Ronsmans C, Vanneste A M, Chakraborty J, van Ginneken J
Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine, UK.
Lancet. 1997;350(9094):1810-4. doi: 10.1016/S0140-6736(97)08012-4.
A study in Matlab, Bangladesh, has provided evidence favouring a community-based maternity-care delivery system. 3 years of this programme coincided with a significant reduction in direct obstetric mortality compared with the 3 years before the programme. We have examined whether the effects of the programme are sustained over time.
Using data from the continuing demographic survelliance system and from special investigations into the rates and causes of maternal mortality during 1976-93, we compared the trends in direct obstetric maternal mortality ratios in the Maternal and Child Health and Family Planning (MCH-FP) area (which has received extensive services in health and family planning since 1977) with those in the comparison area (with no such intensive health inputs). We divided the areas and time periods into discrete groups that best represented the effects of the introduction of the maternity-care programme.
Direct obstetric mortality declined by 3% per year (rate ratio 0.97 per year [95% CI 0.95-0.99]); there was no difference between the MCH-FP and comparison areas (1.00 [0.96-1.05]). Direct obstetric mortality halved between 1976-86 and 1987-89 in the northern MCH-FP area, where the maternity-care programme was initiated in 1987 (0.50 [0.22-0.99]), but showed no change in the southern MCH-FP area, which had no such intervention at that time (1.07 [0.64-1.72]). After 1990, when the programme was expanded throughout the MCH-FP area, the southern part showed a downward (non-significant) trend in direct obstetric mortality (0.68 [0.35-1.32]). However, direct obstetric mortality also declined between 1987 and 1989 in the southern comparison area (0.48 [0.26-0.83]) in the absence of an intense maternity-care programme, and remained stable thereafter. In the northern comparison area, there was no such decline in direct obstetric mortality (0.78 [0.40-1.40]).
Although the introduction of the maternity-care programme coincided with declining trends in direct obstetric mortality in the areas covered by the programme, a decline also occurred in one of the areas not receiving any such interventions. Caution is required in the interpretation of short-term trends in one indicator in studies designed without random allocation of interventions into treatment and control groups.
在孟加拉国进行的一项基于Matlab的研究提供了支持以社区为基础的孕产妇保健服务提供系统的证据。该项目实施的3年期间，与项目实施前的3年相比，直接产科死亡率显著降低。我们研究了该项目的效果是否能长期持续。
利用1976 - 1993年持续人口监测系统的数据以及对孕产妇死亡率和死因的专项调查，我们比较了妇幼保健和计划生育（MCH - FP）地区（自1977年以来在卫生和计划生育方面接受了广泛服务）与对照地区（没有此类密集卫生投入）的直接产科孕产妇死亡率趋势。我们将地区和时间段划分为最能体现孕产妇保健项目引入效果的离散组。
直接产科死亡率每年下降3%（率比为每年0.97 [95%置信区间0.95 - 0.99]）；MCH - FP地区和对照地区之间没有差异（1.00 [0.96 - 1.05]）。在1987年启动孕产妇保健项目的北部MCH - FP地区，1976 - 1986年至1987 - 1989年期间直接产科死亡率减半（0.50 [0.22 - 0.99]），但在当时没有此类干预措施的南部MCH - FP地区没有变化（1.07 [0.64 - 1.72]）。1990年该项目在整个MCH - FP地区扩大后，南部地区直接产科死亡率呈下降（不显著）趋势（0.68 [0.35 - 1.32]）。然而，在没有密集孕产妇保健项目的情况下，南部对照地区1987年至1989年期间直接产科死亡率也有所下降（0.48 [0.26 - 0.83]），此后保持稳定。在北部对照地区，直接产科死亡率没有下降（0.78 [0.40 - 1.40]）。
尽管孕产妇保健项目的引入与项目覆盖地区直接产科死亡率的下降趋势同时出现，但在未接受任何此类干预措施的地区之一也出现了下降。在没有将干预措施随机分配到治疗组和对照组的研究中，对单一指标的短期趋势进行解读时需要谨慎。
