The risk approach to maternal mortality: can it work?

The choice of program strategies as part of the Safe Motherhood initiative is critical for developing countries. Lack of prenatal care is often blamed for a large proportion of maternal deaths because it is believed that by screening health personnel can identify women who will develop complications during pregnancy and delivery. Though much emphasis is put on screening prenatal care should include: 1) treatment of existing diseases; 2) patient education; and 3) screening of women for factors that put them at greater than normal risk of complications during pregnancy and delivery. This paper focusses on the "risk approach" to prenatal care which is based on the belief that by screening health personnel will identify pregnant women who will develop complications. 4 categories of problems are associated with prenatal screening: 1) logistic issues; 2) program content; 3) quality of care; and 4) the efficiency of the screening techniques. Logistical problems include transportation and financial cultural and social factors that prevent women from going to hospital. The establishment of maternity waiting homes near hospitals is a possible solution to some of the logistic problems. Women from rural areas can spend the last few weeks of pregnancy within easy access to medical care. This article also focuses on issues such as the number and timing of prenatal visits and the content of the scheduled visits. 5 prenatal visits are recommended as sufficient to detect any problems and provide adequate care. There are few evaluations of the quality of prenatal screening in developing countries and those that exist are not very encouraging. A study in the Ivory Coast found that 73% of detectable complications were not identified during prenatal visits. Screening cannot identify most of the obstetric complications that women will develop. A Scottish study showed that 30% of pre-eclampsia cases presented during labor or after delivery and were not predicted by screening. Since the majority of complications often occur among low-risk women services should not only concentrate on providing prenatal screening but also concentrate on providing prompt treatment of obstetric complication. (authors)