Should Interventions Focus Only on Complications of Pregnancy and Childbirth?

There is a general lack of emergency care, which contributes considerably to the high adult mortality in Africa (Nordberg 1984, Adult Morbidity and Mortality Project [AMMP] 1997). As shown earlier, many Safe Motherhood Projects restrict the eligibility to use their emergency referral arrangements to obstetric complications and exclude other medical or surgical emergencies. None of the reported case studies cited earlier comments on conflicts arising form this rule, although they are likely to occur. From a district health perspective, a restrictive approach has several shortcomings: There are maternal emergencies, which are often not recognised as such; e.g. ectopic pregnancy with an estimated prevalence of 1/100 pregnancies (Amoko & Buga 1995). Given the transport problems in most rural African communities, it may simply be unethical to deny assistance in case of any life-threatening condition. Maintaining a system for emergency care (e.g. ambulance, radio call) needs constant attention and inputs, even if it is idle. The rarity of referrals in most of the studies (1-2 per month) indicates that the emergency referral arrangements are often under-utilised. Our own experience in a series of village meetings on Safe Motherhood in Southern Tanzania suggests that access to emergency care has a very high priority at the community level but comprises all sorts of emergencies.

There are also projects that have focused on emergency referrals in general. Macintyre & Hotchkiss (Macintyre & Hotchkiss 1999) report on an 8 years experience with a health insurance scheme, covering emergency referral. The most frequent causes for referral were trauma, pregnancy-related, complicated malaria, and severe diarrhoea. Therefore we suggest, expanding Safe Motherhood emergency referral initiatives to other areas of emergency care.