Our study from rural Mali documented a maternal mortality ratio (MMR) of more than 3,000 per 100,000 live births. This MMR is much higher than the latest national estimates suggesting the MMR in Mali to be below 1000 maternal deaths per 100,000 live births [1, 14]. Our study appears to be the first study on MMR from rural Mali, and it estimated the MMR with a time-reference point around the calendar year 1999. Other studies show a lower MMR than ours in Mali, and this may be partly because our study area was distinctly rural, as opposed to the location of studies that informed other estimates. A population based prospective follow-up study with data from the early 1990s with 5,782 pregnant women in urban/semiurban Mali observed 15 deaths and yielded an MMR of 327 per 100,000 live births (95% CI 180-510) . An ecological study with data mostly from the 1990s found, not surprisingly, that the MMR was higher in rural (601/100,000 live birth, 95% CI 529-679) than in urban areas (241/100,000 live births, 95% CI 172-330). This likely reflects the differential availability of emergency obstetric services .
Our study provides a quick reference point for MMR in a rural poorly developed area with a particularly low literacy rate and poor access to health services. Some villages had particularly high maternal mortality, and these villages also had a higher overall mortality rate. Villages with high mortality rates were all remotely located and this underscores the importance of access to health services for the prevention of maternal deaths. Efforts to improve the infrastructure and access to health services in rural areas will probably have a great impact on maternal health. Our study was not designed to detect recent changes in maternal mortality, however, and cannot provide estimates of changes in maternal mortality.
The youngest group of respondents in our study reported that 81 (9%) of their sisters suffered a maternal death. This represents a very high maternal mortality experience as the number of sisters exposed to maternal death was small (95). Age of marriage in the study area was as low as 13 years, in contrast to the 15 years observed in other studies . Low age at marriage could potentially explain the high MMR among the sisters of the youngest respondents, but we could not verify this in our study as we did not have information on the age of the deceased. The deaths in question would have been more recent and information from the youngest respondents was likely more rather than less reliable. Excluding the youngest age group of respondents from the cohort of respondents did not alter the estimated MMR substantially; the MMR remained above 2500 deaths per 100,000 live births. Also, sensitivity analyses showed that alternative assumptions about fertility rates (TFR 9% higher or 28% lower), still resulted in MMR estimates that were well above 2,500 per 100,000 live births. Furthermore, migration out of this area may have led to respondents to miss recalling some of their dead sisters, hence underestimating the maternal mortality ratio.
Deaths due to abortions and ectopic pregnancies may have been misclassified as deaths due to causes unrelated to pregnancy or childbirth and this could have also resulted in an underestimate of the MMR. The frequency of ectopic pregnancies may be in the order of 1% of all pregnancies . Although abortion rates have been increasing in this area the issue remains a sensitive topic and abortion related deaths may have been concealed by respondents. A few abortion related deaths were reported, although we suspect that such deaths may have resulted in an underestimated rather than overestimated MMR.
Our study has several limitations. It refers to the prevailing MMR around 8 years before data collection, and cannot provide the most recent MMR for the study area. Our study sample was taken from Kita and the situation is probably fairly similar to other remote rural areas of Mali. However, differences in access to health services could easily make our results less generalizable to other rural areas. The very high illiteracy rate could have led to misunderstandings during the interviews. To avoid this problem we selected data collectors who were permanent residents and health facility workers in the area; they knew the language and culture very well. Repeated interview for verification of the response was not done. However, looking at the data we see that on average the respondents had between 2 and 3 sisters, increasing by age of respondent. This is expected in a setting with a TFR around 6, and suggests that the study respondents' information was reliable.
Rural areas of Mali need continued strong support for emergency obstetric care services, combined with improvement in roads and transport. As previously mentioned, one important change in health services in the study area had been introduced , with the construction of a new main road. The national policies pertaining to emergency obstetric care have changed following WHO recommendations and this includes a system for referral and transport, and cost sharing with communities . In the southern region of Mali, emergency obstetric care services have been organized with assistance from the Save the Children Fund. Although increased utilization of these health services has occurred, the services still need quality improvement .
Another limitation of our study is that we do not know where the sisters in the cohort were living, and we used the village of the respondents as a proxy for the residence of their sisters. It is not surprising that the maternal mortality varies between villages, as access to health services differs from one village to another. However, our sample size was not designed to permit village-specific comparisons. Nevertheless, our findings are plausible and show that more remote villages have more maternal deaths. The regional authorities should ensure that emergency obstetric care services are offered to every woman in need, taking into account the large seasonal differences in transport accessibility. Furthermore, creating trust by giving good quality services is important for increasing health service utilization .