THE STRATEGY OF RISK APPROACH IN ANTENATAL CARE - EVALUATION OF THE REFERRAL COMPLIANCE

The main goal of antenatal care in developing countries is to identify women whose pregnancy or delivery is likely to raise problems and to refer them at the appropriate time to a hospital facility where the ne cessary medical equipment and expertise (vacuum extractors, cesarian s ections, human skills, etc.) is available. This approach, which is kno wn as the Risk Approach (RA) strategy, is expected to significantly re duce maternal morbidity and mortality. However, the RA will function p roperly only if the women identified at risk agree to give birth in a hospital on the one hand, and if they can indeed reach this hospital o n the other hand. In this article the authors assess to what extent wo men with a risk of difficult labor (nulliparous or primiparous women u nder 150 cm, history of previous difficult delivery or stillbirth, wom en with transverse lie) agreed to give birth in a hospital. This descr iptive survey, which covered 5060 pregnancies monitored in the Kasongo District, Maniema, in eastern Zaire, showed that the referral success rate in this socioeconomically very disadvantaged region was only 33% , despite some favorable conditions, such as a strong emphasis on comm unity participation, a complementarity of health centers and hospital, and the absence of financial barriers within the health services syst em. Of the various hypotheses tested, the geographic accessibility of the hospital and the parturient's perception of the risk status were t he two most important factors determining the compliance rate. A strat ified analysis shows that the intensity of the parturient's perception has a different impact on compliance whether rural or urban situation s are considered. In their conclusions, the authors stress the importa nce of the problem and the need for additional qualitative studies (op en interviews, focus group discussions) to better understand the reaso ns of this low compliance. The phenomenon observed in Kasongo is defin itely not a unique one, and unawareness of this problem is likely to b e one of the reasons for the low success of pregnancy monitoring progr ams when they are assessed in terms of reduction of maternal morbidity and mortality.