Author(s): Koblinsky MA, Tinker A, Daly P
The Safe Motherhood Initiative has successfully stimulated much interest in reducing maternal mortality. To accelerate programme implementation, this paper reviews lessons learned from the experience of industrial countries and from demonstration projects in developing countries, and proposes intervention strategies of policy dialogue, improved services and behavioural change. A typological approach with three hypothetical settings from resource poor to resource rich environments is used to address the variability in health behaviours and infrastructure encountered when programming for safe motherhood. PIP: Safe Motherhood programs have been expanded over the past six years, but funding and evaluation are still insufficient to meet needs in a cost effective manner. Process indicators may be appropriate qualitative and quantitative indicators of how well programs are functioning and of the underlying mechanisms influencing maternal health outcomes. Three important dimensions of the Safe Motherhood Initiative are policy dialogue, improved services, and behavior change. The World Bank/MotherCare Workshop on Guidelines for Safe Motherhood Programming and the World Bank Discussion Paper on Making Motherhood Safe provide guides to action. Many features of the reports are summarized in this paper (a definition of the problem, the lessons learned, essential features of an effective motherhood program, strategies appropriate for specific settings, policy issues, costs of interventions, and measurement of progress). The problems of maternal mortality stem from septic abortion, postpartum hemorrhage, eclampsia, hypertension, obstructed labor, and sepsis/infection. Community-based family planning has been instrumental in rapidly reducing maternal mortality in Bangladesh. Community-based maternity care programs with trained midwives, medical supplies, and a referral system can reduce the risk of dying by 66%. Trained traditional birth attendants alone do not reduce the risk of maternal mortality. Essential, accessible obstetric care has had an impact in Zaire. Community-based maternity waiting homes, referrals, and prenatal screening prevent maternal mortality in Ethiopia. Safe Motherhood begins with a healthy environment (women's status, political commitment, and socioeconomic development), which is influenced by women's health and nutritional status, reproductive and health behavior, and access to family planning and maternal care services. Immediate determinants of maternal mortality are 1) exposure to pregnancy and 2) complications and their management. Important program elements are services, skilled assistance, referrals, and communication.