Maternal mortality in developing countries [letter].

We are pleased to see that the British Journal of Obstetrics and Gynaecology is publishing articles on maternal mortality and the fine commentary by Professor Kelsey A. Harrison (Harrison 1989). Because women in developing countries especially Africa become pregnant so often the situation is even worse than the maternal mortality rate can convey. A more eloquent measure is the cumulative lifetime risk of maternal death which in Africa is 1 woman in 21 compared with 1 in 9850 in Northern Europe (Starrs 1987). There are several specific points of strategy however on which we feel we must respectfully disagree with our valued colleague: 1) the potential for reducing maternal mortality through literacy programs "per se;" 2) the usefulness of traditional birth attendants (TBAs) in reducing maternal mortality; and 3) the advisability of training nurses and midwives to carry out procedures confined to physicians in developed countries. As for TBAs we heartily agree that the vast amount of resources that has gone into retraining them during the last few decades has not reduced maternal mortality in developing countries. While recognizing that TBAs cannot be taught to treat most obstetric emergencies it is also important to recognize their current standing in many communities (rural and urban) in Africa and Asia. We would like to strongly endorse Professor Harrisons emphasis on the necessity to provide adequate and accessible hospital services for women with complications. Without such services maternal mortality cannot be substantially reduced. Regarding the performance of medical procedures by nurses and midwives Professor Harrison is undoubtedly sincere in his concern about this idea and speaks for the medical establishment. Futhermore this is a sensitive issue in developing countries fearful as they are of setting up a "second-class" system of medicine. And certainly where there is a surplus of adequately trained physicians concentrated in cities political will is needed to distribute them more equitably throughout the country. Specially trained nurses are now providing limited surgical services (such as sterilization) in many countries. (full text modified)