Maternal survival in developing countries: what has been done, what can be achieved in the next decade

Transcription

1 Ž. International Journal of Gynecology & Obstetrics Maternal survival in developing countries: what has been done, what can be achieved in the next decade F. Donnay,1 Technical and Policy Diision, UNFPA-FNUAP, New York, NY, USA Abstract Every year, approximately women die of pregnancy-related causes 98% of these deaths occur in developing countries. For every woman who dies, at least 30 suffer injuries and often, permanent disability. The challenge today is to re-orient programmes on priority interventions, and to mobilize sufficient resources for their implementation. More resources have been put into antenatal care than into delivery care and the management of complications of births and unsafe abortions. This article describes the effective strategies for reducing maternal death, their policy requirements and programmatic implications, and provides examples of successful developing country programmes. Priority interventions include: Ž. 1 improving availability and use of essential obstetric care for the management of complications; Ž. 2 strengthening family planning services; Ž. 3 ensuring skilled attendance at birth; Ž. 4 promoting women-friendly health services; Ž. 5 increasing district-level planning with community participation; and Ž. 6 monitoring process with process indicators. Finally, the promotion of safe motherhood as a right is of crucial importance. Needed now is political commitment as well as coordinated action for the implementation of large-scale programmes in low-income countries International Federation of Gynecology and Obstetrics. Keywords: Maternal mortality; Obstetric care; Midwifery Correspondence author. Tel.: ; fax: address: donnay@unfpa.org Ž F. Donnay.. 1 Dr France Donnay, MD, MPH, ObGyn, currently works with the United Nations Population Fund Ž UNFPA. as Senior Technical Officer, Technical and Policy Division. From , she was Senior Adviser for Women s Health, Programme Division, United Nations Children s Fund Ž UNICEF.. The views expressed in this article are those of the author and do not necessarily reflect the policies of these organizations $ International Federation of Gynecology and Obstetrics. Ž. PII: S

2 90 F. Donnay International Journal of Gynecology and Obstetrics Introduction Every year, approximately women die of pregnancy-related causes 98% of these deaths occur in developing countries. Of all the health statistics monitored by WHO, the largest gap between rich and poor nations is seen in maternal mortality levels. Over 90% of maternal deaths occur in Asia and sub-saharan Africa, with India alone accounting for 25% of such deaths worldwide while six other countries Bangladesh, Ethiopia, Indonesia, Nepal, Nigeria, and Pakistan account for a further 30%. At present, one woman in 12 will die of maternal causes in sub-saharan Africa, compared with one woman in 4000 in northern Europe. Furthermore, for every woman who dies, at least 30 suffer injuries and often, permanent disability. It is estimated that one in four women in the developing world suffers from acute or chronic conditions related to pregnancy. Maternal morbidity is highly prevalent, but not accurately reported, neither in developed nor in developing countries 1. While many other health indicators have improved over the last two decades, maternal mortality rates and ratios have remained stagnant. The causes are rooted in the absence of high level commitment to protecting women s health in many countries, and in the powerlessness of women, as there is a clear connection between the low status of women and the risk of maternal illness and death. Maternal death is most likely to occur in families where girls learn they have a lesser right to food and education than boys, and where women believe that their health is less important than that of other family members. It is more likely in nations that give little priority to health services for women including maternal care. It is most likely in cultures where maternal illness, suffering and death are viewed as natural, inevitable, and part of what it means to be a woman. Diseases like HIVAIDS, tuberculosis, and malaria also inflict a heavy and growing toll on women of reproductive age. According to a 1998 WHO report, among women of reproductive age, more than 20% of total years of healthy life is lost due to three main areas of reproductive health maternal morbidity and mortality, sexually transmitted diseases including HIVAIDS and reproductive tract cancers. A heavy toll falls on infants of the approximate 8 million infant deaths each year, around two-thirds occur in the 1st month of life. Approximately 3.4 million deaths occur in the 1st week, and most of neonatal and perinatal deaths are the result of poor maternal health and inadequate care during pregnancy and delivery and the critical immediate postpartum period. Traumatized infants may survive but become physically or mentally disabled for the rest of their lives. When a woman dies in childbirth, she often leaves behind small children who often do not survive without a mother s care, and surviving daughters are especially vulnerable 2. More than 80% of maternal deaths worldwide are due to five direct causes: hemorrhage, sepsis, unsafe abortion, obstructed labor and hypertensive disease of pregnancy. Indirect deaths are due to conditions that in association with pregnancy precipitate the fatal outcome for instance malaria, hepatitis, and increasingly AIDS. Most life-threatening complications occur around the time of birth and require timely recognition and prompt treatment to save the lives of women and their infants. Today, there is great reason to hope that progress can be made in reducing maternal mortality. Firstly, because the practical solutions required to improve the availability, access, quality and use of maternal health services are known and affordable. Secondly, because there is greater awareness of the importance of integrated approaches to development. Maternal health depends on so many factors in the lives of girls and women, that multisectoral approaches are essential involving action in the fields of education, legislation, and the media as well as in the health sector. And thirdly, because the idea that all citizens possess equal rights to health, education, and other social services is becoming more widely accepted by law-makers in many countries. It is growing hand-in-hand with the realization that the achievement of greater equity depends on the participation of citizens, families, and communi-

3 F. Donnay International Journal of Gynecology and Obstetrics ties. These trends are important for building societies based on the fulfillment of human rights and are particularly significant for women. 2. What have we learned from successful safe motherhood programmes in low income countries? Evaluations in countries such as Tunisia, Sri Lanka, Kerala State in India, Cuba, China and the former Soviet Union established that maternal morbidity and mortality can be reduced through the synergistic effect of combined interventions. These included: education for all; universal access to basic health services and nutrition before, during and after childbirth; access to family planning services; attendance at birth by professional health workers and access to good quality care in case of complications; and policies that raise women s social and economic status, and their access to property, as well as to the labor force. In Sri Lanka, for instance, the maternal mortality ratio dropped dramatically from 555 per live births in the 1960s to 95 per in the 1980s, and to 30 per live births in 1990, while Ivory Coast had a rate of 830 yet both countries have a similar gross national product or average annual income per capita of $ In developed countries, historical records also demonstrate the significant improvements that can be achieved when key interventions are in place. Reduction of maternal mortality took place in Sweden as a result of a national policy favoring professional midwifery care for all births-most deliveries took place at home. Strong political will, the accountability of local authorities, and appropriate information systems helped Sweden achieve the lowest MMR in Europe at 228 per by In Denmark, Japan, Netherlands and Norway, similar strategies produced comparable results. In England and Wales, significant reductions in maternal mortality were not apparent until the 1930s; political commitment was achieved only slowly and introduction of professional midwifery was delayed. After 1945, a drastic reduction to current low rates in the industrialized world resulted from access to antibiotics, cesarean sections and safe blood transfusions. Therefore, both historical and contemporary evidence shows that maternal mortality can be reduced without first attaining high levels of economic development. In fact, maternal mortality itself contributes to underdevelopment, because of its severe impact on the lives of young children, the family and society in general. 3. What can be achieved in the next 10 years? In 1997, 10 years after the Safe Motherhood Conference in Nairobi, a Technical Consultation was held in Colombo, Sri Lanka. Representatives from governments, donors, NGOs, and technical experts agreed on key interventions that are critical to reduce maternal mortality. This broad consensus is reflected in the 10 messages included in the meeting report The Safe Motherhood Action Agenda as well as in the Joint Statement on Maternal Mortality Reduction issued in 1999 by WHO, UNICEF, UNFPA and The World Bank. The Joint Statement recommends interventions at three levels: national and local governments, health systems and communities 2. This article focuses on health sector interventions, which should always be seen as part of broader changes in the social fabric, especially those affecting the status of women, as mothers but also as citizens. Women s health is affected not only by biological differences, but also by gender-based social, cultural, and economic inequities. Virtually all countries have safe motherhood programmes that are being increasingly integrated with family planning and interventions addressing reproductive tract infections into core reproductive health packages. The challenge with respect to maternal care is to re-orient programmes on priority interventions, and to mobilize sufficient resources for their implementation. More resources have been put into antenatal care than into delivery and immediate postpartum care and essential care for managing complications 3. Yet the vast majority of complications and deaths arise during and immediately after delivery, because of sudden, unexpected complications, and from unsafe abortions. While

4 92 F. Donnay International Journal of Gynecology and Obstetrics family planning is very effective, antenatal care without linkage to professional delivery care does not greatly reduce maternal mortality, despite its positive impact on perinatal mortality. Health professionals midwives, obstetricians, public health physicians who are very influential in their societies and communities, have a central role to play in the implementation of priority interventions such as providing skilled attendants with essential midwifery skills, and with the needed back up of referral, logistics, managerial and supervisory support. Reproductive health providers also are in a unique position to identify problems resulting from harsh socio-economic conditions, nutritional deficiencies, physical abuse and neglect, and to advise women and their families about healthy behaviors, reproductive choices and opportunities for girls and adolescent girls Improving the availability and use of essential obstetric care EOC Building effective referral systems is critical for ensuring that women who need emergency attention are able to obtain it. While most obstetric complications can be neither predicted nor prevented, they can be successfully treated. Even where EOC services are available, a substantial number of maternal deaths occur because women with obstetric complications fail to receive appropriate care soon enough to save their lives. The three delays model is often used to help programme managers and communities understand the determinants of maternal mortality and put in place the adequate responses: delay in recognizing the need for care and in seeking care, delay in reaching care and delay in obtaining appropriate care at the medical facility. Effective healthcare in rural areas depends on educating communities, including men as husbands and fathers, leaders and decision-makers, about birth preparedness, and on strengthening links between community practitioners and the formal health system. Unless the three delays are addressed, no safe motherhood programme can succeed 5. In Guidelines jointly issued in 1997 by WHO, UNICEF, and UNFPA, it is recommended that for every people there should be four facilities offering basic EOC and one facility offering comprehensive EOC. Basic emergency obstetric care provided in health centers and small maternity homes includes administration of antibiotics, oxytocics, anticonvulsants, manual removal of the placenta, removal of retained products, and assisted vaginal delivery with forceps or vacuum extractor. Comprehensive emergency obstetric care, delivered in district hospitals includes all basic EOC functions plus cesarean section and blood transfusion 6. In addition, obstetric first aid Ž OFA. consists of a set of emergency measures that can be taken by qualified birth attendants at home or in low-level facilities with minimal equipment. It includes for instance uterine massage or bi-manual compression to reduce or stop bleeding, and administration of antibiotics and antipyretics orally as a temporary measure if transport to a higher facility exceeds a few hours. Ongoing trials with prostaglandins to contract the uterus and injection devices pre-filled with oxytocin and antibiotics will increase the knowledge and feasibility of obstetric first aid interventions by low level providers working in peripheral areas. Further research is necessary to establish the impact of OFA on maternal and neonatal survival. In any event, these measures can help save a woman s life if, at the same time, action is taken to call for help and arrange transport to a higher level of care. However, if OFA is viewed as an alternative to hospitalization this would be counterproductive and dangerous. Existing facilities Ždistrict hospitals and health centers. can often, with limited inputs, become capable of providing EOC. These interventions include: renovating an existing operating theater or equipping a new one; repairing or purchasing surgical and sterilization equipment; converting unused facilities within hospitals or health centers into a basic or comprehensive EOC facility;

5 F. Donnay International Journal of Gynecology and Obstetrics training doctors and nurses in life-saving interventions; and improving the management of health services through better use of existing resources. annual cost of providing EOC in each of the 11 Project districts is approximately $ With an average district population of 1.7 million, the annual per capita cost of providing EOC services is approximately 8 US cents Ž US$.08. 1,8,9. A system has to be in place to ensure that staff are available to manage obstetric emergencies 24 hday, including a functioning operating theater and an anesthesiologist, or a nurse with special training 1,7. The government of Mali with support from various donors developed a programme that includes a rapidresponse component. District hospitals and local health centers are linked by a two-way system of radio communication and transportation. A car, equipped with a stretcher, is available to transport women from health centers to district hospitals. Under this system, the time required to transmit an urgent message and transport a patient is reduced from up to a day to just a few hours. Obstetric services are paid for on a cost-sharing basis between village health committees and district authorities. A postpayment arrangement ensures that financial barriers do not impede emergency care. Already, there has been a steady increase in the number of women referred to district level hospitals and in the proportion of cesarean sections to births per district, which currently still is a low 12% 1. In Bangladesh, the UNICEF-supported Women and Maternal Health Project has been implemented in 11 districts, with a combined population of 19 million. A mentoring program links 11 district level hospitals with obstetric departments of teaching hospitals, strengthening the referral system for women to higher levels of care; the linkage also established a mechanism for continuing medical education for district hospital staff. Since implementation, the number of referrals at health facilities has increased by more than 60% and emergency Cesarean sections have increased by 34%. The government contributed salaries, personnel support and training facilities. A project supported by UNFPA complemented this programme by expanding the services of 27 Mother and Child Welfare Centers Ž MCWC., which now can offer comprehensive reproductive health services along with 24-h emergency obstetric care. In its next phase, the Government of Bangladesh with donor support will implement the Project nationally and will broaden its focus to include the social aspects of maternal mortality, including women s lack of power, decision-making abilities, and violence in the home. Men, who together with mothers-in-law are the primary decision-makers when evacuation is needed, will be included in community education programs. The total The International Federation of Obstetricians and Gynecologists, in partnership with UNFPA and with the support of Pharmacia Upjohn, Inc., and the World Bank, has launched the Save the Mothers Fund project. Teams of obstetriciansgynecologists from industrialized countries work with their counterparts in developing countries to launch a demonstration project to provide or improve EOC services Že.g. a Canadian team works with a team in Uganda, Sweden has teamed up with Ethiopia, Italy with Mozambique, United Kingdom with Pakistan.. FIGO will seek funding to expand the Save the Mothers Fund initiative to other countries. This example illustrates that partnership with association of obgyns; general practice doctors and midwives can be a powerful and strategic force for improving women s access to quality EOC services Strengthening reproductive healthcare delivery systems Promoting the integration and quality of a constellation of reproductive health services, including family planning, maternal and infant care and STDs prevention and treatment is an essential component of health sector reform. Improving access to client-centered family planning information and services, where a range of effective contraceptive methods is offered and responsive counseling provided, reduces the number of unplanned pregnancies, that often lead to suboptimal pregnancy care and unsafe abortion procedures. Currently as many as 50% of pregnancies are unplanned, 25% are unwanted, and complications of unsafe abortions are responsible for a substantial proportion of maternal deaths. Meeting the existing demand for family planning services would reduce pregnancies in developing countries by 20% and maternal deaths and injuries by a similar degree or more. Challenges include targeting single women, men and adolescents, and promoting new and underutilized methods such as female condoms, vasectomies or emergency contraception, for instance. Reproduc-

6 94 F. Donnay International Journal of Gynecology and Obstetrics tive tract infections and sexually transmitted diseases in particular are a major cause of maternal and neonatal morbidity and mortality 8,9. In many poor communities, the inter-play between poor nutrition and debilitating diseases, malaria and tuberculosis for example, means that many women are unhealthy at the onset of pregnancy. They are already at the disadvantage if an obstetric emergency arises. For example, approximately 56% of women in developing countries suffer from anemia caused by parasitic infections from malaria and hookworm andor from inadequate intake of iron and folic acid and as a result face an increased risk of maternal death from hemorrhage and infection. Recently, there has been an attempt to address nutritional deficiencies that affect women and newborns by preparing a multiple micronutrient supplement containing vitamins and minerals and distributing the tablets to pregnant women. Trials are underway to determine the effectiveness of this intervention in several developing country settings 1. Although the previous emphasis on prenatal care and TBA training did not succeed in reducing maternal deaths, it is important to establish a relationship between women and the health system by providing good, empathic prenatal care and by fostering the dialogue with TBAs and female community leaders. All pregnant women should have 24 prenatal visits, focusing on birth preparedness Ž place, attendance., TT immunization, iron and folate tablets and when available, a multiple micronutrient supplementation malaria prophylaxis and hookworm treatment, STD and UTI diagnosis and management, and early detection and management of complications such as pre-eclampsia. The risk approach in prenatal care is not effective, although some women are more likely to develop complications than others, for instance if the previous pregnancy had a bad outcome. However, most risk assessment systems have a poor predictive capability. As it is almost impossible to predict which individual woman will develop a life-threatening complication, ALL pregnant women should have access to a qualified health provider, for prenatal AND delivery care, and adequate services should be available at referral level 4, Ensuring skilled attendance at birth Most complications occur at childbirth, and the presence of a professional nurse, midwife, doctor is crucial to take urgency actions that save lives. Women attended by professionals are more likely to avoid serious complications and receive treatment early, when the situation can still be controlled. Professional attendance is as important for home births as for deliveries in health centers, maternity homes and hospitals. The demand for professional health workers increases with urbanization and girls education. Yet, in the developing world today only 58% of all deliveries take place with the assistance of a skilled attendant. Training of traditional birth attendants has had little impact in reducing the risk of maternal death, although it has had some positive benefits in improving cleanliness at birth and reducing neonatal deaths due to tetanus. Health and education systems have failed at developing a strong cadre of professional practitioners to assist women in childbirth, especially the poor and those living in rural areas. Professionally qualified birth attendants include midwives, doctors and practitioners who have received at least 18 months of midwifery training and attend on average, 510 deliveries per month. Throughout the developing world, there is a chronic shortage of midwives and this is most acute in rural areas. Training and deployment of professional midwives as primary birth attendants is a critical intervention that can be done by: establishing a national regulatory framework to enable midwives to practice in variety of settings Žinstitutional and non-institutional, public and private.; encouraging policy makers to review and revise regulations governing the scope of practice of each category of birth attendant, including midwives and general practitioners, and to upgrade curricula accordingly; encouraging the expansion of midwives and family doctors role in providing life-saving interventions, such as manual removal of placenta;

7 F. Donnay International Journal of Gynecology and Obstetrics upgrading professional midwifery education programs and continuing education for practicing midwives or community midwives; establishing partnerships with governments, training institutes, national midwives associations, the International Confederation of Midwives Ž ICM., as well as national and international associations of obstetriciansgynecologists like FIGO, to expand opportunities for midwifery training and professional development; and increasing professionalization of midwifery practice through the development of strong professional midwives associations. In addition, incentives should be provided to midwives and doctors working in rural and semirural areas Ž housing, distance learning,.... and career prospects ensured through a rotation system, and a mix of public-private practice. Care at childbirth can be delivered by a variety of providers. To cover under-served groups, it is necessary to delegate responsibilities to the lowest possible level of care, that can deliver it safely which implies a sufficient case-load, regular supervision and an effective supply system and be responsive to patient s needs. Women often choose the services of TBAs even when clinic and hospital services are available and accessible, indicating that the health system must learn from TBAs to create more culturally acceptable and respectful ways to care for women. TBAs are more financially accessible and also provide other essential support services such as help with household chores and looking after children. Healthcare providers can facilitate women s access to skilled birth attendants by ensuring that TBAs are welcome to accompany women to health centers and that their valuable knowledge and skills are incorporated into maternal health provision 1,3,4,10. In Ivory Coast, midwives have been allowed to perform manual removal of the placenta. This modification in midwives scope of practice directly improved the ability of midwives to manage postpartum hemorrhage, where emergency action is needed to save the woman s life 1. In Mozambique, nurses have been trained to perform cesarean sections. This training is part of an effort to make essential obstetric care available at the lowest levels of the health system possible, particularly in rural areas where distance is often a significant barrier to women. The outcomes of the cesarean sections have been as good as those performed by specialist obstetricians 1, Promoting women-friendly health services All women need access to women-friendly health services that meet established criteria for quality. The responsibility for developing quality assurance mechanisms lies at different levels of the system. The national and regional levels are responsible for assuring the development of standards and protocols, and for establishing an enabling environment for improved quality, including an accreditation system. The district level improves service delivery, adapts the standards locally, and improves service management Žin- cluding procurement of supplies and drugs.. At facility level, the staff is responsible for involving users through improving interpersonal communication between staff and users. Providers can use self-assessment tools to monitor their performance. Women friendly services: are available, accessible and affordable: located as close as possible to where women live, open at convenient hours and reasonably priced for both clients and the healthcare system; provide care with the highest possible technical standards, including infrastructure, infection control, written protocols and necessary supplies and equipment; ensure the satisfaction of both users and providers through support and motivation of providers, client involvement in decision making, and provider responsiveness to the cultural and social norms; and respect women s rights to information, choice, safety, privacy and dignity.

8 96 F. Donnay International Journal of Gynecology and Obstetrics In particular, obstetric emergencies have priority access to the operating rooms, and safe blood transfusion is available 24 hday 1. In Moldova, women admitted to hospitals were often isolated from their families until 5 days after delivery. With assistance from several agencies and the Ministry of Health, a pilot scheme to train trainers in Family Centered Maternity Care was introduced. It focused on the physician-midwife team approach and included neonatal as well as family-based maternity care including rooming-in, emotional support for mothers, family visits. The programme is now expanded to many other areas of the country 1. In Peru, a project called 10 Steps for a Safe Delivery is now being implemented in maternity hospitals. The criteria for certification of a maternal health facility include: a written policy of safe delivery, trained staff, compassionate care, priority to obstetric emergencies, surgery facilities with necessary equipment for cesarean sections and neonatal resuscitation, a functioning and safe blood bank, communication and transportation equipment, care for premature babies and breastfeeding policy, a monitoring committee, and community support groups. A national facilitation team works with local institutions to implement the 10 steps, and accreditation is based on process indicators District-level planning with community participation It has been demonstrated time and time again that interventions that do not incorporate active involvement by communities are destined to fail; community acceptance of an intervention is critical to its success, and is best ensured if the initiative and responsibility for implementation come from the community. In traditional rural communities men and older women often play a lead role. Solidarity mechanisms can be put in place for ensuring both attendance of home deliveries by professional midwives and transportationevacuation to the appropriate level of care in case of complications. Urban communities present other challenges, but depending on the social make-up of the community, participatory approaches can still be successful. Regional and district-level authorities are held accountable for the provision of emergency care at the district level Žtransportation, communication, health infrastructure and personnel., and communities are responsible for asking for help in time, and for the reimbursement of expenses after the procedure. 9. Monitoring progress with process indicators Maternal morality rates and ratios are difficult and expensive to obtain and are often inaccurate because of under-reporting and misclassification. In addition, some of the poorest countries do not have adequate vital registration systems. Process indicators such as the proportion of professionally attended births and the number of referrals of emergency cases are monitoring tools that help to track progress in program implementation. A process indicator series published in 1997 by UNICEF, WHO and UNFPA focuses specifically on monitoring whether women who develop serious obstetric complications receive the services they need. Indicators include the number of facilities offering EOC, their geographic distribution, the percentage of women with complications treated in EOC facilities, the cesarean section rate and the case fatality rate, an indicator of the quality of care provided. This series of process indicators is now often used to assess the outcome of interventions at district and facility level and may be included in national management information systems. UNICEF and the Ministry of Health and Population recently used EOC process indicators to complete an assessment in six districts of upper Egypt. The assessment used available records, site visits to the facilities as well as in-depth interviews with key health officials and staff at the facilities. Results from the Akhmiem District of Sohag Governorate indicated: a high unmet need for essential obstetric care services; treatment in EOC facilities of only 17% of women with serious complications; a low cesarean section rate of 0.04%; a case fatality of 7%; poor use of existing resources such as space in facilities and equipment and poor training and supervision 1,5. The time interval from the onset of a complication to arrival at facility, and to treatment at the referral site is also a very sensitive indicator of

9 F. Donnay International Journal of Gynecology and Obstetrics the effectiveness of the referral system. Common indicators used to monitor and evaluate safe motherhood also include the percentage of pregnant women attending antenatal care at least once and the percentage of women receiving postnatal care. Finally, maternal death audits, undertaken with families, communities and health providers, are a powerful way of improving the delivery of services. Skilled attendance at birth will be used as a global benchmark indicator to monitor progress towards the goal of maternal mortality reduction, as agreed in July 1999 by the United Nations General Assembly during the review and appraisal of the implementation of the Programme of Action of the International Conference on Population and Development held in Cairo in ,4,6,11. Additional indicators need to be developed to measure other interventions, including government compliance in fulfilling the rights of women for example, maternity rights in the work place. 10. A rights-based approach to safe motherhood In recent years safe motherhood has been promoted as a right. This lays the foundation for an integrated, multisectoral approach by relating factors underlying maternal survival and health to fundamental rights enshrined in international conventions and national Constitutions: rights to participation, education, nutrition, healthcare, freedom from discrimination and protection from violence and abuse 1,4,12. The issue of maternal mortality has reached a turning point. We know what works; we know what should be done. What is needed is a better coordination among partners governments, public services, the private sector, NGOs, UN agencies and donors and an expansion of local projects to national programmes. In the next 10 years we should see the implementation of largescale programmes in the most affected countries, in South Asia and sub-saharan Africa. Commitment from national and local authorities and larger donor support are needed, however, to reach significant scale. Maternal death is a very sensitive indicator, not only of the strengthening of the healthcare system, but more broadly of a society s achievement towards equality between men and women. We possess the knowledge and the tools to make permanent disability and death during pregnancy and childbirth almost as uncommon in poor nations as it is in the richer ones. References 1 The World Bank. Safe motherhood and The World Bank: lessons from ten years of experience. Washington, DC: The World Bank, June UNICEF. Programming for safe motherhood. New York: UNICEFHealth SectionProgramme Division, The Safe Motherhood Action Agenda: Priorities for the next decade. New York: Family Care International, UNFPA. Reducing maternal mortality and morbidity. Programme Advisory Note No 5. New York: UNFPA, UNFPA. Safe motherhood: evaluation report No 15. New York: UNFPA, Reduction of Maternal Mortality. A joint WHOUN- FPAUNICEFWorld Bank statement. Geneva: WHO, Maine D, Rosenfield A. The safe motherhood initiative: why has it stalled? Am J Public Health 1999;894: UNICEF, WHO &UNFPA. Guidelines for monitoring the availability and use of obstetric services. New York: UNICEF, Ross SR. Promoting quality maternal and newborn care: a reference manual for program managers. Atlanta: CARE, UN General Assembly. Report of the ad hoc committee of the whole of the twenty-first special session of the general assembly: key actions for the further implementation of the programme of action of the International Conference on Population and Development. New York: United Nations, Berer M, Ravindran S. Safe motherhood initiatives: critical issues. London: Blackwell Science for Reproductive Health Matters, Liljestrand J. Reducing perinatal and maternal mortality in the world: the major challenges Ž RCOG.. Br J Obstet Gynaecol 1999;106: