Vol. 48, No. 1, 1995 World Health STATISTICS Quarterly Rapport trimestriel de STATISTIQUES sanitaires mondiales Safe motherhood La maternite sans risque World Health Organization Organisation mondiale de la Sante Geneve The World health statistics quarterly replaces (since 1978) the monthly World health stallstics report(published since 1967) and its forerunner the Epidemiological and vital stat,stics report(published since 1947). It deals with the detailed analysis of selected health topics of current interest. Starting with Vol 41 (1988), the Quarterly contains articles in either French or English with a summary 1n both languages. 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La mention de firmes et de produ1ts commerc1aux n·1mpl1quc pas que ces firmes et .produ1ts commerciaux sont agrees ou recommandes par l'Organ1sat1on mond1ale de la SantC de preference a d'autres Sauf crreur ou orrnss1on, une ma1uscule 1nit1ale 1nd1que qu'il s'ag1t d'un nom depose IX ISSN 0043-8510 Printed in Switzerland 94/10313 Atar SA. Geneva-5200 World Health Statistics Quarterly Rapport trimestriel de statistiques sanitaires mondiales Sate motherhood: selected research results Contents Maternal health and safe motherhood: Findings from selected research studies (Introduction) Argentina: Risk factors and maternal mortality in La Matanza, Province of Buenos Aires Sara Szmoisz et al. China: Epidemiology of pregnancy-induced hypertension Jiang Dixian China: Lowering maternal mortality in Miyun County, Beijing Xu Zhenxuan Ethiopia: An epidemiological study of vesico-vaginal fistula in Addis Ababa John Kelly The Gambia: Evaluation of the Mobile Health Care Service in West Kiang, The Gambia Frances Foard The Gambia: Cost and effects of a mobile maternal health care service, West Kiang, The Gambia Julia A. Fox-Rushby Guatemala: maternal mortality: assessing the gap, beginning to bridge it Edgar E. Kestler Guinea-Bissau: Maternal mortality assessment Margreet M. Oosterbaan Guinea-Bissau: What women know about the risks: an anthropological study Margreet M. Oosterbaan & Maria V. Barreto da Costa Lao People's Democratic Republic Maternal mortality and female mortality. Report on phase 11: causes of death Vincent A. Fauveau Mexico: Maternal deaths, fertility patterns, and social cost. An anthropological study Maria de/ Carmen Elu Pakistan: The Faisalabad Obstetric Flying Squad Michele M. Andina & Fariyal F. Ftkree Pakistan: Consumer satisfaction and dissatisfaction with maternal and child health services Shameim Kazmi Sudan: Situational analysis of maternal health in Bara District, North Kordofan Martha Campbell & Zeinab Abu Sham Wld hlth statist. quart., 48 (1995) Vol. 48, N° 1, 1995 2 4 8 11 15 18 23 28 34 39 44 47 50 55 60 Maternite sans risque: resultats de certaines recherches Somma ire Sante maternelle et maternite sans risque: conclusions de certaines recherches (Introduction) [anglais seulement] Argentine: Facteurs de risque et mortalite maternelle a La Matanza, province de Buenos Aires, 1990 [resume] Sara Szmoisz et at. Chine: Epidemiologie de !'hypertension gravidique [resume] Jiang Dixian Chine: Reduction de la mortalite maternelle dans le District de Miyun, Beijing [resume] Xu Zhenxuan Ethiopie Etude epidemiologique sur les fistules vesico-vaginales a Addis-Abeba [resume] John Kelly Gambie: Evaluation de l'antenne mobile de soins de sante de West Kiang, Gambie [resume] Frances Foord Gambie: Cout et efticacite d'une antenne mobile de soins de sante maternelle, West Kiang, Gambie [resume] Julia A. Fox-Rushby Guatemala: mortalite maternelle: mesurer l'ecart et comment le combler [resume] Edgar E. Kestler Guinee-Bissau: Evaluation de la mortalite maternelle [resume] Margreet M. Oosterbaan Guinee-Bissau: Oue savent les femmes des risques encourus? - etude anthropologique Margreet M. Oosterbaan & Maria V. Barreto da Costa Republique democratique populaire lao: Mortalite maternelle et mortalite feminine. Rapport sur la phase II: causes de deces Vincent A. Fauveau Mexique: deces maternels, profils de fecondite et cout social - etude anthropologique Maria de/ Carmen Elu Pakistan: La «brigade volante» obstetricale de Faisalabad Michele M. Andina & Fariya/ F. Fikree Pakistan: Les consommateurs sont-ils satisfaits des services de sante maternelle et infantile? Shameim Kazmi Soudan: La sante maternelle dans le district de Bara, au nord du Kordofan - analyse de situation Martha Campbell & Zeinab Abu Sham 2 4 8 11 15 18 23 28 34 39 44 47 50 55 60 Maternal health and safe motherhood: findings from concluded research studies Women in developing countries continue to face a high risk of death or disability as a result of complica- tions arising during pregnancy, delivery or the post- partum period. This situation will be improved only if effective interventions that are feasible in condi- tions where resources are limited can be developed and applied. Research can play an important role in identifying such cost-effective interventions. Essen- tial national health research must be a high priority for every nation where maternal mortality and mor- bidity continue to be major public health problems. Since 1984 the World Health Organization has supported studies to improve the existing body of knowledge on ways to reduce the tremendous bur- den of suffering experienced during pregnancy and childbirth by women throughout the develop- ing world. Concern about continuing high levels of maternal mortality led to the Nairobi International Safe Motherhood Conference, held in 1987, at which the Safe Motherhood Initiative was formally launched, cosponsored by WHO, UNDP, UNFPA, UNICEF, International Planned Parenthood Fed- eration and the Population Council. The Confer- ence ended with "a call to action" which empha- sized the importance of applied research "to gain better country-specific and locale-specific informa- tion on maternal mortality: its immediate causes, which we know, and its root causes, some of which we either do not know or ignore. We need to have continuous operational research and evaluation activities to assess the effectiveness of various pro- grammes. We need to use appropriate technolo- gies at all levels so that women have better care at lower cost".a It was this reasoning that led to the establish- ment of the Safe Motherhood Operational Re- search programme, with WHO as the executing agency. The rationale of the programme was that establishing, documenting and then disseminating the knowledge needed to reduce maternal mortal- ity and morbidity is a prerequisite for effective ser- vices to improve maternal health. Research at country level was seen as an effective way of stimu- lating and encouraging the development of feasi- ble national programmes for the reduction of pregnancy-related deaths and disabilities. a Starrs A. Preventing the tragedy of maternal deaths. A report on the International Safe Motherhood Conference, Nairobi, Kenya, February 1987. Washington: World Bank/WHO/ UNFPA (1987). 2 The overall objective of the research compo- nent ofWHO's Maternal Health and Safe Moth- erhood Programme is to provide new knowledge on scientifically valid and socially and economical- ly acceptable ways of reducing high levels of mater- nal mortality and severe morbidity in order to achieve the global goal of reducing maternal mor- tality to half by the year 2000. The immediate ob- jectives are to support studies in three main areas: (i) Epidemiological and behavioural studies of the magnitude and underlying causes of ma- ternal mortality and severe morbidity. (ii) Operational research concerned with the ap- plication or adaptation of different technolo- gies, or the evaluation of interventions aimed at improving maternal health through coun- try specific or collaborative studies. (iii) Development and assessment of technologies necessary for the reduction of maternal mor- tality, specific to the circumstances of high mortality populations. WHO convened a Steering Committee to guide and advise the Organization on the overall strategy and approaches, on the issues and questions to be addressed and on the appropriate mechanisms to be employed. The Steering Committee, composed of9 experts from a variety of disciplines and coun- tries, met twice a year to review research proposals and monitor the progress of studies, advising on follow-up action where needed. From the start of the programme over 300 ap- plications for support were received; 223 of these were submitted to the Steering Committee and 84 received funding. A detailed progress report and summary description of the studies is available separately.b To date, not all the studies have been completed but among those that have, several have been published in national and international jour- nals. However, not all completed studies have been issued in a format generally available to those work- ing in the area of maternal health and safe mother- hood. The objective of this special issue of World health statistics quarterly is to bring together unpub- lished research results and permit a more wide- spread dissemination of this important body of work. b Maternal Health and Safe Motherhood Programme: Research Progress Report 1987-1992. Division of Family Health WHO, Geneva (1994). Rapp. trimest. statist. sanit. mond., 48 (1995) As a result of this research effort, a considerable volume of knowledge has been acquired on levels or extent of maternal mortality and morbidity in developing countries. Examples of health service and community interventions to improve maternal health have been identified. Information has accu- mulated on the main causes of maternal morbidity and mortality, haemorrhage, anaemia, hyperten- sive disorders in pregnancy, sepsis, obstructed la- bour, and abortion. Conducting health services research under con- ditions prevailing in many developing countries is a special challenge. Constrained resources and diffi- cult field conditions often imposed limitations on the scope and nature of the research and on the methodologies used. Study design, data collection, processing, and report preparation were often ham- pered by inadequate infrastructures, poor transport and civil unrest. Many of the researchers lacked familiarity with the particular difficulties of under- taking research on maternal mortality- lack of statis- tical validity and comparability. Operational re- search was frequently constrained by the fact that the WHO research programme was able to support only the evaluation of an intervention rather than the interventions themselves. And the funds avail- able for each research project were limited. c These research results should be evaluated from a sympathetic standpoint, bearing in mind the conditions from which many emerge. Despite such constraints, many of the findings of these studies contain valuable methodological and prac- tical information. In bringing together these research results, no attempt has been made to impose a uniform struc- ture or framework for analysis. The studies repre- sent a varied collection examining the many di- verse factors which have an impact on maternal health. In one way or another each article address- es the causes of maternal mortality and morbidity in each a specific country context. Despite the modest level of funding, the re- search programme has obtained some important new scientific knowledge in the area of maternal health interventions and treatment. Several of the studies have thrown light on the levels and causes of maternal mortality in countries or areas where little was previously known. The conclusions of epidemiological studies are of value not only in terms of the generation of new data but also, more importantly, because they can result in a significant increase in the awareness of the problem. As a result of the operational research efforts, a number of core protocols have been developed for use by several countries. Multicentre trials have made it possible to apply the results more extensively and to maximize their validity. In many countries re- c Apart from one major multicentre trial on the partograph, the average grant made was under US$ 20,000. Wld hlth statist quart., 48 (1995) search activities have played a crucial catalytic role in the development of national action plans for the reduction of maternal mortality and morbidity. The Maternal Health and Safe Motherhood Pro- gramme will be directing its research, advocacy, training and development efforts in the future to- wards the further strengthening and expansion of such national efforts. Acknowledgment WHO gratefully acknowledges the financial contri- butions made in support of research within the Maternal Health and Safe Motherhood Pro- gramme from the Governments of Australia, Italy, Norway, Sweden and Switzerland; the Rockefeller Foundation, UNDP, UNICEF, UNFPA and the World Bank. Bibliography - Bibliographie Carroli G. Management of retained placenta by umbilical vein injection. British Journal of obstetrics and gynaeco"logy, 98:348-350 (1991). de Groot A.N.J.A. et al. High-performance liquid chromato- graphy of ergometrine and preliminary pharmacokinetics in plasma of men. Journal of chromatography (in press). Dali S.M., Thapa, M. et al. Educating Nepalese women to provide improved care for their childbearing daughters-in-law. World health forum, 13:353-354 ( 1992) Duley, L. Maternal mortality and hypertensive disorders of pregnancy in Africa, Asia, Latin America and the Caribbean. British journal of obstetrics and gynaeco"logy, 99:54 7-553 ( 1992). Duley, L, Grant, A, et al. Edam psia Trial. Edampsia trial news/,etter Nos. 1-3. Perinatal Trials Services, Oxford, NPEU, 1992. Fauveau, V. et al. Effect on mortality of community-based . maternity-care programme in rural Bangladesh. Lancet, 338: 1183-1186 ( 1991). Keeling J.W. et al. Maternal mortality in Jamaica: health care provision and causes of death. International journal of gynaecology and obstetrics, 35:19-27 (1991). Khattab H.A.S. The si/,ent endurance. Social conditions of women's reproductive health in rural Egypt. Cairo, Egypt, UNICEF and the Population Council, 1992. Li Qing et al. Some social factors influencing maternal mortality in rural China. Maternal and child health care in China, 5:1-11 (1990). Lopez-:Jaramillo, P. et al. Agregaci6n plaquetaria en gestantes andinas ecuatorianas con hipertension inducida por el embarazo. Endocrinologia ecuatoriana, 1:4+47 (1992). Merchant, K.M. &: Vtllar,J. Effect of maternal supplementation on risk of perinatal distress and intrapartum cesarean delivery (Abstract). Experimental biowgy 93, 1993. Pino, M.A. Mortalidad materna en el Ecuador y aspectos culturales en la atenci6n de la mujer embarazada. &vista del Instituto Juan Cesar Garcia, I :35-56 ( 1991). Rooney C. Antenatal care and maternal health: How effective is it? A review of the evidence. WHO/MSM/92.4. Geneva, Maternal Health and Safe Motherhood Programme, 1992. Thomas, P ., Ashley, D. et al. Incidence, risk factors and outcome of the hypertensive disorder in pregnancy in Jamaica. Clinical and experimental hypertension. Part B. Hypertension in pregnancy, 89:169-198 (1990). Thonneau, P. et al. Risk factors for maternal mortality: results of a case-control study conducted in Conakry (Guinea), International journal of gynaecowgy and obstetrics, 39:87-92 ( I 992). Toure B. et al. Level and causes of maternal mortality in Guinea (West Africa). Tnternational journal of gynecowgy and obstetrics, 37:89-95 (1992). 3 Argentina: Risk factors and maternal mortality in La Matanza, Province of Buenos Aires, 19908 Sara Szmoisz,b Silvia E. Vuegen,b Alba S. Plaza,b Raul Barracchini,c Susana Checa,c Alberto Derlindati,c Diego A. Espinolac & Estela C. RtJgoloc Introduction A number of measures had been taken to improve the health status of the population since the 1960s. The effectiveness of many of these interventions would need to be monitored, but the vital statistics and health information required for proper health programme planning, particularly in connection with efforts to reduce maternal morbidity and mor- tality, remain inadequate. There are also gaps in appropriate consideration of the socio-economic status and cultural determinants of health-seeking behaviour among the poor strata of society. In order to define national as well as local strat- egies for the reduction of maternal mortality it is important to determine the precise number of ma- ternal deaths among all registered female deaths. Under-reporting of maternal deaths is common, and correcting existing errors in diagnosis and re- porting and recording mechanisms is a first step to remedy the situation. Reductions in health budgets and their impact on health services delivery have led to a general deterioration of services accessible to the poor. The lack of quality of services is reflected in the large numbers of neonatal deaths due to birth asphyxia, maternal hypertension, Rh factor incom- patibility between mother and child, neonatal teta- nus, and congenital syphilis. Preventable maternal deaths are registered for the following causes: sep- tic abortions, haemorrhage, and toxaemia. In or- der to facilitate the identification of most appropri- ate intervention strategies, this study sought to cap- ture as much information as possible on factors surrounding a maternal death. It was therefore felt appropriate to include deaths of women which had occurred beyond the generally accepted cut-off point of 42 days, and to include those which hap- pened up to one year after delivery. Objectives . (i) The identification of risk factors leadmg to female death and in particular those related to obstetrical reasons. a Summary of the final report submitted to the Safe Motherhood Research Programme, WHO, Geneva, 1994. b Investigators, Grupo de lnvestigaci6n y Difusi6n de la Aten- ci6n Primaria de la Salud, Buenos Aires, Argentina. c Consultants. 4 (ii) To describe the impact of a maternal death on the immediate family environment. Materials and method La Matanza municipality of Buenos Aires is a large urban agglomeration which experienced strong population growth over the last decade. The popu- lation was estimated at 1,121,371 during the 1991 census. This figure corresponds to 9% of the total population of the province of Buenos Aires and 3.5% of the country. Although the population of the municipality increased bv 18.5% since the last census in 1980, the offer of public services in general and obstetric care specifically has not kept pace with the demand triggered off by this growth. Women in the age group 10-54 constitute 41.5% of all women resid- ing in the municipality. The National Register of Resources and Services in the Health Sector count- ed 188 obstetric beds for the area in 1980. Service performance was surveyed in 8 hospitals which cor- responds to 66% or 124 of the available 188 avail- able obstetric beds. Each hospital surveyed was chosen after it was found that a maternal death had occurred in the facility during the course of 1990. Interviews were conducted with family mem- bers in their homes and information was elicited on the life of the deceased woman, her reproduc- tive history, and her own and her family's reactions to complications developing during pregnancy. A questionnaire developed to assess the condi- tions prevailing in the local health services of La Matanza area was pretested; it covered the evalua- tion of services offered, the workload, and human resources availability. Results Family interviews A total of 29 female deaths were identified which were suspected to be related to maternal causes. In 21 cases the hypothesis ofa maternal death was confirmed, but approximately half of these cases had not been registered as maternal deaths. All women who died had lived in the poorer sections of the La Matanza area. The living habitat of the women varied within the area. Some parts of the city had no access to running water and sani- tation facilities, others were slightly better equipped, but had little access to health services in the vicinity. Rapp. trimest. statist. sanit. mond., 48 (1995) The interviews with the immediate family mem- bers on the maternal deaths yielded the following results: - Nearly 50% of the family members did not agree with the attending physician's explana- tion of the cause of death, about 40% thought that the deaths could have been avoided, while almost 25% of the families considered the ser- vices given to the women during pregnancy, delivery, and the puerperium as "good". Some families did not provide any answers; these cases were in all likelihood related to attempted abortions and the silence of these families is therefore understandable. The women who died had been under various pressures to conform to social norms and expecta- tions which they could not fulfil. Many of them had come from the rural areas and found themselves under the social pressure of adaptation to city life. Whereas in the rural context accommodation of a child in a family poses few problems, city life, wage labour, and constraints on space and available caretakers frequently forced young women into clandestine abortions with the resulting ill-health and maternal death. Furthermore, a certain "de- valuation" of a woman who becomes pregnant was noted. Maternity and child caring functions are exclusively seen to belong to the female world, and men do not accompany their wives to antenatal care sessions or for delivery nor are they seen to play any other active role concerning the pregnan- cy. Family planning measures are not used and power over reproduction rests with the men. The women who had died had been replaced within a short span of time. However, the general belief that the men abandoned their children upon the death of their mother was proven wrong. The children from the previous marriage were found to be incorporated into the new family. Health services infrastructure A total of 8 professionals of the institutions were visited. Service capacity and information handling concerning maternal health were checked. The two hospitals belonging to the public sec- tor had a regular functioning hospital records sys- tem, although, as is the case in many hospitals and countries, the information collected was oriented towards providing productivity measures rather than information related to patient management. The archives of patient records were not updated and were found lacking in information. There was no system for tracing patients for referral. Demand for obstetric hospital beds exceeded the available supply, especially in the public sector which had reached its carrying capacity and operat- ed at highest occupancy throughout the year. In 1990, a total of 7 644 births were registered in the municipality, 5 638 (74%) of which had been deliv- Wld hlth statist. quart., 48 (1995) ered in the public hospitals. Appropriate post- delivery care of mother and child could not be as- sured under these circumstances. Given the scant capacity of the public hospital sector, pregnant women turned to institutions outside of La Matan- za and over 50% of all newly registered children were born outside of the boundaries of the district. The social security establishment was the only one providing a booking system for admissions. It also stood out as the only establishment with a referral system for high risk pregnancies. The 4 private hospital facilities were inade- quately equipped to provide appropriate maternal care. The main shortcomings identified were: a lack of trained personnel, the absence of adequate installations, particularly for emergency care, and deficient reporting and recording systems. Of a total of 1 167 caesarean sections recorded in the hospitals under study during 1990, 32% were performed in private establishments. While accounting for 19% of all deliveries in the munici- pality during the reference period, delivery by cae- sarean section occurred in 26% of all deliveries in the private sector. This figure is high compared to the caesarean rates of the facilities of the munici- pality (22%), social security (14%), and the prov- ince ( 12%). The high incidence of caesarean deliv- eries in private institutions was considered to be an unnecessary "medicalisation" of delivery. It was seen to increase the risk of development of compli- cations and possible maternal death. The difficulty in accessing private medical records was also noted. The question of whether sufficient staff were available to cater for all the obstetric needs of the La Matanza population was addressed. It was found that for the 7 644 deliveries performed, a total of 221 staff (obstetricians, midwives, other doctors, and residents in obstetrics) were available, giving a ratio of 1 professional per 2.106 women of child- bearing age. The absence of midwives is noted in the provincial hospital and in the health centres depending on the municipality, as well as the lack of social professional workers. In 1990 the munici- pality counted 1 midwife per 14 543 women of childbearing age. Prenatal care was considered inadequate with an average of 4.5 visits per pregnant woman in 1990, the first of which takes place usually at the end of the second quarter. The reasons for hospi- talisation are reproduced in Tabl.e 1 and indicate a high proportion of all admissions related to abor- tions. In both the municipal and the private hospitals a mean of 81 % of admissions were related to abor- tions (92% and 64% respectively). No disaggregat- ed figures for direct causes for admissions were available for the provincial and the social security hospitals. Assuming a similar distribution of abor- tion cases for these institutions and using only the 5 Table 1 Causes of admission to hospitals, La Matanza, Buenos Aires, Argentina, 1990 Tableau 1 Causes d'admission a l'h6pital, La Matanza, province de Buenos Aires, Argentine, 1990 Hospital type - Number of Type d'hopital facilities visited - Oirect Nombre d'etablissements visites Abortion - Molar Ectopic Avortement pregnancy - pregnancy - Grossesse Grossesse molaire extra-uterine Provincial 1 Municipal 2 270 2 9 Social security 1 Private 4 124 6 a Including aggregated figures. - Y compris les chiffres ventiles. lowest figure ( 64 % ) as a measure for estimating the proportion of admissions for abortions, three quar- ters of all admissions would have been related to abortions in the hospitals under review in the dis- trict of La Matanza. Birth registration was greatly deficient, with 4 625 newborns registered for 7 644 deliveries. This results in under-registration of 39% of all new- borns. The opinions of the hospital staff on the service situation were also investigated. The interviews yielded a generally favourable evaluation of the facility conditions and the working environment which were thought to provide adequate maternal and delivery care in view of the shortage of resour- ces. Some proposed to bring the services closer to the poorer communities by extending primary and maternal and child care services including the up- grading of human resources and facilities. The ab- sence of a public health information system which could provide accurate information for decision- making was pointed out by some members of the staff interviewed. Summary An evaluation of the health services infrastructure of the La Matanza part of Buenos Aires in 1990 was carried out in addition to an evaluation of maternal mortality case studies. This procedure allowed for an assessment of factors related to the performance of health services and the health behaviour of women which, concomitant- ly, led to maternal deaths. Approximately 50% of maternal deaths went unreported in La Matanza on the basis of record checks performed 6 Obstetric causes Indirect Placenta Abruptio Tuberculosis - Siphylis Aids - Total previa placentae Tuberculose Sida 1 1 1 95a 5 6 0 0 0 292 9oa 26 19 193a Total 6?1a in the institutions, hence the maternal mortality was twice as high as officially indicated for 1990. Flaws in the proper clinical diagnosis of the causes of deaths were detected and a higher degree of precision was called for. In the case of women who came from the poorest section of La Matanza, most deaths were due to compli- cations related to abortion (either self-induced or non- professionally induced). Most of the maternal deaths could have been avoided. The sociological enquiry revealed conflicting social pressures which led the women onto the path of maternal death. The men were found not to be involved in the health issues arising from pregnancy and delivery, and the reproductive process was seen to lie exclusively in the women's domain. The services were not prepared to cater tor the needs of poor women, and the inadequacy of the existing system to reach the women in need was well documented. Detection of women at risk was lacking in most estab- lishments and, with the exception of one hospital, refer- ral procedures did not exist. At the municipal level the absence of a policy for maternal and child health was noted. Strategies to overcome the deficiencies include the definition of pro- grammatic goals for maternal health based on needs analysis; the abolition of administrative, geographical, technical, financial, and cultural barriers to utilization of antenatal care services; imparting to obstetricians the need to provide continuous prenatal and postnatal care and a willingness to try and understand the social reality of the attending women; and a willingness on the side of the service providers to work in an interdisciplinary manner to reach the women in need and to uphold their attendance at antenatal and postnatal care. Improved Primary Health Care, a referral system, and individual health education during consultations and a more per- sonalized approach could help women to make better use of the existing services and thus reduce maternal mortality. Rapp. trimest. statist. sanit. mond., 48 (1995) Resume Argentine: Facteurs de risque et mortalite maternelle a La Matanza, province de Buenos Aires, 1990. L'evaluation de !'infrastructure des services de sante a La Matanza, province de Buenos Aires, en 1990, s'est accompagnee d'une evaluation d'etudes de cas con- cernant les deces maternels. Cela a permis de mieux cerner les facteurs lies aux performances des services de sante et au comportement des femmes sur le plan sanitaire qui, ensemble, pouvaient conduire a des de- ces maternels. En contr61ant les registres tenus par les etablissements de soins, on s'est aper9u qu'environ 50% des deces maternels n'etaient pas enregistres a La Matanza, et qu'en consequence, la mortalite maternelle etait deux fois plus elevee que ce qui ressortait des chiffres offi- ciels pour 1990. II n'y avait pas toujours de diagnostic clinique correct des causes du deces, et le degre de precision laissait a desirer. Les femmes decedees, qui etaient issues des milieux les plus pauvres de La Matan- za, etaient mortes de complications d'avortements qu'elles avaient provoques elles-memes ou qui avaient ete pratiques par des personnes non qualifiees. La plupart des deces maternels auraient pu etre evites. L'enquete sociologique a mis en evidence des pres- sions sociales antagonistes qui conduisaient directe- ment les femmes sur le chemin du deces maternel. On a constate que les hommes ne s'interessaient pas du tout aux problemes de sante lies a la grossesse et a Wld hlth statist. quart., 48 (1995) l'accouchement, et que tout le processus de reproduc- tion etait per9u comme etant uniquement l'affaire des femmes. Les services n'etaient pas prepares a repondre aux demandes des femmes pauvres, et de nombreux rap- ports et temoignages montraient que le systeme exis- tant etait incapable d'atteindre les femmes ayant besoin d'aide. La plupart des etablissements n'etaient pas capables de depister les femmes a risque et, a !'excep- tion d'un h6pital, ne possedaient pas de structure d'orientation-recours. Au niveau municipal, on a releve !'absence de politique de sante maternelle et infantile. Pour combler cette lacune, ii faudrait definir des objectifs programmatiques en matiere de sante maternelle fondes sur une analyse des besoins; eliminer les obstacles administratifs, geo- graphiques, techniques, financiers et culturels a !'utili- sation des services de soins prenatals; faire compren- dre aux obstetriciens la necessite d'assurer un veritable suivi pre- et postnatal en s'effor9ant de tenir compte de la realite sociale des femmes qui consultent; et imprimer aux dispensateurs des soins de sante la volonte de travailler de maniere pluridisciplinaire afin d'atteindre veritablement les femmes ayant besoin de soins, et d'obtenir qu'elles viennent davantage aux consultations pre- et postnatales. En ameliorant les soins de sante primaires, en mettant en place un systeme d'orientation- recours, en dispensant une education sanitaire indivi- duelle au cours des consultations et en adoptant une approche plus personnalisee, on pourrait aider les femmes a mieux utiliser les services existants et parve- nir ainsi a reduire la mortalite maternelle. 7 China: Epidemiology of pregnancy-induced hypertensiona Jiang Dixianb Introduction A one-year study on the incidence of pregnancy- induced hypertension (PIH) was conducted in 31 provinces and autonomous regions in the north- westem part of China during 1989. The findings include data collected from urban and rural areas. Objectives (i) To determine the incidence of pregnancy- induced hypertension. (ii) To identify urban-rural differences in occur- rence of maternal morbidity and mortality. Materials and methods During the investigation period 39 centres were designated to work with the staff of the local teach- ing hospitals or MCH institutes and made responsi- ble for data collection. Standard cards each con- taining 118 questions for the collection of data on obstetric history were distributed and information was collected on each pregnancy. The diagnoses of PIH cases were established through peer review. a Summary of the final report submitted to the Safe Motherhood Research Programme, WHO, Geneva, 1990. b Shanghai First Maternity and Infant Health Institute, Shanghai, People's Republic of China. Table 1 Classification of pregnancy-induced hypertension Tableau 1 Classification de !'hypertension gravidique Classification Mild - Legere Blood pressure in mm Hg - Tension arterielle en mm Hg 130/90, or a rise of 30 mm Hg in the systolic BP, or in the diastolic BP Cases identified included those in which PIH was superimposed on existing chronic hypertension. Results The study investigated a total of 67 813 pregnan- cies with a total of 68 212 live births. Tabl,e 1 pro- vides the definitions for PIH and Tabl,e 2 summariz- es the characteristics of the PIH cases. There were 7 maternal deaths among the 61 415 pregnant women who did not experience pregnancy-induced hypertension. The PIH and non-PIH maternal mortality ratios were calculated at 46.9 per 100 OOO livebirths and 11.4 per 100 OOO livebirths respectively. Therefore, women suffering from PIH incurred a relative risk (RR) of 4.1 of dying from the condition, although there were significant urban-rural differences. In the rural ar- eas, the maternal mortality ratio per 100 OOO live births was nearly 10 times that found in the urban zones under review ( Tabl,e 3). Women with pregnancy-induced hypertension were also more likely to require caesarian delivery or operative vaginal delivery, or to experience ob- stetrical problems such as postpartum haemor- rhage and premature placental separation (abrup- tio placentae). A significant influence of PIH on pregnancy outcome was documented by this study. Out of Proteinuria - Proteinurie Negative or trace - Absent ou trace Oedema - CEdeme Present or absent - Present ou absent of 15 mm Hg - 130/90, ou augmentation de 30 mm Hg de la pression arterielle systolique ou de 15 mm Hg Moderate - Moderee Severe - Severe de la pression arterielle diastolique Systolic between 130 and 160 mm Hg and diastolic 100 mm Hg - Pression systolique comprise entre 130 et 160 mm Hg et diastolique 100 mm Hg 160/110 mm Hg Present - Presente Present - Presente Eclampsia - Eclampsie: Any of the three conditions above accompanied by convulsion. - Convulsions s'accompagnantde l'une ou plusieurs des 3 pathologiesci-dessus. 8 Rapp. trimest. statist. sanit. mond., 48 (1995) Table 2 Pregnancy-induced hypertension, China, 1989 Tableau 2 Hypertension gravidique, Chine, 1989 Hypertension category - Categorie d'hypertension Mild - Legere Moderate - Moderee Pre-eclampsia - Pre-eclampsie Eclampsia - Eclampsie PIH superimposed by chronic hypertension - Hypertension gravidique surajoutee a une hypertension chronique Total Total pregnancies. - Ensemble des grossesses: 67 813. Table 3 Cases Cas 3 191 1 743 1 192 120 152 6 398 % of all PIH cases - % of all pregnancies - Deaths (number) - % de !'ensemble des % de !'ensemble Deces (nombre) cas d'hypertension des grossesses gravidique 49.87 4.70 27.24 2.57 18.63 1.76 1 1.87 0.18 2 2.37 0.22 100 9.43 3 Influence of pregnancy-induced hypertension on maternal mortality, China, 1989 Tableau 3 Incidence de !'hypertension gravidique sur la mortalite maternelle, Chine, 1989 Area -Zone Pregnant Number of PIH Number MMR- Number of Number MMR- women- cases - Nombre of deaths- MM non-PIH cases - of deaths- MM RR Femmes de cas Nombre Nombre de femmes Nombre enceintes d'hypertension de deces sans hypertension de deces gravidique gravidique Urban - Urbaine 47 738 5 283 1 18.9 42 455 2 4.7 4.0 Rural - Rurale 20 075 1 115 2 179.4 18 960 5 26.4 6.8 Total 67 813 6 398 3 46.9 61 415 7 11.4 4.1 MMR = Maternal mortality ratio per 100 OOO live births. - MM = Mortalite maternelle pour 100 OOO naissances vivantes. RR= Relative risk. - Risque relatif. 68 212 newborns, 1 129 died during the perinatal period (giving a rate of 16.6 per 1 OOO births). There were 7.8 stillbirths and 8.8 early neonatal deaths per 1 OOO births. In comparison with the non-PIH cases, the PIH relative risk for these preg- nancy outcomes was 1.8 (p<O.O 1). For women who already suffered from hypertension and experi- enced additional hypertensive problems due to pregnancy, the relative risk increased to 2. 7 (p<0.01). Elevated incidence of low birth weight was not- ed in PIH cases, with a relative risk of 2.0. Intra- uterine growth retardation and asphyxia each in- curred a relative risk of 1. 7. Factor analysis of the PIH data confirmed the hypertensive risks associated with higher age of the mother (above 35 years), primigravidity and primi- parity, twin and triplet pregnancies, particular po- sitions during labour ( sitting and standing), labour Wld hlth statist. quart., 48 (1995) intensity, health education, body weight/height problems, and the PIH history of a pregnant wom- an's mother. Exposition to extreme hot or cold climates was also found to be linked with PIH inci- dence. Summary The study of 67 813 pregnancies and their outcome confirmed the intrinsic negative impact of hypertension on pregnancy and childbirth. Measures to overcome the differences in hypertensive experience of rural as op- posed to urban women lie in the expansion of the maternal and child health services in the rural areas. Maternity care services need to increase early detection of hypertension, improve monitoring of anticipated twin deliveries, enhance nutrition, reduce anaemia and other known risk factors and improve health education. 9 Resume Chine: Epidemiologie de /'hypertension gravidique L'etude de 67 813 grossesses et de leur issue a confir- me !'impact negatif intrinseque de !'hypertension sur la grossesse et l'accouchement. Parmi les mesures visant a supprimer l'ecart constate entre les femmes des 10 campagnes et celles des villes pour ce qui est de !'incidence de !'hypertension gravidique, ii faudrait de- velopper les services de sante maternelle et infantile dans les zones rurales. Les services de maternite de- vraient mettre davantage !'accent sur le depistage pre- coce de !'hypertension, renforcer la surveillance en cas de grossesse gemellaire, ameliorer la nutrition, reduire l'anemie et les autres facteurs de risque, et ameliorer !'education sanitaire. Rapp. trimest. statist. sanit. mond., 48 (1995) China: lowering maternal mortality in Miyun County, Beijinga Xu Zhenxuanb Introduction Miyun County is one of the outer suburbs of Bei- jing located some 75 kilometres from the city. About 82% of the county territory is mountainous and transport between various locations proves dif- ficult. The county population stood at 410 OOO during the mid-l 980s and experienced a birth rate of approximately 19 per 1 OOO with annual deliver- ies ranging from 7 600 to 8 OOO. The maternal mortality ratio in Miyun County in this remote part of China had been estimated to be thrice the national ratio of 94. 7 per 100 OOO live births. Given uncertainty about the correctness of the data, a study was designed to arrive at a more accurate ratio in order to derive intervention mea- sures. Thus safe motherhood interventions were designed based on the review of a 3-year account of maternal mortality in the county. Changes were introduced into the organization of maternal care services focusing on improving access to care for obstetric emergencies, staff training, and health education of families and the community. The in- terventions were implemented in a pilot zone and checked for their efficacy by observing changes in a control area. In proceeding this way the impact of the measures taken could be compared and quan- tified. Objectives (i) To establish an accurate account of maternal deaths in the county. (ii) To test the impact of improved access to ma- ternal care services, mass health education, and strengthened obstetric emergency ser- vices on the maternal mortality ratio. Materials and methods Members of the WHO Collaborating Centre for Research and Training in Perinatal Care joined with the county project team of the Health Bureau of Miyun County and responsible staff of the "MCH Institution" of the county. The steps to be taken were identified and the advisory team fur- nished technical advice to the project throughout its duration. a Summary of the final report submitted to the Safe Motherhood Research Programme, WHO, Geneva, 1994. b Principal investigator, Health Bureau ofMyiun, Myiun County, Beijing, People's Republic of China. Wld hlth statist. quart, 48 (1995) In order to design highly effective and targeted intervention measures it was felt necessary to first determine a more accurate estimation of the mag- nitude of maternal mortality. A retrospective study of maternal deaths which had occurred in the des- ignated pilot zone and the control area during the years 1985 to 1988 was therefore carried out. This would provide the basis for evaluating the antici- pated impact of the interventions measures in the pilot zone. All maternal deaths were identified and their causes analysed. Based on the analysis the project team designed measures to improve the situation. In order to assess the impact of the future changes, a pilot area and a control area were desig- nated. In the pilot area, the following steps were undertaken: Establishment at obstetric emergency and rescue teams At both the county hospital and the county mater- nity hospital rescue teams were set up. In order to give high visibility to the operation each hospital director was designated as the head of the team. The obstetrics department carried the chief techni- cal responsibility with support from the other units of the hospital. Thus emergency obstetric cases were either resuscitated on-site or transferred to the hospital for immediate intervention to take place. Strengthening at the maternal and child health network The prime organizational unit for MCH activities at county level is the MCH institution. It works in close liaison with the obstetrics and gynaecology and the paediatrics departments of the county hos- pital and the maternity hospital. At the local level the township hospital is the unit responsible for the implementation of increased attention to ma- ternal care. Obstetricians, pediatricians, and pub- lic health physicians were all sensitized to the issues surrounding unnecessary maternal deaths and training programmes were set up to enhance their skills. At the grass roots level the village doctors and birth attendants at the health stations worked closely with women's organizations to educate the community about maternal health issues. 11 Procedural changes and improvements The regulations governing maternal case manage- ment were reinforced: (i) The application of the rules of the Ministry of Public Health governing referral between the three levels (ie. the village health station, the township hospital, and the county hospital) was strengthened. (ii) Clinical procedures were established for the handling of 5 emergency conditions (postpar- tum haemorrhage, severe pregnancy induced hypertension, amniotic embolism, shock, and neonatal asphyxia). The management of perinatal care was strengthened and, in addition, the following steps were taken: (i) Maternal health records were standardized, and standards were imposed for the following: - antenatal examination, management of high-risk pregnancies, - standardized health education during pregnancy, regular meetings on maternal care, - reinforcement of the referral system, a streamlined information system. (ii) A monitoring technique for appropriate peri- natal care was promoted widely. (iii) For the identification and referral of high-risk pregnancies the following measures were taken: - 15 conditions needing referral and the reasons for not delivering at the village health station were identified; - the referral system was reviewed to identify the most appropriate level of care for each type of condition requiring attention and the most suitable level of facility for receiv- ing treatment; the risk-score system for identification of high risk pregnancies was reviewed and modified; for the 5 common high risk factors (preg- nancy-induced hypertension, twins/multi- gravida, antepartum hemorrhage, abnor- mal presentation, and pregnancy compli- cated by other diseases) a diagnostic refer- ence scheme was developed; standardized training materials were devel- oped for the various levels of staff; and health education sessions were conducted which sought to reach women of reproduc- tive age, their parents, their husbands, and their in-laws. For the implementation of the intervention measures 6 pilot areas were chosen to test the effec- tiveness of the steps taken. Health education mes- sages were based on the analysis of causes of mater- 12 nal deaths which had previously occurred in the community. After community health education sessions had taken place members of the commu- nity were interviewed in order to ascertain the level of retention of newly acquired knowledge on the prevention of maternal deaths. Data on the mater- nal health situation was established prior to the implementation of the measures so that the validity of the approach could be tested and the measures modified, if necessary. Results Adjustment of the maternal mortality ratio for the county The analysis of available death certificates for the 3-year period in question revealed an additional 33 maternal deaths. It was found that 27.3% of maternal deaths had not been reported. This led to a revision of the 1985-1988 figure from 83 I 100 OOO live births to 114/100 OOO, an increase of37.35% over the original figure, far below the threefold increase in maternal deaths originally estimated. Further analysis of the records revealed that 60% of these deaths were directly linked to obstet- rical causes. Haemorrhage was the leading cause of death followed by postpartum infections and preg- nancy-induced hypertension. There appears to be a relationship between the number of antenatal visits and maternal deaths since 63% of the de- ceased had had no more than 3 antenatal checks during their pregnancy. This low number of clini- cal visits is considered insufficient for proper pregnancy care, the detection of risks, and the prevention of complications during pregnancy and delivery. The research team considered that almost 40% of all these deaths were unnecessary. They estimat- ed further that 2 out of 3 of these tragic deaths could have been avoided, if appropriate knowl- edge and skills had been available in the surround- ing family environment and the health sector at the time when it was needed. Impact of the strengthened maternal health measures At the level of organization of maternal health services the increased availability of both staff and equipment led to visible improvements as depicted in Tab/,e 1. All the birth attendants in the pilot townships were equipped with delivery packages using the standard treatment regime. The hospi- tals in the pilot townships were reorganized and equipped to provide access to the ambulance ser- vice, X-ray facilities, laboratory test equipment, and other essential services. Obstetric complications During the project implementation period the in- cidence of postpartum haemorrhage, eclampsia, Rapp. trimest. statist. sanit. mond., 48 (1995) Table 1 Maternity care network, pilot area in Miyun County, China, 1992 Tableau 1 Reseau de soins de maternite, zone pilote du District de Miyun, Chine, 1992 Characteristics - Before After Caracteristiques intervention - intervention - Avant Apres !'intervention !'intervention Number of MCH workers - 69 105 Nombre d'agents SMI Number of townships 30 10 without MCH workers - Nombre de municipalites n'ayant pas d'agents SMI Coverage of maternal care - 70.1% 91.2% Couverture des soins de sante maternelle Screened for high risk - 3.9% 11.4% Taux de depistage des sujets a haut risque Table 2 and prolonged labour remained practically un- changed. The impact of reducing maternal mortal- ity due to these conditions was impressive (Tab/,e 2). No more fatalities were recorded for these condi- tions in the pilot zone while they continued to provoke maternal deaths at the control sites. As a consequence of these impressive reduc- tions the maternal mortality ratio in the pilot area positively affected the county figure. Whereas the county as a whole experienced a maternal mortal- ity ratio of 114 per 100 OOO live births during the period 1985-1988, a ratio of 47.37 per 100 OOO live births was recorded for 1993. This was mainly due to a three-quarter reduction in the ratio in the pilot area (Tab/,e 3). Summary In Miyun County in China the medical authorities regis- tered an elevated maternal mortality ratio which needed to be verified in order to design corrective changes. A decision was taken in 1988 to start a project of pilot interventions in the organization of maternal health ser- Obstetric complications before and after interventions.a January 1989 to June 1992, Miyun County, China Tableau 2 Complications obstetricales avant et apres les interventions.a janvier 1989 a juin 1992, District de Miyun, Chine Complication Incidence (%) Case fatality (%) - Cause-specific maternal mortality Taux de letalite (%) (per 100 OOO live births)- Mortalite maternelle par cause (pour 100 OOO naissances vivantes) Control area - Pilot area- Control area - Pilot area- Control area - Pilot area- Zone temoin Zone pilote Zone temoin Zone pilote Zone temoin Zone pilote Before- After- Before- After- Before- After- Before - After- Before- After- Before- After- Avant Apres Avant Apres Avant Apres Avant Apres Avant Apres Avant Apres Postpartum haemorrhage - 1.12 1.34 1.20 1.35 2.14 1.22 3.65 0 24.18 16.56 44.09 0 Hemorragie du post- partum Eclampsia - Eclampsie 0.21 0.17 0.17 0.13 7.93 6.25 25.0 0 17.27 11.04 44.09 0 Prolonged labour - 0.43 0.40 0.07 0.06 0 0 0 0 0 0 0 0 Travail prolonge a Before: January 1985- December 1988.-Avant: janvier 1985 -decembre 1988. After: January 1989 - June 1992. -Apres: janvier 1989 - juin 1992. Table 3 Change in maternal mortality ratio, control and pilot area, Miyun County, China (per 100,000 live births). Tableau 3 Evolution de la mortalite maternelle (pour 100 OOO naissances vivantes) dans les zones temoin et pilote, District de Miyun, Chine Area - Zone Control Pilot January/janvier 1985 - December/decembre 1988 98.8 150.7 Wld hlth statist. quart., 48 (1995) January/ianvier 1989 - June/juin 1992 93.4 36.6 Rate of decrease (%) - Diminution(%) 5.47 75.7 Level of significance - Niveau de signification P>0.05 p<0.001 13 vices and access for obstetric emergencies. A control and pilot area were chosen in order to test the validity of the interventions. The reduction in maternal mortality from the main complications (postpartum haemorrhage and eclampsia) was impressive and no more maternal deaths were registered in the pilot area with reference to these causes. The overall maternal mortality ratio per 100 OOO live births dropped by more than 75% in the pilot area throughout the three-year implementation period. It was therefore shown that the synergistic effect of additional training of medical workers and traditional birth attendants, improved health education, the provi- sion of easier access to emergency care services, the establishment of obstetric rescue teams at the county level, generally improved MCH services, and strength- ened management capacity for high risk pregnancies were the most appropriate interventions to lower mater- nal mortality. Resume Chine: Reduction de la mortalite maternelle dans le District de Miyun, Beijing Dans le District de Miyun en Chine, les autorites medi- cales ont enregistre des taux eleves de mortalite mater- 14 nelle qui devaient etre verifies pour pouvoir prendre des mesures correctives. En 1988, ii a ete decide d'entre- prendre un projet d'interventions pilotes au niveau de !'organisation des services de sante maternelle et de la prise en charge des urgences obstetricales. Une zone temoin et une zone pilote ont ete selectionnees pour tester la validite des interventions. La reduction de la mortalite maternelle due aux principales complications de la grossesse et de l'accouchement (hemorragie du post-partum et eclampsie) a ete spectaculaire et aucun nouveau deces maternel du a l'une de ces causes n'a ete enregistre dans la zone pilote. Le taux global de mortalite maternelle pour 100 OOO naissances vivantes a baisse de plus de 75 % dans la zone pilote au cours des 3 annees d'execution du projet. 11 a ainsi ete prouve que le renforcement de la formation des agents de sante et des accoucheuses traditionnel- les, !'amelioration de !'education sanitaire et de l'acces aux services d'urgence, la formation d'equipes pour la prise en charge des urgences obstetricales au niveau du district, !'amelioration generale des services de sante maternelle et infantile et le renforcement de la capacite de prise en charge des grossesses a haut risque constituaient, en synergie, les interventions les plus appropriees pour faire baisser la mortalite mater- nelle. Rapp. trimest. statist. sanit. mond., 48 (1995) Ethiopia: An epidemiological study of vesico-vaginal fistula in Addis Ababa8 John Kellyb Introduction Vesico-vaginal fistula (WF) associated with ob- structive labour is one of the most distressing causes of maternal morbidity. It is highly prevalent throughout many developing countries with poor access to health services. The prevalence is highest among young primigravida. Little is known about the exact epidemiology of the disease and the bur- den of illness it inflicts upon women in the devel- oping world. In 1975, the Addis Ababa Fistula Hospital for Poor Women with Childbirth Injuries was opened. Caring for about 500 patients a year, the hospital uses simple techniques. Former patients were trained to assist in nursing care and anesthesia, and one of them following several years of training now performs fistula surgery. Patients are treated with respect and dignity. This is an important point because of the social stigma experienced by the affected women. A policy of open access to the hospital is practised. Upon completion of her oper- ation every woman is furnished with sufficient means for her return journey home. She also re- ceives a fistula card which contains essential infor- mation and is a valuable source of information for her future obstetric and gynaecological care. Db/et:tlves of the study (i) To determine the bio-social factors and the extent of the injury of a sample of WF pa- tients admitted to Addis Ababa Fistula Hospi- tal for Poor Women with Childbirth Injuries from 1983-1988; (ii) to determine the geographic scatter, distance from and use of maternity services of these patients; (iii) to revise the fistula card and incorporate addi- tional information for prospective epidemio- logical data collection; and (iv) to establish determinants of subsequent social rehabilitation and obstetric performance of patients who underwent surgical repair of fis- tula 5 years previously (1984).c a Summary of the final project report submitted to the Safe Motherhood Research Programme, WHO, Geneva, 1992. b Principal Investigator and Consultant Obstetrician and Gynaecologist, Queen Elizabeth Medical Centre, Birmingham, United Kingdom. c Field research to achieve objective 4 had to be abandoned due to civil unrest in the country at the time of the study. Wld hlth statist. quart., 48 (1995) (v) To provide information from case reviews of patients whose WF repair has not been com- pletely successful. Mat,rlals and methods A sample of 309 records was drawn randomly from the total of 3 OOO records of vesico-vaginal opera- tions performed at the Addis Ababa Fistula Hospi- tal between 1983 and 1988. Data from the opera- tion records were processed and analyzed. R11ults of the study Social characteristics Patients were on average 22.4 years old with a range from 9 to 45 years. The women had covered great distances in order to reach the hospital. In effect, 82% of them travelled 700 kilometers and more to find help, walking an average of more than 12 hours, and spending on average 34 hours on a bus. More than half of the women suffering from fistulae were rejected by their husbands after the fistulae developed, leaving the women without means oflivelihood. 39% of the women depended on relatives for food, and 22% had to beg or live on donations from voluntary agencies. The time it took the women to come to the hospital for help varied. In 52% of the cases admis- sion took place within 6 months of fistula develop- ment. A small proportion of women ( 4%) came some 10 - 20 years after the fistula had developed. Obstetric history In more than 97% of the cases under review the vesico-vaginal fistula had an obstetric etiology. Eight cases were the result of coital injury, and in one case the treatment of a traditional healer caused the damage. In a small number of patients (8%) a previous, unsuccessful attempt had already been made to repair the fistula. The health status of women presenting for the operation was found to be good ( 45%) or fair (38%), but in 9% of the cases the patients had to receive supplementary feeding before the operation could be performed. The majority of women developed fistulae as a result of their first (63%) or second delivery (12%). The fistulae had developed mainly during unassisted, vaginal delivery (58%) or assisted ones ( 15%). Patients usually sought medical attendance 15 too late to prevent vesico-vaginal damage during delivery. The length of labour ranged from one to six days with a mean of 3.9 days. The destruction caused by the extremely long periods oflabour also extended to the fetus. Stillbirths were recorded in 93% of the fistula inducing deliveries. In addition to the physiological and psychological trauma of long labour and child loss, the women experi- enced such ill health that the mean time before the patient could walk again was 26 days. Extent of injuries and operative steps taken On presenting at the hospital almost 70% of the women were classified as "complicated" cases. 78% suffered from WF alone, 15% presented with combined WF and recto-vaginal fistulae (RVF) , and 7% suffered from RVF alone. The operative interventions, which were usually performed after 2-3 months, are summarized in Tab!P 1. Table 1 Operative techniques in addition to basic interventions in 309 cases, Addis Ababa Fistula Hospital for Poor Women with Childbirth Injuries, Ethiopia, 1983-1988. Tableau 1 Techniques operatoires pratiquees en sus des interventions chirurgicales de base par l'H6pital d'Addis-Abeba, specialise dans le traitement des fistulas, Ethiopia, 1983-1988 Technique/intervention Martius graft - Greffe de Martius Urethers catherized - Pose de sondes ureterales RVF repair combined with WF operation - Reparation de fistulas rectovaginales a !'occasion de !'operation de fistules vesico-vaginales Construction of new urethra - Reconstruction de I' uretre Relocation of ureters - Reimplantation des ureteres G racilis graft - Greffe de gracilis Colostomy - Colostomie Number of patients - Nombre de patients 212 144 40 34 19 12 10 Blood or plasma transfusions were necessary in 173 cases and anaesthesia ( open ether, in addition to spinal) was given in 152 cases. The results of the surgical interventions are en- couraging: 88% of the women were cured com- pletely, 6% continued to suffer from urinary stress incontinence, and in the remaining 6% of cases 16 the operation had failed to produce the desired results. Postoperative be/Javiour Upon discharge the patients are instructed not to have sexual intercourse for a period of time in order to allow for proper healing of the affected areas. The length of the recovery period varies with the extent of damage experienced. It was noted, however, that in some cases the information on the recovery period had not been understood by the women appropriately, as a certain degree of confu- sion was detected about the timing of intercourse. One patient was found to be so afraid that she rejected sexual activity after the operation for sev- eral years resulting in the breakup of her marriage. On other occasions intercourse started too early which resulted in a failure to heal properly. In some cases the women suffered another unattend- ed obstructed labour followed by a stillbirth and fistula recurrence. The cured fistula patient can become a useful primary health care educator in her own right. She can inform women who suffer from the disease on how and where to get help. She can further teach the women in her community about the impor- tance of antenatal care and the early referral to hospital in order to avoid delivery complications during labour. Summary A 10% sample was drawn from 3000 records on vesico- vaginal fistulae operations performed at the Addis Aba- ba Fistula Hospital for Poor Women with Childbrith Injuries and their content were analyzed. In 88% of the cases under review the operation was classified as successful. The results of this study underline the tremendous maternal health gains which can be achieved by appro- priate obstetric care in case of obstructed labour. It also reinforced the need for early detection and referral of high risk births among the very young mothers who are likely to experience an obstructed labour, the loss of the child, vesico-vaginal fistulae and possibly a ruptured uterus. In the absence of likely increases in the availability of transport, the building of waiting homes at maternal clinics is encouraged so that women can await delivery in the vicinity of a referral centre. There is a need for increased attendance of delivery by trained personnel as well as for continuing education for both staff and traditional birth attendants. It is further recommended to train former patients as helpers for the dedicated care which needs to be extended to the unfortunate, and often stigmatized victims. Rapp. trimest. statist. sanit. mond., 48 (1995) Resume Ethiapie: Elude lpldlmialaaique sur 111 lillule, 11l1ictHaainales I Add/1-Absba Sur les 3000 dossiers d'interventions pour fistules ve- sico-vaginales pratiquees au Fistula Hospital d'Addis- Abeba specialise dans le traitement des fistules, on a selectionne et analyse un echantillonnage de 10% des cas. Oans 88% des cas etudies, !'intervention a ete consideree comme reussie. Les resultats de cette etude font apparaitre le gain enorme qui peut etre obtenu sur le plan de la sante maternelle grace a des soins obstetricaux appropries en cas d'accouchement dystocique. lls soulignent aus- si la necessite de depister precocement et d'adresser a des services specialises les sujets a haut risque parmi les tres jeunes meres qui sont susceptibles d'avoir un accouchement dystocique, ou qui risquent de perdre leur enfant ou de souffrir de fistules vesico-vaginales, voire meme d'une rupture de l'uterus. Wld hlth statist quart., 48 (1995) Etant donne qu'il y a peu de probabilite que les trans- ports s'ameliorent, les auteurs preconisent de construi- re des foyers d'accueil pour les femmes enceintes aupres des maternites afin que les femmes qui sont sur le point d'accoucher puissent rester a proximite d'un centre d'orientation-recours. II faudrait que les accou- chements soient davantage supervises par du person- nel qualifie, et que ce personnel, de meme que les accoucheuses traditionnelles, beneficie d'une forma- tion continue. Les auteurs recommandent aussi de former les anciennes patientes pour qu'elles puissent, a leur tour, aider a entourer les malheureuses jeunes meres qui sont souvent en outre victimes de rejet. References I References 1. Kelly,J. Obstetric vesico-vaginal fistulas: evaluation of failed repairs. International urogynecology journa~ 4:271-273 (1993). 2. Kelly, J. Epidemiologic study of vesico-vaginal fistulas in Ethiopia International urogynecology journa~ 4:278-281 (1993). 17 Gambia: Evaluation of the Mobile Health Care Service in West Kiang districta Frances Foordb Introduction For many years, as part of its ongoing nutrition research, the Dunn Nutrition Unit of the British Medical Research Council has been providing clin- ical services to the population in its research area in West Kiang district, the Gambia. The primary health services include antenatal care. Although these services operate in addition to those offered in the neighbouring government facilities, a mater- nal death was registered in 1988. The woman had received antenatal services in the project area. This sparked off renewed interest in identifying feasible ways to reduce maternal mortality in the district. As a consequence a study was designed to measure the effectiveness of a limited range of antenatal and postnatal care measures in a designated interven- tion area. For purposes of comparison a control area with similar geography, population composi- tion, and expected number of pregnancies was identified. The study period covered the period 1989-1991 in order to establish a sufficiently long period for data collection and obtainment of reli- able results. Objectives and methods West Kiang was chosen as the district where inter- ventions should take place. In order to determine the effects of some of the improved antenatal care measures data was also collected from a similarly remote district (Upper Baddibu). The objectives of the research study were to determine the effectiveness of the following inter- ventions: (i) traditional birth attendants (TBAs) to pro- vide surveillance for early identification of pregnant women; (ii) registration of pregnant women in an antena- tal care programme; (iii) treatment of anaemia; (iv) treatment of infections; a Summary of the final report submitted to the Safe Motherhood Research Programme, WHO, Geneva, 1993. b Principal Investigator, Medical Research Council, Dunn Nutrition Unit, Keneba, Gambia. 18 (v) identification of potential obstetric problems, with prompt referral for tertiary care when indicated; and (vi) emergency treatment and rapid transfer of obstetric emergencies for specialist care. Situation analysis: primary and maternal care services in the research area The intervention area - West Kiang West Kiang district covers a peninsula with difficult access to areas which are further removed from the main road. The population consists of subsistence farming communities living in hamlets and villages with populations ranging from 40 to 1 300 inhabit- ants. Karantaba, the project site, is one of the main villages in the district. Before the project began the villages were served by an MCH team and primary health care workers consisting of community health nurses (CHN), trained traditional birth attendants (TBA), and village health workers. Supervision of the village-based health activities was provided from a health centre which was staffed by a mid- wife, 2 CHNs, a health inspector, and a dispenser. A physician was also available intermittently. The health centre acted as a first referral level facility and consists of a dispensary, several small examina- tion rooms, an operating theatre and delivery room, a small laboratory, and 2 wards with a total of 12 beds. The MCH team visited the outlying vil- lages once a month. While women were encour- aged to come to the health centre for antenatal care, poor means of transport and communication severely reduced access to these services for expect- ant mothers from the surrounding villages. Fur- thermore, a male midwife had been posted to the health centre which led to problems of non-accep- tance of services by a number of women con- cerned. In effect, of the 150 women supposed to be registered with the midwife at any one time, only 80 - llO actually attended antenatal care. In addi- tion, shortages of transport, fuel, and drugs re- duced possible clinic attendance. These government services were supported by maternal care provided for 3 villages within the coverage area of the MRC Dunn Nutrition Unit. The antenatal services extended by the Unit consist of early enrolment of pregnant women in antena- tal care, establishment of initial haemoglobin sta- Rapp. trimest. statist. sanit. mond., 48 (1995) tus and repeat measurements during the course of the pregnancy, combined malaria prophylaxis and iron and folate supplementation, identification and treatment of infections, and early referral to deliver at hospital for high-risk pregnancies. A fair- ly good degree of success in preventing maternal morbidity and mortality had been established in the 3 villages covered by these services since the beginning of the programme in 1974. For exam- ple, a survey on haemoglobin levels throughout pregnancies showed that while 41 % of women had a level below 9.5 g/ dl at some stage during their pregnancy, only 11 % still suffered from the condi- tion at the time shortly before delivery or referral, a tribute to a functioning iron and folate supplemen- tation programme. The control area - Upper Baddibu Like West Kiang, Upper Baddibu is remote, most of the population relies on subsistence farming and lives in hamlets and villages of 40 -1 300 inhab- itants. Health services are provided by the govern- ment health centre, with almost similar staffing patterns but very reduced in-patient facilities. Lab- oratory tests for haemoglobin, for example, have to be carried out at a health centre situated at a dis- tance of 20 kilometers from the PHC service base. Throughout the intervention period in West Kiang district no changes were introduced to the opera- tions of health services in Upper Baddibu other than measures to improve the collection of ante- natal and postnatal care data. Operational changes in West Kiang district The main strategy to strengthen the existing ser- vices was to improve the staffing of Karantaba Health Centre and to provide training for tradi- tional birth attendants. Job descriptions for all MCH team members were established and the roles and tasks to be performed by each team mem- ber of the health centre were spelled out for the physician, the midwives, the community health nurses (CHN), and the traditional birth atten- dants. This was considered an important first step to ensure that every health worker knew exactly which tasks had to be performed. Additional training was provided for CHNs in essential laboratory tasks e.g. establishment of hae- moglobin levels, urine testing for protein, and ma- laria test slide preparation and interpretation. Schedules for an increased number of routine visits to the outlying villages were established. In order to provide additional services more staff had to be posted to the study area. They con- sisted of 1 midwife and 2 more CHNs, bringing the total to 2 midwives and 4 CHNs at the health cen- tre. This staffing pattern ensured that continuity in service delivery could always be guaranteed both for staff touring the villages and those present at Wld hlth statist. quart., 48 (1995) the health centre. To ensure essential community support two women were recruited from each vil- lage and given a 4-week course to become trained TBAs. Service delivery Each midwife assumed the responsibility for ante- natal and maternal care for specific villages within the catchment area ofKarantaba Health Centre. By assigning specific villages to each midwife it was felt that this would enhance the continuity of care and increase accountability. Thus each midwife would visit each village under her responsibility twice a month. In order to maximize the utilization of existing transport, visits to the villages were made to coincide with the routine MCH tours. During the village visits routine antenatal checks were undertaken. As anaemia had been identified as one of the major health problems affecting women in the area, specific emphasis was placed on the measurement of haemoglobin lev- els. Iron supplementation was introduced routine- ly after the twelfth week of pregnancy combined with malaria prophylaxis during the rainy season. Health education, postnatal checks, and provision of family planning advice and contraceptives were further parts of the comprehensive ante- and post- natal care included in the scheme. The role of the TBA as part of the maternal care team was also enhanced. They were required to accompany the midwife during the village visits. It was felt that this would facilitate early identification of pregnant women and the payment requested for the TBA services would establish the linkage be- tween the services and the expectant mother. The TBAs and midwives were further expected to en- sure compliance with advice for referral. As an incentive to the women the scheme paid for hospi- tal and treatment charges. In addition to their tasks in assisting home deliveries, the TBAs were also required to accompany women referred during labour to the next level of care. In order to ensure continued support from the TBAs a small amount of money was re-distributed to each TBA for each delivery attended. The pay- ment was made on the occasion of a refresher meeting held once a year. Clinic organisation The organisation of clinic schedules at the health centre and the number of women seen for antena- tal care during any one session were seen as critical elements in the delivery of quality maternal servic- es in the intervention area. A maximum of25 wom- en were seen during an antenatal clinic session thus avoiding the overcrowding, accompanying fragmentation, and routine, poor quality delivery of antenatal services which is characteristic of many service delivery schemes throughout the develop- 19 ing world. In the control area antenatal and infant welfare clinics were scheduled together. The small staff of 1 nurse/midwife, 3 CHNs, and 1 rural nurse attendant sometimes had to cope with more than 100 women attending for antenatal care and more than 200 under-fives for immunization and check- up. This organizational pattern inevitably results in fragmentation of services, and inadequate applica- tion of procedures. By contrast, the additional midwife posted in West Kiang and redistribution of patients over sev- eral clinic sessions throughout the working week allowed for a more holistic approach to maternal care. Midwife and CHN cared for the presenting mothers as a team, and the village TBA was fre- quently present during the antenatal check. In case of problems a treatment plan would be jointly worked out between the midwife, the TBA, and the patient. If appropriate, the husband or another relative would also be called in to prepare for a possible emergency. Timely identification of wom- en at risk was ensured and the referral system im- proved. For the attending staff the new organizational pattern led to higher job satisfaction and increased opportunities to provide quality care. Table 1 Results of the improved service delivery scheme Antenatal care The effects of the new measures were soon appar- ent. Early registration for antenatal care clearly improved in the intervention area. By the end of the 23rd week of pregnancy 63.3% of all pregnant women had registered with the service. By that time only 24% of pregnant women in the control area had presented for antenatal registration and preventive care. Specific emphasis was placed on checking and maintaining haemoglobin levels above 9.5 g/ di. Tab/,e 1 and Fig. 1 summarize the main effects of the increased attention given to the prevention of anaemia by safeguarding adequate haemoglobin levels. In West Kiang the mean haemoglobin level of the women in the sample was 11.0 g/ di through- out the 39-week pregnancy period, whereas in Up- per Baddibu only a mean of 8.4 g/ dl was calcul- ated. Tab/,e 1 indicates that the upgrading of person- nel, diagnostic and therapeutic skills, and adher- ence to established schedules and procedures have resulted in substantial improvements in maternal Antenatal care and haemoglobin levels, end of intervention period, Gambia, 1991 Tableau 1 Suivi prenatal et taux d'hemoglobine, fin de la periode d'intervention, Gambie, 1991 Criterion - Critere Women with at least one haemoglobin check - Femmes ayant subi au mains 1 controle de leur taux d'hemoglobine Average number of haemoglobin checks per woman - Nombre moyen de controles effectues par femme Women receiving one Hb check during last 6 weeks of pregnancy - Femmes ayant eu au mains un controle de leur taux d'hemoglobine au cours des 6 dernieres semaines de grossesse Women with Hb <9.5g/dl (regardless of stage of pregnancy) - Femmes ayant un taux d'hemoglobine <9,5g/dl (quel que soit le stade de la grossesse) Mean Hb level in g/dl - Taux moyen d'hemoglobine en g/dl lron/folate supplementation prescribed (Hb<9.5g/dl) - Prescription d'un supplement de fer/folate (Hb >9,5 g/dl) 20 West Kiang intervention area - Upper Baddibu control area - Zone d'intervention de West Kiang Zone temoin de Upper Baddibu Number of records - Value - Valeur Number of records - Value - Valeur Nombre de dossiers Nombre de dossiers 780 92.7% 669 84.9% 724 2.7 568 724 73.2% 570 23.5% 724 29.4% 568 75.5% 724 11.0 568 8.4 326 57.1% 430 2.3% Rapp. trimest. statist. sanit. mond., 48 (1995) Fig. 1 Mean haemoglobin concentration among pregnant women in West Kiang and Upper Baddibu districts, Gambia, 1991 Taux moyen d'hemoglobine chez les femmes enceintes, districts de West Kiang and de Upper Baddibu, Gambie, 1991 =a 15....-~~~~~~~~~~~~~~~~~-, Cl> Cl> c :g 1 g -~ 11 ::c I i 9 c :0 0 g, 7 Upper Baddibu E ~ 54-_,.........,.--,~~...-................ -.-........ ~....-..-................ -.-........ ~ 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 Weeks pregnant- Semaines de grossesse care in the intervention area. This is further under- lined by an assessment of the amount of minor and major morbidity experienced during pregnancy and subsequently attended to. While the 794 preg- nant women in the intervention area (West Kiang) presented for a total of841 treatment episodes, the ratio was distinctly different in the control area, Upper Baddibu, i.e. 149 treatment episodes over 722 pregnancies (multiple visits included). Pregnancy outcome One of the most striking differences between the intervention and the control area is the number of maternal deaths recorded. In West Kiang 1 mater- nal death occurred giving a ratio of 1.3 per 1 OOO live births. In Upper Baddibu 5 maternal deaths were registered which leads to a ratio of 7.0 per 1 OOO live births in Upper Baddibu. All maternal deaths occurred during or after delivery in the village. In analysing the maternal deaths, it is found that the only maternal death registered in the in- tervention area was, in all likelihood, preventable. The mother was a primigravida who developed eclampsia after a home delivery. Inappropriate checking of blood pressure and lack of immediate referral after the onset of convulsions are quoted as responsible factors for this unnecessary death. In the control area 1 case of pulmonary embo- lus and 1 of postpartum haemorrhage were regis- tered - the latter could possibly have been prevent- able, had appropriate antenatal and postnatal care been available. While medical evidence of the cause of death of the remaining cases was inconclu- sive, the investigator suspects that anaemia may have played a major role. In this connection the preventive action of iron/folate supplementation during pregnancy, and in particular during the period prior to delivery is once again underlined. Wld hlth statist. quart, 48 (1995) Analysis of the other findings of the study, how- ever, gives an inconclusive picture of the impact of the service interventions on pregnancy outcome in West Kiang District. Both stillbirths and early neo- natal (perinatal) deaths were considerably higher in the intervention area than in the control area ( Table 2). Under-reporting of still births in the Table 2 Pregnancy outcome, West Kiang and Upper Baddibu districts, Gambia, 1991. Tableau 2 Issue de la grossesse, districts de West Kiang et de Upper Baddibu, Gambie, 1991 Deaths per 1 OOO births - Nombre de deces pour 1 OOO naissances West Kiang Upper Baddibu Stillbirths - Mortinaissances Perinatal deaths - Deces perinatals 39.9 54.9 24.5 39.6 control area is a possible explanation for this re- sult. It seems that more detailed research and spe- cific attention to data accuracy is necessary in order to further qualify the impact of specific measures on pregnancy outcome. Finally, there is concern that perinatal mortality may not be as readily re- duced as maternal mortality amongst the socially disadvantaged groups. There is evidence of a much lower perinatal mortality ratio amongst socially and economically better placed persons in the in- tervention area. It would appear that improve- ments in general living conditions may have a larg- er impact on perinatal mortality than on maternal mortality. Summary A project to improve the quality of maternal health services was carried out over a 3-year period in West Kiang district, Gambia. Coverage of maternal care was strengthened through upgrading of personnel, TBA training, improved treatment and referral schemes, and increased numbers of visits to rural outreach areas. A control district was used to compare the impact of the interventions. During the project period of 3 years a single maternal death was registered in the intervention district, and 5 in the control area. While improved staff- ing and service provision led to higher degrees of coverage of maternal care services, reductions in ma- ternal morbidity could not be documented in the inter- vention area. Given concern over the quality of the data possibly influencing this result, further research is nec- essary to determine the relationship between improved mobile maternal care services and their impact on maternal morbidity and perinatal outcome. 21 Resume Gambie: Evaluation de l'antenne mobile de soins de sante de West Kiang Dans le district de West Kiang, en Gambie, un projet visant a ameliorer la qualite des services de sante maternelle a ete poursuivi pendant trois ans. La couver- ture des soins de sante maternelle a ete amelioree par un renforcement des qualifications du personnel, une formation des accoucheuses traditionnelles, une ame- lioration des systemes de soins et d'orientation-recours, et une augmentation des consultations dans les zones rurales reculees. L'impact de ces interventions a ete 22 evalue par rapport a une zone temoin. Pendant la periode d'application du projet, un seul deces maternel a ete enregistre dans le district d'intervention, contre 5 dans la zone temoin. Si le renforcement du personnel et des services eux-memes a permis d'obtenir une meilleure couverture des services de soins maternels, aucune reduction de la morbidite maternelle n'a pu etre prouvee dans la zone d'intervention. II est possible que ce resultat soit en partie imputable a la qualite des donnees, et ii faudrait done poursuivre les recherches pour pouvoir determiner le lien existant entre !'ame- lioration des services mobiles de sante maternelle et une evolution favorable de la morbidite maternelle et de l'issue des grossesses. Rapp. trimest. statist. sanit. mond., 48 (1995) The Gambia: Cost and effectiveness of a mobile maternal health care service, West Kianga Julia A. Fox-Rushbyb Introduction and objective Providing adequate maternal health services at af- fordable cost to both the government and the pop- ulation has always been a challenge to health policy makers. It is self-evident that the way services are designed to deliver care will determine their costs. The different ways of serving a population in order to improve maternal health could include, for ex- ample, a nurse or village health worker permanent- ly stationed in a village, a mobile outreach pro- gramme from a health centre which meets preven- tive and curative needs, or access to emergency services. In reality, the determination of priorities in health policy development is always confronted with scarcity of resources, the majority of which are often earmarked to cover on-going capital and re- current expenditures. The challenge to the suc- cessful planning and implementation of maternal health services lies in finding the most cost-effec- tive form of care from the resources available. Dif- ferent mixes in the use or location of capital invest- ments in, for example, health facilities or trans- port, or different combinations of trained staff could all contribute to making services more effi- cient, so that the maximum benefit to maternal health is gained from the available resources. This project attempts to evaluate the cost-effectiveness of introducing a mobile health service to overcome problems of access to maternal health services in a rural district of the Gambia. Materials and methods The costs and effectiveness of the new mobile ser- vice were evaluated using a quasi-experimental de- sign comparing the new service in West Kiang (run from Karantaba health centre) with the usual prac- tices of providing maternal care. Upper Baddibu was selected as the comparison area, where health services were provided from a health post at Ngayen Sanjal village. A detailed description of the two services can be found in the preceding paper by Foord (seep. 18 in this issue). In addition to the provision of maternity care, a new financing scheme was introduced in West Kiang. Each participating woman was asked to • Author's summary of the final report submitted to the Safe Motherhood Research Programme, WHO, Geneva, 1993. b Lecturer in Health Economics, London School of Hygiene and Tropical Medicine, London, United Kingdom. Wld hlth statist. quart., 48 (1995) make a single payment of 25 dalasis (D). c This entitled the woman to comprehensive antenatal and delivery care, including possible hospitaliza- tion and all associated costs. Of the 25 dalasis, 10 were used as payment to trained traditional birth attendants (TBAs). The payment scheme used elsewhere in the Gambia was adopted in the com- parison area. It consisted of a contribution ofD5 to the revolving drug fund and 06 for delivery in a health post or D 12.5 for delivery in a health centre. Any payments to TBAs were at the discretion of individuals. Hospital charges for delivery and in- patient care amounted to 050 and, if a caesarian delivery was required, a further 050 was charged. Pharmaceutical expenses were extra. A number of assumptions which were impor- tant in framing the context of the evaluation are described below. (i) All costs borne by the ministry of health, oth- er agencies as well as patients and their fami- lies were considered; (ii) as the service activities of the mobile unit were considered likely to have an impact on cost incurred at each of the base facilities as well as on referral patterns to hospitals, the bound- ary placed on the scope of the evaluation included a costing of base facilities in West Kiang and Upper Baddibu and hospital care in Banjul; and (iii) costs were categorized by a capital/recurrent split as it reflected patterns of funding for programmes. Routine service data from the participating health facilities in West Kiang and Upper Baddibu as well as from the Royal Victoria Hospital (RVH) in Banjul were collected. Furthermore, a one month period (November 1991) was used to col- lect new data on the utilization of staff time, the use of drugs and medical consumables, vehicle use and direct costs borne by patients and their families. Results Tab/,e 1 shows that the annual total cost of maternity care at Karantaba was US $69,450.5 compared with US $27 ,360. 7 at Ngayen Sanjal. With the additional c US $1 = 7.9 Dalasis, 1991. 23 Table 1 Annual total costs and cost profile for maternal care at Karantaba and Ngayen Sanjal (US $, 1991) Tableau 1 Couts totaux annuels et repartition des coots pour les soins de sante maternelle a Karantaba et Ngayen Sanjal Description Recurrent costsb of health centre/post - Couts de fonctionnemenfb du centre/paste de sante Regional headquarters - Siege regional Utilities - Eau, electricite, etc. Orderlies - Personnel de salle Laundry/kitchen - Blanchisserie/cuisines Administration EquipmenVbuilding operating - Entretien et exploitation des equipements et batiments Vehicle operating - Utilisation des vehicules Maternity - Maternite: Drugs/consumables - Medicaments/ fournitures Laboratory tests - Examens de laboratoire Salaries - Salaires Food - Nourriture Equipment Freight - Transport Other - Autres Subtotal - Total partiel Capital costs of health centre/post - Gout d'investissement pour le centre/paste de sante Equipment - Equipements Buildings - Batiments Land - Terrains Vehicles - Vehicules Training - Formation: TBAs (local) - Accoucheuses traditionnelles locales Midwives - Sages-femmes TBAs (Banjul) - Accoucheuses traditionnelles (Banjul) Subtotal - Total partiel Referralc Orientation - recourse Patient costsd - Couts afferents aux maladesd - Direct - Directs - Indirect - lndirects Grand total - Total general Attendance - Frequentation CosVattendance - Coot par consultation a US$ = 7.9 dalasis. Karantaba us$• 15 860.4 4 000.2 1 576.6 92.8 97.4 832.1 7 087.5 1 730.1 259.9 7 278.9 905.0 1 063.9 290.9 339.0 41 414.7 1 730.1 2 704.0 623.4 1 632.9 14 979.8 602.5 525.1 22 797.8 605.0 4 588.0 45.0 69 450.5 2 058 33.75 Ngayen Sanial % US$ % 22.8 9 898.1 34.9 5.8 0 0 2.3 152.5 0.5 0.1 3.7 0 0.1 92.6 0.3 1.2 92.6 0.3 10.2 4 697.5 16.6 2.4 682.8 2.4 0.4 136.8 0.5 10.5 2 015.3 7.1 1.3 0 0 1.4 503.8 1.8 0.4 132.3 0.5 0.5 0 0 59.6 18 408.0 64.9 2.5 366.8 1.3 3.9 1 086.0 3.8 0.9 194.4 0.7 2.4 2 564.5 9.0 21.6 0 0 0.9 301.2 1.1 0.8 448.2 1.6 32.9 4 961.1 17.5 0.9 165.0 0.6 } 4 243.2 } } 6.6 583.4 } 17.0 100 28 360.7 100 2 217 12.79 b Using the pragmatic definition supplied by Lee in Abel·Smith and Creese• "recurrent costs were defined as those which occur with greater than annual frequency; and capital costs are those which occur at intervals greater than one year". - Selan la definition pragmatique don nee par Lee dans Abel-Smith & Creese•, «les coots de fonctionnement sont ceux qui interviennent plusieurs fois par an, tandis que les coOts d'investissement sont ceux qui interviennent a des intervalles superieurs a un an». c Only recurrent costs (using stepped down overheads) were determined as a change in referrals was considered unlikely to change the capital investment within the hospital. Average costs were multiplied by the number of referrals to arrive at this figure. - Seuls les coGts de fonctionnement ant ete evalues a partirdes frais generaux sur lesquels on a opere certaines deductions car on a estime que quel que soit le nombre de patients evacues, le montant des investissements de capitaux a l'hopital ne variait guere. Les coots moyens ant ete multiplies par le nombre de patients evacues vers l'hopital pour arriver ace chiffre. d Direct cost is the out-of-pocket expenditure of patients, and indirect cost the value of production lost from walking to and from the clinics. The average patient in West Kiang incurred US $2.23, and in Upper Baddibu the average patient incurred US $1.82. - Les couts directs sont les sommes effectivement facturees aux malades, tandis que les couts indirects correspondent au temps perdu pour se rendre au centre de sante et au manque a gagner qui en resulte. Le coGt moyen par malade est de US $2,23 a West Kiang et de us $1,82 a Upper Baddibu. • Lee, K. (1989) Symptoms, causes, and proposed solutions. In: Abel-Smith, B. and Creese, A. (Eds). Recurrent costs in the health sector. USAID (Washington), WHO (Geneva), 1989. Unpublished document WHO/SHS/NHP/89.8 (English only - anglais seulement). 24 Rapp. trimest. statist. sanit. mond., 48 (1995) staffing, the training of 40 TBAs, the use of addi- tional vehicles, and additional overhead costs, it was not surprising that the total costs at the inter- vention site were considerably higher. The total recurrent cost of maternity care in West Kiang was double that in Upper Baddibu. Of the difference of US $41,090 in total costs, 37.4% were attributed entirely to the extent of training at Karantaba, 14.5% to overheads from regional headquarters, 12.8% to maternity salaries and 9. 7% to utilities, as there was no electricity in the comparison area. The recurrent and capital costs of the local rural service comprised at least 82% of total costs. The average cost ( direct and indirect) falling on a patient in Karantaba was slightly higher than in Ngayen Sanjal, which was principally due to the operation of 'risk shar- ing' payments for the new midwifery service. The extra rate of referral also imposed further costs, although a low proportion, on government ser- vices. Average costs of both services were calculated using a range of outcome measures such as num- ber of women delivering, number of antenatal visits, number of haemoglobin tests, and life years gained. In all cases, the average costs were higher in the intervention area, sometimes as much as 5 times. The average cost figures produced for Ngayen Sanjal and Karantaba could be taken as indicators of efficiency. However, these figures concealed too many difficulties for simple inter- pretation. For example, the difference in popula- tion sizes, the size of the static unit or the extent of spare capacity in the health facility meant the dif- ferences between the two areas could not only be attributed to the mobile service, and there was no baseline data to confirm or reject any findings. Therefore the question of how the cost data could be used was raised. Incremental cost analysis was used to estimate the extra cost of the mobile service on top of fixed site services and two ex- treme scenarios were used to help provide a range: Scenario 1: The mobile unit did not extend the service beyond the maternal and child health (MCH) outreach and fixed site out-patient ap- pointments i.e. all those attending would have at- tended anyway. Scenario 2: the mobile unit increased coverage by the number of attendances at mobile maternal clinics (not MCH) .d In the first scenario the opportunity cost of staff time was ignored as patients would have been seen anyway. Many other costs would remain the same if the operation was simply run from the fixed site and MCH treks (i.e. still including haemoglobin d Some of the treks made by the mobile team were run jointly with the MCH treks but we conservatively assumed these would all be attending the MCH clinics. Wld hlth statist. quart., 48 (1995) checks). The only changes would therefore relate to transport, patient payments and indirect costs of travel time. In the second scenario the costs likely to change included; salaries ( time of existing and new staff), drugs, consumables, laboratory tests, midwife/ community health nurse, stationary, ma- ternity equipment, transport, administration and indirect/direct patient costs. Using the two differ- ent scenarios, incremental costs ranged from US $3,300 to US $7,127 per year and, in reality, the truth probably lies somewhere between these two extremes. The estimations of incremental costs were com- bined with the additional benefit of the new mo- bile programme (assuming that differences in effects were as a result of the new mobile unit). Costs and effects should ideally be compared for the same year. However, analysis of the effects in terms of different mortality indicators showed dis- tinct differences for West Kiang in the year 1991 compared with over the whole period of the pro- gramme. Therefore the incremental cost-effective- ness analysis was undertaken with both sets of infor- mation and provided best and worst case estimates. Tab/.e 2 shows the extra costs per extra maternal or child death averted to be US $42.9 and US $206.3 for the best and worst cases. Increasing the dis- count rate significantly affected these figures, and caused the programme to become much more ex- pensive. The cost/ death averted was US $459 and US $2,133 in the best and worst case, highlighting the effect of the varied mortality rates over time. Tab/.e 2 does not take into account the reported differences in stillbirths because of measurement difficulties (see article by Foord, p. 18, in this is- sue). However, if the information presented were accurate, inclusion of still births would dramatical- ly affect the efficiency of the intervention. The incremental cost-effectiveness per death averted would be US $1,658 in the best case. In the worst case the intervention would not only cost more but save fewer lives. Finally, the new financing scheme had a take- up rate of90% and a very high proportion of drug costs were recovered, although in practice 40% of payments were used to recompense the TBAs. It would be interesting to ascertain whether this method of financing could be applied equally suc- cessfully elsewhere. Future questions should focus on who chose not to join the scheme and why. Discussion A relatively small body of knowledge has been gen- erated in the past to identify the cost-effectiveness of mobile versus static clinics, or combinations thereof. The changes introduced by the new mo- bile maternal health care service offered an oppor- tunity to address the issue of cost-effectiveness of changes introduced to a specific geographical area. Considerably higher total costs were m- 25 Table 2 Incremental cost effectiveness of the new mobile maternal care service, West Kiang, Gambia Tableau 2 Gain de coOUefficacite resultant de la creation de la nouvelle antenne mobile de soins maternels, West Kiang, Gambie Costs, effects and cost-effectiveness - Couts, performance Best Case• - Scenario optimiste• Worst Caseb - Scenario pessimisteb et rapport coOUefficacite Additional costs - Couts additionnels (US$, 1991) Maternal deaths avertedc - Deces maternels evitesc Neonatal deaths avertedd - Deces neonatals evitesd Life years gainede -Annees d'esperance de vie gagneese Discounted life years gained (DL VG) -Annees d'esperance de vie gagnees, en donnees actualisees -@ 3% -@ 6% -@10% CosUdeath averted - coot par deces evite CosUL VG - coot par an nee d'esperance de vie gagnee CosUDLVG - CoOt par annee d'esperance de vie gagnee, en donnees actualisees -@ 3% -@ 6% -@10% 3,300 1.92 5.27 251.37 76.92 28.17 10.33 459.0 13.1 42.9 117.1 319.5 7,127 1.36 1.98 102.2 34.55 14.48 6.29 2,133.8 69.3 206.3 492.2 1,133.1 a The 'best case' scenario was based on the first scenario's costs and the better mortality rates from the period 1989-91 or 1991. - Le scenario «optimiste" est fonde sur la premiere hypothese de coot et les taux de mortalite pour la periode 1989-1990. appliquee aux chiffres de 1991 pour l'efficacite. b The 'worst case' scenario was based on the second scenario costs, and the worst mortality rates from the period 1989-1991 or 1991. - Le scenario «pessimiste» est fonde sur la deuxieme hypothese de coOt et les taux de mortalite pour 1991. c Using the example for the worst case scenario, maternal deaths averted were calculated by applying the maternal death rate in the control area, Ngayen Sanjal, to the number of women delivering in West Kiang ie. ((7.0/337)/1000 = 2.539). As one death did occur in West Kiang, this was subtracted to give the number of deaths averted as 1.359. - Sur la base du scenario pessimiste, le nombre de deces maternels evites a ete calcule en appliquant le taux de deces maternels pour la zone temoin de Ngayen Sanial au nombre de femmes ayant accouche dans la zone de West Kiang (c'est-a·dire 7,0/337)/1 OOO= 2,539). Etant donne qu·11 y a eu un deces a West Kiang, ce deces est venu en deduction du nombre total de deces evites, qui se chiffrent done a 1 359. d Using the worst case scenario, the neonatal deaths averted were calculated by applying the death rate in the control area to the number of live births in West Kiang ie. ((32.2x319)/1 OOO= 10.2718). The estimated number of neonatal deaths were then subtracted leaving the number of deaths averted as 1.98. - Sur la base du scenario pessimiste, le nombre de deces neonatals evites a ete calcule en appliquant le taux de mortalite pour la zone temoin au nombre de naissances vivantes enregistrees dans la zone de West Kiang, c'est·a·dire (32,2 x 319)11 OOO= 10,2718). Le nombre de deces neonatals effectivement constates a ensuite ete deduit de ce chiffre, ce qui donne un nombre de deces evites de 1,98. • The number of life years gained (L VG) were calculated separately for women and babies. Using the worst case scenario for women, the following formula was used (mean life expectancy- mean age of death in sample) x (deaths averted)= 17.68 L VG. For total L YG. this was added to the calculation of L VG for the children, giving a total of 102.82 LYG. - Le nombre d'annees de vie gagnees a ete calcule separement pour les femmes et les nouveau-nes. Sur la base du scenario le plus pessimiste pour les femmes. on a utilise la formule suivante (esperance de vie moyenne- age moyen du deces dans l'echantillon considere) x (nombre de deces evites) = 17,68 annees de vie gagnees. Pour calculer le nombre total d'annees de vie gagnees, on y a ajoute le nombre d'annees de vie gagnees pour les enfants, ce qui donne le chiffre total de 102,82 annees de vie gagnees. curred, particularly as a result of increased training and staffing. However, evidence (see p. 20, in this issue) has shown that several key measures of pro- cess, e.g. number of haemoglobin tests taken and haemoglobin levels, increased significantly. There- fore the extra expenditure created clear service improvements. Linking such changes to reduc- tions in mortality was more difficult as the popula- tion size and number of maternal deaths made it difficult to show statistically significant differences. For a number of reasons, the results should only provide part of the information required by decision makers. First, this cost-effectiveness analy- 26 sis provided no information regarding any form of equity. Secondly, many factors affect cost-effective- ness ratios and further investigation of the organi- sation and management of the mobile service may highlight further room for improvement within the service itself, thus improving the efficiency. In this case there were grounds for re-assessing costs in relation to training, undertaking an assessment of staffing needs and increasing accountability in the use of resources. This study gives detailed information on the structure of costs for a mobile unit. It is unusual in its consideration of how a mobile team fits into the Rapp. trimest. statist. sanit. mond., 48 (1995) structure of existing health services and implica- tions of provision on other levels of service. More research is needed to determine the effect of im- provements in staff utilization at static units before adding mobile units. Future studies should also focus on assessing the cost-effectiveness of static versus mobile clinics using different measures of morbidity and the effect of such morbidity on the quality of life. Summary A relatively small body of knowledge has been generat- ed in the past to identify the cost-effectiveness of mobile versus static clinics, or combinations thereof. The changes introduced by the new mobile maternal health care service offered an opportunity to address the issue of cost-effectiveness of changes introduced to a specif- ic geographical area. Considerably higher total costs were incurred, particularly as a result of increased training and staffing. However, evidence (Foard, 1993) has shown that several key measures of process eg. number of haemoglobin tests taken and haemoglobin levels increased significantly. Therefore the extra ex- penditure created clear service improvements. Linking such changes to reductions in mortality was more diffi- cult as the population size and rarity of maternal deaths made it difficult to show statistically significant differ- ences. The results should only provide part of the information required by decision makers, for a number of reasons. First, this cost-effectiveness analysis provided no infor- mation regarding any form of equity. Secondly, many factors affect cost-effectiveness ratios and further in- vestigation of the organisation and management of the mobile service may highlight further room for improve- ment within the service itself, thus improving the efficien- cy. In this case there were grounds for re-assessing costs in relation to training, undertaking an assessment of staffing needs and increasing accountability in the use of resources. This study gives detailed information on the structure of costs for a mobile unit. It is unusual in its consideration of how a mobile team fits into the structure of existing health services and implications of provision on other levels of service. More research is needed to determine the effect of improvements in staff utilization at static units before adding mobile units. Future studies could also focus on assessing the cost-effectiveness of static versus mobile clinics using different measures of mor- bidity and the effect of such morbidity on people's quality of life. Wld hlth statist. quart., 48 (1995) Resume Gambie: coot et efficacite d'une antenne mobile de soins de sante maternelle, West Kiang, Gambie Jusqu'ici on possedait assez peu de donnees permet- tant d'evaluer, en termes de cout/efficacite, les avanta- ges compares des antennes mobiles de soins de sante et des centres de sante fixes, ou d'une combinaison des deux. La mise en service d'une nouvelle antenne mobile de soins de sante maternelle a fourni !'occasion d'exami- ner le rapport cout/efficacite d'une telle innovation dans une zone geographique particuliere. Le cout total a ete considerablement plus eleve, par suite notamment du renforcement des effectifs de personnel et de la forma- tion. Toutefois, ii s'est avere que l'on avait pu accroHre ainsi notablement le nombre de plusieurs examens cles pour le suivi de la grossesse, en particulier le nombre des contr61es du taux d'hemoglobine. Ainsi, les depenses supplementaires s'etaient soldees par une nette amelio- ration des services. II a toutefois ete plus difficile d'etablir un lien avec la reduction de la mortalite car, compte tenu de la taille de la population et de la rarete des deces maternels, aucune difference statistiquement significati- ve n'a pu etre mise en evidence. Ces resultats ne constituent done, pour differentes rai- sons. qu'une partie de !'information dont peuvent avoir besoin les decideurs. Premierement, cette analyse cout/ efficacite ne fournit aucun renseignement en ce qui concerne l'equite des services. Deuxiemement, de nom- breux facteurs influent sur le rapport cout/efficacite et, en etudiant mieux !'organisation et la gestion de l'antenne mobile, on pourrait peut-etre introduire certaines amelio- rations qui permettraient de renforcer l'efficacite du ser- vice. Dans ce cas particulier, ii faudrait reevaluer les couts afferents a la formation. en faisant une estimation des besoins en personnel et en ameliorant la transparen- ce au niveau de !'utilisation des ressources. Cette etude donne des renseignements detailles sur la structure des couts pour une antenne mobile de soins de sante. II s'agit d'une approche originale qui consiste a examiner comment une equipe mobile s'integre dans la structure existante de services de sante et quelles sont les repercussions sur les autres niveaux de service. Avant d'envisager de creer de nouvelles unites mobiles ii faudrait faire davantage de recherches pour essayer d'evaluer les effets d'une amelioration de !'utilisation du personnel dans les unites fixes. Les avantages compa- res, en termes de cout/efficacite des services fixes et des antennes mobiles. pourraient aussi etre evalues en utilisant differentes mesures de la morbidite et en con- siderant les effets de cette morbidite sur la qualite de la vie de la population. 27 Guatemala: maternal mortality in Guatemala: assessing the gap, beginning to bridge it a Edgar E. Kestler b Introduction Although maternal mortality has been recognized as an important preventable cause of death in de- veloping countries, no epidemiological analysis of the maternal mortality ratio in Guatemala has been previously published. Findings indicate that Guate- mala must make vast and rapid improvements, if its the maternal mortality ratio is to reach a world- wide acceptable level by the year 2000. Guatemala is divided into 22 departments, which are in turn divided into 329 municipalities. The country's health system is divided into 8 health regions: north, Peten, northwest, south- west, central, southeast, northeast, and metropoli- tan. The 22 national departments are distributed among these health regions according to geo- graphic and cultural characteristics. In 1985, 59% of Guatemalans lived in rural areas; the country had a literacy rate of 50%; most (56%) of its population is of Latin-American de- scent, with the remaining 44% being of its indige- nous population; these groups speak over 20 in- digenous languages. Women and children made up 86% of the total population. This paper uses vital statistics data to examine maternal mortality in Guatemala. a Final report submitted to the Safe Motherhood Research Programme, WHO, Geneva, 1992. b Director, Epidemiologic Research Center in Reproductive and Family Health, Guatemala. Table 1 Reported maternal mortality ratios, Guatemala, 1960 to 1984. Tableau 1 Mortalite maternelle declaree, Guatemala, 1960 a 1984 Year-Annee 1960 1970 1976 1977 1978 1979 1980 1980 1981 1984 28 Ratio per 100 OOO live births - Deces maternels pour 1 OOO naissances vivantes 232 157 76.9 120.8 119.8 150.3 91.0 69 105.7 75.6 Trends in reporting of maternal mortality Differences in both accuracy and level of reported maternal mortaliryc (1) emerge (Tabl.e 1). Although all data presented were based on official Guatema- lan vital statistics, the difference betwe~n the two sources, as well as annual fluctuation in the yearly report, suggests variation in the completeness of reported data. About 5% of all deaths among Gua- temalan women aged 10-49 are classified as mater- nal deaths; the corresponding figure for U.S. women is less than 1% (2). Materials and methods The analysis used birth and death certificate data for 1986. All children born that year and all women who died between the ages of 10 and 49 were selected. All maternal deaths that were classified according to the International Classification of Dis- eases, Ninth Revision, Clinical Modification (ICD- 9-CM) codes for causes of death for complications during pregnancy, labour and puerperium ( codes 630 - 676) were identified. The analysis by depart- ment and health region was stratified by ethnic group, place of death, attendance at birth, and cause of death. c Figures prepared by the Health Situation and Trend Assessment Program, PAHO. Washington, D.C. 1986. Source Government - GouvernemenVPAHO Government - GouvernemenVPAHO UN - ONU UN - ONU UN - ONU UN - ONU UN - ONU Government - GouvernemenVPAHO UN - ONU UN - ONU Rapp. trimest. statist. sanit. mond., 48 (1995) Results As expected, the maternal mortality ratio by age showed aJ-shaped curve. Over all, these ratios were higher for the indigenous group ( Tabl.e 2). The highest maternal mortality ratio was found in the department of Alta Verapaz (214.2/ 100 OOO live births) and the lowest in the depart- Table 2 ment of Progreso (53.8/100 OOO) (Tabl.e 3). The overall maternal mortality ratio for Guatemala in 1986 was 132.5/100 OOO. In other words, at least 1 pregnant woman died every day. The ratio var- ied greatly for both ethnic groups; again, the indigenous group had the highest overall ratio in each department. Maternal mortality by age at death and ethnic group, Guatemala, 1986 Tableau 2 Mortalite maternelle selon l'age au moment du deces et le groupe ethnique, Guatemala, 1986 Age group- Number of deaths - Number of births - Maternal mortality Maternal mortality by ethnic group, Groupe d'age Nombre de deces Nombre de naissances per 100 OOO live births - per 100 OOO live births - Mortalite Mortalite maternelle maternelle par groupe ethnique, pour 100 OOO naissances pour 100 OOO naissances vivantes vivantes Indigenous - Non-indigenous - lndigenes Non-indigenes 10 - 14 3 1 093 274.4 0 610.9 15 - 19 50 50 279 99.4 151.4 38.7 20 - 24 76 92 331 82.3 104.2 57.6 25 - 29 84 74 880 112.1 97.1 130.5 30 · 34 77 51 367 149.9 145.2 156.2 35 · 39 81 32 794 247.3 259.5 229.1 40-44 40 11 523 347.1 383.0 300.1 45- 49 8 1 924 415.8 552.9 238.3 Total 419 316 191 132.5 146.3 115.5 Table 3 Maternal mortality ratio by department and ethnic group, Guatemala, 1986 Tableau 3 Mortalite maternelle par departement et groupe ethnique, Guatemala, 1986 Ethnic group - Groupe ethnique Maternal mortality ratio Indigenous - lndigenes Non-indigenous - Non-indigenes Department- per 100 OOO live births - Number- Ratio Number- Ratio Departement Deces maternels Nombre Nombre pour 100 OOO naissances vivantes Alta Verapaz 214.2 32 156.3 15 1 019.0 Baja Verapaz 210.0 5 116.2 9 380.5 Huehuetenango 206.6 46 266.0 8 90.4 Peten 178.4 10 353.6 7 104.4 Solo la 175.8 12 136.4 4 1 315.7 Totonicapan 175.1 15 138.9 6 501.2 Sacatepequez 154.9 3 97.6 6 219.4 Escuintla 130.4 15 2 170.7 3 22.8 Jalapa 130.0 2 66.7 8 170.5 San Marcos 129.7 31 172.1 4 44.6 Chiquimula 125.8 6 150.9 6 107.9 Quezaltenango 121.8 18 145.1 9 92.3 Jutiapa 117.4 6 1 079.1 10 76.5 lzabal 111.8 6 134.2 5 93.1 Suchitepequez 110.6 5 61.2 9 200.0 Chimaltenango 107.7 8 82.0 4 289.4 Santa Rosa 105.1 4 1 869.1 5 59.9 Quiche 94.8 6 34.7 12 703.8 Guatemala 84.9 39 213.9 8 21.5 Zacapa 75.5 3 4 054.0 1 19.1 Retalhuleu 74.7 5 148.1 1 21.5 Progreso 53.8 0 2 54.2 All country - Ensemble du pays 132.5 277 165.1 142 94.2 Wld hlth statist. quart., 48 (1995) 29 The northern health region had the highest maternal mortality ratio (213.3/100 OOO), and the metropolitan region had the lowest (84.9/ 100 OOO) ( Table 4). By health region, the percent- age of deliveries that occurred in a hospital ranged from 4. 7% for the northwest region to 70. 7% for the metropolitan region. On average, the maternal mortality ratio decreased by about 1 per 100 OOO for every increase in the percentage of hospital- based delivery. When stratified by ethnic group, however, the maternal mortality ratio for the in- digenous group increased with increasing percent- age of hospital-based delivery (Fig. I). Fig. 1A Maternal mortality ratios for hospital deliveries, Guatemala, 1986 Mortalite maternelle, accouchements ayant lieu a l'hopital, Guatemala, 1986 !i'l 'E .. .,,;;: .,: > t:: .. :s B ., c ,E: :JI o-~ 8:!! ~§ -o 8.~ .. - ~s ., "" ;j c-j! ::il E 250 200- 150- 100- 50- 00 0 00 0 0 0 °<) 0 0 O Oo O 0 0 0 0 0 0 I 0 i j 0-+-~--,,--~""T"""~--.~~....-~-.-~~..-~-1 c O 10 20 30 40 50 60 70 Hospital deliveries(%) -Accouchements ayant lieu a l'hopital (%) Fig. 18 Maternal mortality ratios for hospital deliveries, by ethnic group, Guatemala, 1986 Mortalite maternelle pour les accouchements ayant lieu a l'hopital, par groupe ethnique, Guatemala, 1986 30 .- db 150- 0 • ~o 0 ~ ~ • ·~ ~- • 100- • 0 • IO 0 • • • 0 so.:> • Hospital deliveries(%) -Accouchements ayant lieu a l'hopital (%) o Indigenous - lndigenes • Non-indigenous - Non-indigenes In all health regions, maternal mortality ratios were higher for hospital than for home delivery (Fig. 2). These findings most likely reflect late transfers to hospitals, inadequate levels of care and low number of hospital deliveries. In fact, in the metropolitan region, maternal mortality ratio shows less difference-largely because the region contains the borough of Guatemala City, where 71 % of deliveries are institutional and 23% of the maternal deaths take place at home.d In 6 of the 8 health regions, women who gave birth without assistance ( other than self and fam- ily) had higher maternal mortality ratios (Fig. 3) than women with some assistance. This ratio was highest in the northern region (3539.8/100 OOO). For the whole country 5.5% of women had no assistance at delivery; a comparatively large num- ber of maternal deaths occurred among these women (98 deaths, 17 532 live births). In the metropolitan region, the maternal mortality ratio for women attended to by a physician was 91.5 per 100 OOO live births; for women attended by tradi- tional birth attendant (TBA), the ratio was 96.6/ 100 OOO. Haemorrhage and infection were the leading causes of death for the indigenous group. Discussion In 1986, an assessment report by the Statistical Office of the United Nationse suggested that the vital registration system in Guatemala was reason- ably complete. A crude estimate suggests that more than 90% of births and deaths were being regis- tered. For the first time vital statistics were used to describe the maternal mortality problem in Guate- mala. Vital statistics are not designed to investigate maternal deaths or to provide adequate informa- tion to allow appropriate classification and deter- mination of risk factors and causes of death (3); perfect data, however, are not essential for formu- lating urgently needed health policies and pro- grams. Especially in developing countries, death certi- ficates do not identify all maternal deaths. The underreporting of maternal deaths can be attribut- ed to improper filing of death certificates and to assigning a non maternal cause of death to a mater- nal death or vice versa. Several reasons have been hypothesized as contributing to this misclassifica- tion: (i) the death certificate may not include any indication that the death was preceded by, or asso- ciated with, a pregnancy; ( ii) the death certificate d Kestler E. Mortalidad materna en la ciudad de Guatemala. Regional workshop in Maternal Mortality. OMSTOPS. Mexico, D.F. April 16 - 20, 1990. c Gonzalez-Diaz,J. lnforme de la misi6n a Guatemala en relaci6n con los sistemas de registro civil y estadisticas vitales. Oficina de Estadistica. Naciones Unidas. New York, Noviembre de 1986. Rapp. trimest. statist. sanit. mond., 48 (1995) Fig. 2 Maternal mortality ratio by health region and place of death, Guatemala, 1986 Mortalite maternelle par region sanitaire et lieu de deces, Guatemala, 1986 II Hospital - Hopital Home - Domicile north - nord pet en northwest- nord-ouest southwest- sud-ouest central - centre southeast- sud-est northeast - metropolitan - nord-est zone metropolitaine Health region - Region sanitaire Source: Birth and death certificates - Actes de naissances et de deces. Note: N = 419. Maternal mortality refers to ICD-9 codes 639-676 only. - La mortalite maternelle ne concerne que les codes 639 a 676 de la CIM-9. Fig. 3 Maternal mortality ratio by health region and attendance at birth , Guatemala, 1986 Mortalite maternelle par region sanitaire par type de personnel de sante present lors de l'accouchement, Guatemala, 1986 CJ) .s 1000 c: "' (/) . ~ => t:: CJ) :c ~ 800 Q) c: >"' ::.:: (/) c,.!:!1 0"' O c: 600 c,0 c,O ~o ~o Q)C) a.~ 400 CJ)~ =:::, - 0 ~ c. "'O CJ) -"a; "' c: 200 c: ~~ Q) Q) - 1i, "' :::!!: E CJ) ,Q) 0 u -a, 0 3539.8 • north - nord peten northwest- nord-ouest • Doctor - Medecin ffll Midwife - Sage-femme O TBA - Accoucheuse traditionnelle • None - Aucun central - centre south east - sud-est northeast- metropolitan - nord-est zone metropolitaine Health region - Region sanitaire Source: Birth and death certtticates -Actes de naissances et de deces. Note: N = 419. Maternal mortality refers to ICD-9 codes 639-676 only. - La mortalite maternelle ne concerne que les codes 639 a 676 de la CIM-9. may not include the final cause in the case being investigated or the results of an autopsy; and ( iii) although the death may have been reclassified as a maternal death based on autopsy results, the change in classification may not have been incor- porated into the vital statistics system. For develop- ing countries like Guatemala, however, improving Wld hlth statist. quart., 48 (1995) the reporting of maternal deaths is secondary to targeting high-risk groups and taking other steps to begin reducing high maternal mortality ratios. On the other hand, countries like Guatemala have system-level peculiarities that must be consid- ered in planning maternal and child health pro- grammes. In such countries, the health system is 31 Table 4 Maternal mortality ratio and percentage of hospital deliveries by health region, Guatemala, 1986 Tableau 4 Mortalite maternelle et pourcentage des accouchements ayant lieu a l'hopital, par region sanitaire, Guatemala, 1986 Health region - Region sanitaire Ratio per 100 OOO live births - Deces maternels Hospital deliveries (%) - Accouchements ayant lieu ill'hlipital (%) pour 100 OOO naissances vivantes NORTH - NORD Alta Verepaz Baja Verepaz PETEN NORTHWEST - NORD-QUEST Huehuetenango Quiche SOUTHWEST - SUD-QUEST Solo la Totonicapan Quezaltenango Suchitepequez Retalhuleu San Marcos CENTRAL - CENTRE Sacatepequez Chimaltenango Escuintla SOUTHEAST - SUD-EST Santa Rosa Jalapa Jutiapa NORTHEAST - NORD-EST El Progreso lzabal Zacapa Chiquimula METROPOLITAN - ZONE METROPOLITAINE 213.3 178.4 159.6 130.9 126.8 117.1 102.1 84.9 usually concentrated in urban medical centres, where highly trained personnel (principally physi- cians) provide curative treatment. Technological improvements are needed even in these more de- veloped areas. In rural communities, pregnant women and their newborn children cannot rely on institutional assistance but on services offered by TBA's. In this context, TBA's represent a well- accepted resource that instills leadership and authority within the community and that merits further encouragement and development. As expected, the small number of women from the northern region who had no assistance at birth had the highest maternal mortality ratio (Fig. 3). Similarly, the recent follow-up study of maternal mortality in Honduras found that among at-home deliveries, 16. 7% of maternal deaths occurred 32 9.4 17.9 4.7 11.8 16.6 11.0 16.0 70.7 among women who had had no assistance during delivery/ between 40% and 60% of these deaths occurred during labour or during the first 24 hours postpartum. Interventions are urgently needed to provide some form of assistance to such women in developing countries. In recent years, community birthing centres have been proposed for low-risk pregnant women and maternity waiting homes for high-risk preg- nant women. Such projects are unlikely to be real- ized in many developing countries, not only be- cause financial and human resources are lacking r Castellanos M. de J., Ochoa J.C., David V. Mortalidad de mujeres en edad reproductiva y mortalidad materna. UNAH, MSP, OPS, UNFPA, MSH. Honduras 1990. 43-44. Rapp. trimest. statist. sanit. mond., 48 (1995) but also because few of these countries are serious- ly considering the alternative policies. Scientific evidence is needed to convince health authorities that these are viable solutions to the problem of maternal mortality. Maternity waiting homes have been, or are being, tried in Cuba, Colombia, Uganda and Zaire, but evaluative results are not yet available. Such programmatic research is our next step. Another clear finding in this study was the gap in maternal mortality between the indigenous and non-indigenous populations in Guatemala. The study shows that vital statistics can reveal these and other problems in maternal and child health. De- veloping countries with poor or no specific data on maternal mortality should use vital statistics, if they are available, first to understand the problem and then to generate hypotheses and propose op- erative research. The findings of this study should be analyzed with caution, and conclusions derived from them should be formulated prudently, until trend analy- sis can be conducted through vital statistics. These restrictions point out the need for more detailed studies on the topic of maternal mortality in devel- oping countries and the need to develop national surveillance systems that compile information on maternal mortality (5). Summary Developing countries which have somewhat reliable vital statistics but poor or incomplete information about maternal mortality must make the most of the data available. Such data may require modification for mater- nal mortality analyses. What is important, however, is the decision to use available information and to analyse it properly. The analysis of maternal mortality in Guatemala, using data from 1986 birth and death certificates, identified particular areas, health regions, and particular ethnic groups that had significantly higher maternal mortality ratios than others. Small but disproportionately affected populations that had no available maternal health assistance were iden- tified-a problem found in many developing countries. These groups urgently need the services of traditional birth attendants or other forms of assistance before, during and after delivery. The analysis of vital statistics led to the beginning of operative research and the collection of background information for establishing an epidemiologic surveil- lance programme for maternal mortality. Wld hlth statist. quart., 48 (1995) Resume La mortalite maternelle au Guatemala : une premiere initiative pour comb/er Jes lacunes de /'information Les pays en developpement qui ont des statistiques d'etat civil assez fiables, mais qui n'ont que des don- nees insuffisantes ou incompletes sur la mortalite mater- nelle. doivent tirer parti au maximum des donnees dont ils disposent. Ces donnees peuvent avoir besoin d'etre modifiees aux fins de !'analyse de la mortalite maternel- le, mais ce qui importe le plus, c'est la decision d'utiliser les informations disponibles et de les analyser correcte- ment. On a analyse la mortalite maternelle au Guatemala en utilisant les donnees fournies par les certificats de naissance et de deces depuis 1986. Ces analyses ont permis d'identifier des zones, des regions sanitaires et des groupes ethniques particuliers qui presentaient des taux de mortalite maternelle beaucoup plus eleves que d'autres zones, regions ou groupes ethniques du Gua- temala. On a pu determiner que de petits groupes de popula- tion, qui etaient affectes d'une maniere disproportion- nee, ne disposaient d'aucun type d'assistance sanitaire maternelle - probleme que l'on rencontre dans de nombreux pays en developpement. Ces groupes avaient un urgent besoin des services d'une accou- cheuse traditionnelle ou d'autres formes d'assistance avant, durant et apres l'accouchement. L'analyse des statistiques d'etat civil a permis d'enga- ger un travail de recherche operationnelle et de collecte d'informations de base pour etablir un programme de surveillance epidemiologique de la mortalite mater- nelle. Acknowledgment The author wishes to express his gratitude to the authorities of the National Institute of Statistics in Guatemala for providing vital statistics data for this study. References 1. United Nations, Demographic Yearbook. Natality Statistics. 38th edition, New York, United Nations, 1986, p. 327. 2. National Center for Health Statistics. Vital Statistics of the United States, 1979, vol. II, Mortality, Part A. Washington, D.C. Government Printing Office, 1984. 3. Kestler E. Mortalidad materna en Centro America. Bases para programas nacionales de vigilancia epidemiologica. Revista Latinoamericana de perinatalidad. 9( 4), 167-177 (1989). 33 Guinea-Bissau: Maternal mortality assessmenta Margreet M. Oosterbaanb Introduction Previous estimates of maternal mortality have shown wide discrepancies, with rates ranging from 388/100 OOO live births at the very least and based on community estimates to more than 4 000/ 100 OOO live births in isolated hospital studies. Table 1 describes the base-line demographic and socio-economic characteristics of Guinea-Bissau. Objectives (i) To determine the proportion of all female deaths attributable to maternity in the age group 12-49 years; (ii) To estimate the maternal mortality ratio; (iii) To assess the direct and indirect causes of maternal deaths; (iv) To determine the demographic, socio-eco- nomic and health characteristics of women dying from maternal causes in order to devel- op a profile of high-risk women; (v) To determine which maternal deaths could have been prevented; and (vi) To propose intervention strategies to reduce maternal mortality. Materials and methods The study was carried out between 1989 and 1990 and attempted to identify and trace all female deaths in the reproductive age group during that period. All health centre nurses and midwives were alerted to record all pregnancies and pregnancy- related deaths and report to the regional health authorities. However, it is likely that maternal deaths were missed in the more remote parts of the country due to lacunae in data collection, and difficulties in communication and transportation. A group of interviewers was trained to conduct "verbal autopsies" with surviving family members and determine the likely cause of death. The infor- mation thus obtained was matched with hospital and health centre records in order to increase the degree of precision. After collection of the data, controls were iden- tified in order to determine odds ratios for certain • Summary of the final report submitted to the Safe Motherhood Research Programme, WHO, Geneva, 1992. b World Health Organization, Guinea-Bissau. 34 risk categories. 69 cases of similarly aged women who suffered similar complications during preg- nancy but had not died from them were matched with the characteristics of the 145 identified in the study and whose illnesses ended fatally. Results (Table 2) Altogether 352 female deaths were identified in the age group 12 to 49 years. Of this total 145 ( 41 % ) were related to complications of pregnancy, childbirth, and the puerperium. During the one- year period of the study a maternal mortality ratio of 914 per 100 OOO live births was established for the whole country. The ratio for hospitals was cal- culated to be 779 per 100 OOO live births. The women who died from antepartum haem- orrhage had all sought medical assistance prior to their death. The interviews ascertained, however, that many of the women who had died from post- partum haemorrhage had not sought help at all. Of the women who died from puerperal infections only a few had received antibiotics, which are only available at the hospitals. Previous studies con- firmed that an increasing number of cesarean de- liveries had been accompanied by an increase in obstetric infections at one of the major hospitals during the early 1980s. Malpresentation of the fetus and cephalopelvic disproportion were the main causes of obstructed labour. The women were usually admitted to hospi- tal at a late stage and in 5 of the 19 cases a ruptured uterus was diagnosed. A caesarean section was only performed on 3 of the 19 women. The number of abortion cases needs to be inter- preted with caution. It is very likely that they under- represent the real dimension of induced abortions. It is known that clandestine abortions are per- formed widely in Guinea-Bissau, but the real num- ber of deaths is difficult to ascertain as families are reluctant to talk about the subject. Infectious diseases Malaria and complications resulting from increas- ing chloroquine resistance lead to decreased hae- moglobin levels and resulting anaemia with the well known consequences such as reduced placen- tal growth, low birthweight, spontaneous abortion, and fetal and maternal death. Anaemia and mal- aria stand out as the main indirect causes of mater- Rapp. trimest. statist. sanit. mond., 48 (1995) Table 1 Demographic, socioeconomic and health indicators, Guinea-Bissau, 1990 Tableau 1 lndicateurs demographiques, socio-economiques et sanitaires, Guinee-Bissau, 1990 Indicator - lndicateur Population urban - urbaine rural - ru rale Life expectancy at birth - Esperance de vie a la naisssance men-hommes women - femmes Total fertility rate - Somme des naissances reduites Infant mortality rate - Taux de mortalite infantile Adult literacy rate - Taux d'alphabetisation des adultes men-hommes women - femmes Primary school enrolment - Taux de frequentation de l'ecole primaire men-hommes women - femmes Gross national product (GNP) per capita - Produit national brut (PNB)par habitant Health expenditure - Depenses de sante Expenditure on primary health care - Depenses consacrees aux soins de sante primaire Population covered by health services - Population couverte par les services de sante Population with access to safe water - Population ayant acces a un approvisionnement en eau saine Population with adequate sanitary facilities - Population disposant d'installations d'assainissement adequates Contraceptive prevalence rate - Taux d'utilisation de moyens contraceptifs nal deaths and the well known association between these predisposing diseases and maternal mortality is confirmed. Age distribution of reported maternal deaths Most women who died were at the height of their productive lives usually leaving behind a family into which a number of small children had already been born. Table Jsummarizes the age distribution of the unfortunate victims of maternal mortality. Thus, almost 70% of all the women who died were below the age of 30 years. Amongst the com- plications responsible for these deaths in the group of women below 20 years, eclampsia stood out as a Wld hlth statist. quart., 48 (1995) Value - Valeur 900 OOO (1987) 10% 90% 44 ans 46 ans 5,6 births per woman - naissances par femme 140 per 1 OOO live births - pour 1 OOO naissances vivantes 46% 17% 73% 39% us $200 2% of GNP - du PNB 40% of health expenditure - des depenses de sante 64% 31% 25% 1% major factor in 32% of the cases. In the age group 20-29, eclampsia seemed to play a less prominent role in leading to maternal death with 9% diag- nosed, but its presence was again more marked in the group of 30-39 year old women with 22% dying from it. In this sample, older women tended to be more affected by postpartum haemorrhage with 27% of all deaths caused by the condition in the age group 30-39 years and 33% in the age group 40-49 years. No significant other conditions were noted to affect particular age groups. It may be assumed that the deaths in the older age group were likely to occur in women who were already suffering from a number of other debilitating chronic conditions 35 Table 2 Most likely causes of pregnancy-related deaths in women aged 12-49 years, Guinea-Bissau, 1989-1990 Tableau 2 Causes les plus probables de deces lies a la grossesse chez les femmes a.gees de 12 a 49 ans, Guinee-Bissau, 1989- 1990 Cause of death - Cause du deces Postpartum haemorrhage - Hemorragie du postpartum Hypertensive disorders of pregnancy - Hypertension gravidique Puerperal infection - Infection puerperale Obstructed labour - Dystocie Antepartum haemorrhage - Hemorragie antepartum Spontaneous abortion - Avortement spontane Induced abortion - Avortement provoque All direct obstetric causes - Ensemble des causes obstetricales directes Anaemia - Anemie Malaria - Paludisme Diabetes - Diabete Tuberculosis - Tuberculose Hepatitis - Hepatite Pneumonia - Pneumonie Cardiac problems - Problemes cardiaques All indirect obstetric causes - Ensemble des causes obstetricales indirectes Unspecified causes - Causes non specifiees Total Number - Nombre % of all obstetric causes- 37 24 23 19 3 6 2 114 16 7 28 3 145 % de !'ensemble des causes obstetricales 25.5 16.6 15.9 13.1 2.1 4.1 1.4 78.6 11.0 4.8 0.7 0.7 0.7 0.7 0.7 2.1 2.1 100 with the pregnancy aggravating the general state of already weakened bodies. Factors associated with women at risk of life- threatening pregnancies In using the characteristics of the 69 women who suffered similar complications during pregnancy 36 Table 3 Age distribution of maternal deaths, Guinea-Bissau, 1989-1990 Tableau 3 Repartition par age des deces maternels, Guinee-Bissau, 1989-1990 Age group- Number of cases - % Groupe d'age Nombre de cas 12-19 28 19.3 20-29 69 47.6 30-39 41 28.3 40-49 6 4.1 Unspecified -Non-specifie 1 0.7 Total 145 100 but did not die from them, an attempt was made to assess the possible risk factors. One of the most striking differences in the per- centage distribution of characteristics between the women who died and those whose death was avoid- ed is related to the practice of female genital muti- lation ( Tabk 4). In further analysing the issue it is found that excision or infibulation as practised by a particular tribe and religious group may be an important factor. Moreover, this particular tribe encourages marriage at a very young age which, coupled with a generally smaller maternal stature, may lead to obstructed labour caused by cephalo- pelvic disproportion. Table 4 Social and maternal health characteristics, Guinea-Bissau, 1989-1990 Tableau 4 Caracteristiques sociales et profil sanitaire de la mere, Guinee-Bissau, 1989-1990 Characteristics - Caracteristiques Study group - Control group - Groupe etudie Groupe temoin (%) (%) Rural residence - Residence en zone rurale 77 68 Female genital mutilation - Mutilation genitale feminine 57 38 Illiteracy - Analphabetisme 79 67 Primipara - Primipare 13 14 1-4 pregnancies/grossesses 43 59 +4 pregnancies/grossesses 44 26 Antenatal care, referral, and delivery patterns Pregnancy outcome for women at risk of develop- ing complications depends very much on early de- tection and appropriate action. In analyzing the factors which for many women turned out to be lost opportunities on the way to their premature Rapp. trimest. statist. sanit. mond., 48 (1995) death, the necessary educational strategies can be deduced. Antenatal care The number of antenatal visits is a quantitative indicator of the potential benefit women can de- rive from the services. Tabl.e 5 describes the number of visits for the maternal mortality cases as well as the women in the control group. While the number of unspecified cases gives reasons for concern it nevertheless seems appro- priate to deduce an inverse relationship between the number of antenatal visits and the risk of dying during pregnancy, childbirth, and the following weeks. The highest number of deaths is recorded amongst the women with no visits (45) or only a few ( 41) to modern health facilities, and the small- est number of deaths (33) is found amongst the group of women with more than three visits. Of the Table 5 145 women who died, 103 (71 %) had experienced complications (anaemia, malaria, generalized oe- dema with or without hypertension) at some point during their pregnancy. But only 20.4% had been admitted temporarily to the hospital during their pregnancy as opposed to 30.2% amongst the con- trol group. The timing of the visits for antenatal care and the risk of dying from pregnancy-related condi- tions tends to follow the same inverse pattern. Whereas only 32% of the women who died report- ed during the first trimester, 43% of the women who survived a similar condition came during the first 3 months of gestation. More than twice as many controls delivered at the hospital as at home, whilst among those who died, almost as many women delivered at home as in a health facility. The chance of survival also seemed to depend on the training and skills of the respective providers of delivery care. About 40% of the women who died Number of antenatal care visits in relation to maternal deaths, Buinea-Bissau, 1989-1990 Tableau 5 Nombre des visites prenatales, rapporte au nombre de deces maternels, Guinee-Bissau, 1989-1990 Number of visits - Deaths: - Deces: Nombre de visites Study group - Groupe etudie 0 45 1-3 41 >3 33 Unspecified - Non-specifiees 26 Total 145 Table 6 Risk factors and odds ratios, Guinea-Bissau, 1989-1990 Tableau 6 Facteurs de risques et odds ratios, Guinee-Bissau, 1989-1990 Risk factor - Facteur de risque No prenatal carea - Pas de suivi prenatala >24 hours to place of deliveryb - >24 heures de trajet jusqu'au centre d'accouchementb Home deliveryc - Accouchement a domicile c Female genital mutilationb - Mutilation genitale feminineb Assistance from family member/TBAc -Assistance par un membre de la famille ou une accoucheuse traditionnellec llliteracyb - Analphabetismeb Rural residenceb - Habitat ruralb % 31.0 28.3 22.8 17.9 100 Odds ratio 4.4 3.5 2.6 2.2 2.0 1.8 1.6 • N=119 for the study group and 66 for the control group. - N=119 pour le groupe etudie et 66 pour le groupe temoin. b N=145 for the study group and 69 for the control group. - N=145 pour le groupe etudie et 69 pour le groupe temoin. c N=125 for the study group and 65 for the control group. - N=125 pour le groupe etudie et 65 pour le groupe temoin. Wld hlth statist. quart., 48 (1995) Deaths: - Deces: % Control group - Groupe temoin 8 11.6 27 39.1 31 44.9. 3 4.3 69 100 95% confidence interval - lnvervalle de confiance 95 % 1.9, 10.1 1.4, 8.3 1.3, 5.0 1.2, 4.0 1.0, 3.8 0.9, 3.5 0.8, 3.0 37 had been attended to by family members or a TBA, while in the control group only 26% used family or TBA support. The utilization of trained midwives amongst the women who died was less than 14%, compared with 40% in the control group. Whether this pattern denotes a lack of access to midwives in areas which are deprived of such staff or indicates a bias in provider utilization would need to be estab- lished. However, there is a notable shortage and maldistribution (urban/rural) of midwives through- out the country. Ease of access to a health facility for delivery was likewise related to the survival of the mother. Only 19% of the controls took more than 24 hours to reach a health facility, compared to 28% of the women who died. Pregnancy outcome showed similar disparities: 53. 7% of the women who died had delivered a live baby as opposed to 86.9% in the control group. Almost half of the babies born alive to mothers who died did not survive the first 7 days, whereas the majority of children in the control group did. Women who arrive at the hospitals for emergen- cy care face poorly equipped facilities. Furthermore the inexperience of personnel to deal with obstetric emergencies is quoted as an additional factor which reduces the chance to survive what under more favourable circumstances would be a routine inter- vention to save a mother and her child. Risk factors and odds ratios This study permitted the estimation of the risks and associated probabilities to die from various risk fac- tors prevalent in Guinea-Bissau. Thus, a woman who does not attend any form of antenatal care in a modem care setting e.g. a health centre is four times as likely to die from conditions arising during preg- nancy than the pregnant woman who does attend. Other risks included are distance/travelling time, home delivery, female genital mutilation, delivery care provided by a family member or a TBA, illiteracy and rural habitat. Tab/,e 6 sums up the results. Summary With more than 40 % of all female deaths attributable to pregnancy, delivery, and the puerperium period, the 38 study established a maternal mortality ratio of 914 deaths per 100 OOO live births. The principal risk factors for dying from pregnancy-related causes are: no atten- dance at antenatal care, too great a distance between the home and the nearest hospital facility, home deliv- ery, belonging to specific ethnic/religious groups, and delivery assistance from family members and TBAs. The health policy implications to improve this situation are: increased coverage with appropriate services, in- creased numbers of rural midwives, in-service training of existing staff in maternity issues and problems, cul- ture-specific educational approaches using the existing value system, educational campaigns to discourage harmful practices and behaviour, continued education- al efforts to upgrade the knowledge of TBAs, and a culturally sensitive integration of TBAs into the govern- ment programmes. Resume Guinee-Bissau : Evaluation de la mortalite maternelle Avec plus de 40% de !'ensemble des deces feminins imputables a la grossesse, a l'accouchement et a des problemes survenant au cours de la periode perinatale, l'etude a fait ressortir un taux de mortalite maternelle de 914 deces pour 100 OOO naissances vivantes. Les principaux facteurs de risque sont : la non-frequenta- tion des consultations prenatales, le fait d'accoucher avec l'aide seulement de membres de la famille ou d'accoucheuses traditionnelles, un trop grand eloigne- ment du service hospitalier le plus proche, le fait d'ac- coucher a domicile, l'analphabetisme, l'appartenance a certains groupes ethniques ou religieux et le fait d'habi- ter dans une zone rurale. L'amelioration de cette situation passe par une politique de sante axee sur une meilleure couverture de la popu- lation par des services appropries, un accroissement du nombre des sages-femmes en milieu rural, une formation permanente du personnel existant concer- nant les problemes lies a la maternite, des approches educatives adaptees aux cultures locales et utilisant les systemes de valeur existants, des campagnes d'educa- tion pour decourager les pratiques et comportements nocifs, des efforts de formation continue pour ameliorer les connaissances des accoucheuses traditionnelles et une integration culturellement appropriee des accou- cheuses traditionnelles dans les programmes gouver- nementaux. Rapp. trimest. statist. sanit. mond., 48 (1995) Guinea-Bissau: What women know about the risks - an anthropological studya Margreet M. Oosterbaanb & Maria V Barreto da Costac Introduction Anthropological studies contribute to a better understanding of the social, cultural, and religious belief systems which condition certain attitudes to health and health- seeking behaviour. They illumi- nate the vast array of complex societal relation- ships at work when individuals, faced with disease episodes, seek explanations and a culturally accept- able response. Societies which have for millennia based their lives on strong traditional values and expectations of individuals and the community, and which are now coming under the pressure of cultural transition face tremendous problems of cultural adaptation. The health sector, modern as well as traditional, is not excluded from these de- velopments. In this transitional process reproduc- tive issues and different types of sexual and nutri- tional taboos surrounding motherhood and child- birth affect the behaviour of each member of the community. Anthropological studies can help to identify ways to bridge the gaps in understanding of what may otherwise be explained as "irrational" health behaviour. It can thus clear the way for health policy and health service planning ap- proaches which are more sensitive to the belief system governing the attitudes and behaviour of the community members at their charge. A very high maternal mortality ratio of 1 492 per 100 OOO live births was identified during a pilot study in Bafata Region of Guinea-Bissau during 1988/1989. Concerned about this high number of maternal deaths the Ministry of Public Health de- cided to extend the study nation-wide in order to obtain data for health policy formulation. In addi- tion to the epidemiological study a survey on women's knowledge about the risks of mother- hood was undertaken so that appropriate policy measures could be developed. Objectives (i) To determine whether an education pro- gramme adapted to the knowledge and atti- tudes of women about motherhood increases the frequency of prenatal consultations and the demand for assistance with childbirth. a Summary of the final report submitted to the Safe Motherhood Research Programme, WHO, Geneva, 1990. b World Health Organization, Guinea-Bissau. c Maternal and Child Health Centre, Bissau, Guinea-Bissau. Wld hlth statist. quart., 48 (1995) (ii) To determine whether an awareness pro- gramme for pregnant women will bring about an increase in the number of institutional births and reduce the complications of child- birth. (iii) To identify what women know about risks and danger signs during pregnancy, their etiologi- cal interpretation of symptoms, and their health behaviour upon experiencing the per- ceived danger signs. Materials and methods In each of the 8 administrative regions of Guinea- Bissau 3 villages were chosen at random. In each village 10 women of reproductive age ( 12-49 years) formed one group for group discussions. The au- tonomous region of Bissau, as a main urban ag- glomeration, was also included in the study. Seven different ethnic groups were included. The re- search took place between June 1989 and February 1990. The issues surrounding maternal health and mortality and the choice of topics were discussed during a one-day seminar with participation of re- gional and national health administrations and non-government organizations. This permitted sensitization of high level responsible personnel and served as an entry point for initiating policy change. The focus group technique was chosen as the appropriate method of inquiry. The discussion leaders were chosen from rural extension workers, youth organizations, or members of village com- mittees. They were exclusively female, all spoke the local language, had knowledge of the villages, and easily gained the confidence of the group mem- bers. All discussions were recorded in local lan- guages and transcribed into Portuguese for con- tent analysis. In total, 27 focus groups of 10 participants each were formed. To allow for a certain degree of ho- mogeneity amongst the women, the intention was to restrict participation to women around 30 years of age, with a parity and/ or gravity between 3 and 5. In conducting the field work, however, it was found virtually impossible to keep rigorously to these selection criteria. Women in the villages were so interested in the group meetings and so desir- ous of talking about issues affecting them in their pregnancy that it was hard to limit the group size to exactly the specified criteria. Hence groups tended 39 to be larger and, possibly, less homogeneous. But in the final analysis the opinions expressed proved to be highly relevant for health programme plan- ning. Results Population composition and ethnicity Wide variations in ethnic, religious, and tribal affil- iations exist throughout the rural and urban areas of Guinea-Bissau. Religious affiliation, for exam- ple, includes Animists (63%), Muslims (33%), and Christians ( 4%). The etiological models concern- ing pregnancy, delivery, and childhood vary con- siderably and, moreover, the prevailing belief sys- tems do not form homogeneous entities. Elements from one explanatory frame of reference were also found to be prevalent in others. Almost all tribes were organized in a patriarchal manner with the exception of one in which matri- archy was dominant. The elders play a strong role in each community and uphold religion and tradi- tions which reinforce the status of women in their respective tribal and religious communities. In some communities the women's lives were more rigidly controlled by behavioural norms than in others. Marriage at an early age is encouraged systemat- ically in some tribes, while in some others it is increasingly recommended in order to prevent un- married pregnancies. In some tribes female cir- cumcision was practised in such a manner that vertical cuts were made in the abdomen which did not lead to genital mutilation as such. Others prac- tice excision or infibulation with the resulting health consequences of female genital mutilation. Nutrition Various taboos govern the intake of food in gener- al and specifically during pregnancy. In a world governed by spirits and their presumed impact on human health and well-being, different kinds of food are believed to provoke or restore balances or imbalances between the different spiritual forces at work. Intake of different food items may also be governed by seasonal considerations. All of these factors lead to the well-known phenomenon that the properties attached to certain foods are more important than their availability. With an ethnic diversity as wide as the one iden- tified in this study the multitude of differing beliefs on the impact of various food items on the course of a pregnancy is not surprising. Indeed the same fruit was promoted by one tribe and prohibited by another because of its anticipated positive ( or negative) effect on the mother and the child. The impact of cultural transition was noted. When women consult medical doctors during the course of a pregnancy, specific food items are en- couraged and some women follow the advice. 40 Should there be poor pregnancy outcome the fact of having broken the taboo is perceived by other women as the logical explanation. Som.e foods are encouraged to be eaten during pregnancy and it is generally felt that food must be particularly clean during that period of time. While the older women tended to be more in favour of respecting the taboos, the younger women attached less impor- tance to the issue and it is likely that with the passage of time the impact of negative food habits will disappear. TBA knowledge of the delivery process and consequences Not all TBAs who form part of the village primary health care services had been trained at the time of the study. Gaps in knowledge persisted with nega- tive consequences for the health of the mother. In some cases, neither the pregnant mother nor the TBA knew about basic aseptic measures at birth such as washing their hands before the delivery starts. Most TBAs and women washed their hands only after the delivery. The TBAs were not aware of the different stages of delivery. They encouraged early pushing before the expulsion stage, a practice that frequently leads to vaginal prolapse and uterine rupture. Forced expulsion by hand occurs and results in infections and haemorrhage. Lack of knowledge of pregnancy-related risks In general danger signs in pregnancy were not correctly identified nor was correct and timely ac- tion taken to seek appropriate health care. Abdom- inal pain or swelling was not interpreted correctly and recourse to modern medical help was usually delayed until all other home and traditional reme- dies were exhausted. Oedema, for example, is re- garded as an impurity of the blood or lack of it, or an "ill-wind" caused by spirits. The idea of impurity having in one way or an- other invaded the body and the subsequent need for cleansing were relatively predominant in the etiological models employed. Only on very few occasions was a danger sign correctly interpreted as for example in the case of anaemia. In this case a group of women in one focus group had consulted a fortune teller ("djambaco") for "lack of blood". For some reason or other the fortune teller had related iron-deficiency to the absence of a local, iron-containing vegetable in the diet of the women. Recognition of high-risk factors The onset of puberty tends to mark the age for marriage in the vast majority of the tribes under study. Women correctly identified problems associ- ated with early childbearing and insufficient pelvic development, but accepted them as a matter of Rapp. trimest. statist. sanit. mond., 48 (1995) fate, because of the overwhelming need to prove a woman's fertility. In effect, women think that giv- ing life to about 10 children is a sign of adequate reproductive capacity. Within this framework early pregnancy is encouraged so that around age 35 the woman will have achieved her reproductive goals. Some women felt that it was the husband's re- sponsibility to decide, whether his wife was too young to give birth. Attitudes and practices affecting pregnancy and delivery The utilization of prenatal services was hampered by the perception of clinics as being only curative in nature. Lack of transport and/ or money further prevent the adequate utilization of antenatal care services. Service organisation may present another stumbling block: on the day that the pregnant woman arrives at the clinic, antenatal services may not be offered. In parts of the country in which health education programmes and services have operated for a longer period of time, the women tend to appreciate the value of antenatal care bet- ter. But generally pregnancy and childbirth remain shrouded in myths which militate against the ap- propriate utilization of modern services. The wom- en regard pregnancy as a supernatural phenome- non representing the reincarnation of ancestral spirits. As sorcerers may exert negative influences on the pregnancy outcome the women conceal their pregnancy until after the first three months. When delivery is imminent the same fear of sorcer- ers resurges, the women are so afraid that they prepare themselves for death. Traditional ceremo- nies are performed, advice and assurances on the possible pregnancy outcome sought from different kinds of traditional healers. Within the world of spiritualist interpretations, delivery is seen as a competition between the spirit of the child and the spirit of the mother. It is seen as a game of life and death between these spirits. Labour is regarded as an "open pit", the two participants play, and run the risk of falling into it. The competing spirits are seen as resting outside the bodies of both mother and child. If the mother cries out during the deliv- ery this frightens her spirit, opens the way for sor- cerers to cast spells, and lessens her chance of survival. The attending women therefore close her mouth. In some tribes women deliver alone and preferably in the forest so that they are sheltered from evil spirits when crying. But this practice is disappearing. Delivery usually occurs in a squatting position. Attending women support the delivering mother. The baby is supposed to fall onto the floor, which is interpreted as completion of the passage from the world of spirits to the earth. This procedure is likened to a fruit falling to the ground in order to take root. A successful delivery is interpreted as "having escaped the gate of death". Wld hlth statist. quart., 48 (1995) The baby's spirit is recognized as having en- tered the body when the child cries. Striving to explain an otherwise inexplicable event as a search for balance and harmony between mind and body seems to be the underlying philosophy guiding this explanatory frame. Attempts are made to resolve complications during delivery (retained placenta or prolonged labour) by traditional remedies which may involve the spiritual as well as symbolic activities per- formed by other women and/ or the husband. Health behaviour and seeking health care in the modern medical sector Most of the communities used home remedies, traditional healers of their respective communi- ties, and traditional birth attendants for dealing with pregnancy related diseases and childbirth. The modern medical care offered at government health facilities was used as and when the respec- tive etiological model indicated its usefulness. Childbirth was predominantly conducted by TBAs because of the women's trust bestowed on these well-known, older women of the village. The decision to seek health care from the infor- mal and/ or the modern medical sector usually depends on the perceived severity of the problem, the availability of transport, the distance to be cov- ered, and cost. Government services are described as relatively cheap, but traditional healers' ad- vice is considered expensive. Factors quoted as dis- incentives to service utilization are the following: long waiting times at the facilities, laboratory clo- sures due to electricity shortages, and unavailability of drugs at the nearest pharmacy. Instructions on how to take the prescribed drugs are sometimes illegible or explanations are lacking. At the same time, traditional medicine is perceived to deliver immediate results. This inhibits prolonged utiliza- tion of prescribed drugs which may show the de- sired effect only after some time. Negative experi- ences in the formal sector tend to encourage the use of traditional medicine. Traditional medicine competes with the modem sector and patients seek advice between the two for one and the same ill- ness. Treatment instructions from the modern sec- tor may therefore be interrupted upon consulta- tion of a traditional healer, and substituted with herbal or other prescriptions. Attitudes towards hospital delivery Women did not view the hospital as a safe place for delivery. It is regarded, rather, as a place of last resort, reserved for only the most serious cases. Women resented having to lie down in a bed be- cause of the value attached to their traditional squatting position. The lack of privacy in the wards discouraged attendance. Male doctors and nurses were also listed as discouraging factors. 41 Postnatal events All behaviour of the mother and the interpreta- tion of postnatal behaviour of the child are guid- ed by tradition. If, for example, a child cries fre- quently this is interpreted as indicating that the parents have not correctly identified the reincar- nated spirit and given the child the wrong name. Other beliefs govern the timing of breastfeeding, dealing with the umbilical cord, and the pla- centa. Family planning, birth spacing, traditional practices, and health implications The attitude of women towards family planning and birth spacing is based on the survival chances attached to the newborn child. A lactating woman is not allowed to have sexual relationships for two years. High neonatal mortality, however, leads to inappropriate spacing of pregnancies and reinforc- es the vicious cycle of generally lowered resistance, lowered hemoglobin levels and resulting anemia which, in turn, lowers the survival chances of both mother and child. Most women start childbearing at 16-1 7 years old and those in the 25-39 year age group have between 4-6 children each. Where traditional be- liefs are still strong a two-year period of breast- feeding and sexual abstinence is respected. But the period of abstinence appears to depend pri- marily on the husband's wishes. In effect tradi- tional behaviour prescribes the termination of breastfeeding in case of resumption of inter- course which usually starts after six months after birth. Utilization of modern contraceptives was al- most totally absent. Misperceptions about the different kinds of modern contraceptives and their use were found in abundance. For many women induced abortion is seen as the only way of restricting family size. Fears that modern con- traceptives reduce fertility abound and seem to be linked with a large degree of infertility known to be present in the community. An earlier sur- vey found that 45 percent of women attending antenatal care suffered, amongst others, from Candida albicans, Trichomona vagi,nalis, and gono- coccal infections. Female genital mutilation is practised by some tribes. Excision and infibula- tion contribute to reproductive tract infections leading to bilateral tubal occlusion and infer- tility. At the time of the study access to modern con- traceptives was not widespread because of lack of a government policy for family planning so that only one third of the country had appropriate access to modern contraceptives. Where international aid projects included the provision of modern contra- ceptives the response was favourable. The intra- uterine contraceptive device was the method most frequently used. 42 Summary The study examined the range of traditional and spiritual concepts surrounding pregnancy and childbirth. Most of these beliefs and practices prevent appropriate nutri- tion, antenatal, and delivery care. Knowledge of danger signs and risk factors is virtually absent. When illness becomes manifest the women tend to consult compet- ing sectors of traditional and modern medicine, but no referral or cooperation exists between them. The per- ceived curative orientation of antenatal service results in their underutilization. The study findings reinforce the need to develop appropri- ate health education programmes to overcome prevailing prejudices towards the modern health sector and covering a wide range of health education topics, including danger signs in pregnancy and the accompanying antenatal and delivery care. The integration of traditional practitioners into the existing primary health care system should be encouraged. The modern sector would benefit from the upgrading of personnel, equipment, and drugs as well as the development of integrated maternal and child health and family planning services. Continuous education should help nurses and midwives to become more respon- sive to the special needs of pregnant women and to provide family planning education. Outside the health sector, school health education should include sex education in order to avoid unwant- ed, early pregnancies. Finally the health information system should be im- proved to provide accurate information on pregnancy related morbidity and maternal mortality. Resume Guinee-Bissau : Due savent Jes femmes des risques encourus? - elude anthropologique Cette etude portait sur !'ensemble des croyances tradi- tionnelles ou spirituelles entourant la grossesse et l'accou- chement. La plupart de ces croyances et pratiques empe- chent la mere de se nourrir correctement et de recevoir des soins appropries au cours de la grossesse et pendant l'accouchement. Les signes de danger et les facteurs de risque sont presque toujours meconnus. Lorsque les trou- bles deviennent manifestes, les femmes ont tendance a s'adresser ou bien a la medecine traditionnelle ou bien a la medecine moderne, mais ii n'existe pas de systeme d'orientation-recours ni de cooperation entre les deux. Les services de soins prenatals sont perr;:us comme des services curatifs, ce qui entraTne leur sous-utilisation. Les resultats de l'etude font ressortir encore plus la necessite de mettre au point des programmes appro- pries d'education sanitaire pour lutter contre les preju- ges a l'egard de la medecine moderne et assurer une veritable education sanitaire sur tout un eventail de sujets, y compris les signaux d'alarme au cours de la grossesse et !'attention dont ils doivent faire l'objet dans la periode prenatale et au cours de l'accouchement. L'integration des tradipraticiens dans le systeme de soins de sante primaires existants devrait etre encoura- Rapp. trimest. statist. sanit. mond., 48 (1995) gee. Dans le secteur de la medecine moderne ii faudrait ameliorer les qualifications du personnel, des equipe- ments et des medicaments, et developper des services integres de sante maternelle et infantile et de planifica- tion familiale. Une formation permanente devrait etre dispensee aux infirmieres et aux sages-femmes pour leur apprendre a mieux repondre aux besoins particu- liers des femmes enceintes et a donner des conseils de planification familiale. Wld hlth statist. quart., 48 (1995) En dehors du secteur de la sante, !'education sanitaire a l'ecole devrait comprendre une education sexuelle de maniere a eviter les grossesses non desirees et trop precoces. Entin, le systeme d'information sanitaire devrait etre ameliore pour fournir des informations plus exactes sur la morbidite liees a la grossesse et la mortalite mater- nelle. 43 The Lao People's Democratic Republic: Maternal mortality and female mortality: determining causes of deathsa Vincent A. Fauveaub Introduction It is necessary to identify the exact causes of mater- nal mortality and morbidity in order to provide policy makers with choices for health policy devel- opment to improve maternal health services and, ultimately, maternal health status. This, however, is fraught with difficulties in the absence of precision in determining the cause of death in many coun- tries. The investigation summarized below offers an opportunity to study the research approaches taken and the results obtained. During 1991 and 1992 a number of studies had started to identify the extent of maternal mortality in the Lao People's Democratic Republic, which included a hospital-based case study to assess the causes of maternal mortality. Maternal deaths had been estimated at 484 per 100 OOO live births for the years 1988 to mid-1991 (]). An inter-census survey provided an opportunity to obtain further information on reported female deaths at the household level. The total number of female deaths between the ages of 15 to 49 was thus iden- tified as 466 during the survey which covered 25 413 households representative of ethnic, socio- economic, and geographical distribution. In order to determine a more precise maternal mortality ratio, Dr Phonethep Pholsena, Director of the Ma- ternal and Child Health Institute, Ministry of Health, Vientiane, initiated a study to review these deaths at the household level and determine which of the reported deaths would fall into the ICD 10 classification category of "pregnancy-related deaths" (2). Data on maternal deaths was collected during the last round of the inter-census survey in July 1991 covering 300 villages in all 17 provinces of the country. Objective To investigate causes and determinants of deaths of women of reproductive age using case histories. Materials and methods The verbal autopsy method was used to assess the most likely cause of death. The method involves a Summary of the final report submitted to the Safe Motherhood Research Programme, WHO, Geneva, 1993. b Principal Investigator, Mother and Child Health Institute, Vientiane, Lao People's Democratic Republic. 44 the application of a set of questions to determine the underlying clinical causes of those deaths by interviewing surviving family members. The results of the interviews are reviewed and analysed by medical professionals who then determine the most likely cause of death of each woman. Medical professionals from the different mater- nal and child health departments of the respective provincial administrations were trained in inter- view techniques in order to collect information on the circumstances surrounding the deaths of the women identified during the census phase. Home visits were carried out during a half-year period from April to August 1993. Interviews were con- ducted with husbands (22.6%), fathers/mothers (28.2%), brothers/sisters (17.9%), sons/daugh- ters ( 16.0%), other relatives ( 16.0%), and neigh- bours (6.3%) to collect the data. Screening of the initial 466 cases led to the elimination of 33 cases as they were outside of the age range 15-49. Out- migration of family members or changes in the numbering system of houses further reduced the available number for follow-up by 64. When the interviewers came to some of the investigation sites, however, it was possible to reduce these losses with verbal autopsies from 11 other maternal deaths which had occurred in the immediate vicin- ity in the meantime. These additional records were included in the present analysis as the purpose of the exercise was not to calculate rates, but to esti- mate proportions. Given the losses due to out-migration a total of 380 female deaths in the age-group 15-49 years was investigated for 16 out of the 17 provinces in which maternal deaths had been identified. Results Of the total of 380 cases, 127 were classified as maternal deaths (33.4%). The majority of these deaths occurred during the postnatal period (72%), the remainder during different stages of pregnancy. Almost 40% of the cases were due to postpartum haemorrhage ( Tab/,e 1). Tabk 2 presents an overview of the place of death, an indicative classification of the deceased as belonging to either the "poor" or the "well off' social stratum of society, and their respective place of residence. The majority of maternal deaths were among poor women and the vast majority died at home. The highest number of deaths occurred in the rural areas. Lacunae in the provision of appro- Rapp. trimest. statist. sanit. mond., 48 (1995) Table 1 Most likely causes of maternal deaths in women aged 15-49 years, the Lao People's Democratic Republic, 1988-1991 Tableau 1 Causes les plus probables de deces lies a la grossesse chez les femmes adultes de 15 a 49 ans, Republique democratique populaire lao, 1988-1991 Cause of death - Cause du deces Retained placenta (PP hemorrhage) - Retention placentaire (hemorragie du post-partum) Complications of induced abortion - Complications d'avortement provoque Uterine inertia (PP hemorrhage) - lnertie uterine (hemorragie du post-partum) Hemorrhage during pregnancy - Hemorragie au cours de la grossesse Uterine rupture - Rupture uterine Complication of spontaneous abortion - Complications d'avortement spontane Infection (endometritis) - Infection (endometrite) Other pathologies postpartum - Autres pathologie du post-partum All direct obstetric causes - Ensemble des causes obstetricales directes Malaria - Paludisme Cardiopathies Cholera (acute dehydrating diarrhoea) - Cholera (diarrhee et deshydratation aigue) Acute pneumonia - Pneumonie aigue Neurological pathology - Neurologie pathologique Hepatitis - Hepatite Abscess - Abces All indirect obstetric causes - Ensemble des causes obstetricales indirectes Accident (non-intentional) - Accident (non intentionnel) Homicide All injuries - Total des accidents All other and unspecified - Ensemble des autres causes ou causes non specifiees Total Table 2 Number - Nombre 33 14 9 7 7 8 9 6 93 12 5 4 2 1 1 1 26 3 1 4 4 127 % of all obstetrical causes - % de !'ensemble des causes obstetricales 26.0 11.0 7.1 5.5 5.5 6.3 7.1 4.7 73.2. 9.4 3.9 3.1 1.6 0.8 0.8 0.8 20.5 2.4 0.8 3.1 3.1 100.0 Percentage of maternal deaths by social class, place of residence, the Lao People's Democratic Republic, 1988-1991 Tableau 2 Pourcentage de deces maternels par classe sociale et lieu de residence, Republique democratique populaire lao, 1988-1991 Place of death - Lieu du deces Poor - Pauvres Well Off - Aisees Rural - Rurales Urban - Urbaines (n=98) (n=29) (n=113) (n=14) At home, no prior hospital admission - Au domicile, sans admission prealable a l'hopital 71 55 70 50 At home, on return from hospital - Au domicile, au retour de l'hopital 10 10 10 14 In hospital -A l'hopital 14 28 16 29 On the way to hospital - Sur le chemin de l'hopital 3 0 3 0 Other - Autres 2 3 2 7 Wld hlth statist. quart., 48 (1995) 45 priate clinical services are likewise underlined by the high level of case fatality in the hospitals. Summary A sample of 380 female deaths in the age group 15- 49 years from 16 provinces of the Lao People's Demo- cratic Republic were analyzed to determine the most likely cause of death. 127 deaths were classified as maternal, 28% occurred during pregnancy and the re- maining 72% within six weeks of the termination of preg- nancy. Almost three quarters of all maternal deaths were directly related to obstetrical complications during preg- nancy or childbirth. Many of these deaths could probably have been avoided, if appropriate obstetric care had been available. The level of attention to problems related to maternity and childbirth needs to be raised at all responsible levels of the health service system. This must start at the health facility where attending nurses and midwives should be oriented towards pregnancy-related problems and early detection of high-risk women, with appropriate supervisory support. District and national administrations should also focus more on maternity services within their Primary Health Care programme. Resume Republique democratique populaire /ao: Mortalite maternelle et mortalite feminine: causes de deces Trois cent quatre-vingts deces de femmes a.gees de 15 a 49 ans et venant de 16 provinces de la Republique 46 democratique populaire lao ont ete analyses pour es- sayer de determiner la cause probable du deces. Sur 127 deces classes comme deces maternels, 28% ont eu lieu au cours de la grossesse et 72% dans les 6 semaines suivant l'accouchement. Pres des trois quarts des deces maternels etaient directement lies a des complications au cours de la grossesse ou de l'accouchement. Beaucoup de ces deces auraient pro- bablement pu etre evites par des soins obstetricaux appropries. Le degre d'attention porte aux problemes lies a la maternite et a l'accouchement devrait etre releve a tous les niveaux de responsabilite du systeme de so ins de sante. Cela devrait commencer au centre de sante, ou les infirmieres et les sages-femmes devraient etre sensibilisees aux problemes lies a la grossesse et apprendre a depister precocement les femmes a haut risque, et ou une supervision appropriee devrait etre assuree. Les administrations nationale et de districts devraient aussi mettre davantage l'accent sur les servi- ces de maternite dans leur programme de soins de sante primaire. References 1. Spring, C.A. Maternal mortality in the Lao Peopk's Der,wcratic Republic: populo.tion study, 1991. Analysis of national maternal mortality survey phase 1. Final report submitted to the Safe Motherhood Research Programme, WHO, Geneva, 1992. 2. World Health Organization, International statistical classi· fication of diseasliS and relo.ted health probkms - lOth revision, VoL 2, Geneva, WHO, 1993. Organisation mondiale de la sante. Classification statistique internationak dliS malo.diliS et dliS problimes de sante connexes - Dixieme revision, Vol. 2, Geneve, OMS, 1995. Rapp. trimest. statist. sanit. mond., 48 (1995) Mexico: Maternal deaths, fertility patterns, and social cost - an anthropological studya Maria de/ Carmen EJub Introduction Anthropological studies into culturally determined attitudes and health behaviours permit greater un- derstanding of factors which lie outside the imme- diate reach of health services; they also help deter- mine the perceived usefulness and subsequent uti- lization of these services. Research on sexual and reproductive behaviour, including maternal deaths, is a difficult undertaking due to its sensitive nature. In a study spanning more than 3 years, information was obtained from service providers and families of deceased women. This information was valuable for planning services designed to pre- vent maternal deaths. Objectives (i) To examine fertility patterns and assess the reproductive health of women who died from maternal causes; (ii) To identify the prevailing attitudes among the rural population which are opposed to family planning and assess the demand for perinatal care; (iii) To assess the impact of maternal deaths on family life and child development; (iv) To compile documentary evidence on the lives of women who died from maternal causes; (v) To develop indicators for measuring the social cost of maternal deaths; (vi) To use information obtained for correcting the official maternal mortality ratios for rural areas; and (vii) To contribute to the development of a politi- cal will to carry out specific activities and edu- cational programmes to prevent maternal mortality. Materials and methods The study used qualitative instruments to ascertain the extent of maternal mortality and the resulting consequences for the family. In-depth interviews were conducted with survivors, interviews were held with key informants from the health services and the surrounding community, and participa- a Summary of the final report submitted to the Safe Motherhood Research Programme, WHO, Geneva, 1991. b Mexican Institute of Social Studies, Mexico City, Mexico. Wld hlth statist. quart., 48 (1995) tory observation at clinics and in the community helped to extract and explain the social and cultur- al factors which surrounded maternal deaths. From the urban environment 10 maternal deaths were investigated; they had occurred at the Wom- en's Hospital in Mexico City during the years 1986 and 1987. The district of Juan Cuamatzi in the state of Tlaxcala was chosen to present the rural envi- ronment. A total of 16 maternal deaths occurred in the district facilities during the period 1980-1989. All cases were investigated during a 4-year research period, from 1988 to 1991. Information on the cases to be followed up was obtained from death certificates kept at the Women's Hospital in the urban area, and from birth and death certificates kept in the rural district registry offices. The "reconstruction" of life histories was used to identify the socio-cultural environment in which the women lived prior to their untimely deaths. Key informants in this effort were the mothers-in- law, the widowers, the sisters-in-law, the mothers, sisters, neighbours, and in some cases the children. A good deal of time had to be spent explaining the aims of the study to the informants, gaining their confidence to talk about the delicate matters sur- rounding the death of a relative. In order to gain insight into the attitudes and reproductive behaviour of women in the rural area, a questionnaire was distributed to all women above the age of 15 who attended the rural health centre. Questions covered the age of onset of men- struation and first intercourse, the number of chil- dren and abortions, and the use of contraceptive methods. Interviews were further held with key informants, e.g. private doctors practising in the district, TBAs, the parish priest and the most popu- lar prayer leader in the district, health centre staff, and other opinion leaders. Participatory observation of the interactions be- tween staff and patients both at the rural district health centre and the urban women's hospital deepened the understanding of the cultural fac- tors, attitudes and behaviours towards pregnancy and motherhood. Results Maternal death in the socio-cultural context of eco- nomically deprived urban and rural areas is in many ways related to the social roles and identity assigned to women. These roles and identities are 47 established during childhood and are transformed into the traditional reproductive role in adoles- cence and adulthood. Mothers tradionally spend most of their time caring for their children, and during this time they transmit distinctive values to their boys and girls. Not surprisingly, female children develop a very positive image of mother- hood from a very early age, which leads them to seek to establish marital relations at an early age and thus reach fulfilment through married life and motherhood. It is also seen as proof of female fertility which means acceptability to the part- ner's family, and as means to ensure a commit- ment to long-term marital union on the side of the partner. The woman's contribution to the economic well-being of the family and the community tends to be unrecognized by these prevailing values. Motherhood brings with it status, security, and the capacity to handle reproductive power in a society which places social power in the hands of men. The value of motherhood as a source of coun- terbalance to the predominantly male access to power and influence is also demonstrated by the importance ascribed to large families. Both men and women place value on large families and par- ticularly those with many boys. Preference for male children persists in both urban and rural environ- ments. Boys are seen to be a human resource while they are young, and providers of security and liveli- hood for old age. Thus the cycle of positively rein- forcing values is closed. Paradoxically the high value placed on moth- erhood contrasts with the unwillingness to set aside resources for the care of the pregnant woman and seek appropriate help when prob- lems arise. Motherhood is perceived as a natural process and the prevailing attitudes inhibit a speedy reaction to disorders that may develop during pregnancy. Warning signs are not proper- ly interpreted and decisions concerning the mother's health are not taken in a timely man- ner. In fact the study brought to the fore the fact that women, their husbands, and their wider fam- ilies are all unaware of the maternal health risks associated with pregnancy. Thus the consequenc- es of too short birth intervals, high parity, preg- nancy in older age and the health hazards of unsafe abortions were not perceived important enough to merit intervention. Health-seeking behaviour Women in rural areas and even in Mexico City place a high value on being attended by traditional birth attendants during pregnancy and delivery. TBAs are greatly trusted by both women and their husbands. The preference for TBAs may be related to the fact they are female. Male medical attention was not actively sought because of the sex prefer- ence. 48 The investigation found further that the women who died had been entitled to use the antenatal and obstetric services offered by the health facilities of the social security system or other state supported institutions. But utilization of these services was poor and the advice of medical and other health services personnel had often not been followed. In some cases the women left the hospital despite adverse medical circumstances and under- took long journeys despite manifest disorders. There is rivalry between physicians and TBAs and a lack of collaboration between them as pro- viders of maternal care. In the absence of such collaboration, TBAs lack the necessary diagnostic skills to identify women at risk and decide on refer- ral. In some cases when they did suggest referral, the family did not follow the advice. When a wom- an was referred it was usually too late for the medi- cal intervention to be successful. Sometimes the physician was called only to sign the death certifi- cate. Family implications of a maternal death A maternal death is not just a tragic event unneces- sarily taking the life of an otherwise healthy woman. In most cases the infant dies or suffers damage. In 50% of the cases in the rural area the child died either immediately after birth or within the following year. As a consequence of the loss of the mother the whole social fabric and family environment need- ed to be readjusted to take care of the remaining children. While a patrilineal system is apparently predominant, no coherent pattern of integrating the remaining children exclusively into the fa- ther's family emerged. Pragmatism guided the search for solutions and in some cases all chil- dren were kept together and cared for by the family of either the husband or the deceased mother. In other cases the children were split between various relatives thus reducing their brotherly and sisterly bonds, but all were main- tained within the immediate family unit. No chil- dren were placed in public institutions, and their godparents were found to play no role in their care. If the family already had a girl who was considered old enough to look after the remain- ing children, the mother's role was simply transferred to her and, in the urban area, this was the rule despite other women being present in the household. As a consequence, the girls ceased attending school and sought cohabitation with a man as a way to find help for the heavy burden. This often resulted in early pregnancies, problems of single motherhood, in addition to having to look after brothers and sisters. Widowers found it difficult to remarry after their wife's death since their children were per- ceived as obstacles towards forming a new union. But those who left their children in the care of Rapp. trimest. statist. sanit. mond., 48 (1995) their family found it possible to start again and create a new family. Summary The study of life histories of women who died from a maternal causes identified a lack of value attached to the care of the pregnant woman as one of the main constraints to the prevention of maternal mortality. The immediate family members and women who died had considered pregnancy as a "natural" event. Maternal complications were not perceived as meriting appropri- ate medical attention. This negative scenario combined with rivalry between providers of traditional and modern medical care, led to a passivity which ultimately pre- vented appropriate maternal care. These social and cultural values, which reinforce the lack of attention given to pregnant women call for educational efforts on the part of community leaders and health service providers to change the percep- tions of pregnancy and childbirth as a completely "natural" event which needs little health care attention. The conflict between traditional birth attendants and the medical profession needs to be addressed by the respective authorities and educational solutions must be identified to rectify the existing lack of knowledge amongst TBA's. The question of developing a frame- work for collaboration between the traditional and the modern sector of health care will need to be addressed in the future. Wld hlth statist. quart., 48 (1995) Resume Mexique : Deces maternels, profils de tecondite et coiit social. Etude anthropologique Une etude sur les antecedents de femmes decedees de causes liees a la maternite a revele que le peu d'importan- ce accorde au suivi des femmes enceintes etait l'un des principaux obstacles a la prevention de la mortalite ma- ternelle. Les membres de la famille proche et les femmes decedees elles-memes avaient considere que, la gros- sesse etant un evenement «naturel». les complications maternelles ne meritaient pas d'attention medicale parti- culiere. Cette attitude negative, a laquelle s'ajoutait la rivalite entre les dispensateurs de soins traditionnels et ceux de la medecine moderne, s'etait soldee par une passivite qui avail empeche, en fin de compte, que des soins appropries soient dispenses a la mere. Ces valeurs sociales et culturelles, qui accentuent enco- re le manque d'attention dont souffrent les femmes enceintes, necessiteraient des efforts educatifs de la part des dirigeants communautaires et des dispensa- teurs de soins de sante pour faire evoluer la perception de la grossesse et de l'accouchement comme des eve- nements entierement «naturels» ne necessitant pas d'at- tention medicale particuliere. Les autorites concernees devraient s'efforcer de resoudre les conflits entre accou- cheuses traditionnelles et les medecins et trouver des solutions educatives pour remedier a leur manque actuel de connaissances.11 faudrait, aussi, dans l'avenir. definir des modalites de collaboration entre le secteur tradition- nel et le secteur moderne des soins de sante. 49 Pakistan: The Faisalabad Obstetric Flying Squad8 Michele M. Andinab & Fariyal F. Fikreec Introduction Providing access to obstetric emergency services is a major obstacle to reducing maternal mortality. Whereas rural areas suffer from lack of transport, in urban areas the problem tends to be financial barriers to effective use of transport especially among the poor. In Faisalabad in Pakistan an ini- tiative of the Mother and Child Welfare Associa- tion of Faisalabad (MCWAF) seeks to overcome such problems among the urban poor. This repre- sents a good example of providing outreach ser- vices, bringing together traditional birth atten- dants (dais), lady health visitors and hospital obstetric staff as a team. The Maternal Health and Safe Motherhood Programme considered that the initiative merited attention with a view to replica- tion in other developing country settings. In order to assess the likely costs and impact of such an approach, an evaluation of the functioning of the flying squad was commissioned. The Faisalabad Obstetric Flying Squad (FOFS) is one component in a series of activities undertak- en by the MCWAF to combat maternal and child mortality in the city. Created in 1988 under the leadership of Professor Mrs. Altaf Bashir of Allied Hospital in connection with Punjab Medical Col- lege, FOFS is one part of MCWAF's integrated approaches to the provision of improved maternity services to the community. The programme activi- ties of MCWAF include: (i) training and refresher courses for traditional birth attendants (dais); (ii) establishment of maternal and child health (MCH) centres including family planning ser- vices; (iii) free maternity services at the Allied Hospital; (iv) extensive programmes of public health educa- tion through use of media and "mobile health camps"; (v) improved liaison between dais, lady health vis- itors, hospital staff and patients. a Summary of an evaluation report submitted to the Safe Motherhood Research Programme, WHO, Geneva, 1993. h Project Consultant, Mother Child International, Geneva, Switzerland. c Senior Instructor, The Aga Khan University, Karachi, Pakistan. 50 Objective of the evaluation To evaluate the functioning, organizational mech- anisms, impact and community response to the Faisalabad Obstetric Flying Squad. Materials and methods A ten-day evaluation of the organization of FOFS was carried out in late 1993. The evaluation con- sisted of: (i) a review of documents and reports; (ii) a review of project records and logs; (iii) unstructured interviews with project staff; (iv) participant observation of two FOFS calls; (v) focus group discussions with users, lady health visitors and dais; (vi) open-ended interviews with the general public and staff of six of the twenty MCH health centres; (vii) attendance at a session of the community health education programme and a hospital staff meeting. Description of MCWAF's activities The Faisa/abad Obstetric Flying Squad The Faisalabad Obstetric Flying Squad was created in 1988 in response to high levels of maternal morbidity and mortality in the city. It aims to pro- vide free ambulance services to poor mothers in cases of obstetric emergency. The ambulance ser- vice is directly linked to the Allied Hospital and is composed of trained health care providers able to carry out life-saving procedures such as resuscita- tion. The Allied Hospital serves as the referral cen- tre for obstetric emergencies in the area. At the beginning of the project the hospital provided the ambulance for the flying squad but FOFS recently acquired its own, fully equipped vehicle. Between 1989 and 1992 FOFS received 394 emergency calls, representing 2%-5% of all obstetric hospital admissions.cl Dai training and refresher courses The Association provides training for dais in order to improve the quality of maternal and child health d The reason this range of percentages is given is that there was inadequate data on the total number of obstetric admissions. Rapp. trimest. statist. sanit. mond., 48 (1995) services. The training courses are of three months duration and include how to conduct a normal delivery, detection of high risk and abnormal cases, timely referral, asepsis and sterilization, antenatal care, neonatal resuscitation, and family planning. In addition the Association offers an extended one-year training programme for dais. At the Asso- ciation's health centres lady health visitors con- duct one-day refresher courses. Mother and child health centres The Association runs 20 health centres, each staffed by a lady health visitor, a family planning monitor, and a trained dai. The centres are super- vised by the Association's doctor. Deliveries are conducted both at the centre and at home by dais and by lady health visitors. Community education programme and mobile health camps The Association follows up maternal deaths and uses the case histories as the basis for community education through mobile health education ses- sions. These are set up in the neighbourhood where a maternal death has occurred and include presentations to community members on the im- portance of maternal health, the prevention of maternal deaths and the availability and function- ing of the Faisalabad Obstetric Flying Squad. Dur- ing the mobile education sessions health services (immunization, vitamin supplementation) are pro- vided free of charge to mothers and children. Al- lied Hospital medical students and health centre staff participate actively in such sessions. Survey of maternal deaths in the community Since 1980 efforts have been made to document all maternal deaths in the municipality of Faisalabad, whether occurring in government or private hospi- tals, health centres or at home. This has resulted in the identification of significantly more maternal deaths than those officially registered. A special effort is made to investigate the circumstances leading to these deaths by talking with health workers and family members of the deceased woman. At the same time the neighbours of the dead woman are informed about risk factors for maternal mortality and how to avoid them. Mobile service unit and other activities Two mobile service units provide outreach services for family planning in the rural areas. Each service unit covers 10-12 villages and visits are conducted on a daily basis. A registered nurse or midwife supervises the activities of trained field workers. Community education sessions are also held in the villages. Wld hlth statist. quart., 48 (1995) In addition to the health education sessions, the Association has its own newsletter and has pro- duced videos for more widespread information dis- semination. A 50-bed maternity hospital is currently under construction next door to MCWAF headquarters. This has been built with the aid of donations from Baitul Mal Government of Pakistan and through local fund-rasing activities. A Public Health School has been created to address the shortage of trained lady health visitors and midwives. It will be based at the maternity hospital. The Association is also ad- dressing the issue of women's health and devel- opment from a broader perspective. For example, in order to reduce gender discrepancies in access to education the Association has opened three pri- mary schools for girls. They are housed at health centres in the Faisalabad slum area. A programme to strengthen the skills of women in embroidery and sewing techniques and thus create opportuni- ties to generate income has also been developed. Evaluation of the FDFS At the the start of its operation in 1989 and due to telephone congestion it was often difficult to relay telephone calls through to the labour ward. The flying squad did not have its own transport. The situation improved considerably in 1993 when an ambulance was donated, the Association hired its own driver and telephone connections were im- proved. The evaluation team participated in two obstetric emergency missions of the "Flying Squad". In both cases it took around one hour to travel from the hospital to the patient and back, a reasonable time given the traffic conditions. How- ever, it was not possible to assess delays on the basis of records as the log books were not maintained with a sufficient degree of accuracy. Knowledge of FOFS Users learn about FOFS mainly during pregnancy or during a difficult delivery when a dai or lady health visitor requests relatives or friends to call the service. Discussions with the users indicated a de- gree of resistance to summoning assistance from the hospital. It is a common belief that "people go to the hospital to die". Furthermore, husbands and mothers-in-law play an important role in determin- ing whether or not medical help is sought. The Association is attempting to overcome such resis- tance through its educational campaigns. The Association's dais and lady health visitors were well informed about the role and functions of the flying squad which they learn about during training and refresher courses. Untrained dais working in the community knew very little about the service. Community members learn about the flying squad during community education sessions as well as by word of mouth. 51 FOFS staffing, equipment, recording mechanisms, costs The flying squad differs from ordinary ambulance services in that it is staffed by highly trained obstet- ric personnel. Close collaboration between the hospital administration and FOFS exists, and the hospital cooperates in providing essential staff. Emergency and resuscitation equipment including oxygen is kept in the ambulance. All calls to the flying squad are recorded at Allied Hospital and travel details are kept in the ambulance log book. A questionnaire on the pa- tient's medical history is filled out after arrival at the hospital. Several shortcomings in these data- bases were identified and proposals for streamlin- ing and improving the quality of the data collected were made. The proposed additions and changes would facilitate a quantitative analysis of the efkc- tiveness of FOFS in the long run. FOFS has no separate budget of its own. It is, in effect, an organizational scheme superimposed on the routine operations of Allied Hospital in order to provide poor women with access to obstetric emergency services in the city. With the exception of the donated vehicle, all the running costs of the ambulance service, vehicle maintenance, medical equipment and replacement costs and staff salaries are covered by the routine hospital operations. Profile of FOFS users Users of FOFS are predominantly of low socioeco- nomic status. Most of the users of the service had little or no education ( Table 1) though the educa- tional level of spouses was higher ( Tab/,e 2). In 1990 all users were housewives, whereas in 1992 a small proportion (3%) was employed. Husbands were mainly unskilled labourers (70% in 1990 and 51 % in 1992) and unemployment was high (17% in 1990, 20% in 1992). There is no available tabulated information on age, gravidity, parity, booking sta- tus, prior pregnancy history or distance from the Table 1 hospital though such information is collected dur- ing record keeping. Complications handled by FOFS and outcomes Among the most common indications for FOFS calls were labour pains, abortion, eclampsia and postpartum haemorrhage ( Tab/,e 3). However, due to a lack of comparable hospital admission data for similar conditions it is not possible to evaluate the impact of the service on handling obstetric compli- cations. A key indicator for appropriate and effi- cient use of FOFS is the outcome for mother and infant. Unfortunately this information is not readi- ly accessible preventing a scientifically rigorous as- sessment of the impact of FOFS. Perceptions of FOFS by users and non-users Users stated generally high levels of satisfaction with the service particularly with the fact that it is free of charge. Users noted, with satisfaction, that the service works in conjunction with the tradition- al dais who accompany the women to the hospital which helps to reduce the fear of the institution. The integration between community and hospital services was much appreciated. Focus group discussions revealed that non-us- ers experienced higher costs in trying to reach the hospital during obstetric emergencies than did FOFS users. The dais themselves were very positive in their evaluation of the service. They felt appreciated by the hospital staff and the emergency medical team and were glad to be considered part of a maternal health care team. They felt that the ability to refer women with problems reduced their exposure to major obstetric complications and risk of maternal death - an outcome which reflects poorly on their skills and damages their reputation. Through the recognition of their work by the "institutional" health services, their status in the community was enhanced. More specifically they mentioned the Education level of mothers using Faisalabad Obstetric Flying Squad services, Faisalabad, Pakistan, 1990 and 1992a Tableau 1 Niveau de d'education des meres utilisant les services de la «brigade volante» obstetricale de Faisalabad, Pakistan, 1990 et 1992a Education - Scolarite 1990 1992 Number - Nombre % Number - Nombre % None - Aucune 96 88 65 63 Primary - Primaire 11 10 23 22 Secondary & over - Secondaire et plus 2 2 15 15 Total 109 100 103 100 a Sources: Bashir, A. et al. Faisalabad obstetric flying quad services and analysis 1992. Unpublished paper. 1992, and Bashir, A. et al. Management of eclampsia. A longitudinal study. The Gynaecologist 3(2-3): 29-32 (1993). 52 Rapp. trimest. statist. sanit. mond., 48 (1995) Table 2 Education level of spouses using Faisalabad Obstetric Flying Squad services, 1990, 1992a Tableau 2 Niveau d'education des epoux utilisant les services de la «brigade volante» obstetricale de Faisalabad, Pakistan, 1990 et 1992a Education - Scolarite 1990 1992 Number- Nombre % Number - Nombre % None - Aucune 76 70 53 51 Primary- Primaire 17 15 33 32 Secondary & above - Secondaire et plus 16 15 17 17 Total 109 100 103 100 • Sources: Bashir, A. et al. Faisalabad obstetric flying squad services and analysis 1992. Unpublished paper, 1992, and Bashir, A. et al. Management of eclampsia. A longitudinal study. The Gynaecologist 3(2-3): 29-32 (1993). Table 3 Distribution of indications for FOFS calls, Faisalabad, Pakistan, 1989-1992a Tableau 3 Repartition des indications d'appels a la «brigade volante» obstetricale, Faisalabad, Pakistan 1989 1990 1991 1992 N. % N. % N. % N. % Antepartum haemorrhage - Hemorragie antepartum 10 14 18 16 10 10 11 11 Postpartum haemorrhage - Hemorragie du post-partum 20 28 5 4 6 6 12 12 Pregnancy-induced hypertension/ eclampsia - Hypertension due a la grossese/eclampsie 2 2 8 7 27 26 24 23 Prolonged labour - Travail prolonge 19 26 9 8 7 7 6 6 Ruptured uterus - Rupture de l'uterus 0 0 1 1 0 0 0 0 Puerperal sepsis - Infection puerperale 1 1 6 5 0 0 0 0 Abortion - Avortement 8 11 11 10 24 23 21 20 Ectopic pregnancy - Grossesse extrauterine 0 0 2 2 0 0 0 0 Labour pains - Contractions 12 17 47 41 30 29 27 26 Other - Autre 1 1 4 4 0 0 0 0 Bogus call - Appel bidon 0 0 3 2 0 0 2 2 Total 73 100 114 100 104 100 103 100 • Source: Bashir, A. et al. Faisalabad Obstetric Flying Squad services and analysis 1992. Unpublished paper. 1992. fact that the service comes quickly when called; mothers are transported in comfort; trained staff accompany each case; use of FOFS speeds up hos- pital admission formalities; dais gain respect and status (families make additional payments); and families have more confidence in hospital services. The dais noted some problems in locating tele- phones in the vicinity of the mother's homes as well as problems reaching staff at the hospital due to the congested telephone system. Staff at Allied Hospital were deeply impressed with the services. The additional exposure of jun- ior staff and medical students to preventive obstet- ric care at the community level was appreciated. It contributed to their training and alerted them to the public health aspects of their work. Wld hlth statist. quart., 48 (1995) Conclusions Within the comprehensive Mother and Child Health Care programme developed by MCW AF, the FOFS has the potential to be an effective project for improving maternal and infant health. However, much work remains to be done, on both the organizational and research level, for its impact on maternal morbidity to be measured. Because maternal mortality is a rare event, dem- onstrating the independent effect of the service using maternal deaths as the outcome will be impossible. Instead, indicators should be devel- oped focusing on comparisons of FOFS users and non-users to demonstrate the impact of FOFS in reducing obstetric complications and improving health outcomes. 53 The service has the potential for replication, if integrated within an existing MCH programme where special attention is given to improving com- munity awareness of obstetric complications as well as training of health care providers. Efficient record keeping and outreach programmes are nec- essary components of the service. Due to the lack of financial information it was difficult to evaluate the economic burden of the project. However, in cities such as Faisalabad, where the necessary re- sources can be mobilized within existing health infrastructures, financial arrangements like those under which the FOFS functions may be feasible. Summary The Faisalabad Obstetric Flying Squad was established in 1988 and provides access to emergency obstetric services for the poor women of Faisalabad. The service is highly appreciated by both women and participating dais. The latter receive training from the Mother and Child Welfare Association of Faisalabad and form an integral part of the obstetric care team. While problems in accessing communication facilities exist, the project has made a lasting impact on the provision of emergen- cy obstetric services in the city. Improved recording and reporting mechanisms would permit a more precise assessment of the impact of the service on the reduction of maternal morbidity and mortal- ity. It would also permit an assessment of the operating costs of the service. One of the reasons the service functions effectively is that it is fully integrated into the general operations of the Allied Hospital. If similar institu- tional mechanisms can be established there is good reason to think that the Faisalabad Obstetric Flying Squad could be replicated in other developing country settings. 54 Resume Pakistan : La «brigade volante» obstetricale de Faisalabad La «brigade volante» obstetricale de Faisalabad a ete creee en 1989 pour permettre aux femmes defavorisees des quartiers pauvres de la ville et des campagnes environnantes d'avoir acces a des services obstetri- caux d'urgence. Ce service est tres apprecie tant par les femmes que par les accoucheuses traditionnelles par- ticipant a ces brigades. les dais. Ces dernieres re9oi- vent une formation a !'Association pour la protection maternelle et infantile de Faisalabad et sont basees dans leurs centres de sante. Elles font partie integrante de l'equipe obstetricale et peuvent fournir un recours approprie. Bien que des problemes de communications continuent d'exister, ce projet exemplaire a eu des effets durables sur la fourniture de services obstetricaux d'urgence dans la ville. II a permis de mieux integrer les differentes composantes du travail de !'Association, par exemple !'education des jeunes filles, et la formation professionnelle, !'organisation de campagnes de sensi- bilisation de la communaute et d'education sanitaire, et la fourniture de services de soins pre- et perinatals et de planification familiale ainsi que de soins obstetricaux d'urgence, en tant que contribution a une maternite sans risque. Une amelioration du systeme d'enregistrement et de notification des donnees permettra d'evaluer avec plus de precision l'impact de ce projet sur la reduction de la morbidite et de la mortalite maternelles. II faudrait consolider la structure organique du projet et etablir des systemes dependant mains de !'initiative de contribuants individuels et tirant davantage leur force d'une bonne organisation. Rapp. trimest. statist. sanit. mond., 48 (1995) Pakistan: Consumer satisfaction and dissatisfaction with maternal and child health servicesa Shameim Kazmib Introduction In Sindh province in Pakistan little research into the functioning of maternity services had been per- formed prior to this study. Very little knowledge existed on the socioeconomic and demographic profile of the consumer population, the extent of services utilization, the adequacy and preferences for particular service providers, and the satisfaction of users with the services. A large study was therefore designed to improve the knowledge base for deci- sion-making in maternal health policy. In an admir- able manner of pursuit the data were gathered under extreme conditions of civil unrest through- out parts of the province. Study areas sometimes had to be quickly adjusted to conduct interviews with health staff and women in the community in order to obtain the required information. Objectives (i) To assess the types of maternal and child health care services mothers usually prefer and consider safe for survival, and the reasons for the usage of private and public sector facil- ities or non-allopathic services. (ii) To evaluate the basic maternal and child health care services received by mothers dur- ing the pre- and postnatal period and study the available facilities and evaluate the effec- tiveness of their interventions. (iii) To obtain the consumer viewpoint from moth- ers on the maternal child health services acces- sible to them. (iv) To assess the awareness about the availability of services especially in rural areas, both pre- ventive and curative. (v) To assess the average cost of a delivery through various available services and practi- tioners. (vi) To investigate the reasons for the reluctance of lady doctors, midwives, and lady health visi- tors to serve in rural areas. (vii) To indicate areas for improvement of service outlets aiming at more effective interventions, a Summary of the final report submitted to the Safe Motherhood Research Programme, WHO, Geneva, 1991. b Principal Investigator, Marketing and Research Consultants and National President, Association of Business Professional and Agricultural Women, Karachi, Pakistan. Wld hlth statist. quart., 48 (1995) particularly for maternal and neonatal servic- es, leading to the reduction of maternal mor- tality, morbidity, and neonatal deaths. Sindh province: demographic and health profile A population growth rate of 3.6% has been regis- tered for Sindh province for the years between 1985 and 1988. On average a household consisted of 7 family members during the same period. There is an uneven distribution between males and females in the population (1 000:902, 1981 census), but the difference is expected to diminish. Life expectancy was 60 years for women and 61 years for men (1988 estimates), a pattern which does not correspond to the generally higher life expectancy of women in other countries. In effect, possibly due to inattention to girls' nurturing during the early years of childhood, many die dur- ing infancy, which would explain a part of the unusual difference in life expectancy. Infant mortality has seen remarkable declines during the 1980's in Sindh province. It de- creased from 121.6 per 1 OOO live births in 1984 to 107.7 in 1986. Differences in male and female health status are noted. Women comprised 55% of all persons registered as suffering from one or an- other form of disability. The existing health services infrastructure is considered inadequate. There is one hospital per 45 OOO women and one maternity and child wel- fare centre per 60 OOO women. Sindh has been equipped with 1 552 dispensaries. But with already more than nine million women registered in the province during the 1981 census, it is unlikely that the few dispensaries can adequately provide quality maternal health services. While educational levels are generally low throughout the provinces of the country with 26.2% (1981 census) literacy, Sindh stands out as having a relatively high female literacy rate of 21.6%. Primary school enrolment points to differ- ences in preference for educating boys as opposed to girls. Male primary school enrolment is quoted as reaching 66.64% in 1987 whereas girls' enrol- ment reached only 33.4%. Participation of women in the workforce is diffi- cult to measure. It is not clear whether official statistics include part-time employment of women, self-employed females, and women earning casual income in handicraft, embroidery, and animal hus- bandry and agriculture. Of the women designated 55 as gainfully employed the vast majority is quoted as working in community work, personal social ser- vice work, and the non-metallic minerals sector. Materials and methods The survey of service providers and users extended to four rural (Sanghar, Thatta, Dadu, Nawabshah) and two urban (Karachi, Hyderabad) districts out of fourteen in Sindh province. A total of800 house- hold interviews were conducted in the urban areas and 400 in the rural environment. As methods of enquiry both quantitative and qualitative methods were employed. The latter included focus group discussions, in-depth interviews, and participatory observation. Interviews were further conducted with service providers at all levels from both the private and the public sector including policy decision makers. Thus data was collected from a further 1 500 inter- views reflecting the institutional opinions. Results Socio-demographic and income profile of women interviewed The majority of the women interviewed were in the prime reproductive age group of 21 to 34 years (76.1 %). Few women (3.9%) were below the age of 20, and 20% were in the age group 36-45. Other than in the age group below 20 years (urban: 2.8%; rural 6.3%) there were no marked urban/rural differences in the composition of the interview groups. Educational attainment was expectedly very low. More than half of the women (58.8%) were illiterate, but the educational disadvantage of rural women stood out: 84.8% were illiterate as opposed to 45.8% in the urban sample. Their families tended to be large, both in the urban and in the rural environment with an average of 7 to 8 family members. Household income was mainly generat- ed by the men. Only 7% of the women had access to income in the urban setting and 11 % in the rural areas. But the income earned was low. On a monthly basis more than half of the women (54.2%) earned less than 500 rupees, more than one fourth (27.4%) were in the income bracket above 500 to 1 OOO rupees, a little more than a tenth ( 11.2%) of the women earned between 1 OOO and 2 OOO rupees, and the remainder (7.3%) gained more than 2 OOO. But the general income situation can be described as depressed as three quarters of the families did not dispose of more than 2 OOO rupees per month. Pregnancy experience It is not unreasonable to assume that the number of pregnancies and different delivery experiences influence the attitudes towards the different kinds 56 of service providers and the perceived quality of care. The vast majority of the women (804 of 1 200) had had at least 6 pregnancies at the time of the interview. Many of them had also experienced miscarriages, stillbirths, caesarean sections, and forceps delivery ( Tabl.e 1). In analysing the different types of complica- tions and illness episodes during pregnancy large differences between urban and rural disease pat- terns emerged. A considerably higher percentage of miscarriages was recorded for the rural (13.4%) as opposed to the urban (7.9%) area. Possibly due to the availability of skills and technology a higher degree of caesarean sections was noted in the ur- ban sample with almost 2.6% of all deliveries. In the rural sample only 1 delivery by caesarean sec- tion had been performed in a total of 1896 deliver- ies (0.1%). Delivery assistance was provided by different kinds of prm,iders as depicted in Tabl.e 2. Most deliveries were attended to by the traditional dai (almost 57%), but a large urban/rural difference is evident. While Dai delivery attention reaches more than 90% in the rural sample, it is only 39% in the urban environment. Satisfaction with the services rendered by the different kinds of providers is consistently high with between 93% and 98% for the different pro- viders. Dai services are especially appreciated for the conduct of delivery in the rural areas. But when probing for the reasons of high levels of satisfac- tion it was found that the women mostly formed their opinion on the basis that dais provide the much appreciated service of home delivery. The convenience and lower costs for the associated Table 1 Pregnancy experience and pregnancy outcome, Sindh province, Pakistan, 1990 Tableau 1 Deroulement et issue de la grossesse, province de Sindh, Pakistan, 1991 Characteristics - Value - Nombre % Caracteristiques Respondents - 1 200 Femmes ayant participe a l'enquete Deliveries - 5 642 Accouchements Normal deliveries - 4 809 85.2 Accouchements normaux Miscarriages - 550 9.8 Fausses couches Caesarean section - 98 1.7 Cesariennes Forceps delivery - 18 0.3 Accouchements par forceps Rapp. trimest. statist. sanit. mond., 48 (1995) Table 2 Delivery and delivery attendant, Sindh province, Pakistan, 1990 Tableau 2 Assistance fournie lors des accouchements, province de Sindh, Pakistan, 1990 Attendant - Type d'assistance Deliveries - Accouchements Urban- % Rural- % Total % Zone rurale Zone rurale Traditional birthattendant (dai) - Accoucheuse traditionnelle (dai) 1 461 39.0 1 739 91.7 3200 56.7 Lady doctor - Medecin femme 1 773 47.3 68 3.6 1 841 32.6 Nurse/lady health visitor - lnfirmiere/visiteuse de sante 429 11.5 36 2.0 465 8.2 Relative/neighbour - Parente/voisine 74 2.0 44 2.3 118 2.1 Homeopath/hakeem - Homeopathe/hakeem 7 0.2 0 0.0 7 0.1 Other - Autres 2 0.1 9 1.0 11 0.2 Total 3 746 100 1 896 100 5 642 100 Table 3 Reasons for home delivery, Sindh Province, Pakistan, 1990 (Number and percentage of respondents, multiple answers) Tableau 3 Raisons invoquees pour accoucher a domicile, province de Sindh, Pakistan, 1990 (Nombre et pourcentage de personnes ayant repondu a l'enquete, reponses multiples) Reason - Raison invoquee Urban- Zone urbaine Income too low to afford the hospital - 57 Revenu trap faible pour payer l'hopital Continuity of home/child care - Obligation de 132 continuer a s'occuper de la maison/des enfants Dai/midwife cheaper/available/of good quality - 122 II est mains cher/plus facile de faire appel a une dai/ une sage-femme, dont les services sont de qualite No hospital near home - Pas d'hopital a proximite 25 Delivery sudden/no time to go to hospital - 37 Soudainete de l'accouchemenUpas le temps de se rendre a l'hopital Husband/family forbid out-of-home delivery - 19 Le mari/la famille s'opposent ace que l'accouchement ait lieu en dehors de la maison Hospital staff generally rude and careless - 19 D'une maniere generale, le personnel hospitalier est impoli et sans egards transport and delivery costs seem to underlie the rural preference. Delivery by a dai cost approxi- mately 50 rupees as opposed to 200 - 300 in a hospital for which additional cost had to be borne for transport. Wld hlth statist. quart., 48 (1995) % Rural- % Total Zone rurale 29.8 134 70.2 191 61.1 84 38.9 216 92.4 10 7.6 132 15.9 132 84.1 157 77.1 11 22.9 48 35.2 35 64.8 54 90.5 2 9.5 21 Problems with access to transport persist and high costs, in addition to the expenses for the delivery, have to be covered ( Tab/,e 3). Low income also played a significant role for the preference of rural women to deliver at home (70%), as did the 57 lack of a hospital in the vicinity (84%). Further- more, delivery by a traditional birth attendant al- lowed for the continuation of work at home and did not necessitate arrangements for the care of the children, an opinion which was more pro- nounced in the urban (61 %) than in the rural sample ( 44%). Traditional values determine the delivery procedure in the rural areas. Almost two thirds of the women quoted the family or the hus- band insisting on home delivery. In the cities, hos- pital staff described as "rude" reinforced the wish amongst a minority of women (0.3%) to deliver at home under the care of a dai. In probing the opinion of the women on the perceived safety of home versus hospital delivery, the urban/rural difference was confirmed: 63.5% of the urban women considered the hospital as the safest place, but only 29.5% of the rural women thought so. Pregnancy outcome did not play a major role in the overall positive evaluation of the service provid- Table 4 ers. A maternal or child death was seen as "God's wish" by almost 70% of all women inter- viewed. But 49 women in the study saw the dai as responsible for a negative pregnancy outcome. However, this perception was mainly shared amongst the rural women (83%). Tab/,e 4 sums up the collective opinion which indicates an absence of concern over issues of quality of care and service provider responsibility. Service availability The investigation notes the poor distribution of a medically trained workforce to provide appropri- ate antenatal, delivery, and postpartum care. Most newly graduated medical doctors tend to set up their practice in the urban environment and lady doctors are difficult to recruit and retain in the rural zones. Incentive schemes need to be set up to attract more medical staff to serve the rural popula- tion. Consumers opinions on reasons for maternal or child mortality, Sindh Province, Pakistan, 1990 Tableau 4 Opinion des consommateurs sur les causes de la mortalite maternelle ou infantile, Pakistan, 1991 Reason - Raison evoquee All - Ensemble N. % God's wish - Volante de Dieu 415 69.2 Dai 49 8.2 Physical weakness of mother - 44 7.3 Faiblesse physique de la mere Doctor - Medecin 37 6.2 Hard work/tension/slipping - 22 3.7 Travail difficile/tension/ fausse-couche Lack of health facility - 19 3.2 Absence de services de sante Husband - Mari 9 1.5 Mother-in-law/other 5 0.8 family member - Belle-mere/ autres membres de la famille Total 600 100 Summary The attitudes of a sample of 800 urban and 400 rural women towards pregnancy services and delivery care in Sindh province, Pakistan, were surveyed. The sample consisted of predominantly poor and illiterate women of reproductive age. Generally little access to quality insti- tutional care services existed in the rural areas. Most 58 Urban - Zones urbaines Rural - Zones rurales N. % N. % 145 72.5 270 67.5 8 4.0 41 10.3 3 1.5 41 10.3 28 14.0 9 2.3 8 4.0 14 3.5 0.5 18 4.5 5 2.5 4 1.0 2 1.0 3 0.8 200 100 400 100 rural women delivered at home using the services of the traditional midwife, the dai. Concern for costs and con- venience was found to be coupled with a high degree of trust in the services of the dai. In the urban setting preference for the dais' services was likewise ex- pressed, but the hospital was considered the safest place for delivery by the majority of respondents. The quality of the services rendered by all occupational Rapp. trimest. statist. sanit. mond., 48 (1995) groups was considered highly, in particular those of the traditional dais. The absence of trained doctors in the rural areas is noted and changes to increase their availability and services are proposed. Resume Pakistan : Jes consommateurs sont-ils satisfaits des services de sante maternelle et infantile ? On a etudie !'attitude de 800 femmes citadines et de 400 femmes de milieux ruraux a l'egard des services de soins maternels et des services obstetricaux de la province de Sindh, au Pakistan. Les femmes de l'echan- tillon etaient essentiellement des femmes pauvres et Wld hlth statist. quart., 48 (1995) analphabetes en age de procreer. D'une maniere gene- rale, les femmes des zones rurales avaient peu acces a des services hospitaliers de qualite. La plupart accou- chaient a domicile en faisant appel a une accoucheuse traditionnelle, la dai. Ce choix s'expliquait par des considerations de coot et de commodite, mais aussi par la confiance qu'elles avaient dans les competences de la dai. En milieu urbain, une preference etait egalement exprimee pour les services de la dai, mais la majorite des femmes ayant repondu a l'enquete consideraient que l'hopital etait le lieu le plus sOr pour accoucher. Les femmes avaient une haute idee de la qualite des servi- ces assures par tous les groupes professionnels, en particulier les accoucheuses traditionnelles. L'absence de medecins qualifies dans les zones rurales a ete notee, et des reformes ont ete proposees en vue de renforcer leurs effectifs et leurs prestations. 59 Sudan: Situational analysis of maternal health in Bara District, North Kordofana Martha Campbeflb & Zeinab Abu Shame Introduction Women in Sudan face a high risk of death in preg- nancy and childbirth. Hospital statistics indicate a range of maternal mortality ratios from 541 to 2 270 deaths per 100 OOO live births. Maternal mor- tality rates differ significantly by region with the eastern and western regions having higher rates than the central regions and Khartoum. According to a study conducted in 1989, the maternal mortal- ity ratio is 407 deaths per 100 OOO live births in Bara District of North Kordofan. In partnership with the Ministry of Health, CARE International in Sudan implemented the Bara Maternal Health Project (BMHP) to reduce maternal mortality in selected Rural Councils of Bara District over the period 1990-92. As the first stage of the BMHP, CARE and the Ministry of Health (MOH) conducted a qualitative study on maternal health services and maternal health-seeking behaviour in Bara District. The BMHP Study on maternal health in Bara District explored the factors contributing to the high ma- ternal mortality ratio measured in the region. The study provides in-depth information on maternal health from the perspective of the rural communi- ties and front line health workers. Based on the results of the Study, CARE and the MOH, with assistance from a technical consultant of WHO, identified appropriate interventions to be sup- ported by the BMHP which address the factors directly involved with maternal mortality. Materials and methods The study was based on a simple multi-stage strati- fied format to obtain information from the target groups at four levels: (i) Village (mothers of children under 5 years; community leaders or village health commit- tee; and trained and untrained traditional birth attendants (TBAs)) ;. (ii) PHC unit, Village Midwife Post (village mid- wives (VMWs) and community health workers (CHWs)); a Executive summary of the final report submitted to the Safe Motherhood Research Programme, WHO, Geneva, 1990. h Team Leader, Bara Health Improvement Programme, Care International, Khartoum, Sudan. c Deputy Project Manager, Care International, Khartoum, Sudan. 60 (iii) Rural dispensary (Medical assistants, village midwives and nurses); and (iv) District health centre, rural hospital (Medical of- ficers, nurse-midwives and health visitor). The study was implemented in the rural coun- cils of Bara, Gerejikh and Taiyba. These rural coun- cils were selected because they represent the west- ern and eastern Bara Health Areas and the location of the first referral level in Bara Rural Council. The Study relied on qualitative information collection techniques to reveal beliefs, attitudes and practices of the study groups. The methods applied were focus group discussions, semi-structured individual interviews and direct observations. The study was designed and implemented over the period March to July 1990. In consultation with the Regional and District MOH, the project devel- oped question guidelines. The guidelines consist- ed of open-ended questions for each target group. The BMHP relied on 3 facilitators from the Minis- try of Education and 3 project staff members. The team received 5 days of training. Following each interview or discussion, the interviewer and recorder or supervisor reviewed and expanded their notes in the afternoon or evening. They re- corded the information on prepared forms for fil- ing and later reference. The team met periodically throughout the study to review the guidelines and conduct a pre- liminary analysis of the data. Following the data collection phase, the data were analyzed by reviewing each topic area by stra- ta and identifying the types of responses emerging from the data. This document summarizes the findings of the study. Results Causes of maternal mortality The community groups and health cadres identi- fied several causes of maternal mortality. The direct causes of maternal deaths, caused by compli- cations of pregnancy or delivery, are hemorrhage ( during the first and last trimesters and postpar- tum), puerperal infection, obstructed labour and toxemia. Other existing conditions, such as viral hepatitis, anemia and urinary tract infections, can be aggravated or prove fatal during pregnancy or delivery. The target groups emphasized other contribut- ing factors to maternal mortality or morbidity such Rapp. trimest. statist. sanit. mond., 48 (1995) as pharaonic circumcision, a woman's reproduc- tive history, the inaccessibility of health facilities, women not seeking care unless they are seriously ill, and other socioeconomic factors. Pharaonic cir- cumcision, estimated at 97% in Bara District, caus- es many complications in pregnancy and child- birth for women, including a higher risk of urinary tract, reproductive tract and puerperal infections, the need to be deinfibulated during delivery, tear- ing of scarred vulva tissue that does not dilate prop- erly to allow the safe passage of the baby through the vagina, and urinary or rectal fistula. Within the MOH system, health workers at all levels are limited in their abilities to prevent, diag- nose, treat and manage complications of pregnan- cy and labour due to the chronic inadequate sup- ply of drugs, their lack of training, the lack of supervision within the MOH infrastructure, and the poor status of the health facilities. Prenatal care Factors which influence whether a pregnant woman would seek prenatal care are the location of the facility or post of the village midwife, the travel distance that results from this distribution, the available transportation means necessary to cover the distances, previous experience with the health care system, and perceived quality of care. In areas within access to the District Health Centre, a rural dispensary or a village where a village midwife (VMW) is posted, an overwhelming majority of pregnant women (90-100%) seek pre- natal services from the Health Visitor, VMW or Medical Assistant. If mothers are not within 30 minutes by local transport ( camel or donkey), they generally do not seek prenatal care unless they are very sick. The mothers explain that the finan- cial and opportunity costs are high. In addition, the facilities or the VMW often do not have the supplies to treat their problems or are simply not adequately staffed. The women may travel the long distance only to discover that the health worker is absent. The role that quality of care played in the women's decision to seek care is directly a prod- uct of their own assessment of service delivery made through their and other women's experi- ence with the health system. The mothers involved in the study equated pre- natal care to treatment of any illnesses or disorder present during their pregnancy and referral, if re- quired. The mothers identified several conditions which they recognize as serious enough to justify seeking medical treatment during pregnancy such as bleeding, swelling, dizziness and malaria. An individual's assessment of a health condition is of course influenced by the prevalence of the con- dition. Anemia is endemic in Sudan, yet women with anemia often do not recognize that their con- dition warrants medical care. Wld hlth statist. quart., 48 (1995) The effect of distance on service-utilization var- ies with the quality of care provided. Where the village mothers have access to more than one health post, their responses to questions about ser- vice-utilization reflect that their judgment about the quality of care often takes precedence over concerns about the relative distances involved. For example, mothers in one village in Gerejikh Rural Council prefer to access services from the Health Centre in Bara Town, which is 4 hours by donkey, despite the presence of a VMW and a trained TBA near them, because they desire the higher quality and broader range of services offered at the Bara Health Centre. At the Health Centre and Rural Dispensaries, the health workers offer comprehensive services, including a physical check of the fetal position, urine and blood analysis, and blood pressure mon- itoring, if the equipment is available and function- ing. The health workers at this level are hampered in their delivery of services by the lack or poor state of the equipment and their limited training. The VMWs posted in villages generally provide only physical exams of the fetal position and nutritional advice to pregnant women on a balanced diet. The VMWs generally refer complicated cases to the ru- ral dispensary and, in some cases, the community health workers (CHW) for treatment (e.g. mal- aria). The VMWs are limited in their service provi- sion to mothers by their inadequate equipment (thermometer, weighing scale, blood pressure cuff, or strips or test tubes to test urine for (albu- min or sugar), supplies (anesthesia, drugs and vita- mins), and knowledge to assess risks or diagnose pelvic disproportion and fetal positions. Trained TBAs provide nutritional counseling and physical exams to pregnant women. They know the major signs for referral. The untrained TBAs basically only assist pregnant women at the stage of labour. All through the health system, the health workers focus on screening patients for high risks. Pregnan- cy monitoring through repeated contact is prac- ticed infrequently. In sum, the health workers can only offer limited prenatal care for screening or monitoring of any value. Delivery The mothers prefer to give birth at home where they receive good support and services from their relatives and neighbors. Delivery at home also eliminates high costs of the mother's transport to the referral centre and for her relatives to visit her. The mothers prefer delivery services from trained workers: the trained TBA or the VMW. The mothers interviewed prefer the trained workers because they use hygienic practices, proper "ster- ilized" instruments, local anesthesia and cat gut for stitching the wounds and reinfibulating the wom- en, and assist the women to deliver on local beds, 61 not in a squatting-position, pulling on a suspended rope, which is deemed humiliating. The "wounds" referred to by the mothers and health cadres are incisions to widen the opening for the safe passage of the newborn which involve a decircumcision process and often a lateral incision or anterior lateral episiotomy. After delivery, the VMWs and TBAs reinfibulate women under local anesthesia by sewing together the edges of the scar tissue. Despite the preference of mothers to receive trained assistance, 61 % of mothers in areas with no trained health worker in Bara Rural Council were attended by untrained TBAs, according to a study conducted by UNICEF in January 1990. The indi- vidual caseload of the TBAs, however, is very low relative to the trained health cadres. The un- trained and trained TBAs deliver on average one baby per month. The VMWs posted in villages de- liver two babies per month. The Rural Dispensary has an average caseload of twelve deliveries per month. Referral for emergencies The health cadres make the recommendation to refer a woman, although the husband usually makes the final decision whether a patient will be referred. The village health committee assists when necessary in arranging transport to the referral centre. Generally, a woman will deliver in a referral facility, if the referral recommendation is made by a health cadre. The community groups identified several de- lays in providing prompt, effective treatment to women at risk of death: (i) Delayed recognition by the health worker or TBA of the complication and need for referral. The un- trained TBAs are not aware of simple danger signs of the most common complications and how to stabilize a patient with complications for referral. The untrained TBAs did not re- port any referrals over the last quarter and appear to have little contact with the MOH infrastructure. The health cadres recognized certain conditions which require manage- ment, such as hemorrhage, prolonged labour, and high blood pressure, but they cannot al- ways stabilize a patient before referral due to lack of supplies or knowledge in proper refer- ral procedures. (ii) Delay in decision-making by the husband or commu- nity 'Leaders if the patient shouul, be ref erred. When a woman is identified at high risk or experienc- es complications in delivery, her husband must make the decision whether she can travel to a referral facility. The husband may not be present or may not have the knowledge to make a timely decision. (iii) Delays in obtaining transport to the referral facility. There are no permanent roads throughout 62 Bara District and most travel is on sand tracks. Emergency patients are often transported by camel, donkey or on a stretcher, carried on the shoulders of men-volunteers from the vil- lage. If lorries or other transport means are available, the patient's family may not have the funds to cover the costs of the transport. (iv) Delays in reaiving proper care once the patient ar- rives at a referral facility. An obstetric patient with complications often does not receive prompt and effective care due to the prevailing lack of supplies, equipment, trained manpower, and evidence of poor management, staff errors and misdiagnosis. The status of the Bara Hospital, the first referral level, with its chronic shortages of paper, electricity, essential drugs, supplies, blood and blood substitutes, makes the referral less effective. At the Bara Hospital, the obstet- ric patients are put in the same ward as the surgical and medical patients which increase their risk of infection. The hospital health in- formation system is inadequate. The records do not provide complete information on ma- ternal deaths, time between admittance and treatment, and outcomes of each patient with obstetric complications. Postnatal care Mothers who have delivered at home receive care from their relatives for a period of 40 days after the delivery. The relatives assist with food preparation, child care, water transport, and cleaning. The Medical Assistants, VMWs and trained TBAs provide follow-up visits up to one week after delivery. The untrained TBAs generally make one visit the day after delivery and again 7 days after delivery on the occasion of the traditional ceremo- nies to name the child and celebrate the birth. During their visits, the TBAs will wash the mother's wound and check the child's cord. The VMWs and trained TBAs provide the following services during postnatal visits: detection and referral for hemor- rhage; referral of infants with low birth weight; washing the mother's wound with disinfectant; and counseling on breast feeding, hygiene, birth spac- ing and nutrition. The health workers generally seem unaware of the need to detect and refer mothers for postpartum infection, despite the fact that infections of the uterus, breasts or urinary tract are common after delivery, especially in cir- cumcised women. There was virtually no care of- fered after 4 weeks at any level to examine the woman's uterus and vagina to detect any signs of infection, to make sure the uterus has returned to normal, and for other problems. Birth spacing The mothers state that an ideal birth interval is 2-4 years to allow proper rest for the mother and Rapp. trimest. statist. sanit. mond., 48 (1995) feeding for the child. If a woman becomes preg- nant while she is still breast feeding, the mother abruptly and completely weans the child, whether the infant is 1 month or older. The mothers recog- nize the importance to space children for the health of the child and mother. In Bara, however, women have on average a birth interval of 18-24 months, according to a UNICEF study conducted in January 1990. The Sudan Demographic and Health Survey, conducted in 1989, measured the total fertility rate for women at 5.0; and reported that 58.4% of currently married women would like to limit or space births of their children. The mothers manage birth intervals of 18 months or more by the methods of postpartum separation for 40 days after delivery and sexual abstinence for a period of 14 days after menstrua- tion. With a high proportion of men who seek wage income outside of Bara District on a seasonal basis, it is not clear how this migration of husbands af- fects reproductive patterns. The mothers expressed a high interest in gain- ing knowledge in modern contraceptive tech- niques, although some mothers cautioned that their husbands would strongly object. The mothers prefer to receive birth spacing services from the Medical Assistant or the VMW. The mothers clearly specified their interest in birth spacing and not in limiting their family size. Most of the health cadres support the concept of birth spacing. The Medical Assistants, VMWs, trained TBAs and some CHWs and nurses already promote birth spacing. Two Medical Assistants even purchase contraceptives from private sources to give to patients. The Medical Assistants and VMWs expressed their interest in learning more about modern birth spacing methods and counseling. TBA training The study involved an assessment of the impact of the TBA training conducted in Bara District by the MOH in 1989 with assistance from the Rural Health Support Project. The study analyzed the communities' accounts of TBA performance and TBAs personal observations. In general, the health cadres were supportive of training TBAs. Since the TBAs will continue to offer delivery assis- tance whether or not they are trained, the health cadres feel that it is better to improve TBAs' practices so they are able to offer safer delivery services. The health cadres emphasized, however, that TBAs selected for training should be relatively younger than those TBAs trained recently, whose ages ranged from 40 to 65 years, with the majority in the higher end of the age scale. In general, the community leaders and mothers positively reflected on the training. They particu- larly supported sessions on prenatal check-ups, use of local anesthesia, suturing the wound, and deliv- Wld hlth statist. quart., 48 (1995) ering on a bed. The TBAs, however, are weak in applying the majority of these new skills, according to the different groups interviewed. The health cadres and mothers all commented that the TBAs did not receive enough practical training. They indicated that the TBAs did not get the opportuni- ty to develop fully their skills to inject, sterilize, administer drugs, and deliver on a bed. Some TBAs simply reverted to their old practic- es. Since their training ended in November 1989, the TBAs have not been supervised or followed up by MOH officials. With no follow-up, the TBAs could not develop confidence in their new skills. The training proved to be extremely expensive and inefficient at US $1 OOO per TBA when their casel- oad remains low and when many TBAs were in the age bracket of 50 to 65 years of age. The community leaders and women expressed their willingness to contribute financially or in- kind to the costs of future training courses for TBAs, if they are involved in the selection process and planning for the training. In some areas, how- ever, the community leaders recommended that it would be a more effective use of the resources to allocate the funding toward training of young girls as village midwives, who remain the preferred health cadre for trained assistance it birth. Based on interviews with trained and untrained TBAs, the trained TBAs are more likely to refer women who have signs of being at risk of complica- tions. They are also more likely to observe hygienic procedures of washing their hands before delivery and using a clean, if not sterile, instrument to decircumcise the woman and cut the umbilical cord. The TBAs were also trained in infant and child care: nutrition, ORT and EPI promotion, and birth and death registration. It is clear, however, that the TBAs did not take on this expanded role in their communities as expected by the MOH. Several possible reasons why the TBAs have not provided all of the services for which they received training are outlined below: The TBA., may not identify with these addition- al roles given to them. The TBAs perceive them- selves as first and foremost as birth attendants. Their interest in the training stems from their cen- tral role as birth attendants in the community. The fact that the TBAs do not receive any remuneration in their roles as child health promoters from moth- ers or the community may also negatively affect their motivation in carrying out these tasks. The training was also deficient in addressing child care topics. The focus was clearly on develop- ing the TBAs' delivery skills. The only practical component of the training was in deliveries. Some TBAs complained about the length of the course. They find it difficult to stay three months in training without being able to go back home to see their children and families. The last sessions were 63 devoted to child care when the trainees may have lost interest in the course. The course packed too much information in one course for TBAs who are not used to classroom settings. The TBAs may have left the training satu- rated with information and not able to apply the knowledge they had gained in child care and some aspects of maternal health care. Upon their graduation, the TBAs were given kits with 26 items that help make deliveries cleaner and safer. The TBAs do not use all of the items either for fear of running out of supplies or for being ignorant about their function. Although the kits do represent a symbol of their new status as trained TBAs, the issue of replenishing supplies and even the appropriateness of the kit itself was not given careful consideration. The necessity of constant supervision and fol- low-up is acknowledged. This will be facilitated by decentralizing the supervision to the Dispensary staff or the VMW in the neighboring village. The supervisory system should be established and refer- ral facilities and means to replenish the TBA kit supplies identified before the training activities are initiated. The TBAs should not be over 51 years of age, because the ability of old TBAs to adapt new knowledge and skills is very poor. The training course should not attempt to create a new health cadre, but focus strictly on the enhancement of the TBAs' skills through adopting more hygienic methods of midwifery and to link the TBAs to the referral system. For the training conducted in 1989 in Bara District, these recommendations were not adequately addressed. As a result, the TBAs and the mothers have lost some confidence in the training programme. Supervision The supervision of midwifery services in Bara Dis- trict has also been deficient. It is not uncommon for a VMW not to have received any supervisory visits since her posting. The VMWs feel abandoned in the field. The MOH has no plan for refresher courses, despite that fact many VMWs have been working in the field for over 10 years and evidently forget the proper use of the MOH issued equip- ment or drugs. The Medical Assistants could act as the direct supervisor of the VMWs, but they are not as skilled or trained as the VMWs in the maternal health field. Discussion Maternal mortality is high in Bara District and calls for programmatic action. The direct obstetric caus- es of maternal deaths in Sudan, similar to the caus- es reported throughout the developing world, are hemorrhage, obstructed labour, toxemia and in- fection. Other contributing factors are institution- al, socioeconomic and cultural. The requirements 64 for reducing maternal mortality must involve sever- al fields such as obstetrics, control of infectious diseases, birth spacing, health communications and community development. Low socioeconomic status of the population in the region contributes to the high maternal mor- tality rate through the low awareness of complica- tions in pregnancy or delivery which require medi- cal care, lack of access to health care, malnutrition, poor transportation systems and low social status of women. Within the MOH system, health workers at all levels are limited in their abilities to prevent, diag- nose, treat and manage complications of pregnan- cy and labour due to the chronic inadequate sup- ply of drugs and supplies, their lack of training, the lack of supervision within the MOH infrastructure and the poor status of the health facilities. The TBA training programme and emphasis on prenatal care is predicated on the assumption that the referral system functions. Each higher level of the referral system, however, must provide a wider range of services than the ones available at the sending end. Necessary accompanying compo- nents to risk assessment and referral are transport and a referral site where a woman can receive obstetric emergency care. Presently, the referral system in Bara District is inadequate and unreli- able. The risk approach or prenatal screening would not have a large impact on maternal mortality in Bara District because most maternal deaths occur among low risk women who would not be identi- fied for referral and the health cadres and trained TBAs have not received the training to enable them to provide emergency care or stabilize pa- tients for referral. A real problem exists in determining which cri- teria to use to identify women at high risk of obstet- ric complications. If the basic criteria of age, parity, past history, pelvic disproportion and anemia are used in Bara District for prenatal screening, a large majority of women would be labelled "high risk" and selected for referral to the Bara Hospital. Clearly, the criterion would overwhelm the system. Any training programme must assess the effi- ciency of the costs involved. For example, TBAs have a low caseload of an average of one delivery per month. Training TBAs has cost implications not only for the actual training, but also supervi- sion and replenishing supplies. The TBA training conducted in Bara District was not cost efficient in relation to its benefits, nor did it address the prima- ry factors directly involved with maternal mortality. Programme interventions to prevent maternal mortality should address the above findings and those factors directly related to maternal mortality. In conclusion, the most effective and appropriate programme options would include family plan- ning, improved access to medical treatment for Rapp. trimest. statist. sanit. mond., 48 (1995) complications of pregnancy and treatment, and community education. Summary A high maternal mortality ratio was estimated in Bara District in Sudan during the late 1980's with approxi- mately 407 women dying per 100 OOO live births. In order to design effective intervention strategies, Care Interna- tional and the Ministry of Health in Sudan conducted a study to identify the attitudes of women, staff, and TBAs towards motherhood, prenatal care, and practices af- fecting the health of women in the district. The previously conducted training programme for TBAs was also as- sessed in its impact The study yielded the following results: in addition to the commonly known risk factors for maternal health e.g. haemorrhage, puerperal infection, obstructed labour, and anemia, the women in the villages and health staff identified female genital mutilation (pharaonic circumci- sion) as a major threat to safe motherhood. Health seeking behaviour was linked to problems of access and perceived quality of care: women did gen- erally not wish to spend more than 30 minutes for reaching a facility. But if the quality of a particular institution was considered good, and supplies and equipment were available, women would cover great distances to reach such a facility. Participation in prena- tal care suffered from the equation of preventive with curative care. Women would therefore tend to turn to a clinic or service provider, if symptoms of illness oc- curred during a pregnancy. The village-based services suffered from the lack of equipment and poor staff training, which further undermined the motivation to seek prenatal care. When health staff recommended referral of a pregnant woman for delivery, the advice was usually followed. But the decision to refer had to be agreed upon by the husband which caused delays when a husband was absent and could not be reached quickly. Lack of transport posed a problem for timely referral. Delayed recognition of risk conditions by some health staff and untrained TBAs was also identified. Further delays upon arrival at a facility were considered problematic. Postnatal care was seen as insufficient and in particular with a view to controlling infections which are common amongst circumcised women after delivery. The ideal birth interval was considered to be 2 to 4 years, but it effectively was 18 to 24 months. For reasons of birth spacing women were interested in learning more about modern contraceptives. The completed TBA training programme was generally regarded as satisfactory by the women and health staff in the communities particularly in view of the improved skills of TBAs to provide for timely referral. But there was need to establish supervisory mechanisms and support to the TBAs after conclusion of the training programme. This would enhance the TBAs newly acquired knowl- edge and re-inforce use of the materials in their TBA kit The TBAs regarded the course programme as having Wld hlth statist. quart., 48 (1995) been too lengthy and having surpassed their capacity to absorb all the information offered. The child care com- ponent of the course did not seem to have met its target as it did not correspond to the traditional role perception of TBAs as providers of delivery care only. Resume Soudan : la sante maternelle dans le district de Bara, province du Northern Kordofan - analyse de situation D'apres les estimations. le taux de mortalite maternelle etait eleve a la fin des annees 1980 dans le district de Bara, avec environ 407 deces pour 100 OOO naissan- ces vivantes. Afin de mettre au point des interventions efficaces, l'organisationCare International et le Ministe- re de la Sante du Soudan ont conduit une enquete sur les attitudes des femmes, des personnels et des accou- cheuses traditionnelles a l'egard de la maternite, des soins prenatals et des pratiques qui influent sur la sante des femmes au niveau du district. On a egalement evalue !'impact du programme de formation d'accou- cheuses traditionnelles execute auparavant. L'enquete a donne les resultats suivants : outre les facteurs de risque bien connus pour la sante maternelle que sont l'hemorragie, l'infection puerperale, ladystocie et l'anemie, les femmes des villages et les agents de sante ont indique les mutilations sexuelles feminines (circoncision pharaonique) comme une grave menace pour la sante maternelle. L'attitude des femmes a l'egard des prestations de sante est fonction des possibilites d'acces, et de la fa9on dont est per9ue la qualite des soins : en general. les femmes ne sont pas disposees a perdre plus d'une demi-heure pour aller jusqu'a un centre de sante. En revanche, lorsqu'un etablissement a la reputation de dispenser des soins de qualite et de posseder des fournitures et du materiel, les femmes peuvent couvrir de grandes distances pour y aller. II semble que le recours aux soins prenatals patisse de !'assimilation des soins preventifs aux soins curatifs. Ainsi, les fem- mes tendent a. ne s'adresser a un dispensaire ou autre que lorsque qu'elles presentent des sympt6mes de maladie au cours de la grossesse. Les pastes de sante de village souffrent du manque de materiel et de la formation insuffisante du personnel, ce qui decourage encore plus les femmes de solliciter des soins prenatals. Ouand les agents de sante recommandent a une femme enceinte d'accoucher dans un service competent, leur avis est generalement suivi. Cette decision doit cepen- dant etre approuvee par le mari. ce qui entrai'ne des retards lorsque celui-ci est absent et difficile a joindre. Le manque de moyens de transport est egalement un obstacle a une prise en charge en temps opportun. On a egalement constate que certains agents de sante et accoucheuses non qualifies identifiaient parfois trop tard certains facteurs de risque. Entin, des retards ont egalement ete observes apres l'arrivee au service de recours. 65 Les soins postnatals ont ete juges insuffisants compte tenu en particulier de la necessite de combattre les infections qui sont frequentes apres l'accouchement chez les femmes circoncises. L'intervalle ideal entre deux naissances est considere comme de 2 a 4 ans, mais en realite, ii est de 18 a 24 mois. Les femmes se sont montrees interessees par les methodes modernes de contraception afin d'avoir des grossesses plus espacees. Le programme de formation des accoucheuses tradi- tionnelles a dans !'ensemble ete juge satisfaisant par les femmes et les agents de sante, en particulier dans la mesure ou, grace a leurs competences accrues, les accoucheuses orientent a temps les cas difficiles. II 66 faudrait cependant mettre en place des mecanismes de contr61e et d'appui des accoucheuses traditionnel- les a !'issue de leur formation. Ce serait un moyen de renforcer leurs connaissances nouvellement acquises et de les encourager a se servir davantage des instru- ments et fournitures mis a leur disposition. Les accou- cheuses ont cons id ere pour leur part que le programme etait trop long et trop ambitieux et elles ont eu le sentiment de ne pouvoir absorber toutes les informa- tions donnees. Entin, la partie du programme consa- cree aux soins aux enfants ne semble pas avoir atteint son but car elle ne correspondait pas a la perception traditionnelle qu'ont les accoucheuses de leur role comme consistant a intervenir uniquement au moment de l'accouchement. Rapp. trimest. statist. sanit. mond., 48 (1995) WORLD HEALTH ORGANIZATION PUBLICATIONS ~-~~ ~ k ~ ~---=I ,J? --~ NEW BOOK ANNOUNCEMENT Complications of Abortion Technical and Managerial Guidelines for Prevention and Treatment 1995, 147 pages (available in English; French and Spanish in preparation) ISBN 92 4 154469 4 Sw.fr. 35.-/US $31.50 In developing countries: Sw.lr. 24.50 Order no. 1150418 This book sets out guidelines that can help reduce the high levels of maternal morbidity and mortality associated with abortion, whether spontaneous or induced. Recommendations and advice are backed by extensive practical experience and rooted in Lhe principle that emergency care for Lhe complications of abortion should be available 24 hours a day in every health care system. In view of the need Lo prevent life-threatening complications, the book also establishes standards of safe abortion practice for use in those countries where abortion is permitted by law. Prevention of abortion through education and family plat)ning is likewise discussed. Addressed to health managers, administrators, and care providers, the book follows a step-by-step ap- proach to the provision of emergency and preventive care. Managerial responsibilities are identified and explained at stages moving from planning, through clinical care and the facilities and equipment re- quired, to staff training and the monitoring and evalu- ation of services. Throughout the book, numerous diagrams, summary tables, and lists of questions are used to help managers think through practical prob- lems and make wise decisions. The book has fourteen chapters. The first three de- scribe the magnitude of mortality and morbidity caused by unsafe abortions, define the essential com- ponents of abortion care at each level in the health system, and discuss the ways in which legal and societal factors affect abortion behaviour and care. Against this background, the remaining eleven chap- ters provide technical and managerial guidelines for each component of service, at each level of the health system, needed to ensure that all women have access to care 24 hours a day. A chapter on planning is followed by three chapters outlining the clinical elements of emergency abor- tion care. Of particular value is a chapter on patient information and counselling, which emphasizes the importance of providing information in a support- ive, non-judgemental, and confidentiai manner. Other chapters offer detailed guidance on the facili- ties, equipment and drugs needed for abortion care, on the training and supervision of staff, and on ways to overcome several obstacles that make it difficult for women in remote rural areas to receive timely care. The remaining chapters cover the monitoring, evaluation and cost-effective management of serv- ices, and de line the basic elements of a multifaceted effort to combat unsafe abortion and thus contribute to safe motherhood. further practical information is provided in a series of annexes, which give examples of training materi- als and reproduce model record forms Lhat can be easily adapted to local needs. WHO • Distribution and Sales • 1211 Geneva 27 • Switzerland O R GAN IS AT I O N M O N D I ALE D E LA SANT E VIENT DE PARAITRE La fiche maternelle tenue a domicile Comment la mettre au point, !'adapter et l'evaluer Organisation mondiale de la Sante 1994, viii+ 85 pages (disponible en anglais,version espagnole en preparation) ISBN 92 4 254464 7 Francs suisses 20.- Pays en developpement : Fr.s. 14.- N° de commande 2150408 Ce guide complet portant sur tousles aspects de la mise au point, de !'adaptation et de !'utilisation de la fiche maternelle tenue a domicile, est un nouvel instrument tres interessant qui perm et de reduire la mortalite et la morbidite maternelles et perinatales. La fiche maternelle tenue a domicile, qui est conservee par la femme et lui sert de "passeport" pour recevoir des soins de sante appropries, est une simple carte con9ue de maniere a faciliter l'enregistrement et !'interpretation de donnees detaillees sur l'etat de sante d'une femme avant sa premiere grossesse, au cours de celle-ci, de l'accouchement, du post-partum et de la periode neonatale, et de deux grossesses ulterieures. Cette carte peut aussi servir a enregistrer des informations sur les periodes entre les grossesses, l'allaitement au sein, la planification familiale et la couverture vaccinale de la femme par l'anatoxine tetanique. Bien qu'elle soit d'une conception et d'une presentation fort simples, cette carte s'est averee un instrument tres utile pour detecter rapidement les facteurs de risques, promouvoir l'orientation-recours en temps voulu, suivre la sante de la femme sur des periodes allant jusqu'a dix ans, eduquer celle-ci en matiere de sante, de nutrition et de planification familiale. La fiche maternelle tenue a domi- cile a egalement montre qu'elle pouvait faciliter considerablement l'orientation-recours ainsi que !'utilisation des services de sante, promouvoir l'autodiagnostic et !'initiative personnelle en matiere de soins, accroitre la participation de la communaute et favoriser la collecte d'informations sanitaires. Con9u pour aider les responsables de programmes et les administrateurs a presenter et a utiliser la fiche maternelle tenue a domicile de la fa9on la plus efficace possible, ce livre s'appuie sur les donnees d'experience et les le9ons acquises au cours de la mise a l'epreuve sur le terrain de la fiche de sante maternelle dans le cadre d'une evaluation collective de l'OMS regroupant 20 centres dans 14 pays. La fiche type de l'OMS est certes presentee comme modele, mais le guide met l'accent sur la meilleure maniere d'adapter cette fiche type aux conditions locales, d'eprouver son efficacite, de reperer les problemes et de trouver des solutions, meme lorsque les ressources sont maigres et les populations en grande partie analphabetes. L'information donnee va des questions qu'il taut poser lorsqu'on decide I quels facteurs de risques ii taut inclure dans ladite fiche aux conseils sur les erreurs frequemment commises qui risquent de rendre celle-ci difficile a utiliser, en passant par les instructions permettant de calculer le nombre de cartes necessaires pour couvrir une population donnee et une liste des taches specifiques qui devraient etre envisagees lorsqu'on enseigne aux agents de sante comment recueillir et enregistrer les renseignements voulus. Le guide decrit, au fil des pages, des experiences concretes • soil en reprenant les erreurs de conception de la fiche modele, soit en enumerant les chases a faire ou a ne pas faire • qui permettent une adaptation et une presentation reussies de cet instrument extremement utile. Ce livre comprend cinq chapitres. Les deux premiers decrivent la mise au point de la fiche type de l'OMS, expliquent les similitudes de celle-ci avec la fiche de croissance qui est tres repandue, et passent en revue ses principales fonctions et ses principaux avantages. Les autres chapitres donnent des lignes directrices detaillees et des conseils sur l'adaptation, la presentation et !'utilisation de la fiche maternelle tenue a domicile, y compris sur les taches specifiques qui devront etre accomplies pardiverses categories d'agents. On trouvera d'autres conseils pratiques dans une serie de cinq annexes, qui comprennent les instructions necessaires etape par etape, pour remplir la fiche, une explication des methodes d'evaluation de celle- ci et une elude des dix problemes les plus frequemment rencontres lorsqu'on la presente, avec des conseils sur la maniere de les resoudre. Organisation mondiale de la Sante • Distribution et Vente • 1211 Geneve 27 • Suisse Publications of the World Health Organization 1995 WORLD HEAL TH FORUM An international journal of health development (Separate editions in English, French, Spanish, Arabic, Chinese and Russian) World health forum is a quarterly journal for policy-makers, health planners, administrators, health educators, and public health workers of all kinds. It provides a medium for the presentation and discussion of new concepts in public health and new approaches to health problems, and it is devoted to the improvement of health through the promotion of health services covering the entire population and the undertaking of a wide variety of public health measures, whether or not they are supported by WHO. The Forum is the main organ ofWHO's Member States for the international exchange of health information and an active instrument in technical cooperation among developing countries. 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World Health Organization (WHO) · Journal articles
Health consequences of the Chernobyl accident and other radiological events = Conséquences sanitaires de l'accident de Tchernobyl et d'autres événements radiologiques [full issue]
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