Community-Based Drug Delivery And Improved Health Facility Drug Supply Could Mean Almost 60,000 Fewer Maternal Deaths Across Africa

Main Category: Pregnancy / Obstetrics
Also Included In: Women's Health / Gynecology
Article Date: 23 Sep 2009 - 20:00 PDT

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Improved maternal care, through improvement of health facilities and better access to drugs via community health workers and village volunteers, could potentially mean 60,000 fewer maternal deaths across Africa per year from post-partum bleeding and sepsis-a reduction of 32% in deaths from these two causes. The findings are reported in an Article published Online First and in an upcoming edition of The Lancet, written by University College London (UCL) mathematician Dr Christina Pagel in collaboration with global health specialists Professor Anthony Costello (UCL) and colleagues.

Maternal mortality ratios have changed little since 1990 and progress towards Millennium Development Goal 5 (MDG 5)-to improve maternal health-is far off track in sub-Saharan Africa: the maternal mortality ratio has decreased from 921 per 100 000 livebirths in 1990 to 905 per 100 000 in 2005. In this study, the authors developed a mathematical model with the aim to assess the extent to which 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.

Three possible 'packages' of improvements were studied:

1. Health facility strengthening- ensuring that health facilities are supplied with oxytocin to prevent post-partum haemorrhage and antibiotics to treat sepsis.

2. Package 1 combined with improved drug provision via antenatal-care appointments and community health workers. Drug provision entailed distribution of misoprostol (and instructions on how to take it) to women attending outreach antenatal-care appointments provided that the drug was in stock. Misoprostol is a heat-stable drug that can prevent post-partum haemorrhage and is easily given in tablet form. This package also included distribution of antibiotics by community health workers to women presenting with signs of postnatal infection.

3. Packages 1 and 2 combined with additional access to misoprostol and antibiotics via female volunteers in villages, to ensure maximum coverage of these interventions, especially in rural areas.

With the model the authors 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, the authors 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.

The authors say: "Our model shows that in Malawi (even under pessimistic coverage estimates) and across sub-Saharan Africa, improved access to misoprostol and antibiotics through feasible community interventions could have substantial benefit in reduction of maternal deaths due to post-partum haemorrhage or sepsis after delivery."

The authors call for formal assessment and investigation to gain strong evidence of the effect of improved access to drugs -e.g misoprostol and antibiotics- in community settings, and information about their appropriate use and side-effects.

They conclude: "We believe that debate about the relative merits of health-facility strengthening versus increased community interventions perpetuates a false dichotomy. Both programmes are necessary to tackle maternal mortality... we must immediately attend to the needs of women in the poorest communities for whom delivery in a health facility is infeasible. Drugs to prevent post-partum haemorrhage and to treat sepsis exist and could made more accessible in communities by ensuring supply to health facilities and community outreach. Universal coverage to allow delivery in health facilities within the next 5-10 years is implausible; we must explore the potential of additional, community-based interventions to save maternal lives."

In an accompanying Comment, Dr Richard Horton, Editor of The Lancet, says: "The mathematical model in today's report has the potential to transform our attitudes to maternal health. We might now be able to contemplate donor-funded drug-delivery programmes, akin to those available for HIV-AIDS and tuberculosis, in addition to health-facility strengthening. Such a strategy might radically alter the prospects for pregnant women in low-income settings."

He concludes: "The logic of the available evidence is that existing financing initiatives need to broaden their missions to include additional health goals-notably, maternal, newborn, and child health... It is time to place maternal health-as part of the continuum of care-at the centre of existing global health initiatives. It is the very least that women deserve."

Link to Article and Comment

Source
The Lancet