RHO archives : Topics : Safe Motherhood

Program Examples

The safe motherhood programs in countries listed below illustrate some current strategies to overcome logistic, cost, provider, client, and other obstacles. They also provide lessons learned from experience.

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• Bolivia: A national commitment to improve the quality of maternal and child health care.
• Ethiopia: Repairing obstetric fistula.
• Malaysia: Increasing access to maternity care through birth centers.
• Philippines: Offering postabortion care.
• Senegal: Playing the 3W Safe Motherhood Game.
• Sri Lanka: Focusing on human development and social welfare reduces maternal mortality.

Bolivia

Maternal mortality is a serious health problem in Bolivia:

• The maternal mortality rate is estimated at 390 deaths per 100,000 live births (1989–1994), but there is great regional variation. In the rural, indigenous Altiplano area, the ratio is up to 929 deaths per 100,000 live births.
• Seventy-five percent of maternal deaths occur during pregnancy or delivery.
• Sixty percent of all births take place at home without a trained assistant in attendance; this figure increases to 75 percent in rural areas.
• About half of pregnant women receive some form of prenatal care.
• The main causes of maternal deaths are hemorrhage, induced abortion, and hypertension.
• Between 27 and 35 percent of maternal deaths are abortion-related.

Primary health care services were expanded in 1999, when the Ministry of Health and the World Bank launched Basic Health Insurance (SBS), a package of free health services. SBS covers prenatal, delivery, and postpartum care, as well as treatment for obstetric and neonatal emergencies, including postabortion care.

The World Health Organization has been working with the Ministry of Health in Bolivia to improve maternal health by implementing the Making Pregnancy Safer (MPS) Initiative. This initiative is helping countries strengthen professional care for pregnant women and their newborns, conducting research into the effectiveness of interventions, and testing the effectiveness of drugs through multi-center drug trials.

Improvements in Bolivia include:

• Adoption of Management of Complications in Pregnancy and Childbirth (www.who.int/reproductive-health/impac/index.html) as the national standard of care.
• Revitalization of the epidemiological surveillance system to gather data on maternal and newborn morbidity and mortality.
• Development of a uniform death certificate—specifically indicating maternal deaths—for use nationwide.
• Updating of Bolivian Standards of Health Care, The Contraceptive and Family Planning Standards, and the Basic Health Insurance Technical Guidelines.
• Training of community health advocates to ensure community participation and involvement in monitoring quality of care.
• Establishment of a working group to study cross-cultural issues related to maternal and infant mortality.

The initiative plans to continue to focus on improving the quality of care and to ensure that services are culturally sensitive. It is focusing on increasing comprehensive obstetric care and the capacity for managing obstetric emergencies at the first referral level. The initiative is also promoting "childbirth as in the home" in six urban areas, and is working to make health care facilities more welcoming to indigenous people.

For more information, please see Making Pregnancy Safer, available online at www.who.int/reproductive-health/mps/.

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Ethiopia

Many women, and their babies, die from prolonged or obstructed labor. Those who dont die are often disabled by obstetric fistula, and by associated nerve damage, known as "foot drop." Obstetric fistula is a hole that develops between a womans vagina and bladder (vesico-vaginal) or rectum (recto-vaginal), or both. These women lose urine and/or bowel control, and suffer from constant discomfort and humiliation. They are often ostracized, divorced, abandoned, and left without any support. Fistula is most common among young girls. The underlying causes of fistula are poverty, early marriage, lack of education, insufficient medical facilities, and lack of roads. An estimated 2,000,000 women suffer from fistulas, and another 50,000 to 100,000 new cases occur every year. The Addis Ababa Fistula Hospital in Ethiopia offers these women the chance of a new life. For more information, please see the Addis Ababa Fistula Hospital program example in RHO's Older Women section.

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Malaysia

It is common practice for women experiencing high-risk pregnancy living in rural areas of Malaysia to deliver at home instead of in the hospital. Often, women decide to go to the hospital only when birth complications have developed, at which time their risk of maternal mortality and morbidity has dramatically increased. Hospital delivery is unpopular among rural mothers, whose reasons for not delivering in hospital include discomfort with a hospital environment, concern about being examined and treated by male physicians, fear of being separated from their families, and worry about hospital fees.

To accommodate the needs, beliefs, and practices of mothers in rural communities, while at the same time providing modern medical care, the rural state of Kelantan established several low-risk birth centers beginning in 1991. Each birth center is attached to a health clinic and has four to six beds. The birth centers are staffed by doctors, nurses, and midwives from the respective health clinics. Although the birth centers are intended for use by low-risk pregnant women, high-risk pregnant women who do not want to deliver in hospital are allowed to deliver at the centers. Women who develop complications are sent to the nearest hospital by ambulance.

Records of 171 women delivered at one of these birth centers between June 1995 and September 1996 showed that 93 women (54%) had a normal delivery and were discharged within 24 hours of birth and 78 women were referred to hospital for delivery.

Interviews with women who received care at the Bachok birth center combined with feedback from health personnel showed that all regarded the birth center as beneficial. Clients and providers felt that the establishment of the birth centers had reduced many disadvantages associated with hospital delivery:

• The distances from the women's homes to the birth center were generally shorter.
• Transport was available to the birth center.
• Birth center providers were familiar with the women (who had received antenatal care at the health clinic).
• Women admitted to the birth center were monitored by a midwife.
• Most physical examinations were provided by women (nurses and midwives).
• Spouses, relatives, and traditional birth attendants were allowed to be with the mothers at the birth center, providing them with emotional support.
• The mothers felt safe because they could be sent to hospital if complications arose.

For more information, please contact:
Dr. Zulkifli Ahmad, Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kota Bharu, Kelantan, Malaysia
Telephone: 09 765 1700; Fax: 09 765 3370; Email: zulkifli@kb.usm.my

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Philippines

In the Philippines, an estimated 400,000 women undergo induced abortions every year, and 80,000 to 100,000 end up in hospitals for treatment of complications. Twelve percent of maternal deaths in the Philippines are from unsafe abortions. Induced abortion is illegal in this predominantly Catholic country, but many women feel they have no choice, especially when faced with an unplanned or unwanted pregnancy. The Catholic Church in this geographically dispersed country of islands opposes family planning, and many women are unaware that there are safe ways to prevent pregnancy.
Women suffering from the consequences of unsafe abortions often present to hospitals, only to be turned away or be subject to hostile behavior from providers who believe these women should be punished. Providers have been known to delay treatment, deny painkillers, make women pay for expensive medicines, and threaten to report them to authorities.

Fortunately, this is now changing in Philippines. In 1999, EngenderHealth, a U.S.-based nongovernmental organization, carried out needs assessments in eight health care facilities. Most abortion complications were managed medically, and most patients did not receive counseling or referrals for reproductive health care and family planning. As a result of these findings, EngenderHealth, with funding from the Packard Foundation, helped the Department of Health establish the Prevention and Management of Abortion and its Complications (PMAC) Program at the eight sites.
Established by administrative order as a government program in 2000, PMAC provides postabortion care (PAC) services, including staff training in supportive PAC and family planning counseling, clinical postabortion skills, infection prevention, and quality improvement.

An evaluation of PMAC activities from 2000 through 2002 documents the following achievements:

• 1,078 health providers have participated in postabortion care training.
• 15,349 clients have received postabortion care services.
• 94 percent of providers interviewed (n = 83) believe their PMAC training helped improve the quality of the postabortion care services they deliver.
• Providers now see women suffering from the consequences of unsafe abortion as in need of counseling, not condemnation.

Services have improved dramatically:

• All of the facilities now coordinate provision of family planning and referral for other reproductive health care services.
• 89 percent of PMAC clients interviewed (n = 35) said they were satisfied with the services they received.
• 82 percent of the PMAC clients (n = 15,349) seen from July 2000 to June 2002 received family planning counseling, and 43 percent accepted a method.
• Use of manual vacuum aspiration (MVA) is increasing, and 4 of 6 PMAC hospitals visited were actively using MVA.
• Providers often alternate D&C and MVA to maintain skills in both.

PMAC is also saving money at the facilities. At sites where MVA was used, clients’ average stay was less than one-third as long as at D&C sites. Shifting from D&C to MVA reduced the per client costs by 62 percent. New management systems at PMAC sites enabled providers to spend more time on direct client care.

Efforts are under way to transfer PMAC skills to new staff through formal training of trainers courses. EngenderHealth is also working with the Integrated Registered Nurses of the Philippines (IRNUP) to incorporate counseling in the curriculum of 200 nursing and 200 midwifery schools. The Department of Health and EngenderHealth have been negotiating with a local distributor to ensure availability of MVA equipment, and on developing policies and guidelines for the registration, procurement, distribution, and use of MVA in the Philippines.

Most notably, in 2001 the Filipino government requested assistance from USAID to establish its own program, based on the example of PMAC. This effort is now established at seven Department of Health and local health department sites.

Key elements of PMAC’s success are:

• Flexibility. By allowing flexibility when negotiating with the Department of Health over the components of PMAC, the program avoided making acceptance of MVA an obstacle.
• Small, privately funded efforts provide leverage. Starting small and committing private funds allowed the program to be flexible and sustainable, even in a hostile climate.
• Gain support of providers. Involving providers at all levels and providing culturally appropriate forums for them to reexamine their attitudes and behaviors toward postabortion care enabled them to change their practices.

For more information contact: compass@engenderhealth.org.

See also: EngenderHealth. Changing policies and attitudes: postabortion care in the Philippines. Compass 1:1–4 (2003). Available at: www.engenderhealth.org/pubs/compass/pdf/03-01.pdf.

Raymundo, C.M. et al. Unsafe Abortion in the Philippines: a Threat to Public Health. Manila: University of the Philippines Population Institute (2001).

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Senegal

What does it mean if you see a woman who walks with a heavy load on her head, but has a hard time balancing it? If she is pregnant, the baby may not be in the right position, and she should go to the nearest health center for medical assistance. This is one of the health and cultural lessons you would learn from playing Wure, Were, Werle, also known as the 3W Safe Motherhood Game.

Created by a public health nurse, Amadou Diallo, the game has been used by PLAN International in Thiès, Saint-Louis, and Dakar, Senegal, to increase womens awareness of maternal and child health risks by associating them with cultural images, beliefs, and proverbs. By helping women understand the reasons behind certain health conditions, they are more likely to understand the need for and to seek care from a health professional.

The game consists of a wooden box with 6 drawers, a deck of 72 cards, and 3 colored rows. Red represents risk factors, yellow shows detection methods, and green indicates the solution or the appropriate behavior to address the risk. The winner is the person who successfully completes all three colors of the pattern. She receives a set of marbles to store in the wooden box. Players can prevent each other from completing a series by starting a new color series of their own, and by winning the other players marbles. The cards have cultural images and proverbs representing health risks and protective factors. For example, the goat, who in Senegalese folklore is known to have many offspring, represents having multiple and closely spaced pregnancies. Each time a card is played, the player must repeat the idea of the series, including the risk factor. The use of symbols makes the health messages easier to understand.

The game has been tested in 16 Wolof-speaking villages in the health districts of Khombole, Bambey, and Kaolack. After playing just 10 games, women are able to describe the risk factors related to pregnancy, labor, and delivery; can describe risk factors in newborn babies; and can discuss methods used to detect common risk factors, along with the behaviors appropriate to address them.

A report on child survival activities in Saint-Louis reports "this game has really taken off in the communities as a leisure activity and competitions between villages are sometimes held, all of which enables vital messages about safe motherhood and child survival to be constantly reinforced among local families and traditional midwives and birth attendants." A midterm evaluation of the child survival projects showed a rise in knowledge of risk factors related to safe motherhood, and an increase in the number of pregnant women completing their three antenatal visits. While these gains are not due to the game alone, its use has promoted improved knowledge and practices relating to safe motherhood.

The game was developed with supported from PLAN International in collaboration with the Social Pediatrics Institute of Senegal, World Vision, Reseau Afrique 2000, UK Department for International Development (DfID), and several UN agencies.

For more information, please contact:
Dr. Winnie Tay, PLAN Country Director, Rue 5 X E Pointe E, BP 15042, Dakar, Senegal
Telephone: 221-824-60-60; Email: winnie.tay@plan-international.org
or Dr. Thidiane Ndoye, National Health Coordinator, at Thidiane.Ndoye2@plan-international.org.

Also see the Global Health Council's description of the game, online at www.globalhealth.org/reports/report.php3?id=7.

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Sri Lanka

By focusing on human development, Sri Lanka has achieved noteworthy success in reducing maternal deaths. The country's maternal mortality ratio is 60 deaths per 100,000 live births, one of the lowest in the developing world, and far below the average for south-central Asia (410 deaths). Maternal deaths dropped from 520 in 1990 to 250 in 1998.

Skilled birth attendants assist more than 96 percent of deliveries, and more than 90 percent take place in facilities. A national referral system ensures that first pregnancies, high-risk pregnancies, and those with complications are referred to one of the country's 45 hospitals. Community midwives provide antenatal care for about three-quarters of pregnant women throughout their pregnancies. These statistics are even more significant given that a third of Sri Lanka's population lives below the national poverty line, and in 1998, the gross national product per capita was $810.

The government of Sri Lanka has been able to reduce maternal deaths and improve child survival through its commitment to human development and social welfare. The country's long tradition of free health services enables more than 93 percent of Sri Lankans access to basic health care, and few have to travel more than 1.4 kilometers to a health center. In 1953 the Family Planning Association of Sri Lanka was established, and in 1965, the Ministry of Health initiated its family planning program. In 1997, Sri Lanka committed itself to providing integrated reproductive health care. An estimated 66 percent of Sri Lankan couples use contraception; 44 percent choose modern methods.

Women have relatively high status and levels of education in Sri Lanka. Eighty-eight percent of adult women are literate, and 95 percent of girls receive primary education. In 1993, the average age at marriage was 25 years for women. The total fertility rate is 2.1 children per woman. Women's autonomy is confirmed by studies showing high rates of attendance at antenatal clinics, and independent decision-making in seeking obstetrical care.

Births and deaths have been registered nationally since the late 1800s, and maternal mortality was first recorded in 1921. These statistics have made it possible to monitor and evaluate efforts to improve maternal and child health services.

There are still gains to be made in improving maternal survival in Sri Lanka. A small percentage of women still do not have access to quality maternal health care, and an estimated 5 percent of women deliver at home, often without a skilled attendant. Anemia and low birth weight have been identified as significant problems, in part due to socio-cultural norms about pregnancy, delivery and infant care. Unsafe abortion accounts for 5 to 9 percent of maternal deaths each year.  Specialist hospitals risk being overburdened because of public demand for high levels of care, even in low risk situations. 

Sri Lanka's success in reducing its maternal mortality is a positive lesson, but there is need to stay vigilant. Success has reduced the country's assistance from international donor organizations. Civil unrest, creeping poverty, declining enrollment at the post-primary level for girls, high use of traditional methods of family planning, and increasing rates of abortion are some of the challenges facing the country.

For more information about safe motherhood in Sri Lanka, see:

Fernando D et al. Pregnancy—reducing maternal deaths and disability in Sri Lanka: national strategies. British Medical Bulletin. 2003;67:85–98.

Seneviratne, H.R. and Rajapaksa, L.C. Safe motherhood in Sri Lanka: a 100-year march. International Journal of Gynecology & Obstetrics 70:113–124 (2000). H.R. Seneviratne can be contacted at: sagala@eureka.lk or by telephone: 94-1-501207.

De Silva, W.I. Toward safe motherhood in Sri Lanka: knowledge, attitudes and practices during the period of maternity. Journal of Family Welfare 41(32):18–26 (September 1996).

WHO. Health, A Key to Prosperity: Success Stories in Developing Countries. Geneva: World Health Organization (2001). Available at: www.who.int/inf-new/mate.htm.

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