Inspired by a comment from April – a frequent commenter on my blog – about whether Safe Motherhood saves lives or not, I decided to follow-up that post with this one, which asks the question of whether a policy approach similar to the one adopted in China would be effective in other countries, in particular in sub-Saharan African countries where levels of maternal mortality have remained stubbornly high over the past few decades?
The study I blogged on in China, claims that the SM approach reduced rates of maternal mortality by encouraging more women to delivery in hospitals – that is to have an institutional delivery, which is a more aggressive approach than has generally been adopted in most developing countries where the focus has been on the professionalization on rather than the institutionalization of deliveries (that is ensuring that they are supervised by trained medical personnel, regardless of where the births take place). Encouraging more women to deliver in a hospital would only really improves outcomes if we felt those hospitals would be adequately equipped and prepared to deliver the life saving interventions (c-sections, blood supply, other surgical procedures) that we think are needed to reduce maternal mortality. But what is the evidence on this?
Two recent papers jump immediately to mind – both asking some variant of this question by passionate researchers who strongly believe that access to surgical services have been under valued in public health systems in developing countries. They both argue, I believe correctly, that surgery should be considered and important part of the basic services that should be made readily available even in the most resource constrained settings.
The first, published in PLoS medicine last month assesses the surgical patterns of district hospitals in 3 African countries (Uganda, Tanzania, and Mozambique). The authors find “…low rates of major surgery at district hospitals in East Africa, ranging from 50 to 450 surgical procedures per 100,000 population.” Unsurprisingly, obstetric procedures are the most common of all surgical procedures conducted at this facilities but the authors conclude that the availability of surgical capacity is too low to address the full unmet need for obstetric surgical procedures.
The second, co-authored by Adam Kushner (aka @globalsurgeon on Twitter), evaluated surgical capacity at district hospitals in 8 developing countries and find that less than half of district hospitals in these countries, the normal referral sites for people with complications at the primary level, even had the capacity to conduct caesarean sections – something most people would agree is a relatively straightforward surgical procedure and essential to reducing maternal mortality. Half!
Both of these articles point to some important infrastructure challenges and really raises the question of whether or not broad one-sized fits all strategies should be the right approach. The results from the study in China, while interesting to know that Safe Motherhood can save lives, are not likely that applicable in other settings. In a given country, perhaps we should be asking which components of this strategy are the most likely to improve maternal mortality and how should it be implemented?
Ok, enough blogging about maternal mortality for one week, and back to being 8.5 months pregnant…