Midhet F, Becker S, Berendes H W
National Institute of Child Health and Human Development, Bethesda, MD 20892, USA.
Soc Sci Med. 1998 Jun;46(12):1587-98. doi: 10.1016/s0277-9536(97)10137-x.
Maternal mortality is high in Pakistan, particularly in the rural areas which have poor access to health services. We investigated the risk factors associated with maternal mortality in sixteen rural districts of Balochistan and the North-West Frontier (NWFP) provinces of Pakistan. We designed a nested case-control study comprising 261 cases (maternal deaths reported during last five years) and 9135 controls (women who survived a pregnancy during last five years). Using contextual analysis, we estimated the interactions between the biological risk factors of maternal mortality and the district-level indicators of health services. Women under 19 or over 39 yr of age, those having their first birth, and those having a previous history of fetal loss were at greater risk of maternal death. Staffing patterns of peripheral health facilities in the district and accessibility of essential obstetric care (EOC) were significantly associated with maternal mortality. These indicators also modified the effects of the biological risk factors of maternal mortality. For example, nulliparous women living in the under-served districts were at greater risk than those living in the better-served districts. Our results are consistent with several studies which have pointed out the role of health services in the causation of maternal mortality. Many such studies have implicated distance to hospital (an indicator of access to EOC) and lack of prenatal care as major determinants of maternal mortality. We conclude that better staffing of peripheral health facilities and improved access to EOC could reduce the risk of maternal mortality among women in rural Balochistan and the NWFP.
巴基斯坦的孕产妇死亡率很高，尤其是在那些难以获得医疗服务的农村地区。我们调查了巴基斯坦俾路支省和西北边境省（NWFP）16个农村地区与孕产妇死亡相关的风险因素。我们设计了一项巢式病例对照研究，包括261例病例（过去五年报告的孕产妇死亡）和9135名对照（过去五年中经历过一次妊娠且存活下来的妇女）。通过背景分析，我们估计了孕产妇死亡的生物学风险因素与地区层面医疗服务指标之间的相互作用。19岁以下或39岁以上的妇女、初产妇以及有过胎儿丢失史的妇女孕产妇死亡风险更高。地区周边医疗机构的人员配备模式以及基本产科护理（EOC）的可及性与孕产妇死亡率显著相关。这些指标还改变了孕产妇死亡生物学风险因素的影响。例如，生活在服务不足地区的未生育妇女比生活在服务较好地区的未生育妇女风险更高。我们的结果与多项研究一致，这些研究指出了医疗服务在孕产妇死亡原因中的作用。许多此类研究认为距离医院（EOC可及性的一个指标）和缺乏产前护理是孕产妇死亡的主要决定因素。我们得出结论，改善周边医疗机构的人员配备以及提高EOC的可及性可以降低俾路支省农村地区和西北边境省妇女的孕产妇死亡风险。
