Reducing maternal mortality in Mozambique: challenges, failures, successes and lessons learned.

The aim of this paper is to describe different approaches to make emergency obstetric care (EmOC) accessible to women in Mozambique. The definitions of basic (BEmOC) and comprehensive EmOC (CEmOC), proposed by the UN agencies, were adopted by FIGO and by the Mozambican Ministry of Health as a general strategy to reduce maternal mortality. Four projects are presented: (1) José Macamo and (2) Mavalane Hospitals in Maputo city, (3) Manhiça District in Maputo Province and (4) Sofala Province. José Macamo was staffed by physicians 24 h a day; other hospitals by non-physicians trained in surgical and anesthesiology techniques, as well as nurse-midwives. José Macamo Hospital provided CEmOC to the city of Maputo and the southern area of Maputo Province. In 2001, this hospital attended 32% of deliveries and 38% of cesarean sections in the city, up from 14 and 2.5%, respectively, in 1998. The Mavalane Hospital failed to provide CEmOC; however, the number of deliveries per year almost doubled. The Manhiça hospital carried out 31% of the District's C-sections in 2001, up from 9% in 1998. In Sofala Province, one additional CEmOC and four BEmOCs were installed and case fatality rates decreased. In conclusion, the strategy for ensuring provision of EmOC is feasible even in countries with minimal resources and a scarcity of physicians, such as Mozambique.

Evaluation of the effectiveness of vaginal misoprostol to induce first trimester abortion.

Two doses, 200 and 400 micrograms, of misoprostol, administered vaginally every 12 hours, up to four times, were tested in 101 and 133 healthy women, respectively, for interruption of pregnancies with 35 through 77 days of amenorrhea. The proportion of women who aborted increased with longer duration of treatment and was significantly higher with 400 than with 200 micrograms (66 versus 46 percent at 48 hours). Significance was maintained after controlling by age, body weight, parity, previous abortion and gestational age. Abortions were classified as incomplete or complete, according to the presence or not of embryonic tissue in the uterine cavity, diagnosed by vaginal sonography. Vacuum aspiration was carried out in all cases not classified as complete abortion 48 hours after the initiation of treatment, or earlier in case of persistent bleeding or woman's request. The possibility of increasing effectiveness by using higher dose, shorter intervals or longer duration of treatment is discussed.