Why are pregnant women dying? An equity analysis of maternal mortality in Malawi

Background: Malawi has one of the highest maternal mortality ratios (MMR) in the world at 1,120 per 100,000 live births. Maternal mortality is therefore a priority issue for the Ministry of Health. The Health Sector Wide Approach (SWAp) Equity and Access Subgroup commissioned a synthesis study to explore issues of access and equity relating to maternal mortality in Malawi and provide practical recommendations for SWAp implementation. Methods: The study undertook an equity analysis of existing national health databases and synthesised the available operational and academic research findings. Results: A number of strategies have been developed throughout the past decade to address maternal mortality in Malawi; however there has been a lack of effective implementation. Safe Motherhood interventions account for 46% of the total costs of the essential health package, with 47% of these spent on abortion complications. The expenditure, however, is not equitably distributed: Malawi has only 2% of the basic emergency obstetric care facilities that it requires, but nearly twice as many comprehensive obstetric care facilities, however only 20% of the population lives within 25km of the latter. Additionally, women face high direct and indirect costs in seeking services, even at government facilities which are free at the point of delivery. The total cost of seeking services is approximately 26 days worth of income for a rural woman; for the poorest quintile it can be as much as 50 days worth of income. Maternal mortality, when examined by wealth quintile, does not initially appear to be inequitable in Malawi. However reasons behind the deaths are different, with those in the upper quintiles being more related to complications of HIV and those in the lower quintiles related to lack of access to services. Levels of education and to a lesser degree, wealth have a strong correlation with skilled attendance during delivery. Conclusion: This study provides recommendations on how the current maternal mortality strategy may be implemented more equitably than past strategies therefore resulting in a lower MMR for all women, regardless of their location, poverty or educational status. Malawi Medical Journal Vol. 18 (1) 2006: pp. 32-3