Improved access to comprehensive emergency obstetric care and its effect on institutional marternal mortality in rural Mali

Abstract

Objective To evaluate the effect of a national referral system that aims to reduce maternal mortality rates through improving access to and the quality of emergency obstetric care in rural Mali (sub-Saharan Africa). Methods A maternity referral system that included basic and comprehensive emergency obstetric care, transportation to obstetric health services and community cost-sharing schemes was implemented in six rural health districts in Kayes region between December 2002 and November 2005. In an uncontrolled "before and after" study, we recorded all obstetric emergencies, major obstetric interventions and maternal deaths during a 4-year observation period (1 January 2003 to 30 November 2006): the year prior to the intervention (P-1); the year of the intervention (P0), and 1 and 2 years after the intervention (P1 and P2, respectively). The primary outcome was the risk of death among obstetric emergency patients, calculated with crude case fatality rates and crude odds ratios. Analyses were adjusted for confounding variables using logistic regression. Findings The number of women receiving emergency obstetric care doubled between P-1 and P2, and the rate of major obstetric interventions (mainly Caesarean sections) performed for absolute maternal indications increased from 0.13% in P-1 to 0.46% in P2. In women treated for an obstetric emergency, the risk of death 2 years after implementing the intervention was half the risk recorded before the intervention (odds ratio, OR: 0.48; 95% confidence interval, CI: 0.30-0.76). Maternal mortality rates decreased more among women referred for emergency obstetric care than among those who presented to the district health centre without referral. Nearly half (47.5%) of the reduction in deaths was attributable to fewer deaths from haemorrhage. Conclusion The intervention showed rapid effects due to the availability of major obstetric interventions in district health centres, reduced transport time to such centres for treatment, and reduced financial barriers to care. Our results show that national programmes can be implemented in low-income countries without major external funding and that they can rapidly improve the coverage of obstetric services and significantly reduce the risk of death associated with obstetric complications.Une traduction en français de ce résumé figure à la fin de l'article. Al final del artículo se facilita una traducción al español.

Why Do Mothers Die? The Silent Tragedy of Maternal Mortality

“…Success stories (Bangladesh, Cuba, China, Colombia, Egypt, Honduras [38], Japan [39], Mali [40] Thailand, Malaysia [41], Mexico, Nepal, Sri Lanka [42], Vietnam,) show nevertheless that despite different initial contexts, drastic improvements are achievable; Maternal Mortality can be halved in developing countries every 7-10 years [43]. The most eloquent testimonies show how support and involvement at all levels help to deal with the various components of the MNH strategy implementation.…”

Emergency obstetric care in Mali: catastrophic spending and its impoverishing effects on households

“…The first policy, a national maternity referral system launched in 2002, consists of community cost-sharing schemes to help women pay for transportation to obstetric health centres. 16 The second policy, in effect since 2005, is the elimination of user fees for Caesarean sections. The fee exemption policy is applied to the direct costs of the Caesarean procedure, including preoperative examinations, provision of a Caesarean kit (drugs and surgical supplies), surgery, post-operative treatment, hospitalization and laboratory tests.…”

Impact of inter-facility transport on maternal mortality in the Free State Province

“…It has been documented that access to emergency obstetric care and reduced transport time to such centres for treatment reduce deaths. [1,2] The 'Three Delays Model' proposed by Thaddeus and Maine [3] attempts to describe where gaps occur in obstetric management: (i) delay in seeking help on the part of individual patients; (ii) delay in reaching a suitable healthcare facility; and (iii) delay in receiving adequate care at that facility. The confidential enquiries into maternal deaths have identified transport issues as a factor relating to deaths.…”

“…[4] When dealing with maternal mortality, deaths can be avoided by timely and adequate treatment [5] and programmes that reduce barriers to comprehensive emergency obstetric care can substantially reduce deaths associated with obstetric emergencies. [1] In the Free State Province of SA, antenatal care is provided at all primary healthcare (PHC) clinics. While 90% of the community has access to these sites, giving birth before reaching these remains a problem.…”