Editor's Comment

The 3 papers included in this installment remind us of important points that are often forgotten, yet are essential to national strategies to reduce maternal mortality or disability.

The paper by Geller and colleagues [1] contains an unusually clear demonstration that so-called “low-risk” women may suffer complications and, therefore, need both skilled attendance at delivery and access to good quality emergency obstetric care (EmOC). In a well-controlled trial conducted in India of low-risk women delivered by skilled attendants, 6% suffered a postpartum hemorrhage (PPH; blood loss >500 mL) despite having been given misoprostol, and 12% in the placebo group had PPH. These were not institutional deliveries, and there was no active management of the third stage of labor — only administration of misoprostol (not oxytocin). This trial also reminds us that not all PPH is caused by uterine atony; hence, universal active management of the third stage of labor will not eliminate PPH. Because PPH is not only the most common cause of maternal death but usually the most rapid, we must add effective referral to EmOC and skilled attendance to the strategies needed to reduce maternal mortality.

Fetters and colleagues [2] from Ethiopia remind us of the ever-present contribution of unsafe abortion to maternal mortality, and the potential contribution of easing restrictions to safe abortion to reduce mortality — as Ethiopia has done. Prevention of unwanted pregnancy is, of course, the primary means of preventing maternal mortality. It is sad to learn from this paper that postabortion contraception was often not available in the project facilities at a time when it is most critically needed. This lack reflects the changing priorities (and resources) of national governments and the donor community.

The third paper continues our series of reports on national assessments of availability of quality emergency obstetric care. Leigh and colleagues [3] assessed a random sample of facilities in Malawi where births take place. An important lesson from this paper is that, for a variety of reasons, health facilities do not always provide the services that the government expects and believes them to provide. Regular assessment of services as they are actually provided not only identifies the gaps, but usually also identifies solutions to fill the gaps. Malawi developed, and is implementing, its plan to accelerate maternal mortality reduction from this assessment.