Summaryobjectives Process evaluation has become the mainstay of safe motherhood evaluation in developing countries, yet the extent to which indicators measuring access to obstetric services at the population level reflect levels of maternal mortality is uncertain. In this study we examine the association between population indicators of access to obstetric care and levels of maternal mortality in urban and rural West Africa. results In rural areas, maternal mortality, excluding early pregnancy deaths, was 601 per 100 000 live births, compared with 241 per 100 000 for urban areas [RR ¼ 2.49 (CI 1.77-3.59)]. In urban areas, the vast majority of births took place in a health facility (83%) or with a skilled provider (69%), while 80% of the rural women gave birth at home without any skilled care. There was a relatively close link between levels of maternal mortality and the percentage of births with a skilled attendant (r ¼ )0.65), in hospital (r ¼ )0.54) or with a Caesarean section (r ¼ )0.59), with marked clustering in urban and rural areas. Within urban or rural areas, none of the process indicators were associated with maternal mortality.conclusion Despite the limitations of this ecological study, there can be little doubt that the huge rural-urban differences in maternal mortality are due, at least in part, to differential access to high quality maternity care. Whether any of the indicators examined here will by themselves be good enough as a proxy for maternal mortality is doubtful however, as more than half of the variation in mortality remained unexplained by any one of them.

SummaryOBJECTIVES To report the findings of a direct, community-based, assessment of maternal mortality and medical causes of death using verbal autopsy in three unique cohorts in rural Senegal. Two-thirds of the maternal deaths were from direct obstetric causes, haemorrhage being the most common. Abortion was rare.CONCLUSIONS CONCLUSIONS Demographic surveillance systems are useful tools for the measurement of maternal mortality provided special studies are carried out to arrive at the levels and causes of maternal death. The estimates of maternal mortality reported here are lower than those published by the WHO and UNICEF but remain extremely high, particularly in the very remote areas with very limited health infrastructure, where as many as one in 19 women may be expected to die as a consequence of childbirth.keywords maternal mortality, verbal autopsy, obstetric care, Senegal

We explore a possible link between malaria and maternal death in a rural area of Senegal by assessing the seasonal pattern of maternal mortality by cause and examining whether this pattern coincides with the malaria season. Overall mortality in women 15-49 years of age did not differ by season, while maternal and direct obstetric deaths were significantly more frequent during the rainy/malaria season than during the rest of the year, even after adjusting for place of delivery.

Objective Few prospective studies have been undcrtaken of maternal mortality in sub-Saharan Africa.National statistics are inadequate, and data from hospitals are often the only source of information available. Reported maternal mortality ratios may therefore show large variations within the same country, as in Mali. This study was designed to producc an estimate of the maternal mortality ratio for the population of Bamako.Design Prospective cohort study. SettingPopulation 5782 pregnant women identified during quarterly household visits. MethodsBankoni (population 59,000). a district of Bamako (population 700,000).After enrolment, two follow up visits, at six weeks and one year after delivery, were performed to collect information on the pregnancy, its outcome, thc method of delivery, the puerperium and the first year after birth. Detailed inquiries on deaths were undertaken in the community, the maternity units and the rcference hospital. Main outcome measures Matcrnal mortality ratio, late maternal mortality, likely cause of death.Results Complete data at follow up were available on 4717 women (82%) (4653 single and 64 twin pregnancies). Most of the women had antenatal care were and delivcrcd in a district maternity hospital. There were 4580 live births (96%). Fiftecn maternal deaths were recorded, yielding an overall maternal mortality ratio of 327 per 100,000 live births. Hypertensive disorders and haemorrhage were the main causes of death. Five more deaths occurred within 42 days or one year after delivery. ConclusionsThis study gavc an estimate of the maternal mortality ratio for the population of Bamako, and stressed the need of better emergency obstetric care and the importance of late maternal mortality.

The apparent protective effect of pregnancy on women's health that is observed in this study illustrates the paradoxical nature of the concept of indirect causes of maternal mortality, and the difficulties in measuring the risks of death attributable to the pregnancy. Further studies aimed at separating risks attributable to the pregnancy from those that are incidental to the pregnancy are required.