**2. Context**

*Maternal and Child Health Matters Around the World*

where deliveries are not most of times attended by skilled health professionals with obvious poor-rich inequalities [3]. Cross-sectional surveys in 80 low and middleincome countries have shown inequalities in the coverage of place of delivery and skilled birth attendance (SBA): SBA deliveries at home and facility non-SBA deliveries were more common in rural than in urban areas and among the poorest in all concerned regions including Sub-Saharan Africa [4]. Another multi-country study showed that only 17.7% of the poorest women versus 54.1% of the richest women used public facilities in Sub-Saharan Africa; and among home births in the poorest, 56% were unattended whereas 41% were attended by a traditional birth attendant [5]. Similar findings have also been reported by other studies [6–9], and in remote areas of limited-resources environment, home-birth practices alone or with the assistance of traditional matrons are the rule [10]. These practices are transmitted from generation to generation in the villages of some developing countries. Globally, about 60 million women give birth every year outside health facilities, primarily at home, and 52 million are not attended by qualified health professionals [11]. The lack of universal skilled attendance leading to lowest emergency obstetric care is explained by a number of reasons, namely the health system deficiency, financial and geographical barriers, mother's educational level, husband's occupation, wrong perception of the household decision maker, hostile behaviour of health personnel, traditional beliefs, and age at first pregnancy [5–8, 12, 13]. Among all pregnant women, nulliparae are at higher risk in abovementioned conditions as unplanned caesarean deliveries leading to adverse foeto-maternal outcomes are not an exception in a poor environment [14, 15]. Therefore, most of caesarean sections are emergency ones, as attending matrons always attempt at all costs to deliver vaginally babies regardless of the situation according to certain ethnocultural beliefs. This perception persists even among immigrant women in developed countries [16]. Consequently, in case of cephalopelvic disproportion, unsuccessful attempts to give birth vaginally result in neglected prolonged labour resulting in an emergency caesarian section in appalling conditions, particularly in the presence of transport and financial barriers as is the most common case. This also happens in health centres of urban areas when the health system is completely disorganised. Thus, foeto-maternal morbidity and mortality become higher to the point of making hospitals statistics alarming. In one hand, newborn death, uterine rupture and obstetric fistula are among complications with the saddest impact on a surviving primiparous woman and her family with regard to the pronatalist African culture. In the other hand, cephalopelvic disproportion due to generally contracted pelvis or large foetal head circumference is one of caesarean section indications in nulliparae and pregnant women aged less than 19 [17–20]; and this should also be the case in settings characterised by early marriages and lack of appropriate pregnancy monitoring. Besides, it is also known that external pelvimetry is nowadays controversial and no longer in favour with many obstetricians [21, 22], now that new, more powerful diagnostic tools, e.g. CT pelvimetry using multi detector CT and magnetic resonance-based serial pelvimetry [23, 24], are available and which will take time to reach pregnant women in resource-limited areas. Meanwhile, results from some surveys in Sub-Saharan Africa and elsewhere have shown a significant relationship between some external pelvic diameters and cephalopelvic disproportion or dystocia indication for caesarean section in nulliparae [25–28]. Our aim is in fine to advocate, on the basis of our findings in the African Great Lakes Region, the reintroduction of pelvimeter as a cheap and helpful tool in hands of well-trained health professionals, in order to promote scheduled caesarean sections, and therefore to prevent harmful outcomes such as newborn death, uterine rupture and obstetric fistula in young mothers leaving in

**74**

resource-limited environment.

Apart from background data, findings from surveys and studies concerned in next sections have been collected in two countries of the African Great Lakes Region at the heart of Africa; namely, Rwanda and the Democratic Republic of the Congo. Rwanda is a tiny and landlocked country, which is the more densely populated (519/km<sup>2</sup> ) in Sub-Saharan Africa. Its infrastructure and qualified manpower was greatly impacted by the 1994 genocide in general and specifically in the health sector [29]. About 90% of population is presently covered by the national mutual health insurance, while the country was steadily moving towards reaching some MDG by 2015 deadline [30]. Surely, financial dependence on external assistance is still high, and the shortage of human resources for health still challenging. However, Rwanda is one of the rare African countries that have allocated an appreciated part of their national budget to health, and since more than a decade, efforts and innovative solutions are ongoing to train, deploy and retain health professionals, should education programmes and retention strategies be regularly and appropriately readjusted, as far as human resources remain a tremendous challenge in the public sector [31]. On the whole, Rwanda is rather doing well economically and in the social sectors. The Democratic Republic of the Congo (DRC), as far as it is concerned, is one of the "Big Five" countries in Africa with a surface area estimated at 2,345,000 km<sup>2</sup> and a population of more than 80 million. DRC was all destined to be one of the best performing countries on the continent given its diversified natural resources, the proportion of actual qualified manpower and its basic infrastructure of departure at the time of its independence (30th June 1960). Apart from few ephemeral peaks of light development, this country, undermined by endless rebellions and the neglect of its political class, ended up being one of the failed countries of the world [32]. Its health system is a total mess: no evident leadership and vision, and very far from a minimum of transparency and accountability. As a result, we are witnessing a resurgence of old epidemics, the activation of old endemics, the spread of sexual violence and the worsening of the Ebola virus infection. We are not far from a "not assistance to a people in danger" situation!
