摘要：Maternal mortality remains one of the most daunting public health problems in resource-poor settings, and reductions in maternal mortality have been identified as a prominent component of the United Nations Millennium Development Goals. The World Health Organization estimates that 515000 women die each year from pregnancy-related causes, and almost all of these deaths occur in developing countries. Evidence has shown that access to and utilization of high-quality emergency obstetric care (EmOC) is central to efforts aimed at reducing maternal mortality. We analyzed health care policies that restrict access to life-saving EmOC in most resource-poor settings, focusing on examples from rural India, a country of more than 1 billion people that contributes approximately 20% to 24% of the world’s maternal deaths. THROUGHOUT HISTORY, pregnancy has carried a high risk of death secondary to such complications as obstructed labor, ruptured uterus, postpartum hemorrhage, postpartum infection, hypertensive disease of pregnancy, and complications stemming from unsafe abortion. Significant reductions in maternal mortality began only in the late 19th century in Europe and North America. As late as 1934, there were 441 maternal deaths per 100000 births in England and Wales. 1 By 1950, however, there were 87 deaths, and by 1960 there were only 39. 1 Critical to these reductions was dramatic improvement in maternity care, including improvements in sepsis control, the availability of blood transfusions, the introduction of antibiotics, access to safe cesarean sections and abortion services, and, where abortion is illegal and therefore unsafe, access to effective postabortion care. Although maternal mortality has declined dramatically in the developed world, the risk of such death remains a serious threat for women in much of Asia, Latin America, and Africa, particularly in rural settings. The World Health Organization (WHO) estimates that 515 000 women die each year from pregnancy-related causes, and almost all of these deaths occur in developing countries. The maternal mortality ratio for Africa is approximately 1000 per 100 000 live births, compared to 8 to 12 per 100 000 live births in North America. 2 In the mid-1980s, maternal mortality was identified as one of the developing world’s most neglected tragedies. 3 This situation is particularly tragic because no new technologies or drugs are needed to radically lessen maternal mortality. Rather, we believe that widespread access to emergency obstetric care (EmOC), and more generally to community-based and hospital maternity care services, would lead to dramatic reductions in these unacceptably high ratios. Significant declines in maternal mortality in Sri Lanka and Malaysia over the past 50 to 60 years provide evidence that the implementation of maternal health interventions in developing countries is feasible. Increased access to skilled birth attendance accompanied by the development of EmOC and other complementary health services were key contributors to the reductions achieved in those countries. 4 Antenatal screening alone has been shown to be an ineffective tool in mortality reduction, as it is not feasible to predict or prevent most complications of pregnancy and childbirth. Instead, one must assume that all pregnant women are at risk for complications, and women who develop life-threatening complications such as obstructed labor, infection, or serious hemorrhage must receive treatment within a reasonable period of time. 5 Appropriately trained personnel and the provision of necessary supplies and equipment are critical to the development and implementation of effective EmOC services. With regard to the issue of trained personnel, too little attention has been paid to assessing how medical care policies regarding provider roles can affect the availability of EmOC and other essential services. 6, 7 In this paper we examine how policies related to the practice of obstetrics and the administration of anesthesia affect access to life-saving EmOC services in rural areas, using medical policies in India as a case study.
