Indirect causes of maternal death.

We read with interest the WHO systematic analysis of global causes of maternal death (June issue) and the WHO maternal mortality trends report and press release. However, we urge caution regarding calls for policymakers, funding bodies, and health actors to give greater importance to indirect than direct causes of maternal mortality. With the exception of HIV infection, the systematic analysis does not provide insight into the main indirect causes of maternal mortality, nor into how these causes vary according to region or lifetime risk of pregnancy-related death. Putative causal relations between indirect causes of maternal mortality and pregnancy, and the relative surplus risk that they present, are also not discussed. More detailed information, available in some contexts, could guide targeted investment in indirect causes and could, in the long term, contribute to a reduction of maternal mortality. But at present, in regions such as sub-Saharan Africa where data are insuffi cient and health systems are weak, eff orts and funding should not be diverted from interventions that address known causes. Examples of these interventions include skilled birth attendance; reduction of mortality from haemorrhage, sepsis, pre-eclampsia, and obstructed labour; and provision of safe abortion care and contraceptives. A global policy emphasising indirect causes of maternal mortality will not successfully reduce the burden of maternal death where needs are greatest—priorities and actions tailored to local needs and capacities are needed. Médecins Sans Frontières off ers obstetric care in close to a third of its projects, assisting, in 2013, a total of 182 088 births, 17 647 (10%) of which are through caesarean section. Obstructed labour, abortionrelated complications, pre-eclampsia, haemorrhage, and sepsis are the daily emergencies in Médecins Sans Frontières projects. These issues are the so-called horsemen of maternal death, in contexts for which overall health-care provision is weak, just as these same diffi culties were a century ago in now developed countries.