Maternal and perinatal mortality in resource-limited settings
Authors: John W Bolnga, Marilyn Morris, Jimmy Aipit, Moses Laman
Journal: The Lancet Global Health (2015)

Claudia Hanson and colleagues (July, 2015)1Hanson C Cox J Mbaruku G et al.Maternal mortality and distance to facility-based obstetric care in rural southern Tanzania: a secondary analysis of cross-sectional census data in 226 000 households.Lancet Glob Health. 2015; 3: e387-e395Summary Full Text Full Text PDF PubMed Scopus (90) Google Scholar report that maternal mortality was four times higher in women who lived more than 35 km from a hospital in rural Tanzania than in women who lived within 5 km of a hospital. We strongly agree with the findings of their study, but are interested to know whether a similar association was noted between distance and perinatal mortality. Of the 17 427 deliveries at Modilon Hospital, the only referral hospital in the Madang Province of Papua New Guinea, over a 6-year period, three-quarters of pregnancy-related deaths were recorded in women presenting late to hospital as a result of distance and logistical constrains limiting access to hospital. Additionally, poor quality obstetric care in peripheral health facilities caused a clinically significant increase in the risk of late presentation and maternal deaths in our setting in Papua New Guinea.2Bolnga JW Hamura NN Umbers AJ Rogerson SJ Unger HW Insights into maternal mortality in Madang Province, Papua New Guinea.Int J Gynaecol Obstet. 2014; 124: 123-127Summary Full Text Full Text PDF PubMed Scopus (14) Google Scholar Because of the high maternal mortality in Papua New Guinea, increased efforts have been made by the government and its partners to improve availability and accessibility of quality obstetric care.3University of Technology SydneyMaternal and Child Health Initiative PNG.http://www.uts.edu.au/research-and-teaching/our-research/who-collaborating-centre/key-strength-areas/maternal-and-child-1Date: 2013Google Scholar Consequently, our in-hospital maternal mortality ratio declined from 893 per 100 000 livebirths in 2009 to 363 per 100 000 livebirths in 2014 (p<0·001; figure). We would be interested to know whether Hanson and colleagues noted any correlation between maternal and perinatal mortality in relation to distance in their study.1Hanson C Cox J Mbaruku G et al.Maternal mortality and distance to facility-based obstetric care in rural southern Tanzania: a secondary analysis of cross-sectional census data in 226 000 households.Lancet Glob Health. 2015; 3: e387-e395Summary Full Text Full Text PDF PubMed Scopus (90) Google Scholar Although access to professional health care during childbirth should obviously reduce perinatal mortality in parallel with maternal mortality, we did not find this in our setting (p=0·10; figure). This result highlights the fact that efforts aimed at reducing maternal mortality in developing countries should not overlook neonatal survival. We declare no competing interests. Maternal mortality and distance to facility-based obstetric care in rural southern Tanzania: a secondary analysis of cross-sectional census data in 226 000 householdsLarge distances to hospital contribute to high levels of direct obstetric mortality. High pregnancy-related mortality in those living near to a hospital suggests deficiencies in quality of care. Full-Text PDF Open AccessMaternal and perinatal mortality in resource-limited settings – Authors' replyWe thank John Bolnga and colleagues for raising the question of whether we saw an effect of distance to a health facility on perinatal mortality. We are, unfortunately, not able to report on perinatal mortality as we did not record stillbirths. However, our data show some evidence of neonatal mortality rising with distance to a hospital. Neonatal mortality increased from 29·6 (95% CI 25·4–34·6) per 1000 livebirths for those living less than 5 km from a hospital to 39·7 (33·5–47·1) for those living more than 35 km from a hospital (crude odds ratio 1·31 [95% CI 0·98–1·76], p=0·0139 using a test for trend; figure). Full-Text PDF Open Access