title: The use of audit to identify maternal mortality in different settings: is it just a difference between the rich and the poor?
abstract: OBJECTIVE
  To illustrate how maternal mortality audit identifies different causes of and contributing factors to maternal deaths in different settings in low- and high-income countries and how this can lead to local solutions in reducing maternal deaths.
  
  
  METHODS
  Descriptive study of maternal mortality from different settings and review of data on the history of reducing maternal mortality in what are now high-income countries.
  
  
  METHODS
  Kalabo district in Zambia, Farafenni division in The Gambia, Onandjokwe district in Namibia, and The Netherlands.
  
  
  METHODS
  Population of rural areas in Zambia and The Gambia, peri-urban population in Namibia and nationwide data from The Netherlands.
  
  
  METHODS
  Data from facility-based maternal mortality audits from three African hospitals and data from the latest confidential enquiry in The Netherlands.
  
  
  METHODS
  Maternal mortality ratio (MMR), causes (direct and indirect) and characteristics.
  
  
  RESULTS
  MMR ranged from 10 per 100,000 (The Netherlands) to 1,540 per 100,000 (The Gambia). Differences in causes of deaths were characterized by HIV/AIDS in Namibia, sepsis and HIV/AIDS in Zambia, (pre-)eclampsia in The Netherlands and obstructed labour in The Gambia.
  
  
  CONCLUSIONS
  Differences in maternal mortality are more than just differences between the rich and poor. Acknowledging the magnitude of maternal mortality and harnessing a strong political will to tackle the issues are important factors. However, there is no single, general solution to reduce maternal mortality, and identification of problems needs to be promoted through audit, both national and local.
authors.affiliation: Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Albinusdreef 2, 2333ZA Leiden, The Netherlands. gwamupanda@caiway.nl
authors.forename: Jeroen
authors.initials: J
authors.lastname: van Dillen
authors.forename: Jelle
authors.initials: J
authors.lastname: Stekelenburg
authors.forename: Joke
authors.initials: J
authors.lastname: Schutte
authors.forename: Gijs
authors.initials: G
authors.lastname: Walraven
authors.forename: Jos
authors.initials: J
authors.lastname: van Roosmalen
mesh_terms: D017954:Africa South of the Sahara / Q000453:epidemiology; D002423:Cause of Death; D004522:Educational Status; D005260:Female; D006297:Health Services Accessibility; D054624:Health Status Disparities; D006801:Humans; D007182:Income; D008017:Life Expectancy; D008428:Maternal Mortality; D009426:Netherlands / Q000453:epidemiology