title: Could a simple antenatal package combining micronutritional supplementation with presumptive treatment of infection prevent maternal deaths in sub-Saharan Africa?
abstract: BACKGROUND
  Reducing maternal mortality is a key goal of international development. Our objective was to determine the potential impact on maternal mortality across sub-Saharan Africa of a combination of dietary supplementation and presumptive treatment of infection during pregnancy. Our aim was to demonstrate the importance of antenatal interventions in the fight against maternal mortality, and to stimulate debate about the design of an effective antenatal care package which could be delivered at the lowest level of the antenatal health system or at community level.
  
  
  METHODS
  We collated evidence for the effectiveness of antenatal interventions from systematic reviews and controlled trials, and we selected interventions which have demonstrated potential to prevent maternal deaths. We used a model-based analysis to estimate the total reduction in maternal mortality in sub-Saharan Africa which could be achieved by combining these interventions into a single package, based on a WHO systematic review of causes of maternal deaths.
  
  
  RESULTS
  Severe hypertensive disorders, puerperal sepsis and anemia are causes of maternal deaths which could be prevented to some extent by prophylactic measures during pregnancy. A package of pills comprising calcium and iron supplements and appropriate anti-microbial and anti-malarial drugs could reduce maternal mortality in sub-Saharan Africa by 8% (range <1% to 20%). This estimate is based on Cochrane Review estimates for the effectiveness of daily calcium supplements in reducing the risk of death/serious morbidity due to hypertensive disorders (RR = 0.80, 95% CI 0.65-0.97), anti-microbial prophylaxis in reducing the odds of puerperal sepsis/postpartum endometritis (OR = 0.49, 95% CI 0.23-1.06), anti-malarial prophylaxis in reducing the risk of severe antenatal anemia (RR = 0.62, 95% CI 0.50-0.78), and iron supplementation in reducing the risk of iron deficiency anemia at term (RR = 0.33, 95% CI 0.16-0.69).
  
  
  CONCLUSIONS
  Maternal mortality could be reduced by a combination of micronutrient supplementation and presumptive treatment of infection during pregnancy. Such an approach could be adopted in resource-poor settings where visits to antenatal clinics are infrequent and would complement existing Safe Motherhood activities.
authors.affiliation: Department of Social Medicine, University of Bristol, Canynge Hall, Bristol, UK. simon.collin@bristol.ac.uk
authors.forename: Simon M
authors.initials: SM
authors.lastname: Collin
authors.forename: Rebecca F
authors.initials: RF
authors.lastname: Baggaley
authors.forename: Rudiger
authors.initials: R
authors.lastname: Pittrof
authors.forename: Veronique
authors.initials: V
authors.lastname: Filippi
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara / Q000453:epidemiology; D016001:Confidence Intervals; D019587:Dietary Supplements / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008428:Maternal Mortality; D008429:Maternal Welfare / Q000706:statistics & numerical data*; D018977:Micronutrients / Q000172:deficiency / Q000627:therapeutic use*; D016017:Odds Ratio; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000401:mortality* / Q000517:prevention & control*; D011256:Pregnancy Outcome; D011295:Prenatal Care / Q000706:statistics & numerical data*; D039401:Prenatal Nutritional Physiological Phenomena
chemical_list: D018977:Micronutrients