Academic journal article Bulletin of the World Health Organization

Maternal Mortality in Rural Gambia: Levels, Causes and Contributing Factors

Academic journal article Bulletin of the World Health Organization

Maternal Mortality in Rural Gambia: Levels, Causes and Contributing Factors

Article excerpt

Voir page 611 le resume en francais. En la pagina 612 figura un resumen en espanol

Introduction

Maternal mortality levels are an important indicator of disadvantage within a country as well as between developing and developed countries. Over 99% of the annual global estimate of 585 000 maternal deaths occur in developing countries; a woman in sub-Saharan Africa who becomes pregnant is 75 times more likely to die as a result of this than a woman in Europe (excluding Eastern Europe) or North America (1). Reducing maternal mortality is therefore a high priority goal on the international health agenda. However, because measuring maternal mortality is a complex procedure, reliable estimates of the dimensions of the problem are not generally available and assessing progress towards the goal is difficult.

Much of the information about maternal mortality in developing countries is based on hospital data, which -- especially in rural areas -- are a poor reflection of the extent of the situation in the community (2). Community-based estimates require information on all deaths among women of reproductive age, the cause of the death, and also whether the woman was -- or had recently been -- pregnant at the time of death. Registration of deaths is, at best, incomplete in many parts of the world, and prospective community-based studies need to be very large to be reliable. Other approaches have therefore been devised to overcome the absence of data such as "the sisterhood method" and "the reproductive age mortality survey". The "sisterhood method" questions respondents in household surveys about deaths of their adult sisters during pregnancy, childbirth or the puerperium (3). The advantage of this method is that it requires a relatively small sample size find hence is less expensive and time-consuming than a prospective community-based survey. The disadvantage is that it does not provide current estimates but refers to a period approximately 12 years previously. In the absence of high quality vital registration data, the "reproductive age mortality survey", in which all deaths of women of reproductive age are investigated, is considered the best approach (1). In this type of survey, deaths among women are identified using a variety of approaches including demographic surveillance, census data, health facility records, as well as interviews with community leaders, religious authorities, and cemetery officials. Subsequently, for each death both household members and health care providers are interviewed (verbal autopsy) and health facility records are reviewed to classify the cause of death.

Since 1982, the Medical Research Council Laboratories (MRC) have operated a continuous demographic surveillance system in 40 villages and hamlets in the Farafenni area of the Gambia. In the 1980s three studies used the surveillance system to estimate the level of maternal mortality in the area (Table 1). In the first study, between April 1982 and March 1983, all pregnancies in the Farafenni area were followed prospectively and the maternal mortality ratio was estimated at 2362 per 100 000 live births (with wide confidence intervals due to small sample sizes) (4). In the second study, a reproductive age mortality survey of all deaths in women between April 1984 and March 1987, the maternal mortality ratio was estimated to be 1091 per 100 000 live births (5). The third study, a field trial conducted in the fall of 1987 using the sisterhood method in six of the villages in the Farafenni surveillance area, the maternal mortality ratio was estimated to have been 1005 per 100 000 live births in the mid-1970s (6).

Table 1. Maternal mortality in the Farafenni study area: comparison of present and past estimations

Year      Data source            No. of    No. of
                                maternal    live
                                 deaths    births

1975(a)   Sisterhood, method

1982-83   Prospective              15        635
          pregnancy follow-up
            PHC villages           11        383
            Non-PHC villages        4        252

1984-87   Reproductive age         20       1834
          mortality survey
            PHC villages           13       1159
            Non-PHC villages        7        675

1993-98   Reproductive age         18       4245
          mortality survey
            PHC villages           14       2633
            Non-PHC villages        4       1612

Year      Data source           Maternal       95%
                                mortality   confidence
                                  ratio      interval

1975(a)   Sisterhood, method      1005

1982-83   Prospective             2362      1322-3896
          pregnancy follow-up
            PHC villages          2872      1434-5139
            Non-PHC villages      1587       433-4064

1984-87   Reproductive age        1091       666-1684
          mortality survey
            PHC villages          1122       597-1918
            Non-PHC villages      1037       417-2137

1993-98   Reproductive age         424        251-670
          mortality survey
            PHC villages           532        291-892
            Non-PHC villages       248         68-635

(a) This survey was conducted in 1987 but as a retrospective estimate it refers to about 12 years prior to the data collection. …

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