a mother and a birth doula. As part of my fellowship, I had five wonderful MA (Film & Television) students assisting me in my research.  Leading up to International Mother’s Day, I wanted to initiate a campaign #MothersDayCRISIS on social media, to highlight a maternal mortality crisis most of us are unaware of, to highlight PPH and the E-MOTIVE project. My students helped me design a logo and we launched it on social media through the University of Birmingham (UoB) on International Mother’s Day, 9th May 2021.

Since my fellowship with the University of Birmingham has ended, I hope someone from the medical/midwifery world will step in to continue promoting #MothersDayCRISIS on International Mother’s Day.

Through making MORE THAN BLOOD, I have learnt several things.

Firstly, the WHO guidelines regarding giving birth cannot be applied globally to all pregnant women as they do not work in all countries.  In fact, at times they can create “unintended” negative consequences as mentioned in the film. The guidelines must take into account the huge differences and challenges faced by women especially those living in rural environments and equally be aware of the cultural, social, religious and historical differences and barriers specific to each country.  Unless local voices – particularly those of pregnant women, mothers, and midwives – are heard and taken into account during any consultation process, progress may not take place.

Secondly, midwives are undervalued, underpaid, over worked, and receive very little support if any at all.  Unfortunately, this sometimes leads to some midwives abusing, bullying, and disrespecting pregnant women in their care.  This in turn can cause huge trauma and fear in pregnant women, who will then share “horror” stories in their communities, creating a mistrust of midwives and hospitals. 

Thirdly, there are no statistics available to show how many women die in childbirth when giving birth at home, in a hospital/medical setting and equally on their way to a hospital.  This is important to know for several reasons.  

• There is no guarantee that women will not die from PPH in a hospital if the right interventions are not applied and if the medication needed is missing or out of date. There is also the risk of the journey to the hospital. As Professor Arri Coomarasamy mentions in the film, women could potentially walk for miles, without knowing for sure if they will be returning home alive or not.  
• In many rural settings, there are traditional birth attendants who used to deliver babies until very recently.  Some governments (Kenya & Tanzania) have tried banning them from practicing; since they never trained in a medical environment they are not recognised as “professional midwives”.  They have instead been assigned to accompany pregnant women to a medical facility to give birth. 

However, research shows that pregnant women in villages prefer giving birth at home with a traditional birth attendant.  Because they all live in the same community and know each other, they trust them more. This eliminates many fears.  The fears emerging from a lack of transport to reach a hospital, from a lack of financial means to pay for any unexpected medical bills or medication, and from a lack of trust in medicalised settings are no longer an issue for the mothers and their families.

I believe that it would make sense to empower traditional birth attendants.  With some basic training and tools, they could easily act as bridges between the medical establishment and the mother’s trusted environment.  

A great example illustrating how well this works in reality is the Ngatataek Hospital, in Kenya. In order to encourage Maasai women to access maternity services, it has built a traditional Maasai birthing hut (manyatta) on its grounds. It is the first hospital of its kind. Since it was built in 2018, the number of Maasai women giving birth there has increased from 4 to more than 25. This initiative takes into account the needs of Maasai women: to give birth in a familiar, safe environment with a traditional birth attendant whom they know and trust. Simultaneously, it provides medical assistance in case of any emergency. It combines the best of both worlds: a traditional approach and a medical approach, aimed at serving the women giving birth.

And finally, we must not forget to humanise the birth experience, to listen to pregnant women’s wishes and needs, to consider the problems and social barriers they face and to incorporate them within the WHO guidelines.  This would encourage communities and the medical establishments to find new creative solutions that work best for women.  

MORE THAN BLOOD is available in English, French and Spanish on YouTube.

Produced & Directed by Rani Khanna  (UK / 2021 / 25 mins)

Rani Khanna – Filmmaker / Guest Lecturer / Birth Doula

Website: youandeyefilms.com

Email: [email protected]