Community-based interventions to reduce maternal mortality

Christina Pagel and colleagues1Pagel C Lewycka S Colbourn T et al.Estimation of potential effects of improved community-based drug provision, to augment health-facility strengthening, on maternal mortality due to post-partum haemorrhage and sepsis in sub-Saharan Africa: an equity-effectiveness model.Lancet. 2009; 374: 1441-1448Summary Full Text Full Text PDF PubMed Scopus (48) Google Scholar modelled the effect of three packages of interventions on maternal mortality from post-partum haemorrhage and sepsis in sub-Saharan Africa. They hypothesise that poor women will barely benefit from health-facility strengthening (described as supply of oxytocin and antibiotics to existing health facilities) because few give birth in health facilities.But health-facility strengthening consists of much more than the supply of drugs. When it is embedded into a health system involving a substantial investment in health professionals, strong backup by hospital care, and the removal of user fees, the poor do take up facility-based care, and the benefits on maternal and newborn survival will far exceed those reported by Pagel and colleagues.2WHOThe World health report 2005: make every mother and child count. World Health Organization, Geneva2005Google Scholar, 3Yanqiu G Ronsmans C An L Time trends and regional differences in maternal mortality in China.Bull World Health Organ. 2009; 87: 913-920Crossref PubMed Scopus (38) Google ScholarAdditionally, Pagel and colleagues' estimates from packages 2 and 3 rely heavily on the presumed effectiveness of misoprostol and antibiotics in reducing mortality from post-partum haemorrhage and sepsis in women who give birth at home. To our knowledge, there is no evidence of effect of misoprostol on maternal mortality reduction and substantial heterogeneity of effect on severe postpartum haemorrhage.4Gülmezoglu AM Forna F Villar J Hofmeyr GJ Prostaglandins for preventing postpartum haemorrhage.Cochrane Database Syst Rev. 2007; 3 (CD000494.)Google Scholar Similarly, the effectiveness of a standard antibiotic for the treatment of infection at home will be much lower than in hospital.Finally, Pagel and colleagues overestimate mortality from post-partum haemorrhage and sepsis: only two-thirds of all haemorrhage deaths are due to post-partum haemorrhage and 10% of maternal deaths in sub-Saharan Africa are due to sepsis.5Khan KS Wojdyla D Say L Gülmezoglu AM Van Look PFA WHO analysis of causes of maternal deaths: a systematic review.Lancet. 2006; 367: 1066-1074Summary Full Text Full Text PDF PubMed Scopus (2512) Google ScholarAchieving progress in maternal health demands a long-term commitment to health-facility strengthening, and far greater resources than those currently available. Seductively cheap alternatives will not do.We declare that we have no conflicts of interest. Christina Pagel and colleagues1Pagel C Lewycka S Colbourn T et al.Estimation of potential effects of improved community-based drug provision, to augment health-facility strengthening, on maternal mortality due to post-partum haemorrhage and sepsis in sub-Saharan Africa: an equity-effectiveness model.Lancet. 2009; 374: 1441-1448Summary Full Text Full Text PDF PubMed Scopus (48) Google Scholar modelled the effect of three packages of interventions on maternal mortality from post-partum haemorrhage and sepsis in sub-Saharan Africa. They hypothesise that poor women will barely benefit from health-facility strengthening (described as supply of oxytocin and antibiotics to existing health facilities) because few give birth in health facilities. But health-facility strengthening consists of much more than the supply of drugs. When it is embedded into a health system involving a substantial investment in health professionals, strong backup by hospital care, and the removal of user fees, the poor do take up facility-based care, and the benefits on maternal and newborn survival will far exceed those reported by Pagel and colleagues.2WHOThe World health report 2005: make every mother and child count. World Health Organization, Geneva2005Google Scholar, 3Yanqiu G Ronsmans C An L Time trends and regional differences in maternal mortality in China.Bull World Health Organ. 2009; 87: 913-920Crossref PubMed Scopus (38) Google Scholar Additionally, Pagel and colleagues' estimates from packages 2 and 3 rely heavily on the presumed effectiveness of misoprostol and antibiotics in reducing mortality from post-partum haemorrhage and sepsis in women who give birth at home. To our knowledge, there is no evidence of effect of misoprostol on maternal mortality reduction and substantial heterogeneity of effect on severe postpartum haemorrhage.4Gülmezoglu AM Forna F Villar J Hofmeyr GJ Prostaglandins for preventing postpartum haemorrhage.Cochrane Database Syst Rev. 2007; 3 (CD000494.)Google Scholar Similarly, the effectiveness of a standard antibiotic for the treatment of infection at home will be much lower than in hospital. Finally, Pagel and colleagues overestimate mortality from post-partum haemorrhage and sepsis: only two-thirds of all haemorrhage deaths are due to post-partum haemorrhage and 10% of maternal deaths in sub-Saharan Africa are due to sepsis.5Khan KS Wojdyla D Say L Gülmezoglu AM Van Look PFA WHO analysis of causes of maternal deaths: a systematic review.Lancet. 2006; 367: 1066-1074Summary Full Text Full Text PDF PubMed Scopus (2512) Google Scholar Achieving progress in maternal health demands a long-term commitment to health-facility strengthening, and far greater resources than those currently available. Seductively cheap alternatives will not do. We declare that we have no conflicts of interest. Community-based interventions to reduce maternal mortality – Authors' replyDavid Braunholtz and colleagues comment on the increasing complexity of models used in health research. We used simple mathematics to characterise the pathways to maternal death from postpartum haemorrhage or puerperal sepsis. This approach highlighted gaps in the published evidence concerning key steps in these pathways. Full-Text PDF