Procesos geológicos de geodinámica externa

Humanitarian action did not resolve the complex political and military situation in Bunia and Ituri. (150) Renewed fighting broke out between the national army and armed opposition groups in December 2009. In April 2010 IRIN reported that 167,000 people were displaced in Ituri. After several months of fighting, the Congolese Government decided to establish a humanitarian corridor, allowing people trapped behind the frontline south of Bunia to move to safety.xxxvi

Five years after the peak of the humanitarian crisis, 75% of all CSs in the Bunia Health Zone were performed at BM. Maternal deaths in health structures and in the community were recorded between December 2007 and June 2008. There were no maternal deaths among the women selected to be interviewed. Three of the direct maternal deaths in hospitals during the study period occurred in women who had a CS (0.6%). Therefore, assuming that all CSs were appropriately targeted, CSs were 99.4% effective at avoiding maternal death. However, limited access to services reduced the potential impact of the programme.

To quantify the impact of CSs, as part of humanitarian assistance, on maternal mortality in Bunia, observed maternal and perinatal mortality figures were compared to projected figures based on the expected mortality without EMOCS, as well as on recent national estimates of maternal and perinatal mortality in the DRC. All known methods for measuring maternal mortality are fraught with uncertainties. The estimates obtained in this study are equally subject to errors of measurement. Based on the study findings, the MMR in Bunia was estimated at 345/100,000. This was 37% lower than the expected MMR of 549/100,000 of the 2007 national estimates of the DHS. The MMR estimate of 345 was arrived at by adding 30% to the figure obtained on the basis of all reported deaths in health facilities and in the community. THE DHS estimate was based on the direct sisterhood method, without further adjustments. (87) Estimates of maternal deaths avoided in comparison to a situation without EMOC were considerably higher.

The perinatal mortality estimate of 52/1000 was 32% lower than the expected 76/1000 of the 2006 WHO model for the DRC. The Bunia estimate of perinatal deaths was based on deliveries in all health facilities providing some form of EMOC. Although some perinatal deaths were reported in other health structures and in the community, estimates using the

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Integrated Regional Information Networks (IRIN), a project of the UN Office of the Coordinator for Humanitarian Affairs (OCHA)

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total number of deliveries as the denominator would have resulted in a lower perinatal mortality rate. Detailed records of perinatal deaths by health structure can be found in Annex 10 and 11. The highest estimate was used in the CEA.

Saving the life of the mother has a demonstrated impact on the survival of young children in the family. A recent study in Bangladesh found the cumulative probability of survival up to age 10 after the death of a mother to be 24%, compared with 89% in children whose mother was alive. (151) A study in Haiti found that maternal death was associated with a 55% increase in the odds of losing a child below 12 years of age in the same family. (152) A Medline search did not retrieve similar studies in sub-Saharan Africa. A 1996 study in the north-eastern part of former Zaire (now DRC) found that chronic illness of the mother reduced child survival (RR: 1.2-9.0). The authors of this article underlined the importance of other caregivers for child survival in case of chronic maternal disease.(153)

The impact of EMOCS is related to access and quality. The assessed quality of care at BM was high. A skilled obstetric surgeon was available during most of the study, except for the period around New Year. None of the other EMOC-providing facilities employed a specialist obstetrician. The main identified limitations to access were security and transport problems, and the fact that the BM hospital only admitted emergencies. The study confirmed that EMOCS in Bunia were mainly used by the urban population. Although the security situation had improved, travelling around Ituri was difficult, especially during the rainy season.

Other factors influencing maternal and perinatal survival

Reducing maternal and neonatal mortality requires more than the availability of comprehensive EMOC, including CSs. Developmental strategies emphasise the importance of family planning and safe abortion, together with skilled birth attendance.(154,155) The WHO “CHOICE” (Choosing Interventions that are Cost-Effective) project has ranked priority interventions in order of cost-effectiveness. Most cost-effective were: community- based newborn care (e.g. promotion of breastfeeding), antenatal care (Tetanus Toxoid, pre- eclampsia screening, screening and treatment of asymptomatic bacteriuria and syphilis), skilled attendance at birth, and emergency obstetric and neonatal care around and after birth. Scaling up of all included interventions to 95% would halve maternal and neonatal deaths. (74) The CHOICE project did not evaluate the cost-effectiveness of interventions to prevent HIV transmission. During the first half of 2008, voluntary counselling and testing of pregnant women had not yet started in Bunia.

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A high proportion of women in the Bunia Health Zone attended antenatal consultations. Among the women interviewed as cases or controls, 86.6% reported receiving one or more tetanus toxoid injections during pregnancy, including 71.2% who said they had two doses. With the exception of private health structures and antenatal outpatient facilities associated with hospitals (CME and RW), health centres were unable to perform basic laboratory tests such as haemoglobin checks or urinalysis. Test strips for rapid screening for proteinuria were usually available.

The study population was exposed to environmental risk factors for anaemia, including endemic malaria (Plasmodium Falciparum), Schistosomiasis (S. Mansoni) and hookworm (Ancylostoma duodenale). The 2007 DHS (87) found that 53% of adult Congolese women were anaemic (haemoglobin <12 gm/dl), with 16% having moderate anaemia (7-9.9gm/dl) and 1% suffering from severe anaemia (<7gm/dl). Anaemia in pregnancy is defined by WHO as a haemoglobin level below 11 gm/dl. The most frequent cause of anaemia in pregnancy is iron-deficiency.

Iron and folate supplements were supplied free of charge for the duration of pregnancy. Sulfadoxine-pyrimethamine was given twice in pregnancy as a presumptive malaria treatment. In Mozambique, this was found to be an effective intervention at reducing neonatal mortality. (156) Distribution of insecticide impregnated bed nets to pregnant women in the area was intermittent and coverage incomplete. In 2005, ECHO aimed for 60% retention and correct use of distributed bed nets. (157)

The local prevalence of haemoglobinopathies was unknown. Historically, Pygmies from the Ituri forest are known to have a high incidence of the sickling gene. (158) A recent screening project for sickle cell anaemia in Kinshasa found that 16.9% of newborns had sickle cell trait, while 1.4% were homozygous for HbS.(159)

The 2007 DHS (87) reported that 19% of women aged 15-45 years had a Body Mass Index of less than 18.5 which was the cut-off point for under-nutrition. Malnutrition, together with a high burden of communicable diseases such as HIV and malaria increases the prevalence of anaemia. In 2006 the prevalence of HIV among pregnant women attending antenatal consultations in Bunia was 3.5% according to surveillance figures from the national programme to combat HIV and sexually transmitted infections (Programme National Multi- sectoriel de Lutte contre le SIDA, PNMLS).(88)

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Although the 2006 annual survey of the PNMLS found positive syphilis serology in 4.7% of pregnant women, no systematic screening for syphilis took place and the price of laboratory testing (Rapid Plasm Reagin, RPR) was relatively high (3 USD). HIV testing was not included in antenatal services during the study period. At the time of the study, availability of affordable treatment for HIV positive adults in the DR Congo was limited (estimated 5% of people in need), and there were no established facilities outside major urban centres for treating children with HIV. In 2005 only Kinshasa, Lubumbashi and Mbuji Mayi had laboratories where CD4 count could be performed. (160) Training on prevention of mother- to-child transmission was ongoing.