Improved access to comprehensive emergency obstetric care and its effect on institutional maternal mortality in rural Mali.

Abstract

To evaluate the effect of a national referral system that aims to reduce maternal mortality rates through improving access to and the quality of emergency obstetric care in rural Mali (sub-Saharan Africa).
A maternity referral system that included basic and comprehensive emergency obstetric care, transportation to obstetric health services and community cost-sharing schemes was implemented in six rural health districts in Kayes region between December 2002 and November 2005. In an uncontrolled 'before and after' study, we recorded all obstetric emergencies, major obstetric interventions and maternal deaths during a 4-year observation period (1 January 2003 to 30 November 2006): the year prior to the intervention (P-1); the year of the intervention (P0), and 1 and 2 years after the intervention (P1 and P2, respectively). The primary outcome was the risk of death among obstetric emergency patients, calculated with crude case fatality rates and crude odds ratios. Analyses were adjusted for confounding variables using logistic regression.
The number of women receiving emergency obstetric care doubled between P-1 and P2, and the rate of major obstetric interventions (mainly Caesarean sections) performed for absolute maternal indications increased from 0.13% in P-1 to 0.46% in P2. In women treated for an obstetric emergency, the risk of death 2 years after implementing the intervention was half the risk recorded before the intervention (odds ratio, OR: 0.48; 95% confidence interval, CI: 0.30-0.76). Maternal mortality rates decreased more among women referred for emergency obstetric care than among those who presented to the district health centre without referral. Nearly half (47.5%) of the reduction in deaths was attributable to fewer deaths from haemorrhage.
The intervention showed rapid effects due to the availability of major obstetric interventions in district health centres, reduced transport time to such centres for treatment, and reduced financial barriers to care. Our results show that national programmes can be implemented in low-income countries without major external funding and that they can rapidly improve the coverage of obstetric services and significantly reduce the risk of death associated with obstetric complications.

Full text

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Bull World Health Organ 2009;87:30–38 | doi:10.2471/BLT.07.047076
Objective To evaluate the effect of a national referral system that aims to reduce maternal mortality rates through improving access
to and the quality of emergency obstetric care in rural Mali (sub-Saharan Africa).
Methods A maternity referral system that included basic and comprehensive emergency obstetric care, transportation to obstetric
health services and community cost-sharing schemes was implemented in six rural health districts in Kayes region between December
2002 and November 2005. In an uncontrolled “before and after” study, we recorded all obstetric emergencies, major obstetric
interventions and maternal deaths during a 4-year observation period (1 January 2003 to 30 November 2006): the year prior to the
intervention (P–1); the year of the intervention (P0), and 1 and 2 years after the intervention (P1 and P2, respectively). The primary
outcome was the risk of death among obstetric emergency patients, calculated with crude case fatality rates and crude odds ratios.
Analyses were adjusted for confounding variables using logistic regression.
Findings The number of women receiving emergency obstetric care doubled between P–1 and P2, and the rate of major obstetric
interventions (mainly Caesarean sections) performed for absolute maternal indications increased from 0.13% in P–1 to 0.46% in P2.
In women treated for an obstetric emergency, the risk of death 2 years after implementing the intervention was half the risk recorded
before the intervention (odds ratio, OR: 0.48; 95% confidence interval, CI: 0.30–0.76). Maternal mortality rates decreased more among
women referred for emergency obstetric care than among those who presented to the district health centre without referral. Nearly
half (47.5%) of the reduction in deaths was attributable to fewer deaths from haemorrhage.
Conclusion The intervention showed rapid effects due to the availability of major obstetric interventions in district health centres,
reduced transport time to such centres for treatment, and reduced financial barriers to care. Our results show that national
programmes can be implemented in low-income countries without major external funding and that they can rapidly improve the
coverage of obstetric services and significantly reduce the risk of death associated with obstetric complications.
Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español.
Improved access to comprehensive emergency obstetric care
and its effect on institutional maternal mortality in rural Mali
Pierre Fournier,a Alexandre Dumont,b Caroline Tourigny,a Geoffrey Dunkleyc & Sékou Draméc
.ةلاقلما هذهل لماكلا صنلا ةياهن في ةصلاخلا هذهل ةيبرعلا ةمجترلا
a Unité de Santé Internationale, Centre de Recherche du Centre Hospitalier de l’Université de Montréal, 3875 Saint-Urbain, Montreal, Quebec, H2W 1V1, Canada.
b Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montreal, Quebec, Canada.
c Direction Régionale de la Santé, Kayes, Mali.
Correspondence to Pierre Fournier (e-mail: pierre.fournier@umontreal.ca).
(Submitted: 24 August 2007 – Revised version received: 22 April 2008 – Accepted: 24 April 2008 – Published online: 18 November 2008)
Introduction
Maternal mortality is a major public health problem, particu-
larly in sub-Saharan Africa, where half (50.4%) of all maternal
deaths worldwide occur.1 One objective of the Millennium
Development Goals is to reduce maternal mortality by 75%
between 1990 and 2015.2 In 2005, the maternal mortality
ratio in sub-Saharan Africa, estimated at 900 maternal deaths
per 100 000 live births, was by far the highest in the world.1
Unlike other regions, sub-Saharan Africa has not seen improve-
ments in indicators linked to maternal mortality, leading to
fears that the Millennium Development targets will not be
met.3 In response to this disquieting situation, many African
countries have adopted measures towards reducing maternal
mortality.
The context and causes of maternal mortality and mor-
bidity are well known,4 and strategies to ameliorate them were
recently reported.5 One proven effective strategy is to pro-
vide access to basic emergency obstetric services (parenteral
oxytocics, antibiotics and anticonvulsants; assisted deliver-
ies; manual extraction of the placenta; removal of retained
products) and, if necessary, to comprehensive emergency
obstetric services (basic services plus Caesarean sections and
blood transfusions).6 Access to these services is a key element
of the WHO Making Pregnancy Safer programme.7 Ensur-
ing timely Caesarean delivery when needed is a priority in
sub-Saharan Africa.
In western Africa, maternal mortality is highest in rural
areas where access to emergency obstetric care is limited by
large geographic distances to health facilities and scarce re-
sources.8 While progress has been made in reducing maternal
mortality rates in urban areas, the situation in rural areas is
not improving. In Mali, for example, the population-based
rate of Caesarean delivery in urban areas rose from 1.6% to
3.5% between 1991 and 1998, while in rural areas it remained
unchanged (1.6% and 1.5%, respectively).9 Implementing
emergency obstetric care programmes, and maternity refer-
ral systems in particular, is complicated in settings where
resources are scarce.10 In western Africa, where the Bamako
Initiative has made cost recovery in health care the standard,11
the costs of comprehensive emergency obstetric care represent
a major outlay for households12,13 and several strategies have
been attempted to reduce this financial burden.14,15
In 2002, the Government of Mali launched a nationwide
maternity referral system16 aimed at improving the quality and
accessibility of comprehensive emergency obstetric care services
and at reducing the danger of death associated with obstetric

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Research
Maternal mortality in rural Mali
Pierre Fournier et al.
complications. In this study, we aim to
evaluate the effects of the system in a
rural population of more than one mil-
lion inhabitants.
Methods
Setting
Of 177 countries on the Human De-
velopment Index for 2005, Mali was
ranked 173rd17 and had the 17th high-
est maternal mortality ratio1 The health
region of Kayes, situated in the west of
Mali, has nearly 1.7 million inhabitants
unevenly distributed over 120 760 km².
Rugged terrain and periods of intense
rain with flooding make communica-
tions difficult. The study area consists
of six of the region’s seven districts.
The provincial district was excluded
because it is more urban. The study
area contains just over 1.25 million in-
habitants, and the population density
of the districts varies between 9.7 and
26.2 inhabitants per km² (mean of 14.7
inhabitants per km²).
Despite efforts in recent years, the
geographic accessibility of health ser-
vices remains poor: the distance from
home to a primary health care centre
is more than 5 km for 56% of the
population and more than 15 km for
30%. The public health system, which
is almost the only provider of modern
health-care services, has few resources
(one doctor per 28 000 and one mid-
wife per 96 000 inhabitants). The study
area has 101 community health centres
(15 to 20 in each district) and six district
health centres. Whereas the latter offer
comprehensive emergency obstetric
care, community health centres provide
basic obstetric services, including as-
sisted deliveries. When an emergency
complication arises at the community
health centre, the patient is referred
to a district health centre. The overall
utilization rate of reproductive health
services in the study area resembles
the national average for rural areas in
Mali.18
Intervention
The maternity referral system is a na-
tional programme launched in 2002
to reduce the risk of maternal death
associated with obstetric complica-
tions.16 The system relies on three main
components (Fig. 1). First, it seeks to
improve communication and transport
opportunities to eliminate delays in the
Fig. 1. Components and function of referral system for comprehensive emergency
obstetric care, Mali, 2003–2006
Detection of risk pregnancies
and obstetrical complications
at the community health centres
Governmental
decree for
Caesarean free
of charge
Reduction of the 2nd delay
(transport time)
1. Transport
and communication
Improved radio
communication between
community and
district health services
Improved ambulance
service between
levels of care
Elimination of financial
barriers for women
2. Funding through
community cost-sharing
schemes
Community health
association
Local government
District council
District health centre
Women (patients)
Reduction of risk of death
Increase in coverage
Component of the intervention
Causality link
Improved clinical
management
3. Emergency
obstetric care
Physicians with
surgical competence
Operating rooms
Essential obstetric care
training for staff at
the district health centres
Equipment
Programme objective
delivery of emergency obstetric services.
Funds from overseas donors are used
to improve radio communications be-
tween community health facilities and
district health services, as well as ambu-
lance transport between them. Second,
alternative funding options, including
community cost-sharing schemes, are
accessed to eliminate financial barriers
to obstetric care. Community-funded
schemes receive funds from the local
government, local health services and
community health associations and
then reimburse health providers for all
services they give to women, who con-
tribute only a small co-payment. Third,
training and equipment are provided
to improve the clinical management of
obstetric emergencies.
The programme was designed in
accordance with national guidelines but
is implemented with adaptations for
regional contexts in cooperation with
local health partners. In the study area,
the start-up period was between 2002
and 2005, depending on the district.
Two categories of women use the
programme’s obstetric services: (i) those
with obstetric complications who are
referred by community health centres
and have benefited from all compo-
nents of the system, and (ii) those who
are self-referred to the district health
centre.
There are six categories of obstet-
ric emergency, defined on the basis of
the medical diagnosis or the reason
for referral: haemorrhage, uterine
rupture, pre-eclampsia/eclampsia, dys-
tocic labour, infection and other (for
other obstetric emergencies that cause
maternal death directly, such as abor-
tion, or indirectly, mainly malaria and
anaemia).19
Study design and statistical
analysis
In 2004, a system for ongoing registra-
tion of obstetric emergencies was set up
in all districts of the Kayes region. Dur-
ing an initial pilot phase, data collection
was supported and supervised by the
Regional Health Authority of Kayes and
the research team. The system allowed
for the documentation of each patient
deemed to be an obstetric emergency,
and the data collected included the
sociodemographic characteristics of
the woman, the obstetric diagnosis and
outcome, pregnancy follow-up, etc.
Data were collected retrospectively for
the period from 1 January 2003 to 30
June 2004, after which the data were
collected prospectively until 30 No-
vember 2006. All cases with direct and
indirect obstetric complications were
recorded and classified in accordance
with accepted standards.19
Because the maternity referral sys-
tem is a national programme that all
regions must implement, it was neither
ethical nor practical to include a control
group that would be denied access to
this programme in our study design.
Therefore, we used a quasi-experimental
uncontrolled before-and-after study
design. The main criterion to assess the
effects of the intervention is the risk of

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Research
Maternal mortality in rural Mali
Pierre Fournier et al.
Fig. 2. Data availability, by period and district, in referral system for comprehensive
emergency obstetric care, Mali, 2003–2006
District
P–1 P0P1 P2
5
0
6
2003
Year
20042005 2006
2007
4
3
2
1
Start of intervention
P–1, year before the intervention; P0, year of the intervention; P1, 1 year after the intervention; P2, 2 years after
the intervention.
death among obstetric emergency cases.
To evaluate the efficacy of the mater-
nity referral system, we considered four
periods: before the intervention (P−1),
the year during which the intervention
was implemented (P0) and two 12-
month post-intervention periods (P1
and P2). Data availability and start date
of intervention by district is shown in
Fig. 2.
The maternity referral system was
implemented on a different date in each
of the six districts of the study area. As
a result, the P−1 period lasted from
3 to 34 months, with a mean of 12.2
months; the P0, P1 and P2 periods
all lasted 1 year, except in district 4,
where P0 lasted 11 months, and for
district 1, where P2 lasted 7 months.
District 3 had no P1 or P2 while the
study lasted since implementation of
the programme was delayed because of
the time it took to reach a consensus
regarding community cost-sharing
schemes.
We checked for group comparabil-
ity for the main known risk factors for
maternal death (age, cause of obstetric
complications). Patients came from
districts where access to health services
varies greatly. Districts were classified
according to the percentage of the
population living within 15 km from
a primary health care centre (good ac-
cessibility: > 85%; average accessibility:
from 60 to 85%; poor accessibility:
< 60%). We compared the risk of death
Table 1. Characteristics of the study area and of the obstetric care delivered before, during and after the adoption of a national
maternity referral programme, Mali, 2003–2006
VariableP–1
No. (%)
P0P1 P2
No. (%) No. (%)No. (%)
Population covered (both sexes)
Expected deliveriesa
Institutional deliveriesb
Obstetric emergencies treated
Women referredc
Women not referred
Major obstetric interventionsd
Absolute maternal indicationse
Non-absolute maternal indications
Unknown
1 040 917 (NA)
52 046 (NA)
9 871 (19.0)
475 (0.9)
143 (0.27)
332 (0.64)
120 (0.23)
66 (0.13)
33 (0.06)
21 (0.04)
1 169 061 (NA)
58 453 (NA)
15 576 (26.6)
658 (1.1)
273 (0.47)
385 (0.66)
273 (0.46)
124 (0.21)
107 (0.18)
42 (0.07)
1 037 367 (NA)
51 868 (NA)
16 573 (32.0)
571 (1.1)
246 (0.47)
325 (0.63)
292 (0.56)
156 (0.30)
92 (0.18)
44 (0.08)
976 927 (NA)
48 846 (NA)
19 235 (39.4)
913 (1.9)
452 (0.93)
461 (0.94)
396 (0.81)
225 (0.46)
144 (0.29)
27 (0.06)
NA, not applicable; P–1, year before the intervention; P0, year of the intervention; P1, 1 year after the intervention; P2, 2 years after the intervention.
a Calculated as 5% of the population; this number has been used as a denominator to calculate percentages.
b Includes deliveries at community and district health centres.
c Women with obstetric complications who were referred by a community health centre to a district health centre.
d Includes Caesarean section, hysterectomy, laparotomy, internal version and craniotomy/embryotomy.
e Includes severe antepartum and incoercible postpartum haemorrhage, uterine prerupture/rupture, major cephalopelvic disproportions, abnormal presentations
(transverse and brow).
among obstetric emergency cases across
the different periods of the study by
calculating odds ratios (ORs) and their
95% confidence intervals (CIs). To
evaluate the potential effects of the in-
tervention at different periods, adjusted
ORs were calculated using various
logistic regression models supported by
Stata software, version 9.1 (Stata Cor-
poration, College Station, TX, United
States of America). Confounding vari-
ables included in the model were age,
previous Caesarean section, diagnosis,
district accessibility, Caesarean delivery
and transfusion.
Results
Table 1 presents data on obstetric ac-
tivities in the study area. During the
study, the rate of institutional deliveries
and the number of obstetric emergen-
cies treated in district health centres
increased. The proportion of deliveries

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Pierre Fournier et al.
benefiting from major obstetric inter-
ventions for absolute maternal indica-
tions increased markedly: from 0.13%
(95% CI: 0.10–0.16) at P−1 to 0.46%
(95% CI: 0.26–0.66) at P2.
To take into account the sharp
increase in the number of institutional
deliveries during the study period, we
performed calculations with institu-
tional deliveries as a denominator. These
calculations showed little change in the
rate of obstetric emergencies treated
(P−1 versus P2; 4.8% and 4.7%, respec-
tively) while the rate of major obstetric
interventions has increased (25% to
43%, respectively). Also of note is that
there is little change in the percentage
of major obstetric interventions per-
formed for absolute maternal indica-
tions (55% in P−1 and 57% in P2).
During the study, 2617 obstetric
emergency patients received care in dis-
trict health centres and benefited from
all or some components of the mater-
nity referral system. Across the different
periods, they differed significantly in
terms of age, diagnosis, previous obstet-
ric history and case management (Cae-
sarean section), as well as in geographical
access to primary care services in their
district of residence (Table 2).
Table 3 shows the causes of mater-
nal death in the different study periods.
The crude case fatality rate (defined
as the ratio of total deaths observed,
regardless of cause among cases, to the
total number of cases observed) also de-
creased from 10.1% to 5.13% between
P−1 and P2. Nearly half the reduction
in mortality could be attributed to fewer
deaths from haemorrhage. Overall, the
risk of death decreased, and among
women with haemorrhage, the reduc-
tion in risk was nearly three-fold and
was statistically significant (OR: 0.37;
95% CI: 0.17–0.79). The decrease in
the risk of death from haemorrhage was
greater among referred women and was
also statistically significant (OR: 0.17;
95% CI: 0.04–0.68].
Table 4 presents the adjusted odds
ratios between the pre-intervention, im-
plementation and two post-intervention
periods. The risk of death was reduced
by about half for all women, and the
reduction was statistically significant
between P−1 and P1 (P = 0.027) and
between P−1 and P2 (P = 0.002). The
reduction was even more marked among
referred women, for whom the risk of
death was three times lower in P2 than
in P−1 (P = 0.002). The statistical tests
for trends in case fatality rates did not
yield significant results.
Discussion
This study had the advantage of being
set within a national programme, so
that the measurement of its effects and
the analysis of processes allowed us to
draw lessons that are directly applicable
not only to Mali but also to other
resource-poor countries in sub-Saharan
Africa. Existing studies on the imple-
mentation of transport systems, emer-
gency loans, community financing,
communications, or various combina-
tions of these elements20–22 offer few
or no empirical data on whether they
Table 2. Characteristics of women with obstetric emergencies before, during and after the adoption of a national maternity referral
programme, Mali, 2003–2006
CharacteristicP–1 P0 P1 P2P-value (DF)
n = 475
No. (%)
n = 658
No. (%)
n = 571
No. (%)
n = 913
No. (%)
Age in years
£ 16
17–34*
³ 35*
Unknown*
Previous Caesarean section
Diagnosis
Haemorrhage*
Dystocic labour*
Uterine rupture
Pre-eclampsia/eclampsia**
Infection**
Other
Referred womena
Accessibility of primary health
care servicesb
Good*
Average*
Poor*
Caesarean delivery
Transfusion
64 (13.5)
300 (63.2)
93 (19.6)
18 (3.8)
15 (3.2)
95 (14.4)
435 (66.1)
105 (16.0)
23 (3.5)
17 (2.6)
83 (14.5)
370 (64.8)
107 (18.7)
11 (1.9)
24 (4.2)
125 (13.7)
664 (72.7)
114 (12.5)
10 (1)1
46 (5.0)
< 0.01 (9)
0.07 (3)
115 (24.2)
107 (22.5)
12 (2.5)
59 (12.4)
11 (2.3)
171 (36.0)
143 (30.0)
163 (24.8)
232 (35.3)
18 (2.7)
47 (7.1)
5 (0.8)
193 (29.3)
273 (41.5)
135 (23.6)
189 (33.1)
10 (1.8)
49 (8.6)
3 (0.5)
185 (32.4)
246 (43.1)
140 (15.3)
351 (38.4)
16 (1.8)
91 (10.0)
12 (1.3)
303 (33.2)
452 (49.5)
< 0.01 (15)
< 0.01 (3)
40 (8.4)
354 (74.5)
81 (17.1)
112 (23.6)
11 (2.3)
176 (26.7)
225 (34.2)
257 (39.1)
258 (39.2)
17 (2.6)
198 (34.7)
166 (29.0)
207 (36.3)
286 (50.1)
19 (3.3)
300 (32.9)
284 (31.1)
329 (36.0)
383 (41.9)
22 (2.4)
< 0.01 (6)
< 0.01 (3)
0.70 (3)
* c² level of significance < 0.05; **c² level of significance < 0.01.
DF, degrees of freedom; P–1, year before the intervention; P0, year of the intervention; P1, 1 year after the intervention; P2, 2 years after the intervention.
a Women with obstetric complications who were referred by a community health centre to a district health centre.
b Accessibility was categorized according to the percentage of the population in a woman’s district of residence that lived within 15 km from a primary health care
centre: good accessibility, over 85%; average accessibility, from 60% to 85%; poor accessibility, less than 60%.

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Research
Maternal mortality in rural Mali
Pierre Fournier et al.
reduce institutional maternal mortal-
ity. Furthermore, the usefulness of data
from these studies is limited by study
designs that are less than robust.
Our data show that Mali’s national
maternity referral system increases the
coverage of obstetric emergencies and
reduces the risk of death among women
delivering with obstetric complica-
tions. This risk reduction is achieved
primarily in those with haemorrhage,
whose prognosis is directly related to
whether appropriate care is received
within 2 hours or not.23 Furthermore,
the reduction in risk among women
with haemorrhage is distinctly more
marked in those who are referred by
community health centres than in those
who come to the district health centre
on their own. This point is particularly
important because the referred women
have benefited from all components
of the intervention, particularly faster
modes of communication and transport
that reduce treatment waiting times.
Thus, improved access to comprehen-
sive emergency obstetric care and to
Caesarean sections has contributed to
the programme’s success.
The effects of the intervention were
quick to be noted because there were
considerable unmet needs in emergency
obstetric care and baseline case fatality
rates were very high. Over the study
period, the number of women attend-
ing community health centres for nor-
mal deliveries increased progressively.
Furthermore, obstetric complications
became more likely to be diagnosed at
an earlier stage in the labour or post-
partum stages, allowing more women
to benefit from the intervention sooner.
Indeed, the number of obstetric emer-
gencies and of major obstetric inter-
ventions performed in reference health
centres increased dramatically during
the study period. However, 2 years after
implementation of the referral system,
the rates of major obstetric interven-
tions performed for absolute maternal
indications remained low (0.46%) by
comparison to rates reported in 2003
from a study in an urban setting in
neighbouring Burkina Faso. In that
study, the number of major obstetric
interventions for absolute maternal in-
dications increased significantly (from
0.75% to 1.42%) the year after imple-
mentation of a cost-sharing mechanism
for emergency obstetric care.15
An analysis of the conditions in
which the intervention described herein
was implemented made it possible to
identify its strengths and weaknesses.10,24
One of its strengths was the sustained
political support it received at both the
regional and national levels. Reproduc-
tive health is a major component of
Mali’s national health plan, and the
Table 3. Case fatality rates (CFRs) and crude odds ratios, by cause of death,a before, during and after the adoption of a national
maternity referral programme, Mali, 2003–2006
Cause of
death
P–1P0P1 P2P–1 versus P2
DeathsCFRDeaths CFRDeaths CFRDeathsCFRAbsolute
changeb
Attributa-
blec
Crude odds
ratio (95% CI)
Haemorrhage
Referred
Not referred
Dystocic labour
Referred
Not referred
Uterine rupture
Referred
Not referred
Pre-eclampsia/
eclampsia
Referred
Not referred
Infection
Referred
Not referred
Other
Referred
Not referred
Total
Referred
Not referred
183.79
4.89
3.31
1.68
4.19
0.60
0.84
1.40
0.60
2.11
16 2.43
2.93
2.08
1.67
2.56
1.04
0.30
0.37
0.26
1.52
132.28
2.03
2.46
1.23
0.81
1.54
0.18
0.41
0.00
1.40
131.42
1.55
1.30
0.88
1.11
0.65
0.44
0.66
0.22
0.99
–2.37
–3.34
–2.01
–1.81
–3.08
0.05
–0.40
–0.74
–0.38
–1.12
47.5
35.4
57.4
16.2
32.7
–1.42
8.1
7.9
10.9
22.5
0.37 (0.17–0.79)
0.17 (0.04–0.68)
0.38 (0.13–1.13)
0.52 (0.18–1.52)
0.26 (0.07–0.96)
1.08 (0.15–9.27)
0.52 (0.11–2.47)
0.47 (0.06–4.06)
0.36 (0.01–5.04)
0.46 (0.17–1.24)
78
8
5
8
7
6
8
5
3
4
3
1
9
11
8
6
2
4
2
2
1113
7
4
2
1
1
2
5
1
1
0
8 1010
5
5
2
0
2
6
2
4
3.50
1.51
0.42
0.00
0.60
1.26
1.40
1.20
10.1
15.4
7.83
3
7
2
1
1
9
5
4
1.10
1.82
0.30
0.37
0.26
1.37
1.83
1.04
7.59
9.16
6.50
5
3
0
0
0
6
2
4
2.03
0.92
0.0
0.0
0.0
1.05
0.81
1.23
6.14
6.09
6.15
8
1
3
2
1
1.77
0.22
0.33
0.44
0.22
1.07
0.44
1.74
5.13
5.97
4.33
–1.73
–1.29
–0.09
0.44
–0.38
–0.19
–0.96
0.54
–4.98
–9.43
–3.50
18.3
36.9
1.9
–4.67
10.9
3.8
10.2
–15.4
100.0
100.0
100.0
0.50 (0.14–1.78)
0.14 (0.01–1.25)
0.78 (0.11–6.67)
NA
0.36 (0.01–5.04)
0.87 (0.29–2.69)
0.31 (0.03–3.14)
1.45 (0.39–5.76)
0.48 (0.31–0.75)
0.35 (0.18–0.66)
0.53 (0.28–1.01)
10
2
8
48
22
26
50
25
25
35
15
20
47
27
20
CFR, case fatality rate; CI, confidence interval; P–1, year before the intervention; P0, year of the intervention; P1, 1 year after the intervention; P2, 2 years after the
intervention.
a Total number of obstetric emergency cases for P–1 = 475; P0 = 658; P1 = 571; P2 = 913.
b The difference between CFR P2 and CFR P–1 for a specific cause (e.g. 1.42 – 3.79 = –2.37 for haemorrhage).
c Absolute change in maternal mortality for a specific cause (e.g. –2.37 for haemorrhage) expressed as a percentage of the total absolute change in maternal
mortality rates (–2.37 ¸ –4.98 = 47.5).