Maternal mortality remains a major public health issue in developing countries, particularly those in sub-Saharan Africa, and is one of the key indicators of the Millennium Development Goals. Compared with developed countries, Africa cumulates many physical, economic, social, and psychological handicaps, especially in its rural areas: scattered settlements, poor health infrastructure, shortage of qualified health-care personnel, transportation, and health awareness, and low levels of income and education. Understanding of all these conditions needs to improve to enable accurate directing of interventions aimed at reducing maternal mortality to low levels.In The Lancet Global Health, Claudia Hanson and colleagues present their study of access to obstetric care in Tanzania. Their approach illustrates how risks of maternal mortality can be clarified in the difficult conditions of rural Africa. Hanson and colleagues assessed census data collected for 818 583 people in 225 980 households in five rural districts of southern Tanzania. Heads of households were asked about any deaths between June 1, 2004, and May 31, 2007, and women of childbearing age were asked about birth history. Information on women of reproductive age who had died was collected by verbal autopsy. Distance to a health facility was a major risk factor of obstetric maternal mortality (adjusted odds ratio for more than 35 km vs 5 km 3·68, 95% CI 1·37–9·88). Hanson and colleagues also found high pregnancy-related mortality of 664 deaths per 100 000 livebirths even though 72% of women gave birth in hospital and 8% had delivery by caesarean section. The authors suggest that this finding highlights deficiencies in quality of care.

The study is noteworthy because it was large scale, which is necessary for estimating maternal mortality and its risk factors, simply because maternal deaths are rare events. For example, in a population of 100 000 people with a high birth rate of 40 per 1000 and a high maternal mortality ratio of five per 1000, 20 maternal deaths would occur every year. Thus, even this population size would produce a sample too small for estimating rates and risk factors. Most demographic sample surveys are based on similar values. Therefore, population census, which by nature involves exhaustive or very large samples, is the choice method for investigating maternal mortality in countries without vital registration.

Hanson and colleagues stress the importance of assessing the causes of maternal death, which can be easily done by verbal autopsy when medical records of causes are not available. They rightly make a clear distinction between direct obstetric causes and other causes of death. In terms of levels of mortality, the pregnancy-related mortality ratio might be strongly influenced by causes that have no relation to pregnancy, such as HIV/AIDS, tuberculosis, cholera, diabetes, road traffic accidents, street violence, and so on. As a consequence, peculiar disease environments or external conditions might be reflected in the ratio, as was found in South Africa, where obstetric causes account for a small proportion of pregnancy-related deaths, but HIV/AIDS, tuberculosis, accidents, and violence account for a large proportion. This consideration also applies to risk factors: if distance to hospitals or clinics, speed of referral, quality of obstetric care, blood bank availability, etc, are important for direct obstetric mortality, they are largely irrelevant for other causes of death and, therefore, they must be considered separately. If chronic infectious or non-infectious diseases are important, prevention and treatment might need means of intervention that would be better provided by another organisation or part of the health sector other than that which provides the obstetric services.

Hanson and colleagues’ findings are a reminder that distance to hospitals or clinics is likely to play a part in maternal mortality if quality of care is high, but not when it is low (eg, drugs or equipment are not available or the staff is poorly trained).  The experience of Morocco, however, shows that even in a low-income country with a difficult mountainous terrain that makes access to obstetric care difficult, maternal mortality can be strongly reduced by appropriate policies and programmes, as happened all over Europe a century ago.

Besides classic risk factors, such as those investigated by Hanson and colleagues, it would be useful to obtain more information from studies about the effects of special programmes implemented in developing countries, such as maternity waiting homes, important risk factors (eg, illustrated by partographs), or the use of drugs, such as misoprostol to prevent haemorrhage (which was the leading cause of obstetric deaths in the Hanson and coworkers’ Tanzania study). Additionally, exploration of the roles of social conditions peculiar to African countries, such as health education of pregnant women before delivery, and social and family support, would be interesting. The first case of maternal death I investigated with verbal autopsy in rural Senegal was in a woman aged 17 years who had received no information on how to handle her first delivery. She had delivered alone in the bush and died totally isolated. No matter whether the number of such cases is declining, there is still a huge need for better information for young women and their families and caretakers about how to handle pregnancy, delivery, and potential complications, especially for the first pregnancy. Even with limited resources, most cases of maternal death could be easily averted with proper health education, adequate support, proper screening of risks, quick referral, and appropriate obstetric care.

Michel Garenne

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