Improved Access to Comprehensive Emergency Obstetric Care and Its Effect on Institutional Maternal Mortality in Rural Mali/Amelioration De L'acces a Des Soins Obstetricaux D'urgence Complets et Effets Sur la Mortalite Maternelle En Milieu Hospitalier, Dans Une Region Rurale Du Mali/Mejora del Acceso a Atencion Obstetrica De Urgencia Integral Y Efecto Sobre la Mortalidad Materna Institucional En Zonas Rurales De Mali

Introduction Maternal mortality is a major public health problem, particularly in sub-Saharan Africa, where half (50.4%) of all maternal deaths worldwide occur. (1) One objective of the Millennium Development Goals is to reduce maternal mortality by 75% between 1990 and 2015. (2) In 2005, the maternal mortality ratio in sub-Saharan Africa, estimated at 900 maternal deaths per 100 000 live births, was by far the highest in the world. (1) Unlike other regions, sub-Saharan Africa has not seen improvements in indicators linked to maternal mortality, leading to fears that the Millennium Development targets will not be met. (3) In response to this disquieting situation, many African countries have adopted measures towards reducing maternal mortality. The context and causes of maternal mortality and morbidity are well known, (4) and strategies to ameliorate them were recently reported. (5) One proven effective strategy is to provide access to basic emergency obstetric services (parenteral oxytocics, antibiotics and anticonvulsants; assisted deliveries; manual extraction of the placenta; removal of retained products) and, if necessary, to comprehensive emergency obstetric services (basic services plus Caesarean sections and blood transfusions). (6) Access to these services is a key element of the WHO Making Pregnancy Safer programme. (7) Ensuring timely Caesarean delivery when needed is a priority in sub-Saharan Africa. In western Africa, maternal mortality is highest in rural areas where access to emergency obstetric care is limited by large geographic distances to health facilities and scarce resources. (8) While progress has been made in reducing maternal mortality rates in urban areas, the situation in rural areas is not improving. In Mali, for example, the population-based rate of Caesarean delivery in urban areas rose from 1.6% to 3.5% between 1991 and 1998, while in rural areas it remained unchanged (1.6% and 1.5%, respectively). (9) Implementing emergency obstetric care programmes, and maternity referral systems in particular, is complicated in settings where resources are scarce. (10) In western Africa, where the Bamako Initiative has made cost recovery in health care the standard, (11) the costs of comprehensive emergency obstetric care represent a major outlay for households (12,13) and several strategies have been attempted to reduce this financial burden. (14,15) In 2002, the Government of Mali launched a nationwide maternity referral system (16) aimed at improving the quality and accessibility of comprehensive emergency obstetric care services and at reducing the danger of death associated with obstetric complications. In this study, we aim to evaluate the effects of the system in a rural population of more than one million inhabitants. Methods Setting Of 177 countries on the Human Development Index for 2005, Mali was ranked 173rd (17) and had the 17th highest maternal mortality ratio (1) The health region of Kayes, situated in the west of Mali, has nearly 1.7 million inhabitants unevenly distributed over 120 760 [km.sup.2]. Rugged terrain and periods of intense rain with flooding make communications difficult. The study area consists of six of the region's seven districts. The provincial district was excluded because it is more urban. The study area contains just over 1.25 million inhabitants, and the population density of the districts varies between 9.7 and 26.2 inhabitants per [km.sup.2] (mean of 14.7 inhabitants per [km.sup.2]). Despite efforts in recent years, the geographic accessibility of health services remains poor: the distance from home to a primary health care centre is more than 5 km for 56% of the population and more than 15 km for 30%. The public health system, which is almost the only provider of modern health-care services, has few resources (one doctor per 28 000 and one midwife per 96 000 inhabitants). The study area has 101 community health centres (15 to 20 in each district) and six district health centres. …