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The Power of Simplicity: Reducing Maternal Mortality in Sierra Leone and Burundi

Following my piece about maternal health in India, and in advance of the UCL symposium on community-based global maternal care next week, I wanted to focus on two smaller-scale success stories and examine what makes them work. Medecins Sans Frontieres has been working on two projects aimed at reducing women’s risk of death in childbirth in the Kabezi district in Burundi and the Bo district in Sierra Leone.

MSF has produced an analysis of the challenges and gains of its work in a report called Safe Delivery (link takes you to a short précis) which looks at their work in Kabezi since the 2006 start of the project, and in Bo since the MSF began running a hospital there in 2003.

Both Sierra Leone and Burundi are at a disadvantage when it comes to maternal care as their health infrastructures—along with much else —have broken down during and in the aftermath of civil war. The long effect of such breakage is a deficit of human, educational and practical resources: so medical facilities are needed, as are qualified healthcare workers, as are the systems to employ them in a sustainable way and the educational infrastructures required to train them. This is before we tackle the important issue of patients’ own access to healthcare and the importance of antenatal and postpartum care.

All this requires investment, establishment, organisation and management. According to MSF Burundi has a national average of 800 maternal deaths per 100,000 live births, and Sierra Leone has a national average of 890 maternal deaths per 100,000 live births. Sierra Leone has the third-highest rate of maternal death, after Chad and Somalia. The main causes of maternal death are haemorrhage (25%), sepsis (15%), unsafe abortion (13%—and the report states clearly that “abortions need to be performed by skilled medical workers in a safe and hygienic environment”), hypertensive disorders like eclampsia and pre-eclampsia; and obstructed labour.

As the report—which can be read in full here—states,

"Every year, some 287,000 women die from  complications during pregnancy and childbirth. Most are young, active and healthy. And for every woman who dies, another 20 women suffer from chronic ill health or disability due to conditions such as obstetric fistula.*

"Across the world, in every country and every  population group, approximately 15 percent of  pregnant women develop complications that are potentially life-threatening. But the fate of a  pregnant woman is very much dictated by where  she gives birth in the world. In fact, 99% of maternal deaths occur in poor countries, where—for many people—medical services are out of reach or simply unaffordable."

Yet the local district projects to address this issue (serving a population of nearly 600,000 in Bo and just under 200,000 in Kabezi) have shown that the implementation of basic—or rather, obvious—measures has steeply reduced rates of maternal death. The report stresses that the problem is not a lack of “state of the art facilities” and demonstrates that the establishment of an ambulance system and the availability of emergency in-hospital emergency obstetric care, with trained staff and appropriate medical supplies, twenty-four hours a day, for free, have brought the Kabezi figures down to 74% less than the national level for Burundi and the Bo figures down to 61% less than the national level for Sierra Leone. In both cases the cost of providing such measures to the population for free is less than 2 Euros per head in Bo and a tiny bit over 3 Euros in Kabezi.

One of the UN Millennium Development Goals is to reduce maternal mortality (in comparison with figures from 1990) by 75% by 2015. Judging by the success of the two projects I’ve described above, extreme change is possible through the implementation of simple but profoundly important measures. As the report states, "A common assumption is  that improving access to emergency obstetric care is too costly, but MSF’s experience shows that this need not be the case."

*Despite the triumphs of the two projects I’ve described above, in February of this year MSF released a press alert announcing that Burundi’s only free provider of treatment for obstetric fistula, which is caused by complications during childbirth, is under threat of close due to a lack of trained medical staff. The Urumuri Center, in the city of Gitega, is run jointly by Burundi’s Ministry of Health and MSF and treatment is provided by foreign volunteer surgeons on short-time assignments.

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