WUNRN
Africa - Village Access to Medicines, Fewer Maternal Deaths
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Mother
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DAKAR, 29 September 2009 (IRIN) -
Putting medicines for haemorrhage and infection in the hands of community
health workers could mean significantly fewer maternal deaths in
Africa, according to researchers at University College London (UCL).
The
safest place for a woman to give birth is an equipped and staffed health
facility, but in many countries such conditions do not exist and
community-based access to drugs for two primary causes of maternal death should
be studied, the researchers said in a paper published in The Lancet on 23 September.
“The
reality for many is that a skilled attendant and a well-equipped facility is a
distant dream,” said Anthony Costello, global health specialist and professor
at UCL, one of the researchers.
“What
we’re saying is, as in other areas of public health, the best should not be the
enemy of the good.” He cited the example of villagers’ access to oral
rehydration solution for children. “This has made a considerable impact on
child health. Of course it is not the optimal care for dehydration but it’s the
difference between something that could be quite effective, and nothing.”
More
than half a million women die from pregnancy or childbirth complications per
year – some 90 percent in Africa and Asia, according to the UN Population Fund
(UNFPA).
Some
top causes of maternal mortality as of 2005 were: haemorrhaging, infection,
unsafe abortion, eclampsia and obstructed labour, according to the UN World
Health Organization.
The UCL
researchers developed a mathematical model to show the impact of making
misoprostol (for haemorrhage) and antibiotics available through village health
workers or volunteers. This community-based drug access would be in addition to
strengthening health systems.
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Maternal
health |
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Dual approach
The
researchers say the two approaches can be complementary. “We believe that
debate about the relative merits of health system strengthening versus
community intervention perpetuates a false dichotomy,” the paper said. “Both
programmes are necessary to tackle maternal mortality and the correct balance
of approaches crucially depends on the local context.”
Costello
told IRIN: “We are not saying we should go and roll out these drugs in
communities immediately but that this approach should be evaluated on a large
scale and with mortality rates of mothers and infants carefully
monitored."
In a
2008 report UNFPA said progress in some countries had led to a consensus in the
global health community on three elements most effective in reducing maternal
mortality and morbidity: universal access to family planning, a skilled health
professional present at every delivery, and access to emergency obstetric and
newborn care when needed.
“Lack
of access to simple interventions such as oxytocics to prevent or treat
haemorrhage or antibiotics to treat infection often leads to death or severe
disability,” UNFPA says in a maternal health plan.
But
community use of ueterotonic drugs is often resisted by obstetricians, Costello
said. He said they call for the use of oxytocics which are injected, rather
than misoprostol (administered orally). “But in most cases in these poorer
countries it would be misoprostol or nothing.”
Luc de
Bernis, UNFPA senior maternal health adviser, said community-based use of
misoprostol for post-partum haemorrhage prevention is still not an established
strategy, but said experts agreed on further study into the approach.
“Safety and feasibility questions remain. Ongoing programmes focusing on this
should be carefully monitored and evaluated.”
Johanne
Sundby, specialist and professor in international health at the University of
Oslo said given the weakness of health sectors in many countries there is not
enough evidence that the facility-based approach works.
“There
are two solutions to maternal mortality: bring the women to the services (and
strengthen the services) or bring the services to the women,” Sundby said. “I
am tempted to say yes – try to implement the latter, and research the evidence.
The justification is there.”
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DIrect Link to Full Report:
Lancet Website Article:
The
Lancet
23
September 2009
ESTIMATION OF POTENTIAL EFFECTS OF IMPROVED COMMUNITY-BASED DRUG
PROVISION, TO AUGMENT HEALTH-FACILITY STRENGTHENING, ON MATERNAL MORTALITY DUE
TO POST-PARTUM HEMORRHAGE AND SEPSIS IN SUB SAHARAN AFRICA: AN
EQUITY-EFFECTIVENESS MODEL
Dr Christina
Pagel PhD a 
,
Sonia
Lewycka MSc b d, Tim
Colbourn MSc b d, Charles
Mwansambo FRCPCH d,
Tarek
Meguid MRCOG c, Grace
Chiudzu MRCOG c,
Martin
Utley PhD a,
Prof Anthony
ML Costello FRCP b
Summary
Background
Maternal
mortality in Africa has changed little since 1990. We developed a mathematical
model with the aim to assess whether improved community-based access to
life-saving drugs, to augment a core programme of health-facility strengthening,
could reduce maternal mortality due to post-partum haemorrhage or sepsis.
Methods
We
developed a mathematical model by considering the key events leading to
maternal death from post-partum haemorrhage or sepsis after delivery. With
parameter estimates from published work of occurrence of post-partum
haemorrhage and sepsis, case fatality, and the effectiveness of drugs, we used
this model to estimate the effect of three potential packages of interventions:
1) health-facility strengthening; 2) health-facility strengthening combined
with improved drug provision via antenatal-care appointments and community
health workers; and 3) all interventions in package two combined with improved
community-based drug provision via female volunteers in villages. The model was
applied to Malawi and sub-Saharan Africa.
Findings
In
the implementation of the model, the lowest risk deliveries were those in
health facilities. With the model we estimated that of 2860 maternal deaths
from post-partum haemorrhage or sepsis per year in Malawi, intervention package
one could prevent 210 (7%) deaths, package two 720 (25%) deaths, and package
three 1020 (36%) deaths. In sub-Saharan Africa, we estimated that of
182 000 of such maternal deaths per year, these three packages could prevent
21 300 (12%), 43 800 (24%), and 59 000 (32%) deaths,
respectively. The estimated effect of community-based drug provision was
greatest for the poorest women.
Interpretation
Community
provision of misoprostol and antibiotics to reduce maternal deaths from post-partum
haemorrhage and sepsis could be a highly effective addition to health-facility
strengthening in Africa. Investigation of such interventions is urgently needed
to establish the risks, benefits, and challenges of widespread implementation.
Funding
Institute
of Child Health and Faculty of Mathematical and Physical Sciences, University
College London, and a donation from John and Ann-Margaret Walton.
a Clinical
Operational Research Unit, Department of Mathematics, University College
London, London, UK
b Centre for International
Health and Development, University College London Institute of Child Health,
London, UK
c Department of
Obstetrics and Gynaecology, Kamuzu Central Hospital and Bwaila Hospital,
Lilongwe, Malawi
d Parent and
Child Health Initiative, Department of Paediatrics, Kamuzu Central Hospital,
University of Malawi, Lilongwe
Correspondence to: Dr Christina Pagel, Clinical
Operational Research Unit, Department of Mathematics, University College
London, 4 Taviton Street, London WC1H 0BT, UK
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