CONTEXTUAL DETERMINANTS OF MATERNAL MORTALITY IN RURAL PAKISTAN

Maternal mortality is high in Pakistan, particularly in the rural area s which have poor access to health services. We investigated the risk factors associated with maternal mortality in sixteen rural districts of Balochistan and the North-West Frontier (NWFP) provinces of Pakista n. We designed a nested case-control study comprising 261 cases (mater nal deaths reported during last five years) and 9135 controls (women w ho survived a pregnancy during last five years). Using contextual anal ysis, we estimated the interactions between the biological risk factor s of maternal mortality and the district-level indicators of health se rvices. Women under 19 or over 39 yr of age, those having their first birth, and those having a previous history of fetal loss were at great er risk of maternal death. Staffing patterns of peripheral health faci lities in the district and accessibility of essential obstetric care ( EOC) were significantly associated with maternal mortality. These indi cators also modified the effects of the biological risk factors of mat ernal mortality. For example, nulliparous women living in the under-se rved districts were at greater risk than those living in the better-se rved districts. Our results are consistent with several studies which have pointed out the role of health services in the causation of mater nal mortality. Many such studies have implicated distance to hospital (an indicator of access to EOC) and lack of prenatal care as major det erminants of maternal mortality. We conclude that better staffing of p eripheral health facilities and improved access to EOC could reduce th e risk of maternal mortality among women in rural Balochistan and the NWFP. (C) 1998 Elsevier Science Ltd. All rights reserved.