The obstetrical dilemma hypothesis: there's life in the old dog yet

The term ‘obstetrical dilemma’ was coined by Washburn in 1960 to describe the trade-off between selection for a larger birth canal, permitting successful passage of a big-brained human neonate, and the smaller pelvic dimensions required for bipedal locomotion. His suggested solution to these antagonistic pressures was to give birth prematurely, explaining the unusual degree of neurological and physical immaturity, or secondary altriciality, observed in human infants. This proposed trade-off has traditionally been offered as the predominant evolutionary explanation for why human childbirth is so challenging, and inherently risky, compared to that of other primates. This perceived difficulty is likely due to the tight fit of fetal to maternal pelvic dimensions along with the convoluted shape of the birth canal and a comparatively low degree of ligamentous flexibility. Although the ideas combined under the obstetrical dilemma hypothesis originated almost a century ago, they have received renewed attention and empirical scrutiny in the last decade, with some researchers advocating complete rejection of the hypothesis and its assumptions. However, the hypothesis is complex because it presently captures several, mutually non-exclusive ideas: (i) there is an evolutionary trade-off resulting from opposing selection pressures on the pelvis; (ii) selection favouring a narrow pelvis specifically derives from bipedalism; (iii) human neonates are secondarily altricial because they are born relatively immature to ensure that they fit through the maternal bony pelvis; (iv) as a corollary to the asymmetric selection pressure for a spacious birth canal in females, humans evolved pronounced sexual dimorphism of pelvic shape. Recently, the hypothesis has been challenged on both empirical and theoretical grounds. Here, we appraise the original ideas captured under the ‘obstetrical dilemma’ and their subsequent evolution. We also evaluate complementary and alternative explanations for a tight fetopelvic fit and obstructed labour, including ecological factors related to nutrition and thermoregulation, constraints imposed by the stability of the pelvic floor or by maternal and fetal metabolism, the energetics of bipedalism, and variability in pelvic shape. This reveals that human childbirth is affected by a complex combination of evolutionary, ecological, and biocultural factors, which variably constrain maternal pelvic form and fetal growth. Our review demonstrates that it is unwarranted to reject the obstetrical dilemma hypothesis entirely because several of its fundamental assumptions have not been successfully discounted despite claims to the contrary. As such, the obstetrical dilemma remains a tenable hypothesis that can be used productively to guide evolutionary research.     

The multifactor pelvis: An alternative to the adaptationist approach of the obstetrical dilemma

The obstetrical dilemma describes the competing demands that a bipedally adapted pelvis and a large-brained neonate place on human childbirth and is the predominant model within which hypotheses about the evolution of the pelvis are framed. I argue the obstetrical dilemma follows the adaptationist program outlined by Gould and Lewontin in 1979 and should be replaced with a new model, the multifactor pelvis. This change will allow thorough consideration of nonadaptive explanations for the evolution of the human pelvis and avoid negative social impacts from considering human childbirth inherently dangerous. First, the atomization of the pelvis into discrete traits is discussed, after which current evidence for both adaptive and nonadaptive hypotheses is evaluated, including childbirth, locomotion, shared genetics with other traits under selection, evolutionary history, genetic drift, and environmental and epigenetic influences on the pelvis.     

A Wider Pelvis Does Not Increase Locomotor Cost in Humans,with Implications for the Evolution of Childbirth

The shape of the human female pelvis is thought to reflect an evolutionary trade-off between two competing demands: a pelvis wide enough to permit the birth of large-brained infants, and narrow enough for efficient bipedal locomotion. This trade-off, known as the obstetrical dilemma, is invoked to explain the relative difficulty of human childbirth and differences in locomotor performance between men and women. The basis for the obstetrical dilemma is a standard static biomechanical model that predicts wider pelves in females increase the metabolic cost of locomotion by decreasing the effective mechanical advantage of the hip abductor muscles for pelvic stabilization during the single-leg support phase of walking and running, requiring these muscles to produce more force. Here we experimentally test this model against a more accurate dynamic model of hip abductor mechanics in men and women. The results show that pelvic width does not predict hip abductor mechanics or locomotor cost in either women or men, and that women and men are equally efficient at both walking and running. Since a wider birth canal does not increase a woman’s locomotor cost, and because selection for successful birthing must be strong, other factors affecting maternal pelvic and fetal size should be investigated in order to help explain the prevalence of birth complications caused by a neonate too large to fit through the birth canal.     

The evolutionary history of childbirth

Consideration of the evolutionary and cross-cultural history of childbirth reveals many differences between the ways in which most human females have experienced childbirth and the ways in which most women in contemporary industrialized obstetric settings experience the event. In this paper I review two of these differences: the pain and anxiety of labor and delivery and the discontinuity of care provided for the mother and infant. I argue that much of the dissatisfaction with birth practices in the United States results from the failure of modern obstetric practice to meet the evolved needs of mothers and infants. Wenda Trevathan is an associate professor of anthropology at New Mexico State University. Her research interests focus on evolutionary and biosocial aspects of human female reproductive behavior, including childbirth, sexuality, and menopause. She is the recipient of the 1990 Margaret Mead Award and has received midwifery training.     

Between Scylla and Charybdis: renegotiating resolution of the ‘obstetric dilemma’ in response to ecological change

Hominin evolution saw the emergence of two traits—bipedality and encephalization—that are fundamentally linked because the fetal head must pass through the maternal pelvis at birth, a scenario termed the ‘obstetric dilemma’. While adaptive explanations for bipedality and large brains address adult phenotype, it is brain and pelvic growth that are subject to the obstetric dilemma. Many contemporary populations experience substantial maternal and perinatal morbidity/mortality from obstructed labour, yet there is increasing recognition that the obstetric dilemma is not fixed and is affected by ecological change. Ecological trends may affect growth of the pelvis and offspring brain to different extents, while the two traits also differ by a generation in the timing of their exposure. Two key questions arise: how can the fit between the maternal pelvis and the offspring brain be ‘renegotiated’ as the environment changes, and what nutritional signals regulate this process? I argue that the potential for maternal size to change across generations precludes birthweight being under strong genetic influence. Instead, fetal growth tracks maternal phenotype, which buffers short-term ecological perturbations. Nevertheless, rapid changes in nutritional supply between generations can generate antagonistic influences on maternal and offspring traits, increasing the risk of obstructed labour.     

Multivariate morphometrics,quantitative genetics,and neutral theory: Developing a “modern synthesis” for primate evolutionary morphology

Anthropologists are increasingly turning to explicit model‐bound evolutionary approaches for understanding the morphological diversification of humans and other primate lineages. Such evolutionary morphological analyses rely on three interconnected conceptual frameworks; multivariate morphometrics for quantifying similarity and differences among taxa, quantitative genetics for modeling the inheritance and evolution of morphology, and neutral theory for assessing the likelihood that taxon diversification is due to stochastic processes such as genetic drift. Importantly, neutral theory provides a framework for testing more parsimonious explanations for observed morphological differences before considering more complex adaptive scenarios. However, the consistency with which these concepts are applied varies considerably, which mirrors some of the theoretical obstacles faced during the “modern synthesis” of classical population genetics in the early 20th century. Here, each framework is reviewed and some potential stumbling blocks to the full conceptual integration of multivariate morphometrics, quantitative genetics, and neutral theory are considered.     

Developmental plasticity and evolutionary explanations

Developmental plasticity looks like a promising bridge between ecological and developmental perspectives on evolution. Yet, there is no consensus on whether plasticity is part of the explanation for adaptive evolution or an optional “add‐on” to genes and natural selection. Here, we suggest that these differences in opinion are caused by differences in the simplifying assumptions, and particular idealizations, that enable evolutionary explanation. We outline why idealizations designed to explain evolution through natural selection prevent an understanding of the role of development, and vice versa. We show that representing plasticity as a reaction norm conforms with the idealizations of selective explanations, which can give the false impression that plasticity has no explanatory power for adaptive evolution. Finally, we use examples to illustrate why evolutionary explanations that include developmental plasticity may in fact be more satisfactory than explanations that solely refer to genes and natural selection.     

Home Birth Midwifery in the United States

Human childbirth is distinct in requiring—or at least strongly profiting from—the assistance of a knowledgeable attendant to support the mother during birth. With economic modernization, the role of that attendant is transformed, and increased access to obstetric interventions may bring biomedicine into conflict with anatomical, physiological, and behavioral adaptations for childbirth. This article provides an overview of the role of midwifery in human evolution and ways in which this evolutionary heritage is reflected in home birth in the contemporary United States. Opportunities remain for evolutionary scholars to apply their knowledge and skills to strengthen culturally consonant, evolutionarily grounded maternity care within a complex, multilevel, pluralistic medical system.     

Evolutionary theory and systematics: relationships between process and patterns

The relevance of the Modern Evolutionary Synthesis to the foundations of taxonomy (the construction of groups, both taxa and phyla) is reexamined. The nondimensional biological species concept, and not the multidimensional, taxonomic, species notion which is based on it, represents a culmination of an evolutionary understanding. It demonstrates how established evolutionary mechanisms acting on populations of sexually reproducing organisms provide the testable ontological basis of the species category. We question the ontology and epistemology of the phylogenetic or evolutionary species concept, and find it to be a fundamentally untenable one. We argue that at best, the phylogenetic species is a taxonomic species notion which is not a theoretical concept, and therefore should not serve as foundation for taxonomic theory in general, phylogenetics, and macroevolutionary reconstruction in particular. Although both evolutionary systematists and cladists are phylogeneticists, the reconstruction of the history of life is fundamentally different in these two approaches. We maintain that all method, including taxonomic ones, must fall out of well corroborated theory. In the case of taxonomic methodology the theoretical base must be evolutionary. The axiomatic assumptions that all phena, living and fossil, must be holophyletic taxa (species, and above), resulting from splitting events, and subsequently that evaluation of evolutionary change must be based on a taxic perspective codified by the Hennig ian taxonomic species notion, are not testable premises. We discuss the relationship between some biologically, and therefore taxonomically, significant patterns in nature, and the process dependence of these patterns. Process-free establishment of deductively tested “genealogies” is a contradiction in terms; it is impossible to “recover” phylogenetic patterns without the investment of causal and processual explanations of characters to establish well tested taxonomic properties of these (such as homologies, apomorphies, synapomorphies, or transformation series). Phylogenies of either characters or of taxa are historical-narrative explanations (H-N Es), based on both inductively formulated hypotheses and tested against objective, empirical evidence. We further discuss why construction of a “genealogy”, the alleged framework for “evolutionary reconstruction”, based on a taxic, cladistic outgroup comparison and a posteriori weighting of characters is circular. We define how the procedure called null-group comparison leads to the noncircular testing of the taxonomic properties of characters against which the group phylogenies must be tested. This is the only valid rooting procedure for either character or taxon evolution. While the Hennig -principle is obviously a sound deduction from the theory of descent, cladistic reconstruction of evolutionary history itself lacks a valid methodology for testing transformation hypotheses of both characters and species. We discuss why the paleontological method is part of comparative biology with a critical time dimension ana why we believe that an “ontogenetic method” is not valid. In our view, a merger of exclusive (causal and interactive, but best described as levels of organization) and inclusive (classificatory) hierarchies has not been accomplished by a taxic scheme of evolution advocated by some. Transformational change by its very nature is not classifiable in an inclusive hierarchy, and therefore no classification can fully reflect the causal and interactive chains of events constituting phylogeny, without ignoring and contradicting large areas of corroborated evolutionary theory. Attempts to equate progressive evolutionary change with taxic schemes by Haeckel were fundamentally flawed. His ideas found 19th century expression in a taxic perception of the evolutionary process (“phylogenesis”), a merger of typology, hierarchic and taxic notions of progress, all rooted in an ontogenetic view of phylogeny. The modern schemes of genealogical hierarchies, based on punctuation and a notion of “species” individuality, have yet to demonstrate that they hold promise beyond the Haeckel ian view of progressive evolution.     

The evolutionary context of postnatal depression

“Postnatal depression” denotes the syndrome of dysphoria, debility, and anxiety that follows childbirth in about 10–20% of women (as variously estimated). Its etiology is seen to be lodged in a variety of psychosocial as well as biological factors, among which the isolating and pressured culture of contemporary society (especially for women/mothers) is commonly singled out as a powerful precipitator. This view is extended here through the evolutionary perspective which casts maternal distress as a set of adaptive responses with the function, in ancestral environments, of soliciting support for a mother who feels that her maternal responsiveness may be threatened. As continuous caretaking of the infant is the active expression of evolved maternal responsiveness, departures from this pattern result in anxiety and distress that seek resolution. Manifestations of maternal distress in contemporary society are dysfunctional, however, since the present social structure does not provide spontaneous and immediate support that can spring forth within small, closely knit social units. Furthermore, for present-day mothers distress is self-perpetuating since the ingrained tendency toward continuing responsiveness rarely finds practical expression and is thus converted into anxious vigilance and depression. This view generates the hypothesis that the emotional and cognitive contents of maternal vigilance are associated with the needs of the infant and will therefore be focused on crying and feeding. A number of qualitative studies of women’s experiences during the postpartum bear out this prediction and support the feasibility of the evolutionary hypothesis of “postnatal depression” as a set of adaptive responses, now out of place in a novel environment.     

Relationships of maternal and paternal anthropometry with neonatal body size,proportions and adiposity in an Australian cohort

The patterns of association between maternal or paternal and neonatal phenotype may offer insight into how neonatal characteristics are shaped by evolutionary processes, such as conflicting parental interests in fetal investment and obstetric constraints. Paternal interests are theoretically served by maximizing fetal growth, and maternal interests by managing investment in current and future offspring, but whether paternal and maternal influences act on different components of overall size is unknown. We tested whether parents' prepregnancy height and body mass index (BMI) were related to neonatal anthropometry (birthweight, head circumference, absolute and proportional limb segment and trunk lengths, subcutaneous fat) among 1,041 Australian neonates using stepwise linear regression. Maternal and paternal height and maternal BMI were associated with birthweight. Paternal height related to offspring forearm and lower leg lengths, maternal height and BMI to neonatal head circumference, and maternal BMI to offspring adiposity. Principal components analysis identified three components of variability reflecting neonatal “head and trunk skeletal size,” “adiposity,” and “limb lengths.” Regression analyses of the component scores supported the associations of head and trunk size or adiposity with maternal anthropometry, and limb lengths with paternal anthropometry. Our results suggest that while neonatal fatness reflects environmental conditions (maternal physiology), head circumference and limb and trunk lengths show differing associations with parental anthropometry. These patterns may reflect genetics, parental imprinting and environmental influences in a manner consistent with parental conflicts of interest. Paternal height may relate to neonatal limb length as a means of increasing fetal growth without exacerbating the risk of obstetric complications. Am J Phys Anthropol 156:625–636, 2015. © 2014 The Authors American Journal of Physical Anthropology Published by Wiley Periodicals, Inc.     

The individuality of the species: A Darwinian theory? — from Buffon to Ghiselin, and back to Darwin

Since the 1970s, there has been a tremendous amount of literature on Ghiselin's proposal that “species are individuals”. After recalling the origins and stakes of this thesis in contemporary evolutionary theory, I show that it can also be found in the writings of the French naturalist Buffon in the 18th Century. Although Buffon did not have the conception that one species could be derived from another, there is an interesting similarity between the modern argument and that of Buffon regarding the “individuality of species’. The analogy is strong enough to force us to recognize that genuine evolutionary (or Darwinian) questions might be of secondary importance in the discussion. In consequence, the third section of the paper proposes an alternative schema for the “logical structure” of the Darwinian concept of species. Darwin distinguished the problem of the designation of a concrete species, and the problem of its signification of species within his theory of descent? The resulting notion of species involves a logical structure based on the fusion of the logical operations of classification and ordering. The difficulty — and interest — is that this interpretation of species does not entail any precise operational definition of species; it can only tell us what the ultimate signification of classification is within the theory of descent with modification through natural selection.     

Testing evolutionary models of senescence: traditional approaches and future directions

From an evolutionary perspective, the existence of senescence is a paradox. Why has senescence not been more effectively selected against given its associated decreases in Darwinian fitness? Why does senescence exist and how has it evolved? Three major theories offer explanations: (1) the theory of mutation accumulation suggested by PB Medawar; (2) the theory of antagonistic pleiotropy suggested by GC Williams; and (3) the disposable soma theory suggested by TBL Kirkwood. These three theories differ in the underlying causes of aging that they propose but are not mutually exclusive. This paper compares the specific biological predictions of each theory and discusses the methods and results of previous empirical tests. Lifespan is found to be the most frequently used estimate of senescence in evolutionary investigations. This measurement acts as a proxy for an individual’s rate of senescence, but provides no information on an individual’s senescent state or “biological age” throughout life. In the future, use of alternative longitudinal measures of senescence may facilitate investigation of previously neglected aspects of evolutionary models, such as intra- and inter-individual heterogeneity in the process of aging. DNA methylation data are newly proposed to measure biological aging and are suggested to be particularly useful for such investigations.     

The Burden of Eclampsia: Results from a Multicenter Study on Surveillance of Severe Maternal Morbidity in Brazil

Objective

Maternal mortality (MM) is a core indicator of disparities in women’s rights. The study of Near Miss cases is strategic to identifying the breakdowns in obstetrical care. In absolute numbers, both MM and occurrence of eclampsia are rare events. We aim to assess the obstetric care indicators and main predictors for severe maternal outcome from eclampsia (SMO: maternal death plus maternal near miss).

Methods

Secondary analysis of a multicenter, cross-sectional study, including 27 centers from all geographic regions of Brazil, from 2009 to 2010. 426 cases of eclampsia were identified and classified according to the outcomes: SMO and non-SMO. We classified facilities as coming from low- and high-income regions and calculated the WHO’s obstetric health indicators. SPSS and Stata softwares were used to calculate the prevalence ratios (PR) and respective 95% confidence interval (CI) to assess maternal characteristics, clinical and obstetrical history, and access to health services as predictors for SMO, subsequently correlating them with the corresponding perinatal outcomes, also applying multiple regression analysis (adjusted for cluster effect).

Results

Prevalence of and mortality indexes for eclampsia in higher and lower income regions were 0.2%/0.8% and 8.1%/22%, respectively. Difficulties in access to health care showed that ICU admission (_adjPR 3.61; 95% CI 1.77–7.35) and inadequate monitoring (_adjPR 2.31; 95% CI 1.48–3.59) were associated with SMO.

Conclusions

Morbidity and mortality associated with eclampsia were high in Brazil, especially in lower income regions. Promoting quality maternal health care and improving the availability of obstetric emergency care are essential actions to relieve the burden of eclampsia.     

Les débuts du placement familial des aliénés en france et la visite du docteur paetz. parcours croisés dvns la psychiatrie du xixéme siècle

During the second hall oi the nineteenth century hardly any other issue in European psychiatry has been discussed as controversially and aggressively as the question of the asylum. In these debates over mote than hall a century, a central topic which had been discussed again and again, was the placing of “mad people”, psychiatric patients, into ordinary families For both, German and Trench psychiatrists, a little Belgian town served as the model of the so-called “family care”. Gheel, the Flemish “colony of the mad”, existed because oi a pilgrimage dating back to the medieval ages. In the last decade of the 19th century family care has been introduced m Central France Psychiatrist Albrecht Pactz of Alt-scherbitz, Saxony, was one of the German experts on the issue, although he dedicated himself more to what was called “colonie agricole”, the integration of panents into agricultural work. This article portrays Paetz’ visit to Central France in 1899; and contextuailizes his travel report published in Germanin the following. by highlighting some ol the differences and similarities in the history of family care in France and Germany.     

Maternal mortality and women's condition: “The distress in being a woman”

For millenaria, maternal mortality has been considered as a fatality inherent to women's condition. Thanks to the progress of the obstetric technology, the world M.M.R. fell from 2.000 to 400 per 100.000 births during the past 150 years. At the same time women's condition improved chiefly because of a better level of education. Is there any relationship between them: the decrease of Maternal Mortality and the amelioration of women's general status? Or, in other words, can the decrease of Maternal Mortality Rate be considered as an “indicator” of the situation of women? After a historical review of the importance of the maternal mortality drama as it occured in older times before the “obstetric era”, which began with the improvement of the obstetric technology, this paper will present the actual situation of maternal mortality in relation with the obstetric coverage, the female literacy level and some other socio-economic variables, and in relation with the Gross National Product (G.N.P.) as an indicator of governmental interest in the specific female problems of giving-life.     

Causal mechanisms of evolution and the capacity for niche construction

Ernst Mayr proposed a distinction between “proximate”, mechanistic, and “ultimate”, evolutionary, causes of biological phenomena. This dichotomy has influenced the thinking of many biologists, but it is increasingly perceived as impeding modern studies of evolutionary processes, including study of “niche construction” in which organisms alter their environments in ways supportive of their evolutionary success. Some still find value for this dichotomy in its separation of answers to “how?” versus “why?”questions about evolution. But “why is A?” questions about evolution necessarily take the form “how does A occur?”, so this separation is illusory. Moreover, the dichotomy distorts our view of evolutionary causality, in that, contra Mayr, the action of natural selection, driven by genotype-phenotype-environment interactions which constitute adaptations, is no less “proximate” than the biological mechanisms which are altered by naturally selected genetic variants. Mayr’s dichotomy thus needs replacement by more realistic, mechanistic views of evolution. From a mechanistic viewpoint, there is a continuum of adaptations from those evolving as responses to unchanging environmental pressures to those evolving as the capacity for niche construction, and intermediate stages of this can be identified. Some biologists postulate an association of “phenotypic plasticity” (phenotype-environment covariation with genotype held constant) with capacity for niche construction. Both “plasticity” and niche construction comprise wide ranges of adaptive mechanisms, often fully heritable and resulting from case-specific evolution. Association of “plasticity” with niche construction is most likely to arise in systems wherein capacity for complex learning and behavioral flexibility have already evolved.     

The ripples of modernity: How we can extend paleoanthropology with the extended evolutionary synthesis

Contemporary understandings of paleoanthropological data illustrate that the search for a line defining, or a specific point designating, “modern human” is problematic. Here we lend support to the argument for the need to look for patterns in the paleoanthropological record that indicate how multiple evolutionary processes intersected to form the human niche, a concept critical to assessing the development and processes involved in the emergence of a contemporary human phenotype. We suggest that incorporating key elements of the Extended Evolutionary Synthesis (EES) into our endeavors offers a better and more integrative toolkit for modeling and assessing the evolution of the genus Homo. To illustrate our points, we highlight how aspects of the genetic exchanges, morphology, and material culture of the later Pleistocene complicate the concept of “modern” human behavior and suggest that multiple evolutionary patterns, processes, and pathways intersected to form the human niche.     

Bioarcheology has a “health” problem: Conceptualizing “stress” and “health” in bioarcheological research

This article provides a critical historical overview of the stress concept in bioarcheological research and critically evaluates the term “health” in reference to skeletal samples. Stress has a considerable history in 20th century physiological research, and the term has reached a critical capacity of meaning. Stress was operationalized around a series of generalized physiological responses that were associated with a deviation from homeostasis. The term was incorporated into anthropological research during the mid-20th century, and further defined in bioarcheological context around a series of skeletal indicators of physiological disruption and disease. Emphases on stress became a predominate area of research in bioarcheology, and eventually, many studies utilized the terms “health” and “stress” interchangeably as part of a broader, problem-oriented approach to evaluating prehistoric population dynamics. Use of the term “health” in relation to skeletal samples is associated with the intellectual history of bioarcheological research, specifically influences from cultural ecology and processualist archeology and remains problematic for two reasons. First, health represents a comprehensive state of well-being that includes physiological status and individual perception, factors that cannot be readily observed in skeletal samples. Second, the categorization of populations into relative levels of health represents a typological approach, however unintentional. This article advocates for the integration of methodological and theoretical advances from human biology and primatology, while simultaneously incorporating the theoretical constructs associated with social epidemiology into bioarcheological research. Such an approach will significantly increase the applicability of bioarcheological findings to anthropological and evolutionary research, and help realize the goal of a truly relevant bioarcheological paradigm. Am J Phys Anthropol 155:186–191, 2014. © 2014 Wiley Periodicals, Inc.     

Rural-Urban Inequity in Unmet Obstetric Needs and Functionality of Emergency Obstetric Care Services in a Zambian District

Background

Zambia has a high maternal mortality ratio, 398/100,000 live births. Few pregnant women access emergency obstetric care services to handle complications at childbirth. We aimed to assess the deficit in life-saving obstetric services in the rural and urban areas of Kapiri Mposhi district.

Method

A cross-sectional survey was conducted in 2011 as part of the ‘Response to Accountable priority setting for Trust in health systems’ (REACT) project. Data on all childbirths that occurred in emergency obstetric care facilities in 2010 were obtained retrospectively. Sources of information included registers from maternity ward admission, delivery and operation theatre, and case records. Data included age, parity, mode of delivery, obstetric complications, and outcome of mother and the newborn. An approach using estimated major obstetric interventions expected but not done in health facilities was used to assess deficit of life-saving interventions in urban and rural areas.

Results

A total of 2114 urban and 1226 rural childbirths occurring in emergency obstetric care facilities (excluding abortions) were analysed. Facility childbirth constituted 81% of expected births in urban and 16% in rural areas. Based on the reference estimate that 1.4% of childbearing women were expected to need major obstetric intervention, unmet obstetric need was 77 of 106 women, thus 73% (95% CI 71–75%) in rural areas whereas urban areas had no deficit. Major obstetric interventions for absolute maternal indications were higher in urban 2.1% (95% CI 1.60–2.71%) than in rural areas 0.4% (95% CI 0.27–0.55%), with an urban to rural rate ratio of 5.5 (95% CI 3.55–8.76).

Conclusions

Women in rural areas had deficient obstetric care. The likelihood of under-going a life-saving intervention was 5.5 times higher for women in urban than rural areas. Targeting rural women with life-saving services could substantially reduce this inequity and preventable deaths.