HEALTH TOPICS A TO Z

Safe Blood for Safe Motherhood

Globally, more than half a million women die each year during pregnancy, childbirth or in the postpartum period – 99% of them in the developing world. An estimated 25% of those deaths are caused by severe bleeding.

• Of the 20 countries with the highest maternal mortality ratios, 19 are in sub-Saharan Africa where the lifetime risk of maternal death is 1 in 16, compared with 1 in 2 800 in rich countries.
• Severe bleeding during delivery or after childbirth is the most common cause of maternal mortality and contributes to around 34% of maternal deaths in Africa, 31% in Asia and 21% in Latin America and the Caribbean.

Postpartum bleeding is unpredictable and the quickest of maternal killers. It can kill even a healthy woman within two hours, if unattended. Blood transfusion has been identified as one of the eight key life-saving functions that should be available in healthcare facilities providing comprehensive emergency obstetric care. Access to a safe and sufficient blood supply could help to prevent the deaths of a significant number of mothers and their newborn children each year.

The impact that access to safe blood can have on health outcomes for pregnant women with severe bleeding is illustrated by Malawi. In 2003, the country established the Malawi Blood Transfusion Service. In 2005, the maternal mortality rate due to severe blood loss had fallen by more than 50%.

Global data

WHO has collected data from 172 countries, covering 95% of the world’s population, based on 2004 figures

Blood transfusion saves lives and improves health, but millions of patients requiring transfusion do not have timely access to safe blood. Despite advances in medical science, it will be many years before artificial blood substitutes can routinely replace the need for the donation of human blood. Every country needs to avoid blood shortages and ensure that blood supplies are free from HIV, hepatitis viruses and other life-threatening infections that can be transmitted through unsafe transfusion.

Blood supply

While the need for blood is universal, there is a major imbalance between developing and industrialized countries in access to safe blood.

• Only 45% of the global blood supply is collected in developing countries, which are home to more than 80% of the world’s population
• In sub-Saharan Africa, fewer than 3 million units of blood are collected each year for a population of more than 700 million people
• Out of 80 countries that have donation rates of less than 1% of the population (fewer than 10 donations per thousand people), 79 are in developing regions; it is generally recommended that 1-3% of the population give blood to meet a country's needs
• The average number of blood donations per 1,000 population is 11 times higher in high-income countries than in low-income countries.

Types of blood donation

The safest blood is donated by the safest blood donors. The prevalence of HIV, hepatitis viruses and other blood-borne infections is lowest among voluntary unpaid blood donors who give blood purely for altruistic reasons. Higher infection rates are found among family or family replacement donors who give blood only when it is required by a member of the patient's family or community. Worldwide, the highest rate of infection is found among donors who give blood for money or other form of payment. Adequate stocks of safe blood can only be assured by regular donation by voluntary unpaid blood donors.

The 2004 data reveal some tangible improvements since 2001-2002, but family/replacement donors and paid donors still remain a significant source of blood for transfusion in many developing and transitional countries.

• A total of 60 countries reported an increase in the percentage of blood donated by voluntary unpaid blood donors and a further 41 countries maintained the same level; 37 countries showed a decline in the percentage of blood donations from unpaid voluntary blood donors.
• In 2002, 39 countries had achieved 100% unpaid voluntary blood donation, of which five were developing countries. By 2004, this had risen to 50 countries. Out of the 11 new countries that achieved this, three were least developed countries.
• Ministries of health in three countries reported very significant strides in achieving 100% voluntary unpaid donation. These are Central African Republic (where the proportion increased from 25% to 100%), Egypt (from 15% to 100%) and Uruguay (28% to 100%).
• More and more countries are moving towards voluntary blood donation. In 2002, 63 countries were collecting less than 25% of their blood from voluntary unpaid donors; by 2004, this had fallen to 46 countries.
• Particularly striking was the increase from 25% to 47% in the proportion of total donations collected from voluntary non-remunerated blood donors in developing and transitional countries.
• The number of units donated in transitional countries has increased from 29 million in 2002 to 36 million in 2004.
• 92% of donations in developed countries are from voluntary unpaid donors as compared to about 67% in developing and transitional countries. This means that family/replacement donors still remain a significant source of blood for transfusion in low HDI and medium HDI countries.
• More than 2.2 million units were still collected from paid blood donors in 2004 in which the level is the same as compared to the last survey. The majority of these (94%) were collected in medium HDI countries.

Blood screening

WHO recommends that, at minimum, all blood for transfusion should be screened for HIV, hepatitis B, hepatitis C and syphilis. Complete and accurate data on the testing of donated blood are not available in the majority of developing countries, particularly in those where blood services are fragmented, but many do not yet have reliable systems for testing because of staff shortages, poor quality test kits or irregular supplies, and lack of basic laboratory quality systems. The advanced technology used in many developed countries is unable to detect very recent infections and is not affordable or cost-effective in most developing and transitional countries.

• 41 out of 148 countries (28%) that provided data on screening for transfusion-transmissible infections including HIV, hepatitis B and C, and syphilis were not able to screen all donated blood for one or more of these infections.
• However, globally, the number of tests not performed for the markers for four main infections (HIV, HBV, HCV and syphilis) decreased from 6 million in 2002 to 1.5 million in 2004. The most marked reduction was seen in the African region where the number of tests not performed was reduced from more than 1 million in 2001-02 to 380 000 in 2004.
• In 2004, the following countries achieved universal screening for all four recommended markers of transfusion-transmissible infections: Benin, Burundi, Chile, Democratic Republic of Congo, Ecuador, Guinea-Bissau, Honduras, Mauritania, Uzbekistan and Democratic Republic of Korea
• Out of 40 countries in sub-Saharan Africa, 28 countries have yet to implement national quality systems in their blood transfusion services.

Blood usage

Data on blood utilization are limited, but studies suggest that transfusions are often given unnecessarily when simpler, less expensive treatments can provide equal or greater benefit. Not only is this wasteful of a scarce resource, it also exposes patients unnecessarily to the risk of serious adverse transfusion reactions or transfusion-transmitted infections.