The evidence for emergency obstetric care.

PURPOSE: We searched for evidence for the effectiveness of emergency obstetric care (EmOC) interventions in reducing maternal mortality primarily in developing countries. METHODS: We reviewed population-based studies with maternal mortality as the outcome variable and ranked them according to the system for ranking the quality of evidence and strength of recommendations developed by the US Preventive Services Task Force. A systematic search of published literature was conducted for this review, including searches of Medline, PubMed, Cochrane Database of Systematic Reviews, the Cochrane Pregnancy and Childbirth Database and the Cochrane Controlled Trials Register. RESULTS: The strength of the evidence is high in several studies with a design that places them in the second and third tier in the quality of evidence ranking system. No studies were found that are experimental in design that would give them a top ranking, due to the measurement challenges associated with maternal mortality, although many of the specific individual clinical interventions that comprise EmOC have been evaluated through experimental design. There is strong evidence based on studies, using quasi-experimental, observational and ecological designs, to support the contention that EmOC must be a critical component of any program to reduce maternal mortality.

The AMDD program: history, focus and structure.

The AMDD (Averting Maternal Death and Disability) Program was established at the Mailman School of Public Health in 1999. In this article, we discuss four key aspects of the program: the focus on emergency obstetric care; the use of process indicators; working with partners; and applying human rights.

How do socioeconomic factors affect disparities in maternal mortality?

Socioeconomic factors affect nearly every cause of death, but not always in the same ways. Understanding which components of socioeconomic development were responsible for the great declines in maternal mortality in the United States and Britain can help us design effective programs in developing countries. The literature shows that maternal mortality is most strongly influenced by women's access to medical care for complications of pregnancy. In addition to international disparities in maternal mortality, there are still great disparities among racial groups in the United States. Here, too, analysis of the factors at work may be helpful in tailoring interventions.

Role of nutrition in the prevention of toxemia.

Toxemia of pregnancy is called the disease of theories because, over decades of research, numerous causes have been proposed but none proved. Although many nutritional factors have been suggested as playing a causal role in the etiology of toxemia, mortality from this disease has not varied over time or between circumstances as one would expect a nutritional disease to do. This does not mean that there is no nutritional influence, but it does mean that the available evidence does not show that nutrition makes a major difference in maternal mortality from toxemia of pregnancy.

Calcium-induced calcium release from intracellular stores is developmentally regulated in primary cultures of cerebellar granule neurons.

The properties of depolarization-evoked calcium transients are known to change during the maturation of dissociated cerebellar granule neuron cultures. Here, we assessed the role of the calcium-induced calcium release (CICR) mechanism in granule neuron maturation. Both depletion of intracellular calcium stores and the pharmacological blockade of CICR significantly reduced depolarization stimulated calcium transients in young but not older (>/=1 week) cultures. This functional decrease in the CICR signaling component was associated with the reduction of ryanodine receptor (RyR) immunoreactivity during granule neuron maturation both in culture and in the intact cerebellum. These observations are consistent with the idea that changes in RyR expression result in functional changes in calcium signaling transients during normal neuronal development in the intact mammalian cerebellum as well as in reduced neuronal cultures. Pharmacological disruption of CICR during neuron differentiation in vitro resulted in dose-dependent changes in survival, GAP-43 expression, and the acquisition of the glutamatergic neurotransmitter phenotype. Together, these results indicate that CICR function plays a physiologically relevant role in regulating early granule neuron differentiation in vitro and is likely to play a role in cerebellar maturation.

The Safe Motherhood Initiative: why has it stalled?

Complications of pregnancy and childbirth are still the leading cause of death and disability among women of reproductive age in developing countries. After decades of neglect, the founding of the Safe Motherhood Initiative in 1987 promised action on this problem. A dozen years later, there is no evidence that maternal mortality has declined and there are still few sizeable programs. A major reason for this disappointing record is that the initiative lacks a clear, concise, feasible strategy. This article reviews the available options and proposes a strategy based on improving the availability and quality of medical treatment of obstetric complications. Once district hospitals and health centers provide such needed care, community mobilization to improve prove utilization may be beneficial. Substantial reductions in maternal deaths would be possible in a relatively short period of time if this strategy were embraced.

The strategic model for the PMM Network.

The projects of the PMM Network are based on a strategic model that focuses sharply on the interval between the obvious onset of a serious obstetric complication and the provision of emergency obstetric care (EmOC). The reason for this is that most of these complications cannot be predicted or prevented, but they can be successfully treated. The implications of this model for program design are profound. The emphasis is on improving the accessibility, quality and utilization of EmOC for women who develop such complications, rather than on having contact with all pregnant women.

Lessons for program design from the PMM projects.

The Prevention of Maternal Mortality (PMM) Network designed and tested projects for reducing maternal deaths. The focus was on improving the availability, quality and utilization of emergency obstetric care (EmOC) for women with serious complications. Teams' projects included interventions in health facilities (to improve skills and services and reduce delays in treatment) and in communities (to address lack of transport, funds and information concerning obstetric complications). The teams' results, reported in this volume, offer several lessons for program planners. Despite difficult conditions in the project countries, the teams demonstrated that it is almost always possible to make improvements in the delivery of EmOC. Their work shows that EmOC can be improved not only by concentrating on hospitals and physicians, but also by focusing on peripheral facilities and other qualified staff. The teams' findings regarding utilization of EmOC suggest that more people utilize services when they know them to be functioning well. Community efforts, including education and mobilization, have a role to play in improving utilization once services are in place. Improving EmOC need not be costly, because in many areas the necessary facilities exist and staff are already in place.

Why perinatal mortality cannot be a proxy for maternal mortality.

In recent years, the perinatal mortality rate (PNMR) has been proposed as a proxy measure of maternal mortality, because perinatal deaths are more frequent and potentially more easily measured. This report assesses evidence for an association between these two statistics. This study, based upon data from Matlab, Bangladesh, shows that the maternal mortality ratio (MMR) and the PNMR do not vary together over time, and that the PNMR does not reliably indicate either the magnitude or the direction of change in the MMR from year to year. Statistical analysis shows that the correlation between the PNMR and the MMR is not significantly different from zero. An examination of the major causes of maternal and perinatal deaths indicates that the two measures cannot be expected to vary together. Almost half of perinatal deaths result from causes that do not pose a threat to the mother's life, and almost half of maternal deaths result from causes that do not lead to perinatal death. Monitoring of the PNMR can give an inaccurate picture of maternal mortality and should not be used as a proxy.

Why did maternal mortality decline in Matlab?

In 1991, an article on the Maternity Care Program in Matlab, Bangladesh, reported a substantial decline in direct obstetric deaths in the intervention area, but not in the control area. The decline was attributed primarily to the posting of midwives at the village level. In this article, data are presented from the same period and area on a variety of intermediate events. They indicate that the decline in deaths was probably due to the combined efforts of community midwives and the physicians at the Matlab maternity clinic. Their ability to refer patients to higher levels of care was important. The data further indicate that the decline in deaths depended upon the functioning of the government hospital in Chandpur, where cesarean sections and blood transfusions were available. Midwives might also have made a special contribution by providing early termination of pregnancy, which is legal in Bangladesh.

PIP: Data were collected during 1993 from the Matlab Demographic Surveillance System, midwives' cards, the Matlab maternity clinic record book, and records at the government's district hospital. This study analyzed these data in order to determine why maternal mortality declined in the intervention area. Direct obstetric deaths declined from 20 deaths during the 3 years before the Maternity Care Program was implemented to 6 deaths during the 3 years after program implementation. In the control area, mortality remained stable at 20 deaths during the same time period. The declines were apparent among diagnoses for induced abortion, eclampsia and pre-eclampsia, and prolonged obstructed labor. There were few changes in causes of death in the control area. During the intervention period, midwives in villages administered services to 49 women with preeclampsia, of whom 6 later developed eclampsia. There were 20 referrals to the maternity clinic for a variety of complications including eclampsia. The Matlab clinic received 54 patients during the intervention period with a primary diagnosis of pre-eclampsia or eclampsia. Midwives provided care for 77 women with prolonged labor. Matlab clinic received 116 patients due to prolonged labor. 4% of the 2364 midwives' cards indicated referral. 83% of referrals were to the Matlab clinic. The Matlab maternity clinic had 300 admissions during the study period, of which 65% (194 women) were from the intervention area. Women from the intervention area were 2.3 times more likely to be treated at the Matlab clinic than women from the control area. 69% of admissions at Chandpur District Hospital were from the Matlab intervention area. Case fatality rates in the hospital did not differ among intervention and control populations. The authors conclude that greater use of midwives, referrals and proper transport, and better service conditions significantly contributed to maternal mortality decline.

Suicide during pregnancy and its neglect as a component of maternal mortality.

OBJECTIVES: To raise awareness about the socio-cultural factors which may lead pregnant women to commit suicide. METHODS: This paper reviews and compiles current international literature on this topic, and suggests comparison with evidence from the past. RESULTS: Suicide during pregnancy is often due to the limited choices women face when confronted with an unwanted pregnancy. Neglect of this subject is due in part to the exclusion of suicide from classification as 'maternal death,' and other difficulties in collecting reliable data. CONCLUSIONS: The problem of suicide during pregnancy underscores the need for sex education at an early age, access to family planning, and access to safe abortion services.

The bad old days are still here: abortion mortality in developing countries.

Each year, complications related to unsafe abortion account for at least one in seven maternal deaths worldwide. Nearly all of these deaths occur in developing countries and most are preventable. The authors argue that to prevent abortion-related deaths, all women must have access to safe abortion and contraceptive services, and they discuss the strategies used to prevent abortion-related deaths--preventing unwanted pregnancy, preventing abortion, preventing unsafe abortion, and treating abortion complications. Some of these strategies have been effective, while others have failed. Preventing unwanted pregnancy is a very important starting point, but evidence suggests that it alone cannot solve the problems of abortion-related deaths. Efforts to prevent abortion, whether through legal or cultural sanctions, do not significantly reduce the number of abortions, and may even increase mortality. The technology to perform safe abortions is available, but remains underused. Finally, even under the best of circumstances, women will experience abortion complications (induced or spontaneous) and only through the prompt and effective treatment of these and other obstetric complications will deaths be averted.

Too far to walk: maternal mortality in context.

The Prevention of Maternal Mortality Program is a collaborative effort of Columbia University's Center for Population and Family Health and multidisciplinary teams of researchers from Ghana, Nigeria and Sierra Leone. Program goals include dissemination of information to those concerned with preventing maternal deaths. This review, which presents findings from a broad body of research, is part of that activity. While there are numerous factors that contribute to maternal mortality, we focus on those that affect the interval between the onset of obstetric complication and its outcome. If prompt, adequate treatment is provided, the outcome will usually be satisfactory; therefore, the outcome is most adversely affected by delayed treatment. We examine research on the factors that: (1) delay the decision to seek care; (2) delay arrival at a health facility; and (3) delay the provision of adequate care. The literature clearly indicates that while distance and cost are major obstacles in the decision to seek care, the relationships are not simple. There is evidence that people often consider the quality of care more important than cost. These three factors--distance, cost and quality--alone do not give a full understanding of decision-making process. Their salience as obstacles is ultimately defined by illness-related factors, such as severity. Differential use of health services is also shaped by such variables as gender and socioeconomic status. Patients who make a timely decision to seek care can still experience delay, because the accessibility of health services is an acute problem in the developing world. In rural areas, a woman with an obstetric emergency may find the closest facility equipped only for basic treatments and education, and she may have no way to reach a regional center where resources exist. Finally, arriving at the facility may not lead to the immediate commencement of treatment. Shortages of qualified staff, essential drugs and supplies, coupled with administrative delays and clinical mismanagement, become documentable contributors to maternal deaths. Findings from the literature review are discussed in light of their implications for programs. Options for health programs are offered and examples of efforts to reduce maternal deaths are presented, with an emphasis on strategies to mobilize and adapt existing resources.

A framework for analyzing the determinants of maternal mortality.

Hundreds of thousands of women in developing countries die each year from complications of pregnancy, attempted abortion, and childbirth. This article presents a comprehensive and integrated framework for analyzing the cultural, social, economic, behavioral, and biological factors that influence maternal mortality. The development of a comprehensive framework was carried out by reviewing the widely accepted frameworks that have been developed for fertility and child survival, and by reviewing the existing literature on maternal mortality, including the results of research studies and accounts of intervention programs. The principal result of this exercise is the framework itself. One of the main conclusions is that all determinants of maternal mortality (and, hence, all efforts to reduce maternal mortality) must operate through a sequence of only three intermediate outcomes. These efforts must either (1) reduce the likelihood that a woman will become pregnant; (2) reduce the likelihood that a pregnant woman will experience a serious complication of pregnancy or childbirth; or (3) improve the outcomes for women with complications. Several types of interventions are most likely to have substantial and immediate effects on maternal mortality, including family planning programs to prevent pregnancies, safe abortion services to reduce the incidence of complications, and improvements in labor and delivery services to increase the survival of women who do experience complications.

Too far to walk: maternal mortality in context.

PIP: This article briefly capsules some of the thinking about obstacles obstetrics patients encounter on the way to a care facility, which is based on over 200 research studies or articles. The bibliography is available on request and not included in the article. Delay in seeking care is presented in 3 ways. The 1st is in the decision to seek care and discussion is presented in Newsletter 35. The 2nd delay is in reaching a facility after the decision is made, which is the subject of this article. The 3rd delay is in receiving the needed care and will appear in Newsletter 37. Based on interviews of rural Kenyan women, of the 47% intending to deliver in a hospital, only 36% actually did so. Distance and unavailability of public transportation in other studies were expressed as obstacles that prevented women from reaching the hospital. There is not systematic documentation in the literature of these types of delays. Consequently, programs which identify high risk women for hospital delivery and raising community awareness may be ineffective if there is inaccessibility of the facility. Urban areas have better access to health facilities, and there is uneven distribution in rural areas even in developed countries such as Portugal. The example of an equitably distributed health network exists in Cuba. The implications of the shortage of health facilities and health care providers and the uneven distribution are that limited access interferes with usage. The nature of the terrain and the condition of the roads and the actual distances are considerations. Many inhabitants must walk or improvise a means of transportation to reach health care, because there is a scarcity of public transportation. The patients condition may deteriorate on the way which makes treatment more difficult, provided the patient is still alive upon arrival. An example is given of a Tanzanian women bleeding to death waiting for a taxi. A decision to seek care may be timely, but impaired access prevented utilization. An additional complication is a situation where the nearest facility is not equipped to treat the condition or even administer essential first aid. A further delay occurs in transporting the patient to the proper facility. Death enroute data is scarce, and may be included in home deaths, but maternal mortality study data is available.^ieng

Maternal mortality: a problem whose time has come.

PIP: This article discusses the prevention of maternal deaths in developing countries through the use of contraception. High risk women (those younger than 18, those 35 or older, or those with 4 or more children) have usually been the focus of such efforts. The author argues however that family planning programs which are not focused on any particular age or parity group may actually be more effective. Most women probably use contraceptives to limit family size or for spacing purposes, not to avoid dying in childbirth. In the World Fertility Survey, about 4 in 10 married, fecund women said they wanted no more children, yet 7 in 10 were not using an effective method of contraception. If all these women were able to avoid unwanted pregnancies, an estimated 3 out of 10 maternal deaths could be averted. Other reasons concentrating on certain age or parity groups may be inappropriate include: 1) high risk women have lower birth rates; therefore the majority of maternal deaths may actually occur among "low risk" women, 2) many women wish to stop having children before they reach age 35 or have 4 children, 3) illicit abortions are a major cause of death in developing countries; therefore any unwanted pregnancy is high risk, 4) some women genuinely want more children although they have 4 or more, or are 35 or older, and, 5) confining attention to the usual high risk groups encourages an inappropriately clinical view of contraceptives. The main conclusion is that making family planning services available and accessible to all women is one of the ways which must be used to prevent maternal deaths in the Third World.^ieng

Emergency obstetric surgery performed by nurses in Zaïre.

In rural northwestern Zaïre nurses at Karawa and Wasolo hospitals were trained to do caesarean sections, laparotomies, and supracervical hysterectomies. In Karawa 278 of 321 caesarean sections were done by nurse-surgeons in 18 months, with two deaths. In Wasolo all 32 caesarean sections in 13 months were done by the nurse-surgeons, with 1 death. Of the 37 laparotomies done in both centres, 16 were by nurse-surgeons, and there were two deaths. Four of the five deaths were attributable to protracted labour with septicaemia (1), postoperative infection (2), and protracted labour with no blood pressure on admission (1). Obstetric operations could safely be performed by specially trained nurses in rural areas of developing countries and the high maternal mortality rate in such areas could thus be reduced.