Abstract
BackgroundReducing maternal mortality is a key goal of international development. Our objective was to determine the potential impact on maternal mortality across sub-Saharan Africa of a combination of dietary supplementation and presumptive treatment of infection during pregnancy. Our aim was to demonstrate the importance of antenatal interventions in the fight against maternal mortality, and to stimulate debate about the design of an effective antenatal care package which could be delivered at the lowest level of the antenatal health system or at community level.MethodsWe collated evidence for the effectiveness of antenatal interventions from systematic reviews and controlled trials, and we selected interventions which have demonstrated potential to prevent maternal deaths. We used a model-based analysis to estimate the total reduction in maternal mortality in sub-Saharan Africa which could be achieved by combining these interventions into a single package, based on a WHO systematic review of causes of maternal deaths.ResultsSevere hypertensive disorders, puerperal sepsis and anemia are causes of maternal deaths which could be prevented to some extent by prophylactic measures during pregnancy. A package of pills comprising calcium and iron supplements and appropriate anti-microbial and anti-malarial drugs could reduce maternal mortality in sub-Saharan Africa by 8% (range <1% to 20%). This estimate is based on Cochrane Review estimates for the effectiveness of daily calcium supplements in reducing the risk of death/serious morbidity due to hypertensive disorders (RR = 0.80, 95% CI 0.65–0.97), anti-microbial prophylaxis in reducing the odds of puerperal sepsis/postpartum endometritis (OR = 0.49, 95% CI 0.23–1.06), anti-malarial prophylaxis in reducing the risk of severe antenatal anemia (RR = 0.62, 95% CI 0.50–0.78), and iron supplementation in reducing the risk of iron deficiency anemia at term (RR = 0.33, 95% CI 0.16–0.69).ConclusionMaternal mortality could be reduced by a combination of micronutrient supplementation and presumptive treatment of infection during pregnancy. Such an approach could be adopted in resource-poor settings where visits to antenatal clinics are infrequent and would complement existing Safe Motherhood activities.
Highlights
Reducing maternal mortality is a key goal of international development
We identified severe hypertensive disorders, puerperal sepsis and anemia as causes of maternal deaths which could be prevented by micronutrient supplementation and presumptive treatment of infection during the antenatal period
We could not identify any simple prophylactic or nutritional interventions which have potential to prevent the other causes of maternal deaths identified by the WHO systematic review
Summary
Reducing maternal mortality is a key goal of international development. Our objective was to determine the potential impact on maternal mortality across sub-Saharan Africa of a combination of dietary supplementation and presumptive treatment of infection during pregnancy. The Millennium Development Goal of halving maternal mortality by 2015 is unlikely to be achieved in sub-Saharan Africa, where little or no progress has been reported [1]. It is clear that such strategies require health care professionals that the poorest countries cannot afford to train or retain in sufficient numbers over the decade [3]. These strategies might be insufficient in view of the increasing proportion of maternal deaths attributable to infectious disease, in sub-Saharan Africa [4]. The effectiveness of various components of antenatal care has been studied, but the overall potential impact on maternal mortality has not been estimated, as it has been for neonatal outcomes [6,7]
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