Childbirth in rural areas: maternal deaths, village deliveries and obstetric service use

Abstract

We explored village maternal deaths in an area of the East Sepik Province of Papua New Guinea where most women delivered at home. Postpartum haemorrhage, retained placenta and puerperal sepsis were common causes of death. Follow-up of a group of pregnant women showed that abnormal labour was frequent. 24% of multigravidae (95% CI 17-33) reported a labour that lasted longer than 24 hours. In 9% of all births (95% CI 5-15) the third stage lasted longer than one hour, or products were retained. Despite a high proportion of obstetric complications in apparently low-risk villages births, few women attend a health facility for delivery. Health centre attenders were a relatively privileged group. Some hospital users complained about staff attitudes. A poor reputation means that women are less likely to use health services for delivery. Providers need to improve the acceptability of the care provided, and communities should be encouraged to help with transport for their women to go to a health facility when they are in labour.

PIP: In 46 villages in the Wosera Subdistrict in the East Sepik Province of Papua New Guinea, interviews with 1008 women of reproductive age, other villagers, and 89 women who were admitted for delivery or in the early postnatal period to Maprik District Hospital or Kaugia Health Subcentre during 1984-1986 and the follow-up of 144 pregnant women among the 1008 were conducted to describe maternal deaths, the labor pattern, and influences on how women used obstetric services in this lowlands area. 14 maternal deaths were identified. Probable causes of maternal death were postpartum hemorrhage (6), puerperal sepsis (3), obstructed labor (1), anemia (1), meningitis (1), and retained products (1). Cause of death could not be identified in one case. Only five of the cases used health services. 11 of the 144 women delivered in a health facility. The remaining 131 delivered at home. 27% of these deliveries were unattended. Attendants were present at all the deliveries of nulliparous women. Female relatives attended 60% of home deliveries. The husband attended 12% of the home deliveries. Women who attended the hospital or health subcenter tended to have a higher household income than their counterparts. Ambulances or church vehicles transported 49% of women who used a health facility. 26% of women who used a health facility delivered in the village then was referred to a health facility. Labor complications were the reason for using a health facility for 40% of the women who used a health facility. The remaining 60% made the decision to use a health facility prenatally. Many women did not complain about the obstetric care at the hospital. Some complaints among those who did complain included no staff in the labor ward during delivery, angry nurses, reprimanding staff, and patient threatened with jail. These findings indicate that, to reduce maternal mortality, health services need to improve the quality and the acceptability of health care and that communities need to help transport pregnant women during labor.