Summaryobjectives 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. 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 ¼ 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 ¼ )0.65), in hospital (r ¼ )0.54) or with a Caesarean section (r ¼ )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.

The VA described in the present paper left 30% of the maternal deaths unclassified without a specific diagnosis. Had all interviews been with husbands, only 14% would have remained unclassified. If we had only asked people who were present during the terminal phase of the victim's illness the proportion of classified deaths would have risen from 70% to 75%. It is likely that delayed maternal deaths have not been adequately covered by the present algorithms, but they may also simply be more difficult to describe due to the duration of the disease episode. In contrast to methods by which cause of death is established by a panel of medical experts, the present VA should be economically and technically viable in areas where health workers have only minimal training.

Objective To evaluate whether routine administration of sublingual misoprostol 600 g after delivery reduces postpartum haemorrhage. Design Randomised double blind placebo controlled trial. Setting Primary health centre in Bissau, Guinea-Bissau, West Africa. Participants 661 women undergoing vaginal delivery. Intervention Misoprostol 600 g or placebo administered sublingually immediately after delivery. Main outcome measures Postpartum haemorrhage, defined as a loss of ≥ 500 ml and decrease in haemoglobin concentration after delivery. Results The incidence of postpartum haemorrhage was not significantly different between the two groups, the relative risk being 0.89 (95% confidence interval 0.76 to 1.04) in the misoprostol group compared with the placebo group. Mean blood loss was 10.5% ( − 0.5% to 20.4%) lower in the misoprostol group than in the control group. Severe postpartum haemorrhage of ≥ 1000 ml or ≥ 1500 ml occurred in 17% (56) and 8% (25) in the placebo group and 11% (37) and 2% (7) in the misoprostol group. Significantly fewer women in the misoprostol group experienced a loss of ≥ 1000 ml (0.66, 0.45 to 0.98) or ≥ 1500 ml (0.28, 0.12 to 0.64). The decrease in haemoglobin concentration tended to be less in the misoprostol group, the mean difference between the two groups being 0.16 mmol/l ( − 0.01 mmol/l to 0.32 mmol/l). Conclusion Sublingual misoprostol reduces the frequency of severe postpartum haemorrhage.

Aim: With the increasing incidence of HIV and TB, motherless children are becoming a rapidly growing problem in Africa. However, few studies describe the survival patterns of these children. The aim of this study was to investigate the mortality of motherless children in urban and rural areas of Guinea‐Bissau. Methods: A historical cohort study was set up in urban and rural areas in Guinea‐Bissau. Motherless children were selected from two study cohorts under demographic surveillance since 1990. The relatives of 128 motherless children from the rural cohort and 192 from the urban area, as well as a total of 807 controls, were examined and interviewed. Results: Controlling for significant background factors revealed that motherless children had a markedly higher mortality than that of controls in both urban (mortality rate ratio (MR) 2.32 (95% confidence interval 1.11‐4.84)) and rural areas (MR = 4.16 (2.79‐6.22)). Virtually all the excess mortality occurred among children under 2 y of age when their mother died. Few motherless children had been provided with surrogate breastfeeding. Conclusions: Since nearly all children in Guinea are breastfed until 2 y of age, premature weaning may be one of the major causes of the higher mortality rates observed among motherless children.