Assisted vaginal delivery in low and middle income countries: an overview.

OBJECTIVE: To assess the use of assisted vaginal delivery (AVD) in low- and middle-income countries (LMICs), highlighting what level of care procedures were performed and identifying systemic barriers to its use. DESIGN: Cross-sectional health facility assessments. SETTING: Up to 40 countries in Latin America, sub-Saharan Africa and Asia. POPULATION: Assessments tended to be national in scope and included all hospitals and samples of midlevel facilities in public and private sectors. METHODS: Descriptive secondary data analysis. MAIN OUTCOME MEASURES: Percentage of facilities where health workers performed AVD in the 3 months prior to the assessment, instrument preference, which health workers performed the procedure, and reasons AVD was not practiced. RESULTS: Fewer than 20% of facilities in Latin America reported performing AVD in the last 3 months. In sub-Saharan Africa, 53% of 1728 hospitals had performed AVD but only 6% of nearly 10 000 health centres had done so. It was not uncommon to find <1% of institutional births delivered by AVD. Vacuum extraction appears preferred over forceps. Lack of equipment and trained health workers were the most frequent reasons for non-performance. CONCLUSIONS: The low use of AVD in LMICs is in contrast with many high-income countries, where high caesarean rates are also associated with significant rates of AVD. In many LMICs, rising caesarean rates have not been associated with maintenance of skills and practice of AVD. AVD is underused precisely in countries where pregnant women continue to face hardships accessing emergency obstetric care and where caesarean delivery can be relatively unsafe. TWEETABLE ABSTRACT: Many LMICs exhibit low use of assisted vaginal delivery where access to EmONC continues to be a hardship.

[Knowledge, attitude and perception about obstetric fistula by Cameroonian women]. / Connaissance, attitude et perception vis-à-vis des fistules obstétricales par les femmes camerounaises Une enquête clinique conduite à Maroua, capitale de la province de l'extrême Nord du Cameroun.

INTRODUCTION: This study seeks to identify what the women who live in Maroua Cameroon know and think about obstetric fistula. POPULATION AND METHOD: It is a single hospital, cross-sectional, descriptive and comparative study. Ninety-nine women in the maternity service of the Maroua Provincial Hospital were interrogated on obstetric fistula between May and July 2005, by enquirers who were trained health agents using a questionnaire which required both closed and open answers. RESULTS: The women who had no previous knowledge of it were generally the illiterate (41.7% compared to 18.8%). More than a third of the women who had an idea of the fistula do not know that there is a surgical treatment for it. Whether they had the previous information on fistula or received it from us, one-tenth of the women suggested that suicide was the solution to fistula where as one-third of the women suggested that a patient suffering from fistula should be isolated. CONCLUSION AND INTERPRETATION: Illiteracy contributes significantly to the lack of knowledge of this affection. The population has a poor perception and a strong negative attitude towards obstetric fistula as they see isolation or suicide as the solution to it.

The attitude and knowledge of cervical cancer by Cameroonian women; a clinical survey conducted in Maroua, the capital of Far North Province of Cameroon.

This study was conducted to assess the knowledge, attitudes, and assumption of cervical cancer by women living in Maroua, the capital of the Far North Province of Cameroon. In a 1-month period, 171 women were surveyed as to their socioeconomic status, sexual habits, prior knowledge of cervical cancer, its prevention, and their attitudes toward cervical cancer. Of 171 women, 48 (28%) had prior knowledge of cervical cancer; they were classified as the "aware group" compared with 123 of 171 (72%) women who were uninformed about cervical cancer and they were classified as the "unaware group" (UG). The UG of women tended to be single mothers, illiterate, housewives, and had their first child before the age of 20 (P < 0.005). Despite the awareness of cervical cancer by 28% of women, only a minority of them, 4 of 48 (8.3%), underwent a preventative screening test. Only 71 of 171 (41.5%) women stated that they would be having a screening test in the future. The awareness of cervical cancer by women in Cameroon is still inadequate. Thus, to avoid deaths from cervical cancer, a curable and preventable disease, the need of an aggressive campaign to make Cameroonian women aware of cervical cancer and its prevention is needed.

Obstetric fistula: guiding principles for clinical management and programme development, a new WHO guideline.

It is estimated that more than 2 million women are living with obstetric fistulas (OFs) worldwide, particularly in Africa and Asia, and yet this severe morbidity remains hidden. As a contribution to the global Campaign to End Fistula, the World Health Organization (WHO) published Obstetric fistula: Guiding principles for clinical management and programme development, a manual intended as a practical working document. Its 3 main objectives are to draw attention to the urgency of the OF issue and serve as an advocacy document for prompt action; provide policy makers and health professionals with brief, factual information and principles that will guide them at the national and regional levels as they develop strategies and programs to prevent and treat OFs; and assist health care professionals as they acquire better skills and develop more effective services to care for women treated for fistula repair.

"Good obstetrics" revisited: too many evidence-based practices and devices are not used.

INTRODUCTION: As countries are designing and implementing strategies to address maternal and newborn mortality and morbidity (Millennium Development Goals 5 and 4), it appears that a large number of evidence-based obstetric practices are not used in many settings, and this is a major obstacle to the improvement of quality obstetric care. OBJECTIVES: To remind readers of the existing, relatively easy-to-implement, evidence-based interventions that are currently not being universally applied in obstetric care and, second, to foster research to expand the evidence base further for obstetric care practices and devices, especially those that could be used in resource-poor settings. METHODS: We review possible reasons why changes into practices are difficult to obtain, and we list the key evidence-based interventions known to effectively deal with the main obstetric complications, with supporting references and sources of documentation. We also list some promising interventions that require more research before being recommended. CONCLUSION: Professionals and health services managers have a crucial role in producing the best quality obstetric and neonatal care through implementing the listed evidence-based interventions and make them accessible to all pregnant women and their newborns without delay, even in poor settings. Reasons for which progress is slow should be addressed. One of these reasons being the lack of access to scientific knowledge from the part of professionals in developing countries, we give the key references and also websites which are freely accessible through the Internet. It is hoped that this paper will stimulate the discussion on the dissemination and use of good obstetric practices, and contribute to better maternal and newborn health.

Maternal mortality and access to obstetric services in West Africa.

OBJECTIVES: Process evaluation has become the mainstay of safe motherhood evaluation in developing countries, yet the extent to which indicators measuring access to obstetric services at the population level reflect levels of maternal mortality is uncertain. In this study we examine the association between population indicators of access to obstetric care and levels of maternal mortality in urban and rural West Africa. METHODS: In this ecological study we used data on maternal mortality and access to obstetric services from two population-based studies conducted in 16 sites in eight West African countries: the Maternal Mortality and Obstetric Care in West Africa (MAMOCWA) study in rural Sénégal, Guinea-Bissau and The Gambia and the Morbidité Maternelle en Afrique de l'Ouest (MOMA) study in urban Burkina Faso, Côte d'Ivoire, Mali, Mauritanie, Niger and Sénégal. RESULTS: In rural areas, maternal mortality, excluding early pregnancy deaths, was 601 per 100,000 live births, compared with 241 per 100,000 for urban areas [RR = 2.49 (CI 1.77-3.59)]. In urban areas, the vast majority of births took place in a health facility (83%) or with a skilled provider (69%), while 80% of the rural women gave birth at home without any skilled care. There was a relatively close link between levels of maternal mortality and the percentage of births with a skilled attendant (r = -0.65), in hospital (r = -0.54) or with a Caesarean section (r = -0.59), with marked clustering in urban and rural areas. Within urban or rural areas, none of the process indicators were associated with maternal mortality. CONCLUSION: Despite the limitations of this ecological study, there can be little doubt that the huge rural-urban differences in maternal mortality are due, at least in part, to differential access to high quality maternity care. Whether any of the indicators examined here will by themselves be good enough as a proxy for maternal mortality is doubtful however, as more than half of the variation in mortality remained unexplained by any one of them.

[Maternal mortality in developing countries: what strategies to adopt?]. / Mortalité maternelle dans les pays en développement: quelles stratégies adopter?

Despite an international consensus on the strategies necessary to achieve a massive reduction of maternal mortality and related neonatal mortality, many countries have made no progress in these areas. The main reason for this failure is that this aspect of public health and the basic human right to bear children under acceptably safe and respectable conditions have received neither sufficient attention from governments in developing countries nor long-term technical and financial support from rich countries. Yet a sound health care system that is accessible to the poorest classes is prerequisite for durable socio-economic development. Implementation of the UN Millennium Development Goals (MDG) provides an excellent opportunity to reaffirm the need for massive support of programs undertaken in this domain by developing countries and for implementation of an effective strategy to enhance access to quality care for the poorest classes. The purpose of this article is to review the main points in a strategy to reduce maternal mortality, i.e., use of practices with documented effectiveness; access to qualified personal during pregnancy and delivery; availability of health services and underlying facilities; the role of individuals, families, and communities; and the political and legal framework. This article also stresses the fact that programs designed to enhance maternal and newborn health can significantly strengthen the health care system for the community as a whole: maternal health offers a gateway for strengthening health care services in general.

[Determinants of risk factors associated with severe maternal morbidity: application during antenatal consultations]. / Le poids des facteurs de risque de la morbidité maternelle grave: application à la fiche de consultation prénatale.

In order to assess the incidence of severe maternal mortality (SMM) and search for associated determinants of risk factors, a population-based survey of 20,326 pregnant women was conducted in six counties in West Africa (MOMA study). Complete files were available for 19,545 (96.2%) women. The rate of SMM, assessed with an overall indicator, was 6.7% (5.7-6.4). The relationship between SMM and various socio-economic features, gyneco-obstetrical antecedents and characteristics of the current pregnancy was studied. Multivariate analysis identified 10 factors of risk of SMM. Prevalence, adjusted odds-ratio, positive predictive value and adjusted attributable risk were determined for these ten factors. By decreasing order of positive predictive value, these factors were: hemorrhage during pregnancy (51.5%), antecedent cesarean (27.1%), high blood pressure (diastolic pressure 10 (18.9%), systolic pressure 14 (14.6%)), antecedent multiple pregnancy (15.8%), height 150 cm (12.9%), lack of fetal movements (12.6%), history of 3 stillborns (9.3%), age over 35 years (8%), nulliparity (7.3%), presence of disease during the pregnancy (7.1%). These results show the importance of antenatal consultation during which these factors are easily identifiable.

[Maternal morbidity and qualification of health-care workers: comparison between two different populations in Senegal]. / Morbidité maternelle et qualification du personnel de santé: comparaison de deux populations différentes au Sénégal.

OBJECTIVE: High fertility rates and high maternal mortality ratios have led most cooperation agencies to place high priority on health of women and children. The objective of this study was to compare maternal morbidity and mortality tin two populations with widely contrasting availability of health care in order to test the hypothesis that differences in maternal outcome mainly result from the qualification of health carers. METHODS: This population-based study included a cohort of pregnant women which was part of a multicenter study of maternal morbidity in six countries in West Africa (MOMA). We compared health outcome in two different populations of Senegal (Saint-Louis and Kaolack).3,777 pregnant women were follow through pregnancy, delivery and pureperium. Maternal morbidity was assessed from the women's recall at each visit of the investigator and from obstetric complications diagnosed by the birth attendant within health facilities. RESULTS: Maternal mortality was higher in the Kaolack area where women gave birth mainly in district health care centers, most often assisted by traditional birth attendants, than in Saint-Louis where women giving birth in health facilities were principally referred to the regional hospital and were generally assisted by midwives (874 and 151 maternal deaths per 100,000 live births respectively, p<0.01). Diagnosed maternal morbidity, however, was higher in Saint-Louis than in the Kaolack area, especially for births in health facilities (9.50 and 4.84 episodes of obstetric complications per 100 lie births respectively, p<0.01). Univariate and multivariate analyses showed that diagnosed morbidity was mainly associated with degree of training of the health attendant in facility deliveries and that antenatal care had no effect. DISCUSSION: Midwives in health facilities appear to detect more obstetric complications than traditional birth attendants. Immediate detection leads to immediate care and to a lower case-fatality rate. This could explain the differences in maternal outcome between two urban centers with contrasting health care availability. CONCLUSION: These results suggest that one of the strongest weapons in the fight against maternal mortality is the employment of the most qualified personnel possible for monitoring labor.

[Potential role of prenatal care in reducing maternal and perinatal mortality in sub-Saharan Africa]. / Rôle potentiel de la consultation prénatale dans la lutte contre la mortalité maternelle et la mortalité néonatale en Afrique sub-saharienne.

Prenatal care has been implemented in developing countries according to the same mode as applied in industrialized countries without considering its real effectiveness in reducing maternal and neonatal mortality. Several recent studies suggest that the goals should be revisited in order to implement a program of prenatal care based on real scientific evidence. Based on the current literature, we propose a potentially effective content for prenatal care adapted to the context of developing countries. Four antenatal consultations would be enough if appropriately timed at 12, 26, 32 and 36 weeks pregnancy. The purpose of these consultations would be: 1) to screen for three major risk factors, which, when recognized, lead to specific action: uterine, scare, malpresentation, premature rupture of the membranes; 2) to prevent and/or detect (and treat) specific complications of pregnancy: hypertension, infection (malaria, venereal disease, HIV, tetanus, urinary tract infection); anemia and trace element deficiencies, gestational diabetes mellitus; 3) to provide counseling, support and information for pregnant women and their families (including the partner) concerning: severe signs and symptoms of pregnancy and delivery, community organization of emergency transfer, delivery planning. These potentially effective actions can only have a real public health impact if implemented within an organized maternal health system with a functional network of delivery units, if truly quality care is given, and if the relationships between health care providers and the population are based on mutual respect. Sub-Saharan African women use prenatal care extensively when it is accessible; this opportunity must be used to implement evidence-based actions with appropriate and realistic goals.

[Estimate of expected cesarean section rate for maternal indications in a population of pregnant women in West Africa (MOMA survey)]. / Estimation du taux attendu de césariennes pour indications maternelles dans une population de femmes enceintes d'Afrique de l'Ouest (enquête MOMA).

OBJECTIVES: There is still some debate about the optimal rate of cesarean section (CS) needed to achieve better outcome for both mothers and infants in developing countries. We examine here two aspects of the question: i) a simple method to estimate the expected rate of CS according to obstetrical risk; ii) a test of the method to estimate the appropriate rate for maternal indications in a general population of pregnant women in West Africa. METHODS: This population-based study was conducted in a cohort of pregnant women in six West African countries (MOMA survey): Abidjan (Ivory Coast), Bamako (Mali), Niamey (Niger), Nouakchott (Islamic Republic of Mauritania), Ouagadougou (Burkina Faso), and in three areas of Senegal, two small towns (Fatick and Kafrine, Kaolack region), and one major city (Saint-Louis). 19,459 women with singleton pregnancies with expected breech presentation were followed to delivery and puerperium. Maternal indications for CS were defined as dystocia (prolonged labor over 12 hours), malpresentation, previous cesarean section, abruptio placentae, placenta paevia and eclampsia. A standardized method was used to calculate the number of expected CS in the MOMA population, according to the level of the obstetrical risk. RESULTS: The minimal needs for Cs for maternal indications were estimated between 3.6 and 6.5 per 100 deliveries. However, we observed a rate of 1.3 CS per 100 deliveries. DISCUSSION: These findings underline the lack of CS for maternal indications in urban West Africa. The method of standardization we propose could help policy makers, health planners and obstetricians to design programs to reach the appropriate level of CS and to monitor and follow-up these programs.

[Uterine rupture in Senegal. Epidemiology and quality of management]. / Rupture utérine au Sénégal. Epidémiologie et qualité de la prise en charge.

The purpose of this prospective longitudinal study was to analyze data concerning patients treated for uterine rupture at surgical maternity hospitals in Senegal between January 1 to December 31, 1996. A total of 50 cases of uterine ruptures were recorded during the study period, i.e., 1 rupture for every 45 cesarian sections. Typical epidemiological features were rural residence (68%), age over 30 years (66%), multiparity (64%), and presence of obstetrical risks factors (76%). In 96% of cases, rupture usually occurred after failure or natural delivery assisted by personnel with limited skills in non-surgical facilities. Treatment consisted of uterine suture in 22% of cases and obstetrical hysterectomy in 78%. As a result of poor facilities for emergency transportation (68% of cases), mean delay between the indication for operative treatment and intervention was 11 hours. Maternal mortality and morbidity were 16% and 14% respectively. Neonatal mortality was 95%. The incidence of uterine rupture could be lowered by improving emergency obstetrical care and identifying risk factors for dystocia during prenatal examinations.

Caesarean section rate for maternal indication in sub-Saharan Africa: a systematic review.

INTRODUCTION: Rates of caesarean sections in more-developed countries have been rising since 1970, and vary greatly between less-developed countries. Present estimates, based on data from more-developed countries need to be validated with data from less-developed countries. We estimated the need for caesarean section for maternal indication in a population of pregnant women in west Africa (MOMA survey). METHODS: The expected caesarean section rate was calculated from the rate of obstetric risk in the MOMA population, and rates of caesarean section in published work. FINDINGS: Three-quarters of women from hospitals of sub-Saharan Africa were delivered by caesarean section for maternal reasons. Such intervention was needed for six main reasons, protracted labour, abruptio placentae, previous caesarean section, eclampsia, placenta praevia, and malpresentation. Although the observed rate of caesarean section in west African women is 1.3%, our results, combined with those of published work suggest a range of 3.6-6.5% (median, 5.4%). INTERPRETATION: Our method might not be strictly accurate, but it is simple and provides informative findings that can help policy makers and health planners in sub-Saharan Africa to design and follow up programmes to reach the optimum caesarean section rate. Moreover, application of this method to hospital data could improve practitioners' assessments in these countries.

Evidence for a 'healthy pregnant woman effect' in Niakhar, Senegal?

BACKGROUND: Although it is generally believed that pregnancy exposes women to a wide variety of excess health risks that go beyond the direct obstetric complications of pregnancy, the epidemiological evidence in support of such excess indirect risks is inconclusive. In this article we attempt to document the contribution of indirect causes of death to maternal mortality in rural Senegal by using an epidemiological approach whereby the time spent during pregnancy and postpartum is considered a transient period of exposure to the health hazards of childbearing. METHODS: We use data from an ongoing demographic surveillance system in Niakhar, Senegal and calculate rate ratios comparing death rates in pregnant or recently pregnant women (exposed) with death rates in other women (unexposed), including and excluding direct obstetric deaths. RESULTS: Between ages 20 and 44, pregnancy does not confer additional risks to women. After excluding direct obstetric deaths, exposed women aged 20--39 have surprisingly lower risks of death than unexposed women of the same age. For the very young (15-19) and the very old (45-49), on the other hand, the excess risks associated with pregnancy are considerable and, among women age 45 or older, persist even after excluding direct obstetric deaths. CONCLUSION: The apparent protective effect of pregnancy on women's health that is observed in this study illustrates the paradoxical nature of the concept of indirect causes of maternal mortality, and the difficulties in measuring the risks of death attributable to the pregnancy. Further studies aimed at separating risks attributable to the pregnancy from those that are incidental to the pregnancy are required.

[Uterine rupture in Senegal. Results of 2 surveys taken in 1992 and 1996]. / Ruptures utérines au Sénégal. Résultats de deux enquêtes effectuées en 1992 et 1996.

OBJECTIVES: National prospective descriptive study on dystocia were conducted in Senegal in 1992 and 1996. We examined more closely the data on uterine rupture to determine trends between these two surveys. METHODS: Data were collected for all patients undergoing an obstetrical intervention between January 1st and December 31st in 1992 and in 1996 in one of the referral maternity-obstetrical surgery units in each of the 10 regions in Senegal. RESULTS: The rate of uterine rupture was 1 per 51 interventions in 1992 (1.87%) versus 1 per 53 interventions in 1996 (1.94%). This dramatic event was recurrent in 7 of the 10 regions. The patients involved were aged 25-35 years (68% in 1992 versus 70% in 1996), multiparous or grand multiparous (52% in 1992 versus 70% in 1996), illiterate (90%), with poor follow-up (less than 3 prenatal consultations in 56% of the cases), and were generally evacuated to the unit (80% in 1992 versus 97% in 1996) without medical care (55%). Maternal mortality was high (28% in 1992 versus 12% in 1996). Infant mortality was also very high (98% in 1992 versus 86.6% in 1996). Conservative treatment of uterine rupture was used increasingly: the rate of conservative suture rose from 3.3% in 1992 to 22% in 1996. CONCLUSION: Prevention is a challenge for healthcare workers, public authorities and the population in general. Health policy should be directed towards forming general practitioners in obstetrical surgery. Emergency surgery kits should be made available to improve the quality of care in all maternity units throughout the country.

Risk factors for perinatal mortality in West Africa: a population-based study of 20326 pregnancies. MOMA group.

UNLABELLED: The aim of the study was to identify simple clinical risk factors for perinatal mortality (PNM) in different areas of West Africa, to quantify their prevalence among pregnant women and to estimate their relative contribution in the definition of high-risk status of PNM. The MOMA study was a prospective population-based study in which data were collected on 20 326 pregnant women in various, primarily urban, areas of Burkina Faso, Ivory Coast, Mali, Mauritania, Niger and Senegal. The present report analyses 19 870 singleton births and 31 simple clinical variables with univariate and multivariate methods. The mean PNM ratio was 42 per 1000 total births, and 62% of these deaths were stillbirths. In the crude analysis, after adjustment or taking prevalence into account, the principal risk factors were: vaginal bleeding (immediately antenatal and intrapartum), hypertension (especially during labour), dynamic (prolonged labour and use of oxytocin) and mechanic (non-cephalic presentation) dystocia, and infection (prolonged rupture of the membranes and intrapartum fever). CONCLUSIONS: Most of the principal risk factors for PNM cannot be detected during antenatal care visits but only in early labour. High-risk status should not be based solely on antenatal care visits, but should also take into account monitoring during labour.

Severe maternal morbidity from direct obstetric causes in West Africa: incidence and case fatality rates.

Data on maternal morbidity make it possible to assess how many women are likely to need essential obstetric care, and permit the organization, monitoring and evaluation of safe motherhood programmes. In the present paper we propose operational definitions of severe maternal morbidity and report the frequency of such morbidity as revealed in a population-based survey of a cohort of 20,326 pregnant women in six West African countries. The methodology and questionnaires were the same in all areas. Each pregnant woman had four contacts with the obstetric survey team: at inclusion, between 32 and 36 weeks of amenorrhoea, during delivery and 60 days postpartum. Direct obstetric causes of severe morbidity were observed in 1215 women (6.17 cases per 100 live births). This ratio varied significantly between areas, from 3.01% in Bamako to 9.05% in Saint-Louis. The main direct causes of severe maternal morbidity were: haemorrhage (3.05 per 100 live births); obstructed labour (2.05 per 100), 23 cases of which involved uterine rupture (0.12 per 100); hypertensive disorders of pregnancy (0.64 per 100), 38 cases of which involved eclampsia (0.19 per 100); and sepsis (0.09 per 100). Other direct obstetric causes accounted for 12.2% of cases. Case fatality rates were very high for sepsis (33.3%), uterine rupture (30.4%) and eclampsia (18.4%); those for haemorrhage varied from 1.9% for antepartum or peripartum haemorrhage to 3.7% for abruptio placentae. Thus at least 3-9% of pregnant women required essential obstetric care. The high case fatality rates of several complications reflected a poor quality of obstetric care.

Maternal morbidity and mortality in two different populations of Senegal: a prospective study (MOMA survey).

OBJECTIVE: To compare maternal morbidity and mortality in two urban populations with contrasting availability of health care, and to test the hypothesis that differences in maternal outcome result mainly from the management of delivery in health facilities. DESIGN: A population-based study of a cohort of pregnant women which was part of a multicentre study of maternal morbidity in six countries of western Africa (MOMA). SETTING: Two different urban areas of Senegal (Saint-Louis and Kaolack). POPULATION: 3,777 pregnant women who were followed up throughout pregnancy, delivery and puerperium. MAIN OUTCOME MEASURES: Maternal morbidity and mortality: morbidity was assessed from women's recall at each visit by the investigator and from obstetric complications diagnosed by the birth attendant within health facilities. RESULTS: Maternal mortality was higher in the Kaolack area where women gave birth mainly in district health care centres, usually assisted by traditional birth attendants, than in Saint-Louis where women giving birth in health facilities went principally to the regional hospital and were usually assisted by midwives (874 and 151 maternal deaths per 100,000 live births, respectively, P < 0 x 01). Maternal morbidity, however, was higher in Saint-Louis than in Kaolack area, especially for births in health facilities (9 x 50 and 4 x 84 episodes of obstetric complications per 100 live births, respectively, P < 0 x 01). Univariate and multivariate analyses showed that morbidity was mainly associated with the training of the birth attendant in facility deliveries and that antenatal care had no effect. CONCLUSION: Midwives in health facilities appear to detect more obstetric complications than traditional birth attendants. Immediate detection leads to immediate care and to low fatality rates. This could explain differences in maternal outcome between two urban centres with contrasting health care availability. These results suggest that one of the strongest weapons in the fight against maternal mortality is the employment of the most qualified personnel possible for monitoring labour.