Improving access to comprehensive emergency obstetric care in the poorest countries: Impact on institutional maternal mortality in rural settings in Kayes, Mali

Objective. Maternal mortality is a major public health problem in low-income countries. We evaluate the impact of a national referral programme to improve access to emergency obstetric care in a population of 1 million inhabitants living in six health districts in rural sub-Saharan Africa. The program has three components: emergency obstetric care improvement by making major obstetrical interventions available at the district level, ambulance transportation between community and district health centres and funding through a community financial scheme that decreases meaningfully the financial burden borne by women.

Methods. We used a before/after design. The observation period was four years. The primary outcome was the risk of death for obstetric emergencies. The analyses were adjusted for confounding variables (case mix [obstetrical diagnosis], age, geographical accessibility, previous caesarean section, caesarean delivery and blood transfusion).

Findings. Two years after the start of the intervention, the number of assisted pregnancies receiving comprehensive emergency obstetric care doubled (from 475 to 913) and the number of major obstetric interventions (mainly caesarean sections) performed for absolute maternal indications increased from 0.13% to 0.46% (denominators: expected deliveries). Among women treated for obstetric emergencies, two years after the intervention, the risk of death was half of what it was before the intervention [ORa: 0.48 (0.30 – 0.76)]. Improvement of maternal prognosis was even more marked among referred women than among those who came to the district health centre on their own [ORa: 0.34 (0.18 – 0.70)]. Nearly one-half (47.5%) of the reduction in deaths is attributable to a decrease in deaths from haemorrhage.

Conclusion. The intervention was more beneficial for women living far from district health centres, as transportation became easier and total costs were lower. In a setting where initial coverage for emergency obstetric care is very low, this intervention's rapid impact is due to the availability of major obstetric interventions in the district health centres, the reduction in transport time, and the elimination of financial barriers thanks to community and public funding. In low income countries, it is possible to implement national programs, funded mainly by local and public resources that rapidly improve coverage for obstetric services and reduce the risk of death faced by women with obstetric complications.