Ronsmans C, Etard J F, Walraven G, Høj L, Dumont A, de Bernis L, Kodio B
Maternal Health Programme, Department of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK.
Trop Med Int Health. 2003 Oct;8(10):940-8. doi: 10.1046/j.1365-3156.2003.01111.x.
Process evaluation has become the mainstay of safe motherhood evaluation in developing countries, yet the extent to which indicators measuring access to obstetric services at the population level reflect levels of maternal mortality is uncertain. In this study we examine the association between population indicators of access to obstetric care and levels of maternal mortality in urban and rural West Africa.
In this ecological study we used data on maternal mortality and access to obstetric services from two population-based studies conducted in 16 sites in eight West African countries: the Maternal Mortality and Obstetric Care in West Africa (MAMOCWA) study in rural Sénégal, Guinea-Bissau and The Gambia and the Morbidité Maternelle en Afrique de l'Ouest (MOMA) study in urban Burkina Faso, Côte d'Ivoire, Mali, Mauritanie, Niger and Sénégal.
In rural areas, maternal mortality, excluding early pregnancy deaths, was 601 per 100,000 live births, compared with 241 per 100,000 for urban areas [RR = 2.49 (CI 1.77-3.59)]. In urban areas, the vast majority of births took place in a health facility (83%) or with a skilled provider (69%), while 80% of the rural women gave birth at home without any skilled care. There was a relatively close link between levels of maternal mortality and the percentage of births with a skilled attendant (r = -0.65), in hospital (r = -0.54) or with a Caesarean section (r = -0.59), with marked clustering in urban and rural areas. Within urban or rural areas, none of the process indicators were associated with maternal mortality.
Despite the limitations of this ecological study, there can be little doubt that the huge rural-urban differences in maternal mortality are due, at least in part, to differential access to high quality maternity care. Whether any of the indicators examined here will by themselves be good enough as a proxy for maternal mortality is doubtful however, as more than half of the variation in mortality remained unexplained by any one of them.
过程评估已成为发展中国家安全孕产评估的主要手段，但在人群层面衡量产科服务可及性的指标在多大程度上反映孕产妇死亡率仍不确定。在本研究中，我们考察了西非城乡地区产科护理可及性的人群指标与孕产妇死亡率之间的关联。
在这项生态学研究中，我们使用了来自西非八个国家16个地点开展的两项基于人群的研究中有关孕产妇死亡率和产科服务可及性的数据：塞内加尔农村、几内亚比绍和冈比亚的西非孕产妇死亡率和产科护理（MAMOCWA）研究，以及布基纳法索、科特迪瓦、马里、毛里塔尼亚、尼日尔和塞内加尔城市的西非孕产妇发病率（MOMA）研究。
在农村地区，排除早期妊娠死亡后，孕产妇死亡率为每10万活产601例，而城市地区为每10万活产241例[相对危险度=2.49（可信区间1.77 - 3.59）]。在城市地区，绝大多数分娩在医疗机构进行（83%）或由熟练医护人员接生（69%），而80%的农村妇女在家分娩且无任何熟练医护人员在场。孕产妇死亡率水平与有熟练医护人员接生的分娩百分比（r = -0.65）、在医院分娩的百分比（r = -0.54）或剖宫产的百分比（r = -0.59）之间存在相对紧密的联系，在城乡地区均有明显的聚集现象。在城市或农村地区内，没有任何一个过程指标与孕产妇死亡率相关。
尽管这项生态学研究存在局限性，但毫无疑问，孕产妇死亡率存在巨大城乡差异至少部分归因于获得高质量产科护理的机会不同。然而，这里所考察的任何指标本身是否足以作为孕产妇死亡率的替代指标值得怀疑，因为死亡率超过一半的变异无法由其中任何一个指标解释。
