Providing access to emergency obstetric and neonatal care units in resource-poor settings is vital to reducing the global maternal mortality rate.
In a developed setting such as Australia, women may ask: ‘Who will I choose to look after me during pregnancy and where will I choose to deliver my baby?’ The question for women in settings where Médecins Sans Frontières (MSF) works is more often: ‘Will there be someone skilled to look after me during my pregnancy and delivery?’
The maternal mortality ratio in developing countries is 290 per 100 000 live births compared with 14 per 100 000 live births in developed countries.1 Of the maternal deaths worldwide, 99 per cent occur in the developing world.1 According to WHO, a woman dies every 90 seconds from pregnancy-related complications, yet an estimated 74 per cent of maternal deaths could be averted if all women had access to the interventions required for preventing or treating pregnancy and birth complications.1 Preventing and treating the five direct causes of maternal mortality – haemorrhage, sepsis, hypertension, unsafe abortion and obstructed labour – has been possible for at least 50 years. However, in developing countries many women deliver their babies at home. These births can take place in dangerous conditions, unattended or attended by unskilled birthing assistants. The absence of a trained birth attendant, the correct medication and appropriate medical equipment means treatments that could reduce the risk of death are often not provided in time, if at all. While levels of antenatal care have increased during the past decade, only 66 per cent of women in developing countries benefit from skilled care during childbirth.2
MSF conducts medical programs in resource-poor settings in more than 70 countries around the world. Many of these projects include emergency obstetric activities. MSF encourages all pregnant women within a project’s catchment area to come to its clinics or hospitals for pregnancy care and to deliver their babies. Maternal mortality can occur at any time in pregnancy, but delivery is by far the riskiest time for the mother and for the baby. There are clear guidelines to assess a high-risk pregnancy and manage it, thereby reducing risk to the mother and her child. What remains difficult, however, is that high risk deliveries are unpredictable and complications can arise with little or no warning at all, even among women with pregnancies that have been assessed as low risk. Since it is difficult to predict which deliveries will develop a complication, MSF believes that all deliveries should take place in an accredited health structure, with access to appropriate drugs and equipment, where a skilled birth attendant can monitor both the woman and the fetus during labour and delivery, in order to promptly identify and treat those complications. This is what we take for granted in the developed world and is what we sometimes struggle to provide in resource-poor settings, particularly when the cultural norm is to birth at home. This remains a major challenge for MSF; in most of the settings where we work, women deliver at home. This is due to a variety of factors including issues of poverty, gender and other inequalities, insecurity, a lack of information, weak healthcare systems, cultural barriers and a lack of political commitment to maternal health.
‘…the ability to access essential drugs to treat infection, instruments to expedite delivery if required and a skilled attendant who can identify and treat complications, is the key to assisting a safer pathway to pregnancy and birth.’
The safety of the location of the delivery should take into consideration the structure, supplies and skilled human resources available. Research shows that by identifying alarm signs and treating on time mortality can be reduced. This can be achieved by skilled attendants and there is multiple evidence of its benefits.2–5 Such good documentation and evidence is lacking regarding the place of birth even in developed settings and most investigations underestimate the risks associated with planned homebirth as many require intrapartum transfer to hospital.6–10 However, the risks are magnified where MSF works, since women in these settings are the least likely to receive adequate health care. MSF considers a safe delivery one that takes place in an Emergency Obstetric and Neonatal Care (EmONC) unit, where a skilled attendant will be in charge, at a structure that achieves the specific conditions needed (in terms of hygiene, drugs and equipment) for the mother and the newborn. This can be in a Basic Emergency Obstetric and Neonatal Care (BEmONC) unit, which provides: administration of antibiotics, oxytocics and anticonvulsants; manual removal of placenta; removal of retained products; assisted vaginal delivery and newborn care. It can also be in a Comprehensive Emergency Obstetric Care (CEmONC) unit, which includes the availability of surgery, blood transfusion and care for sick and premature newborns. For example, the ability to access essential drugs to treat infection, instruments to expedite delivery if required and a skilled attendant who can identify and treat complications, is the key to assisting a safer pathway to pregnancy and birth. Different activities are carried out, depending on the specific needs of a project, from within a wide range that includes direct patient care as well as training of local staff by international doctors and midwives.
While this article specifically addresses maternal death, it should also be considered that for every woman who dies as a result of an unsupervised delivery at home, many more will face serious or long-lasting medical problems. Women who survive severe, life-threatening complications (due to conditions such as vesico vaginal fistula) often require long recovery times that can have profound and devastating consequences for the patient’s physical and psychological health.
MSF provides humanitarian assistance to populations affected by wars, epidemics and natural or man-made disasters, and considers women’s health an integral aspect of its emergency healthcare provision. MSF currently has large-scale obstetric programs in Pakistan, Nigeria, South Sudan and the Democratic Republic of Congo. In 2010, the organisation’s staff delivered more than 151 000 babies in its facilities worldwide. The number of programs incorporating maternal and child health activities is increasing each year and MSF remains committed to addressing maternal mortality as a global health priority.
- The critical role of the skilled attendant. A joint statement by WHO, ICM and FIGO. Geneva: WHO; 2004.
- Mavalankar DV, Rosenfield A. Maternal mortality in resource-poor settings: policy barriers to care. Am J Public Health 2005; 95: 200-3 doi: 10.2105/AJPH.2003.036715 pmid: 15671450.
- George A. Persistence of high maternal mortality in Koppal district, Karnataka, India: observed service delivery constraints. Reprod Health Matters 2007; 15: 91-102 doi: 10.1016/S0968-8080(07)30318-2
- Mavalankar D, Vohra K, Prakasamma M. Achieving Millennium Development Goal 5: is India serious? Bull World Health Organ 2008; 86: 243- doi: 10.2471/BLT.07.048454 pmid: 18438507.
- Wax JR, Lucas FL, Lamont M, et al. Maternal and newborn outcomes in planned homebirth vs planned hospital births: a metaanalysis. AJOG 2010;203:243.e1-8 .
- Shearer JML. Five year prospective survey of risk of booking for a homebirth in Essex. BMJ 1985;219:1478–80.
- Wiegars TA, Keirse MJNC, van der Zee J,Berghs GAH. Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in theNetherlands. BMJ 1996;313:1309–13.
- Lindgren HE, Radestad IJ, Christensson K,Hildengsson IM. Outcomes of planned homebirths compared to hospital births in Sweden between 1992 and 2004: a population-based register study. Acta Obstet Gynecol 2008;87:751–9.
- Ackermann-Liebrich U, Voegeli T, Günter-Witt K, et al. Home versus hospital deliveries:follow up study of matched pairs for procedure and outcome. BMJ 1996;313:1313–8.