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RHO archives : Topics : Safe Motherhood

Annotated Bibliography

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AbouZahr C. Safe motherhood: a brief history of the global movement 1947-2002. British Medical Bulletin. 2003;67:13-25.The drastic reductions in maternal mortality observed in developed countries in the early part of the 1900s is attributable to the bringing together of the technical requirements (data systems, professional expertise, and access to technologies) with the necessary political awareness and commitment to act. The author asserts although the technologies are available, the political will exist (as evidenced by the UN-sponsored Millennium Development Goals), and professionals are committed to the cause, similar reductions in maternal mortality are not taking place in less developed countries. The cause is lack of readiness in the health sector due to insufficient financial, human, and organizational resources. Translating the existing political and professional will into action requires greater investment by recipient and donor countries.

Anonymous. About the PMM network. International Journal of Gynecology & Obstetrics 59 (Suppl. 2):S3-S6 (November 1997).
This article describes the contributions of the Prevention of Maternal Mortality (PMM) Network to the Safe Motherhood initiative. First, the PMM Network developed a strategic model of maternal mortality that emphasized the importance of emergency obstetric care over prevention efforts. Second, it developed a model to explain common delays in receiving emergency obstetrical care. Third, it developed process indicators to evaluate interventions aimed at reducing maternal mortality.

Berer, M. Women's Groups, NGOs and Safe Motherhood. Geneva: WHO, Maternal Health and Safe Motherhood Programme, Division of Family Health. WHO/FHE/MSM/92.3 (1993).
This document contains descriptions of efforts by grassroots women's groups, women's organizations, and other NGOs in developing countries to prevent and reduce maternal mortality and morbidity. These efforts include: community-based research; information, education, and communication activities; media campaigns; public education programs; health service delivery; local and international events, meetings and workshops; and campaigns for better laws and policies. The range of issues addressed through these efforts includes: pregnancy and childbirth; unwanted pregnancy; abortion; adolescent sexuality and pregnancy; quality of care; counseling; reproductive tract infections; women's rights; and HIV/AIDS.

Berer, M. and Ravindran, T.K., eds. Safe Motherhood Initiatives: Critical Issues. London: Blackwell Science Ltd. (1999).
This collection of papers on safe motherhood covers measurement issues, national policies and programs, case studies on the causes of maternal mortality and morbidity, and preventing maternal deaths. The editors provide an overview of developments during the past decade toward safer motherhood, the key lessons learned, and what remains to be done.

Campbell, O. et al. Off to a rapid start: appraising maternal mortality and services. International Journal of Gynecology & Obstetrics 48 (Suppl.):S33-S52 (1995).
Before initiating a safe motherhood program, priorities need to be set based on an assessment of the country's maternal mortality situation. This paper provides an overview of safe motherhood program components, and offers a tool to enable health planners and providers to use existing information to guide maternal mortality reduction in their country. This tool was developed by the MotherCare project of John Snow, Inc. and The Methodologies for Measuring Maternal Health Program of The London School of Hygiene and Tropical Medicine using experiences gained from more than 20 country assessments. It provides a framework for the collection of information on relevant health policies, laws, customs, and resources. It suggests data sources that can be used to estimate the magnitude and causes of maternal morbidity and mortality, as well as available services. The paper explains the potential drawbacks of certain types of information, and ways to assess its quality and validity. The appendices clearly define the quantitative indicators used to measure maternal morbidity and mortality, and explain how they are calculated. It also includes a list of questions to use when appraising the maternal health situation in a specific country.

Centers for Disease Control and Prevention (CDC). Safe Motherhood: Preventing Pregnancy-Related Illness and Death 2001. Atlanta, Georgia: CDC (2001).
Although the majority of maternal deaths occur in developing countries, each day between two and three women die of pregnancy-related causes in the United States. The risk of dying of pregnancy-related complications in the United States has dropped significantly in the last 50 years, but it has not changed since 1982. The leading causes of maternal deaths are hemorrhage, embolism (a blockage in the blood stream), pregnancy-induced hypertension, sepsis/infection, anesthesia complications, and cardiomyopathy (heart muscle disease). African American women are four times more likely than white women to die of pregnancy-related causes. Hispanic women have a 1.7 greater risk than white women. In addition to maternal deaths, at least 30 percent of the women who get pregnant every year suffer complications. The CDC and state health departments are collecting information about maternal health in order to develop programs to reduce maternal deaths.

Creatsus, G. Improving adolescent sexual behavior: a tool for better fertility outcome and safe motherhood. International Journal of Gynecology & Obstetrics 58:85-92 (1997).
This article discusses why adolescent health care should be a priority in the coming century. It reviews sexual behavior patterns, pregnancy and abortion rates, contraceptive use, and STI rates among adolescents. The author recommends increased efforts to provide adolescents with accurate information about reproductive health as well as special preventive and curative services.

Danel, I. et al. Magnitude of maternal morbidity during labor and delivery: United States, 1993-1997. American Journal of Public Health 93(4):631-634 (April 2003).
Using data from the National Hospital Discharge Survey (NHDS) for 1993 through 1997, this study assessed the prevalence of maternal morbidity during labor and delivery in the United States. Overall morbidity was high: 43 percent of women experienced some type of morbidity (an obstetric complication, a preexisting medical condition, a cesarean delivery, or any combination of these) during their hospital stay. Thirty-one percent of women had at least one obstetric complication or at least one preexisting medical condition.

De Brouwere, V. and Van Lerberghe, W., eds. "Safe Motherhood Strategies: a Review of the Evidence." In: Studies in Health Services Organisation and Policy 17:1-450 (2001). Available in English, French, and Spanish on CD-ROM by request to info@jsiuk.
This book is the result of an expert meeting sponsored by the European Community and held November 27-28, 2000, in Brussels. It includes the edited versions of seventeen papers by noted experts on specific topics in maternal health care. Each paper is the result of a review and assessment of the evidence in published and gray literature on a given topic. Each paper includes an extensive bibliography and summarizes what is known to date about the topic. Consequently, this volume offers a comprehensive update on the state of safe motherhood interventions, including: antenatal care, micronutrients, traditional birth attendants, unsafe abortion, appropriate technologies, over-medicalization of maternal care, quality audits, referral, costs, monitoring progress, privatization of care, health-sector reform, international agencies, and health policies.

Fathalla, M.F. Imagine a world where motherhood is safe for all women—you can help make it happen. International Journal of Gynecology & Obstetrics 72:207-213 (2001).
This is the text of the Hubert de Watteville Memorial Lecture presented to the International Federation of Gynecology and Obstetrics (FIGO) World Congress of Gynecology and Obstetrics in September 2000. Professor Fathalla presents ten propositions for making motherhood safe: (1) safe motherhood is a womans human right; (2) a womans life is to be considered worth saving; (3) life-saving emergency obstetric care is to be made accessible to all women when they need it; (4) all deliveries are to be attended by skilled birth attendants; (5) all pregnant women are to have access to prenatal care; (6) motherhood is to be a womans voluntary choice; (7) making motherhood safe for all women is to be an international commitment; (8) lack of resources in developing countries cannot be accepted as an excuse for inaction; (9) women, North and South, should mobilize for womens right to life; and (10) obstetrics should be a profession without borders.

Gay, J. et al. What Works: A Policy and Program Guide to the Evidence on Family Planning, Safe Motherhood, and STI/HIV/AIDS Interventions—Module 1, Safe Motherhood. Washington, DC : POLICY Project (2003).
The first of three modules, this document summarizes interventions that research has shown are effective at improving safe motherhood. Given the growing number of studies on the subject, this document helps policy makers, program planners, and providers identify promising interventions. It provides an overview of the problem of maternal morbidity and mortality, and then describes interventions for (1) labor and delivery, (2) postnatal care, (3) care during pregnancy, and (4) pre-pregnancy. Each intervention is listed in a table, along with summaries of the corresponding supporting research. The appendices include specific information on the UN Process Indicators, skills required of skilled birth attendants, and maintaining a blood supply to reduce risk of HIV transmission. A final list summarizes the interventions themselves, including those that have been shown not to be effective, those that can be harmful, and those for which more evidence is needed.

Geelhoed, D.W. et al. Trends in maternal mortality: a 13-year hospital-based study in rural Ghana. European Journal of Obstetrics & Gynecology 107:135-139 (2003).
This study measures the impact of a variety of activities begun in 1987 to address hospital-based maternal mortality in Berekum, Ghana. A review of hospital records from January 1, 1987, to January 1, 2000, showed 229 maternal deaths with 21,674 women giving birth to 21,265 live children. The overall rate of maternal mortality is high—1,077 deaths per 100,000 live births. A review of the annual mortality rates shows little overall change during the period (with the exception of 1994, where a peak in mortality was due to certain events discussed in the article). However, there was an increase in the overall coverage of maternity care in the district. The causes of maternal deaths also changed. Mortality due to causes addressed by the local safe motherhood initiative (sepsis, hemorrhage, obstructed labor, anemia, and eclampsia) all diminished, while deaths due to abortion complications increased. Abortion complications became the greatest single cause of maternal death (18.8% of all deaths). Additional efforts to reduce maternal mortality should further the efforts already begun, but should also include efforts to address unsafe abortion.

Gelband, H. et al. The Evidence Base for Interventions to Reduce Maternal and Neonatal Mortality in Low and Middle-Income Countries. CMH Working Papers Series, WG5 Paper No. 5. Geneva: Commission on Macroeconomics and Health, World Health Organization (2001). Available at:
This report summarizes maternal and neonatal mortality in low- and middle-income countries, along with the factors that contribute to the large differences in mortality between these and high-income countries. It includes the epidemiology of the problem, interventions, cost estimates and cost-effectiveness of maternal health care, and constraints. A historical review of changes in care that reduced maternal mortality in Europe and the United States is also included.

Goodburn, E. and Campbell, O. Reducing maternal mortality in the developing world: sector-wide approaches may be the key. British Medical Journal 322:917-920 (2001).
Various approaches have been taken by donors to address high levels of maternal mortality in developing countries. The focus has been on funding vertical programs and broad reproductive health programs. The authors instead propose taking a sector-wide approach to funding. Donors already make substantial investments to the health and population sectors, but little of this is spent on vertical safe motherhood programs. Secondly, health sector reforms (e.g., introduction of user fees) can have significant impacts on safe motherhood. Long-term, sustainable, affordable improvements in safe motherhood depend on improving the functioning of entire health systems. Experiences in Sri Lanka and Malaysia are evidence of the impact of health sector improvement on maternal health. Using safe motherhood indicators along with other essential health indicators would ensure that maternal health services receive needed attention.

Initiative, Inc. Integrating safe motherhood. Issues 1(3) (October 1998).
This quarterly newsletter addresses the complex programmatic, material and evaluative questions that arise in planning and implementing strategies to integrate reproductive health services. This issue focuses on integration of safe motherhood reproductive health services. It provides some strategies to increase program effectiveness and activities that community-based health workers/volunteers and community groups can do to make motherhood safer. (Send requests for copies of Issues to: [email protected].)

International Planned Parenthood Federation (IPPF). Planned Parenthood Challenges. 1:1-29 (1998).
This issue of Planned Parenthood Challenges is devoted to safe motherhood. Five articles outline current program challenges, which include advancing safe motherhood as a human right, empowering women, reorienting maternal health services away from risk screening and toward skilled attendance at delivery, and improving access to good quality maternal health services. Six other articles describe maternal health programs in Bangladesh, Brazil, Cambodia, Ghana, Lebanon, and Somalia.

Kwast, B.E. Safe motherhood—the first decade. Midwifery 9:105-123 (1993).
This article reviews the history of the Safe Motherhood Initiative, its accomplishments, and the prospects for the future. It describes safe motherhood activities undertaken by international agencies, regional and national Safe Motherhood Conferences, midwifery organizations, the Prevention of Maternal Mortality Network, and MotherCare Country Projects. Key lessons learned are: (1) the need for integrated programs to reduce maternal mortality; (2) the need for trained midwives to back up trained TBAs; and (3) the importance of early identification and treatment of complications among all women, rather than screening to identify high-risk women.

Liljestrand, J. Strategies to reduce maternal mortality worldwide. Current Opinion in Obstetrics and Gynecology 12:513-517 (2001).
The brief article reviews the current strategies to reduce maternal mortality. It acknowledges the problems inherent in measuring maternal deaths and summarizes current strategies to improve measurement. Efforts are being increased to improve access to emergency obstetric care and to improve the coverage and quality of skilled attendance at delivery. Postabortion care, better reproductive health care for adolescents, and improved family planning services are also part of the strategies to improve maternal health and survival. New information about the impact of malaria, nutrition, violence, and HIV/AIDS on maternal health is also highlighted. The review concludes with a summary of recent efforts to emphasis a human rights approach to maternal health.

Lucas, A.O. History of the prevention of maternal mortality network. International Journal of Gynecology & Obstetrics 59 (Suppl. 2):S11-S13 (November 1997).
This article describes key moments in the evolution of the Prevention of Maternal Mortality (PMM) Network and explains the importance of the PMM approach to primary health care and safe motherhood.

Luck, M. Safe motherhood intervention studies in Africa: a review. East African Medical Journal 77(11):599-607 (2000).
A review of published literature (1988-1998) on interventions designed to reduce maternal mortality in Africa reveals little evidence of effective interventions. Few of the 34 intervention studies identified used double-blind, randomized, controlled designs or outcome measures directly related to maternal mortality. Six of the studies did show reasonably convincing evidence of a positive effect of the intervention on maternal health. Three showed that inexpensive changes in delivery practices (use of partogram, antiseptic wipe of birth canal, and training of medical assistants to perform cesarean section) can improve maternal outcomes. One showed that improving hospital management and equipment can reduce facility-based maternal mortality. Two studies showed that upgrading emergency obstetric care in hospitals along with community education can substantially increase the number of major obstetric complications treated in hospitals, without increasing the case-fatality rate. The author recommends that future studies be designed using at least quasi-experimental protocols to improve the strength of results. Attention should also be focused on measuring relevant outcome measures. The author notes that syphilis screening of pregnant women can reduce perinatal and maternal mortality. Provision of safe abortion services is one of the most effective safe motherhood interventions, and interventions designed to increase the quality and quantity of emergency obstetric care could have a significant impact.

Magadi M et al. The inequality of maternal health care in urban sub-Saharan Africa in the 1990s. Population Studies. 2003;57(3):347-366.
In this analysis of data from 23 Demographic and Health Surveys in sub-Saharan African countries from the 1990s, poor urban women appear to receive worse maternal health care than their urban non-poor and rural counterparts. The urban poor are more likely to begin antenatal care later, make fewer visits to a health facility during pregnancy, and receive non-professional delivery care than urban non-poor. While these results are not uniform across countries, the data indicate that the disadvantages of urban poor relative to non-poor in terms of antenatal and delivery care is worse in countries where indicators show better overall maternal health. The urban poor in these countries fare even worse than rural women, indicating that improvements in maternal health care have not benefited urban poor women.

Magadi, M. et al. Analysis of factors associated with maternal mortality in Kenyan hospitals. Journal of Biosocial Science 33:375-389 (2001).
This analysis of hospital records for 58,151 obstetric admissions in sixteen public hospitals in Kenya showed 182 maternal deaths. This is one of the few studies that attempts to understand maternal mortality in hospitals on the national level. The risk of a maternal death is associated with higher maternal age, lack of antenatal clinic attendance, and lower educational attainment. Maternal death is also associated with choice of hospital, which may be due to unobserved hospital factors such as resources, equipment, supplies, and hospital administration and management. There may also be a regional effect on maternal mortality. Hospitals in remote, poor areas with limited transportation and high levels of malaria (such as western Kenya) have higher levels of maternal mortality than those in the more developed central and eastern parts of the country. The risk of death at high-risk hospitals for women 35 years or older who had low levels of education and did not attend antenatal care is about 280 deaths per 1,000 admissions. The risk for a similar woman at low-risk hospitals is about 4 deaths per 1,000 admissions. Ensuring that hospitals provide adequate health care services and educating women about the risks of pregnancy and childbearing at older ages can help reduce maternal mortality in Kenya.

Maine, D., ed. Prevention of maternal mortality network. International Journal of Gynecology and Obstetrics 59 (Suppl. 2) (November 1997).
This supplement of International Journal of Gynecology and Obstetrics reviews the work of the Prevention of Maternal Mortality (PMM) Program in reducing maternal mortality in West Africa. The Program began in 1987 with the goals of strengthening capacities in developing countries, providing program models for preventing maternal deaths, and informing policy makers about the importance of maternal mortality. Included in this supplement are key articles on the conceptual framework and strategic model of PMM, and project examples related to improving the quality and utilization of, and access to, emergency obstetric care and related services. Important lessons learned on monitoring and evaluation, program design, and overall program experience from the PMM projects are reviewed.

Maine, D. Safe Motherhood Programs: Options and Issues. New York: Center for Population and Family Health, Columbia University (1991).
This publication reviews the problem of pregnancy-related deaths and examines the main strategies that have been adopted or proposed to reduce maternal mortality. It is intended for use by health professionals, program managers, researchers, and policy makers in their work to find solutions to make motherhood safe. A strategy is proposed consisting of three priority areas: ensure access to medical treatment for obstetric emergencies; reduce exposure to the risks of unwanted pregnancy; and establish and improve other maternal health services.

McCaw-Binns, A. Access to care and maternal mortality in Jamaican hospitals: 1993-1995. International Journal of Epidemiology 30:796-801 (2001).
The Ministry of Health in Jamaica reviewed all maternal deaths in public hospitals for 1993-1995 as part of its reproductive health quality-assurance program. In Jamaica, 89 percent of births are attended by a skilled practitioner, and 82 percent of all births take place in public hospitals. The review of hospital records found a maternal mortality ratio of 106.2 deaths per 100,000 live births. This level is virtually unchanged from the levels observed in 1986-87 (119.7) and 1981-83 (118.6). Regional differences in mortality levels suggest that re-allocating personnel and improving quality of care can reduce mortality by at least 50 percent.

Mella PP. Major factors that impact on women’s health in Tanzania: the way forward. Health Care for Women International. 2003;24:712-722.
This speech, given at the thirteenth International Congress on Women’s Health Issues, June 26, 2002 in Seoul, Korea, reviews the major maternal health problems in Tanzania. Maternal deaths, estimated at 300-400 per 100,000 women, are mainly caused by sepsis, hemorrhage, and uterine rupture. Some of the health risks that contribute to maternal deaths are short stature, age, closely-spaced and high-order births, malaria, anemia, maternal depletion, HIV and AIDS, and female genital mutilation. While the government is committed to improving women’s health and survival, economic hardship is diminishing equality in access and use of services. Many sectors need to join together to improve the status of women in Tanzania in order to improve women’s health.

Mirsky, J. Birth Rights: New Approaches to Safe Motherhood. London: Panos Institute (2001).
This report reviews obstacles to progress in reducing maternal mortality worldwide. Many countries have laws and cultural practices that affect womens survival. These include early age at marriage and lack of access to safe abortion. Another factor is under-resourced maternity care facilities that are unable to provide emergency obstetric care. The procedures followed in many health centers do not reflect scientifically proven best practices and are not beneficial to women. Many even prove harmful. There has also been a growing focus on womens reproductive health as a human right. Achieving the latest International Safe Motherhood Initiative target of a 75 percent reduction in maternal mortality (from 1990 levels) by 2015 is possible, according to this report. It will require changes in laws and policies that constrain womens choices about childbearing, and improvements in maternity care services.

National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. Safe Motherhood: Promoting Health for Women Before, During, and After Pregnancy. Atlanta, Georgia: CDC (2003).
The majority of maternal deaths occur in less-developed countries, but every day in the United States two to three women die of pregnancy complications. This report reviews maternal mortality and morbidity in the United States. While maternal deaths in the United States. declined dramatically between 1900 and 1982, there has been no decline since that time. Women’s race, ethnicity, and age determine her risk of maternal death. The risk of maternal death for African American women is four times greater than for white women. The CDC is conducting research in safe motherhood to better understand these disparities and to take action to address them.

PATH. Safe motherhood: successes and challenges. Outlook 16 (Special Issue):1-8 (July 1998). Available
This article reviews the components of safe motherhood programs, lessons learned from field experience, and their policy and program implications. To reduce maternal mortality and morbidity, programs can prevent unintended pregnancies, reduce the effects of unsafe abortion, detect and manage pregnancy-related complications during antenatal care, manage obstetric complications appropriately, make skilled midwives widely available, and train TBAs to serve as a liaison between the community and the formal health care system. The authors conclude that achieving safe motherhood will require policy changes, the allocation of adequate resources, the provision of model maternal health services, and changes in community behavior.

Rahlenbeck, S. and HakiImana, C. Deliveries at a district hospital in Rwanda, 1997-2000. International Journal of Gynecology & Obstetrics 76:325-328 (2002).
All delivery records from January 1997 to December 2000 at Byumba District Hospital were analyzed to determine pregnancy outcomes and maternal mortality. Of the 3,408 women delivering, there were 19 maternal deaths, yielding a maternal mortality ratio of 600 deaths per 100,000 live births for the hospital. Nine of these women died during or after cesarean section, and six died from uterine rupture. Most deaths occurred in women who were referred to the hospital from distant communities. Earlier referrals from health centers would help reduce maternal deaths.

Ramarao, S. et al. Safer maternal health in rural Uttar Pradesh: do primary health services contribute? Health Policy and Planning 16(3):256-263 (September 2001).
The government of India failed to achieve its goal of a reduction in maternal mortality from 407 to 200 per 100,000 live births by the year 2000. This paper examines utilization of maternal and child health services and the readiness of primary health care facilities to provide maternity services to determine why the state of Uttar Pradesh continues to have one of the highest levels of maternal mortality in the country. Less than half of pregnant women in rural Uttar Pradesh sought any antenatal care. Almost 90 percent of deliveries took place at home, and nearly half were attended by family or relatives. While the primary health care system has rudimentary equipment and some staff competency in detecting and managing maternal complications, there is need for improvement. Reducing maternal mortality will not be easy without increased skilled attendance at delivery backed by access to emergency obstetric care. Auxiliary nurse midwives need training in life-saving skills, and high-volume hospitals need emergency obstetric care equipment. Community interventions are needed to emphasize skilled care at birth, identify emergency complications, and overcome traditional beliefs that prevent postpartum women from seeking care for complications. Antenatal care visits can be emphasized as a point of contact between pregnant women and health care services.

Ransom, E. and Yinger, N. Making Motherhood Safer: Overcoming Obstacles on the Pathway to Care. Washington, DC : Population Reference Bureau (February 2002). Available at:
This booklet provides an overview of maternal mortality worldwide and recommends policy options to make motherhood safer. These options—from the central government to the family level—are organized to address the "4 delays" that contribute to maternal morbidity and mortality. The booklet focuses on increasing skilled attendance at delivery, but also includes a range of program examples. Maternal mortality can be reduced, but only when women are able to plan their pregnancies, give birth in the presence of a skilled attendant, and have access to high-quality emergency obstetric care in the event of complications.

Ross, S.R. Promoting Quality Maternal and Newborn Care: A Reference Manual for Program Managers. Atlanta: Cooperative for Assistance and Relief Everywhere, Inc. (CARE) (December 1998).
This technical reference manual is intended to assist program managers in the field to design, implement, monitor, and evaluate maternal health programs. It summarizes the latest literature and lessons learned in maternal and neonatal care a decade after the start of the Safe Motherhood Initiative. While it is intended as a reference manual, it also can be used for training. The chapters include: (1) Why Women and Newborns Die; (2) Prepregnancy Factors; (3) Pregnancy-related Factors; (4) Program Design, Monitoring and Evaluation; (5) Interventions and Current Best Practices; and (6) Lessons Learned Through Country Programs. It includes clear, easy-to-follow tables summarizing the problems and current solutions to maternal and newborn health care. The lessons learned chapter offers brief descriptions of project activities worldwide and their results, organized by topic. Appropriate references are included with the many tables, and a comprehensive list, arranged by subject, is appended to the manual.

Save the Children. State of the World's Mothers 2004. Westport, Connecticut: Save the Children; 2004. Available at:
The fifth annual State of the World’s Mothers focuses on the health impacts of pregnancy and childbirth among young girls aged 15 to 19. An estimated 70,000 adolescent mothers die every year, and complications from pregnancy and childbirth are the leading cause of death for girls aged 15 to 19 years in low-income countries. The report includes an “Early Motherhood Risk Ranking” for 50 countries where the risks are greatest, and the annual Mother’s Index providing data on health, nutrition, education, and political participation for mothers in more than 100 countries.

Save the Children. State of the World's Mothers 2003. Westport, Connecticut: Save the Children (May 2003). Available at:
This edition of the annual State of the World’s Mothers features a Conflict Protection Scorecard that analyzes 40 of the current conflicts in the world. It tells where women and children are most at risk, and highlights six types of protection needed in war zones. In particular, the report emphasizes women’s vulnerability to sexual abuse in times of war, and their needs for reproductive health and family planning services.

Shiffman, J. Generating political will for safe motherhood in Indonesia. Social Science & Medicine 56:1197-1207 (2003).
Using safe motherhood in Indonesia from 1987 to 1997 as a case study, and based on scholarly literature on agenda setting, this paper identifies four factors that increase the likelihood that an issue will gain national-level attention. These are: (1) the existence of clear indicators showing that a problem exists; (2) the presence of effective political entrepreneurs to push the cause; (3) the organization of attention-focusing events; and (4) availability of policy alternatives that are politically feasible and that make the problem surmountable. In Indonesia, safe motherhood gained political priority following the 1987 International Safe Motherhood Conference in Nairobi, and continued with national seminars on safe motherhood. With data from a 1994 national survey showing that maternal mortality remained high in Indonesia, a key government bureaucrat developed a national campaign to increase attention on maternal health. A village midwife training program was developed to address the issue. The development of political will as detailed here has lessons for other countries as they increase attention to safe motherhood.

Starrs, A. The Safe Motherhood Agenda: Priorities for the Next Decade. New York: Inter-Agency Group for Safe Motherhood, Family Care International (1998).
This is a report of the Safe Motherhood Technical Consultation in Colombo, Sri Lanka, October 18-23, 1997. It explains the ten action messages of the meeting and includes key elements from the presentations. It also includes informational boxes and figures. This is a comprehensive summary of the key issues facing safe motherhood programs and the most important next steps for the years ahead.

UNFPA and EngenderHealth. Obstetric Fistula Needs Assessment Report: Findings from Nine African Countries. New York: UNFPA and EngenderHealth (2003). Available at:
This report provides information on the prevalence of obstetric fistula in nine sub-Saharan African countries. Fistula is a debilitating injury, and often affects young, poor, illiterate women. The condition is preventable and treatable through surgery. However, few women know about these options and where to receive care. This report assesses the capacity of 35 hospitals to treat patients with fistula and determines their needs for equipment, skilled staff, and supplies.

World Health Organization (WHO). Mother-Baby Package: Implementing Safe Motherhood In Countries. Geneva: WHO, Maternal Health and Safe Motherhood Programme, Division of Family Health. WHO/FHE/MSM/94.11 (1994).
This document is designed to facilitate national strategies and plans of action to reduce the problems of maternal and neonatal mortality in the developing world. It is intended for use by policy makers and persons responsible for health planning. The Package contains a cluster of interventions designed to support activities to achieve the goals of the Safe Motherhood Initiative and strategies on how to operationalize these interventions.

World Health Organization (WHO). Reduction of Maternal Mortality, A Joint WHO/UNFPA/UNICEF/World Bank Statement. Geneva: WHO (1999). Available at:
This joint statement represents the consensus between WHO, UNFPA, UNICEF, and the World Bank toward supporting programs designed to reduce and prevent maternal mortality and neonatal mortality and morbidity. It is addressed to governments, policy makers, program managers, and each of the respective agency's personnel, and is intended to guide their decision making to ensure safer pregnancy and childbirth. It summarizes the key issues relating to maternal mortality and its reduction. The statement also defines maternal deaths, and explains maternal mortality ratios and rates. Safe motherhood is a human rights issue, not just a health problem. Although the direct medical causes of maternal deaths are the same worldwide, the risk of maternal death is much greater in the developing world. The low social status of girls and women in many countries is a fundamental determinant of maternal mortality. The statement reviews actions to be taken to address maternal mortality, including legislative and policy actions, society and community interventions, and health sector actions. Process indicators, which show progress in reducing maternal mortality through access to essential obstetric care, allow policy makers and program managers to target specific interventions to reduce maternal morbidity and mortality.

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Causes of high maternal mortality

Bicego, G. et al. The effect of AIDS on maternal mortality in Malawi and Zimbabwe. AIDS 16(7):1078-1080 (2002).
Nationally representative surveys in Malawi and Zimbabwe during the 1990s showed that pregnancy-related mortality has increased 1.9 and 2.5 times, respectively, during the past decade. At the same time, HIV prevalence among pregnant women has increased nearly 10 times. While there is little data on the interaction between HIV/AIDS and pregnancy, studies have shown that HIV-positive women experience higher maternal mortality than HIV-negative women. The increases in maternal mortality in Malawi and Zimbabwe noted in this research letter eliminate any potential gains made through safe motherhood programs. In order to better understand the affect of HIV/AIDS on pregnancy-related mortality, it is important to separate direct obstetric and other causes of maternal death. Collaborative efforts to reduce HIV and maternal mortality need to be developed. Programs aimed at reducing mother-to-child transmission of HIV are appropriate places to begin.

Castro, S. et al. A study on maternal mortality in Mexico through a qualitative approach. Journal of Women's Health & Gender-Based Medicine 9(6):679-690 (2000).
This report presents the findings of a verbal autopsy study carried out in three states of Mexico. A review of death certificates issued in 1995 identified 164 households with a maternal death. Interviews were held in 145 of these households to determine the socioeconomic and living conditions, as well as the cause of death. An open-ended question was included to allow relatives to narrate the facts associated with the maternal death. This study analyzes the answers to this question following the "delays" model in seeking care (delay in deciding to seek care, in reaching a care facility, and in receiving care after arrival). The answers are also grouped according to three levels of causality: structural, interactional, and subjective factors. Despite the limitations of the study, the findings provide information about the care-seeking process. The authors recommend that interventions aimed at preventing maternal mortality focus on early stages of a complication to avoid cumulative problems as documented by the study. Better communication and transportation services, and improved quality of care are needed. Programs need to consider that the conditions of poverty and gender dominance affect women's vision of the world and lead them to underestimate the danger signs that appear during pregnancy. The domination of women by men and by the medical establishment as shown in this study is also an important risk factor for maternal mortality.

Chiwuzie, J. et al. Causes of maternal mortality in a semi-urban Nigerian setting. World Health Forum 16:405-408 (1995).
This article analyzes the factors that prevent or delay effective care for women with pregnancy-related complications in a semi-urban community of Nigeria. Focus-group discussions with community members and TBAs found that women and their birth attendants did not seek help promptly because they lacked knowledge of warning signs, believed that supernatural forces caused complications, faced transportation difficulties, and believed that hospitals provided poor care. Site visits to hospitals documented a host of problems with obstetric care, including inadequate staffing, supplies, and equipment and a lack of commitment by health workers. The authors recommend educating community members about when to seek care and improving the quality of care in obstetric institutions.

Conde-Agudelo, A. and Belizan, J. Maternal morbidity and mortality associated with interpregnancy interval. British Medical Journal 321:1255-1259 (November 2000).
This cross-sectional retrospective study analyzed data on more than 450,000 births from the Perinatal Information System of the Latin American Centre for Perinatology and Human Development in Montevideo, Uruguay (1985-1997). Compared to women conceiving within 18-23 months of a previous birth, women with interpregnancy intervals of 5 months or less had higher risks for maternal death (odds ratio 2.54), third-trimester bleeding (OR 1.73), premature rupture of membranes (OR 1.72), puerperal endometritis (OR 1.33), and anemia (OR 1.30). Women with interpregnancy intervals longer than 59 months had higher risks of pre-eclampsia (OR 1.83) and eclampsia (OR 1.80).

Cot M, Deloron P. Malaria prevention strategies. British Medical Bulletin. 2003;67:137-148.
Pregnancy-associated malaria (PAM) has the most severe consequences—materno-fetal death or cerebral malaria—in unstable malaria areas. In regions known to be endemic, the consequences of PAM are mainly maternal anemia and low birth weight. Placental malaria appears more frequently and more severely among HIV-positive women. Chemoprophylaxis can increase birth weight and reduce anemia, except among HIV-infected women. There is need for more study on effective treatment of malaria among HIV-positive women. Intermittent treatment with sulfadoxine-pyrimethamine two or three times during pregnancy in antenatal clinics appears to be the best way to prevent PAM. Preventive measures, such as use of bednets, systematic treatment of all malaria infections, prevention of maternal anemia and reduction in mother-to-child HIV transmission should also be pursued. Research into vaccines to prevent pregnancy associated malaria shows promise.

Dafallah, S.E. et al. Maternal mortality in a teaching hospital in Sudan. Saudi Medical Journal 24(4):369-372 (2003).
This retrospective study of case notes of all maternal deaths from 1985 to 1999 at the Medani Teaching Hospital, Sudan found a decline in maternal mortality. Of 44,605 deliveries, there were 877 deaths. For 1985-1989, the maternal mortality ratio was 2,661 deaths per 100,000 live births; for 1990-1994, it was 2,021; for 1995-1999, it was 1,363. For the entire period, sepsis was the main direct cause of death (27.3%), and malaria was the primary indirect cause of death (37.2%). Further study and attention to the problems of malaria, sterilization, anesthesia, vascular accidents, and indication for cesarean section could continue to reduce maternal morbidity and mortality.

Etard, J.F. et al. Assessment of maternal mortality and late maternal mortality among a cohort of pregnant women in Bamako, Mali. British Journal of Obstetrics and Gynaecology 106(1):60-65 (January 1999).
Maternal mortality rates in West Africa are very high because of a combination of high fertility and high risk of maternal death. However, estimates of the maternal mortality ratio vary significantly, especially in Mali. This study of urban Bamako, Mali, is one of the few prospective, population-based surveys undertaken in sub-Saharan Africa, and seeks to produce an accurate estimate of the maternal mortality ratio. Complete data available for 4,717 women showed that most women received at least one antenatal care visit and delivered at a district maternity hospital. There were fifteen maternal deaths, yielding a maternal mortality ratio of 327 per 100,000 live births. The main causes of death were hypertensive disorders and hemorrhage. There were five additional "late" maternal deaths 42 days to one year after delivery. These late maternal deaths often are missed in retrospective studies. The authors conclude that, despite the high percentages of antenatal visits and hospital deliveries, the maternal death rate is unacceptably high and reflects inadequate maternity care.

Fauveau, V. et al. Epidemiology and cause of deaths among women in rural Bangladesh. International Journal of Epidemiology 18(1):139-145 (1989).
This article analyzes data from the Demographic Surveillance System in Matlab, Bangladesh on the causes and determinants of death among women of reproductive age. From 1976 to 1985, 542 women aged 15-44 died in the Matlab control area, yielding a mortality rate of 290 per 100,000 women. The leading causes of death were infectious disease (32%) and direct obstetric complications (30%). Prior to their deaths, 33 percent of the women saw no health practitioner, 42 percent saw a traditional practitioner, 25 percent saw a registered allopathic physician, and 11 percent sought care at a modern medical facility. To reduce the female death rate, the authors recommend a comprehensive maternity care program and easier access for women to medical care for treatment of infectious disease, nutritional diseases, and injuries.

Granja, A. et al. Violent deaths: the hidden face of maternal mortality. BJOG: An International Journal of Obstetrics and Gynaecology 109:5-8 (January 2002).
A review of maternal deaths due to injuries at Mozambique's Maputo Central Hospital during 1991-1995 indicates that violence is an important factor in maternal mortality. Twenty-seven cases of injury-related maternal deaths were identified. This is comparable to the magnitude of maternal deaths attributed to pregnancy-induced hypertension identified in other studies in Maputo. Ten cases were due to alleged homicide, nine to alleged suicide, and six to alleged accident. Two deaths were due to induced abortion, but not classified as homicide or suicide. Fifty-nine percent (16/27) of the injury-related maternal deaths and two-thirds (14/21) of the violent maternal deaths were among women younger than age 25. The authors conclude that the contribution of violence-related deaths to maternal mortality is significant, and should not be neglected in safe motherhood programs. They recommend that all pregnant women be screened for domestic violence.

Granja, A. et al. Adolescent maternal mortality in Mozambique. Journal of Adolescent Medicine 28:303-306 (2001).
This audit reviewed all deaths among women ages 10 to 45 in Maputo General Hospital, Mozambique, during 1989 to 1993. There were 239 deaths classified as maternal. The overall maternal mortality ratio was 320: among adolescents (under 20 years) the ratio was 387; and among non-adolescents the ratio was 294 deaths per 100,000 live births. The main causes of death for adolescents were malaria (27%), pregnancy-induced hypertension/eclampsia (21%), puerperal infection (15%), and abortion (10%). Adolescents were less likely than others to die of hemorrhage. In this study adolescents had a 30 percent higher maternal mortality ratio than non-adolescents. Many of these deaths may be preventable through community education programs; provision of antenatal, safe delivery, and safe abortion services; strengthening of essential obstetric care services; and training of staff in adolescent-specific health care.

Griffiths, P. and Stephenson, R. Understanding users perspectives of barriers to maternal health care use in Maharashtra, India. Journal of Biosocial Science 33:339-359 (2001).
Using in-depth, semi-structured interviews of women in two rural and urban areas of Maharashtra, India, this study examined utilization of maternal health care services. It aimed to identify social, economic, and cultural factors influencing womens use of services. Socioeconomic status was not found to be a barrier to maternal health service use if women perceived the benefits of the service to outweigh the cost, and if the services were within reasonable distance of the womans home. Many women thought private services were superior to public services, but their use was often prevented by their higher cost. Even when services are provided, they may not be used. Women have to perceive that using services will benefit them and their unborn child before they will use them. Many women, even if they received antenatal care services at a facility, preferred to deliver at home in a familiar environment, often with the assistance of someone known to them. Antenatal care could be used to link a woman to a trained health professional for delivery. Women also cite poor quality of care at government facilities as a reason to deliver at home.

Haque, Y.A. and Clarke, J.M. The Woman Friendly Hospital Initiative in Bangladesh: setting standards for the care of women subject to violence. International Journal of Gynecology and Obstetrics 78 (Suppl. 1):S45-S49 (2002).
The Woman Friendly Hospital Initiative (WFHI) is part of a strategy to reduce maternal mortality in Bangladesh. A key part of the strategy is the management of violence against women. Demographic studies indicate that 14 percent of maternal deaths in Bangladesh are associated with violence and injury. The WFHI addresses Quality of Care, Mother-Baby Service Package, Management of Violence Against Women, and Gender Equity within the hospital. It focuses on the active participation of the staff and community members in addressing these issues. To improve the Management of Violence Against Women, the initiative developed a service protocol and provided a six-day training course to staff. It is too early to assess the impact of this initiative, but its success will depend on strong administrative support and effective alliances.

Heise, L. et al. A global overview of gender-based violence. International Journal of Gynecology and Obstetrics 78 (Suppl.1):S5-S14 (2002).
This paper reviews the prevalence and types of violence against women, and their health effects. Globally, as many as one woman in four is physically or sexually abused during pregnancy, although rates vary widely. Studies show that women who have experienced violence are more likely to delay seeking prenatal care, and are less likely to gain sufficient weight. They are more likely to have a history of STIs, unwanted or mistimed pregnancies, vaginal or cervical infections, kidney infections, and bleeding during pregnancy. Violence has also been associated with increased risk of miscarriage, abortion, premature labor, fetal distress, and low birthweight. Health care providers can be instrumental in helping women who are survivors of violence, but they need support and training.

Hieu, D. T. et al. Maternal mortality in Vietnam in 1994-95. Studies in Family Planning 30(4):329-338 (Dec. 1999).
This report uses data from communal and hospital registers (reproductive age mortality studies, or RAMOS methodology) in three provinces of Vietnam to estimate maternal mortality. Maternal mortality was the fifth most common cause of death for women ages 15-49 in these provinces during 1994-95, and the maternal mortality ratio was 155 deaths per 100,000 lives births. This ratio is well below the WHO estimates of 430 deaths globally, and 390 deaths for Asia. Maternal mortality in the delta regions of these provinces was half that of the mountainous and semimountainous areas. Because most of Vietnam's population lives in the delta regions, the national level of maternal mortality is probably lower than that of the three provinces studied. Maternal mortality in Vietnam is relatively low because a high proportion of deliveries take place in clinics and hospitals, and the road system is good in delta regions. Mortality from abortion is also very low in Vietnam (5 percent of maternal deaths) because the procedure is legal, easily accessible, and therefore safe. The number of maternal deaths will likely fall as fertility declines in Vietnam, and as improvements are made to roads and transportation. Increasing the percentage of deliveries that take place at health centers, and training more health personnel in communal health care centers will also help reduce maternal mortality.

Khlat, M. and Ronsmans, C. Deaths attributable to childbearing in Matlab, Bangladesh: indirect causes of maternal mortality questioned. American Journal of Epidemiology 151(3):300-306 (2000).
Little is known about the indirect causes of death during pregnancy and childbirth. Using population-based data from rural Matlab, Bangladesh, during the period 1976-1993, this study sought to clarify the contribution of indirect causes of death to maternal mortality using an epidemiologic perspective.  The study found that deaths rates for all causes during pregnancy or shortly after are more than twice as high as outside this period. Deaths during the exposed period (during pregnancy and 90 days postpartum) represent 35.3 percent of all deaths in women 15-44 years, and the majority (72.8%) are attributed to direct obstetric deaths. Deaths from injuries account for 8.6 percent of deaths in women while exposed and 13.4 percent of deaths in women while not exposed. However, among women ages15-19, the death rate from injury is more than twice as high in women while they are exposed than while they are not. Data also show that death rates from causes other than direct obstetric causes were lower in women during exposure, as if pregnancy were somehow "protective" with respect to these causes. Several interpretations of this finding are proposed, including data quality, differential care-seeking behavior, protective effects of pregnancy, and selective factors associated with pregnancy. This study highlights the complexity of the concept of indirect causes of maternal deaths. Deaths from accidents, suicides, or homicides are not usually considered as related to the pregnancy, yet they may be indirectly associated.

Kilpatrick, S. et al. Preventability of maternal deaths: comparison between Zambian and American referral hospitals. Obstetrics & Gynecology 100(2):321-326 (August 2002).
All pregnancy-related deaths at Kabwe General Hospital in Zambia (1998-1999), and at the University of Illinois at Chicagos Perinatal Network of ten hospitals (1992-2000) were reviewed for cause, potential preventability, and identified preventability factors. There were 108 and 33 deaths at the Zambian and American hospitals, respectively, yielding maternal mortality ratios of 1,540 and 20.4 deaths per 100,000 live births. The leading cause of death in the Zambian hospital was infection, while hemorrhage was the major factor in the American hospitals. At the Zambian hospital, 82 percent of the maternal deaths were determined to be preventable, and in almost three-quarters of these deaths, system factors were the likely contributing factors. In the American hospitals, 42 percent of the deaths were deemed preventable, and provider factors were identified as the likely cause in 86 percent of these deaths. The majority of the preventable deaths in the American hospitals had provider factors related to not appreciating the severity of the symptoms or delayed diagnosis. In Zambia, issues relating to poor referral systems, lack of transport, and the subsequent critical condition of the patient contributed to preventable maternal deaths. Even after arrival at the hospital, system factors such as lack of supplies, delays in surgical treatment, and unavailability of an anesthetist all contributed to deaths. Efforts to reduce maternal mortality worldwide need to consider site-specific preventable causes of death.

Kyomuhendo, G.B. Low use of rural maternity services in Uganda: impact of women’s status, traditional beliefs and limited resources. Reproductive Health Matters 11(21):16-26 (2003).
This study in rural Hoima, Uganda, assessed the role of sociocultural factors in maternal mortality. Focus group discussions, key informant interviews, a quantitative survey of 808 women and maternal death inquiries were undertaken between November 2000 and October 2001. Women in this study area rely on traditional birth practices because they are familiar and accepted. Pregnancy is viewed as a test of endurance, and maternal deaths are a sad, but normal event. While antenatal attendance at primary health care units is high for first births, use of services for normal delivery was low, and considered only as a last resort. Women are not necessarily choosing riskier, home-based, unskilled care for deliveries, but their environment limits their choices. Lack of skilled staff at the primary health care level, complaints of abuse of patients, neglect and poor treatment in the hospital, poorly understood reasons for procedures, lack of money to pay for care and medicines, and health workers’ views that patients are ignorant explain the unwillingness of women to deliver in facilities. Community education on all aspects of essential obstetric care, and sensitization of service providers to the situation of rural mothers are needed.

Le Bacq, F. and Rietsema, A. High maternal mortality levels and additional risk from poor accessibility in two districts of Northern Province, Zambia. International Journal of Epidemiology 26(2):357-363 (1997).
This article reports on retrospective community-based surveys of maternal mortality using the sisterhood method that were conducted in two districts of Zambia in 1995. The maternal mortality ratio was 764 deaths per 100,000 live births in the district which had a hospital and 1,549 in the district which did not. The authors calculate that maternal mortality could be reduced by 29 percent and 65 percent, respectively, by making hospital services accessible to all women in these districts.

Li, X.F. et al. The postpartum period: the key to maternal mortality. International Journal of Gynecology & Obstetrics 54:1-10 (1996).
This meta-analysis of nine studies of maternal mortality focuses on postpartum deaths. In both developing countries and the United States, over 60 percent of maternal deaths occur during the postpartum period, and nearly half of those deaths take place during the first day after delivery. The risk of dying declines with time but remains significant until the second week after delivery. Hemorrhage, hypertension, and infection are responsible for four-fifths of postpartum maternal deaths in developing countries. The authors conclude that safe motherhood programs must pay more attention to postpartum care, including two follow-up visits to mothers at 2-3 days and 7-10 days after delivery.

McFarlane, J. et al. Abuse during pregnancy and femicide: urgent implications for womens health. Obstetrics & Gynecology 100(1):27-36 (July 2002).
This case-control study of abuse during pregnancy and femicide (homicide of women) in ten U.S. cities found that the risk of femicide is increased for women abused during pregnancy. Cases, identified from police and medical examiner records, were defined as attempted or completed femicides (n = 437). Controls were randomly identified women from the same cities, who had been physically assaulted, threatened with serious violence, or stalked in the past two years (n = 384). Abuse during pregnancy was reported by 7.8 percent of the controls, 25.8 percent of the attempted femicides, and 22.7 percent of the completed femicides. After adjusting for significant demographic characteristics, the risk of becoming an attempted or completed femicide victim was more than three times greater for women abused during pregnancy. Abuse during pregnancy is a sign of a dangerous batterer. Femicide is an important, often underreported cause of maternal mortality. There is immediate need to screen all pregnant women for abuse.

McIntyre J. Mothers infected with HIV. British Medical Bulletin. 2003;67:127—135.
HIV infection and AIDS-related deaths have become a major cause of maternal mortality in many resource-poor settings. It is difficult to quantify the full impact of HIV/AIDS because women’s HIV status is not always known. Nonetheless, HIV is associated with an increase in anemia, postpartum hemorrhage, and puerperal sepsis—all direct causes of maternal deaths. HIV also contributes to indirect causes of maternal mortality by increasing susceptibility to infections such as Pneumocystis carinii pneumonia, tuberculosis, and malaria. Appropriate antiretroviral therapy started in pregnancy can improve survival. Widespread use of this therapy, along with increased HIV prevention, are needed to preserve gains made in safe motherhood.

Midhet, F. et al. Contextual determinants of maternal mortality in rural Pakistan. Social Science and Medicine 46(12):1587-1598 (1998).
The goal of this nested case-control study was to identify the risk factors associated with maternal mortality in the provinces of Balochistan and North-West Frontier, Pakistan. The study evaluated 9,393 cases: 261 maternal deaths reported during the last five years, and 9,135 controls who survived a pregnancy during the last five years. Study results showed that women under 19 or over 39 years of age, those giving birth for the first time, and those with a previous history of fetal loss were at greater risk of maternal death. In addition, risk of maternal death was significantly associated with staffing patterns at the district's peripheral health facilities and access to essential obstetric care. The researchers concluded that better staffing of the peripheral health facilities and improved access to essential obstetric care could reduce the risk of maternal mortality among women in these rural provinces.

Okolocha, C. et al. Socio-cultural factors in maternal morbidity and mortality: a study of a semi-urban community in southern Nigeria. Journal of Epidemiology and Community Health 52:293-297 (1998).
The goal of this study was to examine the community-based factors that determine maternal mortality and morbidity in Ekpoma, Nigeria. Data were gathered through focus group discussions (with women, men, and TBAs) and follow-up interviews. The main themes discussed included: perceived causes and signs of hemorrhage, dangers and possible sequelae of hemorrhage, patterns of use and accessibility of types of treatment for hemorrhage, and ways of preventing and treating for hemorrhage. The study found that women have a fairly good understanding of hemorrhage and its associated risk in pregnancy. TBAs were found to share similar beliefs and practices with the general population (such as induction of bleeding after delivery to eliminate "bad" blood). The researchers found that there are community-based or socio-cultural factors including attitudes, practices, and situations (for example, existing hostility between modern and traditional health care delivery systems) that prevent or delay women from seeking obstetric care, especially in emergencies. They noted the importance of considering cultural and societal factors in studies of maternal mortality and morbidity and of community education in efforts to reduce maternal deaths and illnesses.

Olsen, B.E. et al. Causes and characteristics of maternal deaths in rural northern Tanzania. Acta Obstetrica Gynecologica Scandinavica 81:1101-1109 (2002).
This 1995-1996 study used both population-based and health facility data to assess the causes and characteristics of maternal deaths in a remote area of Tanzania. Of the 45 maternal deaths, severe hemorrhage was the main direct obstetric cause of death (5/13) and cerebral malaria was the most common indirect cause of death (20/32). Pulmonary embolism was the second most important indirect cause of death (7/32). This study shows the importance of malaria epidemics on maternal mortality, with 44 percent of the maternal deaths in this study due to malaria. Malaria prevention and treatment programs are needed, not only for pregnant women, but also in the postpartum.

Pradhan, E.K. et al. Risk of death following pregnancy in rural Nepal. Bulletin of the World Health Organization 80(11):887-891 (2002).
As part of a large, population-based trial of micronutrient supplementation, data from women in the control group were analyzed to investigate the length of time following pregnancy during which the risk of mortality was elevated among women in rural Nepal. The analysis found the relative risk (RR) of death during pregnancy, but prior to labor was .93 (95% confidence interval = 0.38-2.32). During the perinatal period (labor until seven days after birth), the relative risk of death was 37.02 (95 % CI = 15.03-90.92). The RR for 2-6 weeks, 7-12 weeks, and 13-52 weeks after delivery were 4.82, 2.59, and 1.01. For the normal period of maternal mortality (pregnancy through 6 weeks postpartum, the RR was 2.26 (95% CI = 1.03-4.71). When the period was extended to 12 weeks postpartum, the RR was 2.26 (95% CI = 1.05-4.90). The risk of maternal mortality should be assessed over 12 weeks postpartum, instead of the current 6 weeks.

Ronsmans, C. et al. Evidence for a healthy pregnant woman effect in Niakhar, Senegal? International Journal of Epidemiology 30:467-473 (2001).
Although it is generally believed that pregnancy exposes women to a range of excess health risks beyond direct obstetric causes, the epidemiological evidence for these risks is limited. Using data from a demographic surveillance system set up in Niakhar, Senegal, this study attempts to document the contribution of indirect causes of death to maternal mortality. Data on pregnancy-related deaths and their causes were collected and verified by two obstetricians for the period 1984 to 1997. The study uses a period of exposure from pregnancy through 90 days postpartum. In this rural Senegalese population, death rates were not found to be higher in pregnant or recently pregnant women, except for the very young (ages 15-19) or old (ages 45-49). Excluding direct obstetric deaths, currently or recently pregnant women ages 20-39 were between two and five times less likely to die than women not recently pregnant. This apparent protective effect of pregnancy may be explained by selection bias. If women suffering from ill health are less likely to be pregnant, they will be over-represented in the non-pregnant group and inflate death rates for women not recently pregnant. Secondly, if healthier women are more likely to become pregnant, their selection in the pregnant or recently pregnant group could lower the death rates from communicable and non-communicable diseases in these women. Further studies separating out risks attributable and not attributable to pregnancy are needed to better understand the effects of indirect causes of maternal deaths.

Roungsipragarn, R. et al. Maternal mortality in Ramathibodi Hospital: a 28-year comparative study.  Journal of the Medical Association of Thailand 82(4):358-362 (April 1999).
This review of maternal mortality at Ramathibodi Hospital compares data from the period 1969-1982 with data from 1983-1996. The maternal death rate at this tertiary care hospital fell from 35.7 deaths per 100,000 live births to 18.4 during the two time periods. There was a significant decline in direct obstetric deaths (from 27.4 deaths per 100,000 live births to 7.7 deaths), especially due to infection and toxemia. The death rate due to indirect causes was unchanged during this period, and deaths due to malignancies increased. The study finds that the quality of obstetric care has improved, and further reductions in maternal deaths might be achieved through identification of high risk patients prior to conception.

Rush, D. Nutrition and maternal mortality in the developing world. American Journal of Clinical Nutrition 72 (Suppl.):212S-240S (2000).
This article summarizes evidence linking nutrition and maternal mortality. Much of the data on which current policies are based are incomplete, conflicting, or unclear. However, data show that nutrition can be a clear determinant of hemorrhage and obstructed labor. Maternal mortality is higher among women who are severely anemic, but data do not show that universal iron supplementation reduces these deaths. Obstructed labor is common in short women, yet safe ways to increase adult height are unknown. Supplemental feeding for pregnant women can increase fetal size, thus increasing the risk of obstructed labor. In the absence of accessible obstetric services, women shorter than 1.5 meters and delivering for the first time should not be part of supplemental feeding programs. There is need for more research to determine the exact relationships between nutrition and maternal mortality, and how nutritional interventions can improve the outcome of pregnancy for both mother and child.

Shulman, C.E. Malaria in pregnancy: its relevance to safe-motherhood programmes. Annals of Tropical Medicine & Parasitology 93(1)S59-S66 (1999).
Severe anemia in pregnancy is very common in sub-Saharan Africa, and has been reported as the main cause of 8 to 20 percent of maternal deaths in some hospitals. Malaria is one cause of severe anemia in pregnant women, but often is asymptomatic. One study in Kenya showed that pregnant women given intermittent treatment with sulfadoxine-pyrimethamine (SP) reduced severe anemia in primigravidae by 39 percent. The author concludes that the role of malaria in causing severe anemia in pregnant women is clear; the challenge now is to integrate such treatment for all pregnant women in malaria endemic areas in order to control anemia.

Stekelenburg J et al. Waiting too long: low use of maternal health services in Kalabo, Zambia. Tropical Medicine and International Health. 2004;9(3):390-398.
Although most women in Kalabo District, Zambia, say they would like to deliver in a clinic, only 54 percent actually do. Barriers include distance, lack of transport, user fees, lack of adequate health education during antenatal care, inadequate staffing, and poorly equipped clinics. This cross-sectional, descriptive study relied on semi-structured interviews with 332 women, focus group discussions, and reviews of hospital data. Women who are more likely to deliver in a clinic are unmarried, more educated, have formal employment, can pay, and/or live near the clinic. Even clinic delivery is risky due to the inadequacies of staff, training, and equipment. Maternal mortality in Kalabo is high and related to delays in seeking and obtaining quality maternity care.

Sule-Odu, A.O. Maternal deaths in Sagamu, Nigeria. International Journal of Gynecology & Obstetrics 69:47-49 (2000).
A review of maternal mortality data at Ogun State University Teaching Hospital, Sagamu, Nigeria, from 1988-1997 found 103 maternal deaths out of 5320 deliveries. This gives a maternal mortality ratio of 1936.1 deaths per 100,000 live births. Eighty-six percent of the deaths were due to obstetric causes, and 11 percent related to septic induced abortions. Maternal deaths were higher for unbooked than booked cases, those delivered operationally as compared with vertex delivery, and women who have given birth to 5-10 children as compared with 0-4. These mortality figures are alarmingly high, especially given they are based on hospital data. The true level of maternal mortality, encompassing the more than 60 percent of deliveries that take place at home, is likely to be far higher. Reducing maternal mortality will require good blood banking systems, easy access to health care services, and good communication systems. Women also should be empowered educationally, economically, socially, and politically.

Treffers, P.E. et al. Care for adolescent pregnancy and childbirth. International Journal of Gynecology & Obstetrics 75:111-121 (2001).
Declining age at menarche, increased schooling, delay of marriage, inadequate contraception, and poverty have all influenced adolescent pregnancy in recent decades. The major health problems associated with adolescent pregnancies are preterm labor, hypertensive disease, anemia, severe forms of malaria, obstructed labor among some girls in some regions, poor maternal nutrition, and poor breastfeeding. HIV is a problem in some regions, and the infants of adolescent mothers are at greater risk of low birth weight and increased neonatal morbidity and mortality. While pregnant adolescents tend to be at lower risk during labor, they may need more empathetic care. This review concludes that pregnant adolescents need care adjusted to their specific needs.

Thonneau PF et al. Distribution of causes of maternal mortality during delivery and post-partum: results of an African multicentre hospital-based study. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2004;114(2):150-154.
A prospective descriptive study (May to October 1999) in 12 reference maternities in three West African countries (Benin, Ivory Coast, Senegal) confirms high maternal mortality in these units. Analysis of hospital records indicate that of 10,515 women, 1,495 presented with a major obstetric complication with dystocia or inappropriate management of labor as the cause. There were 85 maternal deaths, giving a maternal mortality rate of 800 per 100,000. Twenty-five deaths were due to hypertensive disorders and 13 due to postpartum hemorrhage. Fourteen cases of sepsis were reported leading to three deaths.

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Preventing maternal mortality

Allen, L. Anemia and iron deficiency: effects on pregnancy outcome. American Journal of Clinical Nutrition 71 (Suppl.):1280S-1284S (2000).
This article reviews current knowledge of the effects of maternal anemia and iron deficiency on pregnancy outcome. Iron deficiency during pregnancy is a risk factor for preterm and low birth weight, and may have long-term health effects for the infant. Research indicates that maternal iron deficiency during pregnancy may lead to reduced fetal iron stores; this deficiency may continue into the first year of life. Iron deficiency among infants is known to be associated with developmental problems in infants. Despite the gaps in knowledge about the adverse health effects of maternal anemia and iron deficiency on pregnancy outcome, this author feels that routine iron supplementation during pregnancy is warranted, especially for women who develop anemia.

Asowa-Omorodion, F.I. Women's perceptions of the complications of pregnancy and childbirth in two Esan communities, Edo State, Nigeria. Social Science and Medicine 44(12):1817-1824 (1997).
The goal of this study was to examine Esan women's perceptions of the complications and treatments experienced during pregnancy and delivery. Data were gathered from 20 focus group discussion sessions. The women identified miscarriage, separation of the placenta, hemorrhage, obstructed labor, and the retention of the placenta as complications experienced in pregnancy, labor, or delivery. Of these complications, the women ranked hemorrhage as the most severe. Both traditional and modern treatments are prevalent amongst the Esan women. The most prevalent, inexpensive, obtainable, and trusted are traditional methods. The author concluded that strategies taken to reduce maternal mortality need to consider women's reproductive health problems in context of the conditions in which they live, and to involve them in the planning and implementation processes.

Beard, J. Effectiveness and strategies of iron supplementation during pregnancy. American Journal of Clinical Nutrition 71 (Suppl.):1288S-1294S (2000).
Iron deficiency anemia is the leading single-nutrient deficiency in the world, and the majority of the more than 2 billion people affected live in developing countries. Pregnancy depletes iron stores, and can lead to increased anemia. At least half of anemia cases occurring during pregnancy are due to nutritional iron deficiency. Scientific opinions differ as to the effects of iron deficiency on the mother and the fetus. Similarly, there is no clear evidence of the benefit of iron supplementation during pregnancy. There are known health risks associated with excess iron intake. Because of side effects and cost, compliance with daily iron supplementation is low, even in more developed countries. Successful iron supplementation requires substantial investments in infrastructure, personnel training, targeting of at-risk groups, quality control of supplements and the delivery systems, and monitoring of compliance. Given the high global prevalence of iron deficiency anemia during pregnancy, there is need to better understand how iron supplementation can be used to address this deficiency.

Bogg, L., Wang, K., and Diwan, V. Chinese maternal health in adjustment: claim for life. Reproductive Health Matters 10(20):95-107 (November 2002).
This retrospective household survey (n=5,756), carried out in six counties in three provinces of China in 1995, found that use of maternal health services was significantly affected by type of payment. Cost recovery became an important feature of health sector reform in the country during 1985-89. Health care financing shifted from the public sector to fee-for-service, and providers were given incentives. The study found that utilization of antenatal care services rose during 1990-1995, but only for women covered by prepayment schemes or health insurance. Amount of savings in the bank, coverage by a maternal prepayment scheme, and health insurance were significantly associated with delivery in the hospital and skilled attendance at delivery. This study shows the importance of financing schemes and their effect on maternal health care. Health insurance coverage appears to contribute to a higher utilization of hospital delivery and skilled attendants.

Brugha R, Pritze-Aliassime P. Promoting safe motherhood through the private sector in low- and middle-income countries. Bulletin of the World Health Organization. 2003;81(8):616-623.
The formal private sector, especially nurses and midwives, have the potential to contribute to safe motherhood practices if they are actively recruited to be part of the health care continuum. This largely overlooked group of private providers serves many women, especially in poor, rural areas. However, they are often cut off from accessing higher-level obstetric care services. A health systems approach that includes mapping of all health care services can reduce the overprovision and underprovision of care that exists in countries.

Bulatao RA, Ross JA. Which health services reduce maternal mortality? Evidence from ratings of maternal health services. Tropical Medicine and International Health. 2003;8(8):710-721.
Using ratings of maternal health services in 49 developing countries (the Maternal and Neonatal Program Index), the authors report on the results of running cross-national regressions for maternal mortality ratios. Per capita income and access to maternal health services are the most important indicators of maternal mortality. In this analysis, having a trained attendant at delivery does not have a significant effect. These factors are associative, not causally related.

Chamberlain J et al. The role of professional associations in reducing maternal mortality worldwide. International Journal of Gynecology and Obstetrics. 2003;83:94-102.
This paper calls on professional associations of obstetricians, gynecologists, and midwives to become advocates for women’s health by lobbying, promoting and educating about the necessary levels of health care for women. These groups can have a significant impact on establishing standards for quality in many developing countries and promoting the use of clinical audits and self-assessments. They can also take an active role in continuing education and promoting best practices.

Daulaire, N. et al. Promises to Keep: The Toll of Unintended Pregnancies on Womens Lives in the Developing World. White River Junction, Vermont: Global Health Council (2002). Available at:
This analysis quantifies the consequences of unintended pregnancies, and seeks to determine if extending family planning services would play a significant role in reducing maternal mortality. During the six years following the Cairo International Conference on Population and Development (1995-2000), more than one-quarter of the 1.3 billion pregnancies worldwide were unintended. An estimated 700,000 women died as a result of these unintended pregnancies. The majority (400,000) died from complications of unsafe abortions. Of all the maternal deaths during the six-year period, one in five deaths was due to an unintended pregnancy. The report details the causes and costs of these deaths. It concludes that family planning not only prevents needless deaths, but empowers women, their partners, and their families. The global community has not kept the promises made at the Cairo conference, and women worldwide suffer as a result.

De Brouwere, V. et al. Strategies for reducing maternal mortality in developing countries: what can we learn from the history of the industrialized West? Tropical Medicine and International Health 3(10):771-782 (October 1998).
This article discusses the political and social strategies that have led to reduced maternal mortality ratios in developed countries, and strategies linked to continued high maternal mortality in developing countries today. The authors provided examples from Sweden, the United States, England, and Wales, and reviewed some of the key changes that were advocated and implemented in these countries. They concluded that efforts to reduce maternal mortality in developing countries today are hindered by limited awareness of the magnitude and manageability of the problem, and ill-informed strategies focusing on antenatal care and training of traditional birth attendants.

Donnay, F. Maternal survival in developing countries: what has been done, what can be achieved in the next decade. International Journal of Gynecology and Obstetrics 70:89-97 (2000).
While other health indicators have improved over the last two decades, maternal mortality rates and ratios have not. Nonetheless, experience has shown which strategies are effective, and large-scale implementation of such programs in developing countries can reduce maternal mortality. The most important and effective interventions include improving the availability and use of essential obstetric care for the management of complications; strengthening family planning services; ensuring skilled attendance at birth; promoting women-friendly health services; increasing district-level planning with community participation; and monitoring progress with process indicators. The article also describes successful programs in several countries.

Family Health International (FHI). The importance of family planning in reducing maternal mortality [fact sheet]. (April 1995). Available at:
This article summarizes how family planning can have an effect on maternal mortality. For the individual, family planning can reduce the number of times a woman becomes pregnant, and can help her to plan pregnancies during the safest time for her and her baby. Family planning can also reduce the number of unintended and unwanted pregnancies. These pregnancies are more likely to end in induced abortion, and are less likely to receive prenatal care. Family planning also reduces the overall number of pregnancies and births.

Fauveau, V. et al. The effect of maternal and child health and family planning services on mortality: is prevention enough? British Medical Journal 301:103-107 (July 14, 1990).
Community health workers (CHWs) making home visits in Matlab, Bangladesh offered families a variety of services, including contraception, oral rehydration therapy, immunization, vitamins for pregnant women, nutritional advice for babies, treatment of minor ailments, referrals of seriously ill people to a clinic, and TBA training. This article analyzes the impact of these services on maternal and child mortality. Women aged 15-44 were almost twice as likely to die of direct obstetric causes in a comparison area without CHWs as in the program area (RR 1.73); the relative risk was even greater for abortion-related deaths (RR 2.7). Differences in infant and child mortality were also marked. The authors believe that use of family planning was responsible for the difference in maternal mortality, and conclude that increased access to curative services and better quality of care, particularly for infectious diseases, are needed to reduce mortality further.

Festin, M.R. et al. International survey on variations in practice of the management of the third stage of labour. Bulletin of the World Health Organization 81(4):286-291 (2003).
This cross-sectional survey of 15 university-based obstetric centers in ten developing and developed countries found significant variations in the practice of active management of the third stage of labor. The Global Network for Perinatal and Reproductive Health (GNPRH), an international group of obstetricians, pediatricians, and educators formed in 1996, conducted the observational survey between March and December 1999. Data collected on 30 consecutive deliveries at each center showed that active management was practiced in 111 of 452 deliveries (25%). Several studies, including systematic reviews in the Cochrane Collaboration and the WHO Reproductive Health Library, document the advantages of active management of third-stage labor in hospitals with sufficient equipment, drugs and trained personnel. Nonetheless, this study shows a large gap between evidence and practice. There was also wide variation in the use of the three components of active management; only Dublin had high use of all three (98%). There is need to implement active management as a routine clinical practice, as well as increase access to systematic reviews in developing countries, and to conduct clinical trials to assess the impact of active management.

Fortney, J.A. The importance of family planning in reducing maternal mortality. Studies in Family Planning 18(2):109-114 (March-April 1987).
This article explains how differences in the measurement of maternal mortality lead to conflicting evidence on the impact of family planning on maternal deaths. The maternal mortality ratio (deaths as a proportion of live births) is compared to the maternal mortality rate (deaths as a proportion of all women of reproductive age). The ratio measures only the risk of dying during pregnancy, while the rate also reflects the risk of becoming pregnant. Because family planning prevents pregnancies, it has more of an impact on the rate than the ratio. Family planning reduces maternal mortality in three ways: by reducing the proportion of births to high-risk women, by eliminating unwanted pregnancies that may end in unsafe abortions, and by reducing the total number of births. Family planning has a greater impact on maternal mortality in high-fertility populations.

Galloway, R. et al. Womens perceptions of iron deficiency and anemia prevention and control in eight developing countries. Social Science & Medicine 55:529-544 (2002).
The prevalence of maternal anemia, a significant problem among pregnant women in developing countries, has not changed significantly despite the initiation of large-scale iron supplementation programs. From 1991-1998, the MotherCare Project and its partners conducted formative, qualitative research to determine the barriers and facilitators to iron supplementation programs in eight countries (Bolivia, Burkina Faso, Guatemala, Honduras, India, Indonesia, and Malawi). Many similar barriers were found across regions, including inadequate supply, inadequate counseling and distribution of iron tablets, difficult access and underutilization of antenatal care services, beliefs against consuming too much medication during pregnancy, and fears that taking too much iron could cause excessive bleeding or a big baby. Side effects are not a problem for most women. Factors that facilitate iron supplementation include womens recognition of improved physical well-being, better appetite, less fatigue, increased appreciation of the benefits for the fetus, and subsequent increased demand for prevention and treatment of iron deficiency anemia. These findings were used to develop pilot projects in several countries. Addressing supply and distribution problems is necessary to improve supplementation programs.

Geelhoed, D. et al. Active versus expectant management of the third stage of labor in rural Ghana. Acta Obstetricia Scandinavica 81:172-173 (2002).
This retrospective study shows the effect of introducing routine management of the third stage of labor on the incidence of postpartum hemorrhage in a rural hospital in Ghana. Routine active management (10 IU oxytocin intramuscularly, early cord clamping, and controlled cord traction) was introduced in 1996. All women who gave birth in the hospital between 1992 and 1999 were included. Postpartum hemorrhage occurred less often in the active management group (13.7 percent versus 17.4 percent in the expectant group). Manual removal of the placenta also occurred less frequently in the active group (2.6% versus 3.5%). However, maternal mortality due to postpartum hemorrhage remained unchanged after the introduction of active management. Despite a lack of drugs and skilled staff, the authors recommend the use of active management of third-stage labor in rural hospitals in developing countries.

Global Health Council. Making Childbirth Safer Through Promoting Evidence-Based Care. Technical Report (May 2002). Available at:
New research findings on the best care often do not get put into practice for a variety of reasons. This report highlights efforts to promote an evidence-based approach to obstetric care, and to close the gap between information and practice. It summarizes new research-based practices to prevent maternal deaths due to eclampsia and postpartum hemorrhage. It includes a chapter on the World Health Organizations Reproductive Health Library, which offers the most up-to-date information about the effectiveness of various reproductive health interventions. It also highlights the Better Births Initiatives efforts to help providers in South Africa put into practice evidence-based clinical policies and practices, and abandon less effective or harmful practices.

Guyatt, H. et al. Free bednets to pregnant women through antenatal clinics in Kenya: a cheap, simple and equitable approach to delivery. Tropical Medicine and International Health 7(5):409-420 (2002).
The Kenya government strongly supports providing insecticide-treated bednets (ITNs) free of charge to pregnant women, and in April 2001 with assistance from UNICEF, 70,000 nets and K-O tabs (deltamethrin) were distributed to pregnant women in 35 districts. This is the single largest distribution effort of ITN services in Kenya to date. The tracking process indicates that 53 percent of the nets had been distributed to pregnant women throughout the country within 12 weeks. About one-quarter of the nets had not been distributed, but most had reached the district level and many were at antenatal clinics awaiting distribution. One-fifth of the nets had been distributed to individuals other than pregnant women, often at the request of district teams. Only 2,870 nets (4%) "went astray." The total cost of delivering a bednet and tabs to the antenatal care center was US$3.81. Including the nets that went to those other than pregnant women, the cost increases to US$5.26. Using the existing antenatal care system to deliver ITNs to pregnant women is equitable, efficient, and can help improve the delivery and use of antenatal care services.

Jowett, M. Safe motherhood interventions in low-income countries: an economic justification and evidence of cost-effectiveness. Health Policy 53:201-228 (2000).
This article reviews the economic reasons for investing in safe motherhood interventions. It finds that providing antenatal care in low-income countries can reduce maternal mortality by about 26 percent, and providing essential obstetric care can reduce maternal deaths by another 48 percent. Investing in these and other maternal care services can reduce the need for hospital beds. By reducing spending on interventions that may cause more harm than good (e.g., routine enemas, withholding food and drink during childbirth), and that are ineffective (routine episiotomies) or of low effectiveness (risk assessments) also saves money. This frees up funds to spend on interventions proven to be cost-effective (e.g., prevention and treatment of anemia related to malaria, treatment of STIs, tetanus toxoid vaccination, and use of manual vacuum aspiration instead of dilation and curettage). The evidence in this article indicates that improving access to essential obstetric care is the key to reducing maternal mortality.

King, J.C. The risk of maternal nutritional depletion and poor outcomes increases in early or closely spaced pregnancies. Journal of Nutrition 133(5):1732S-1736S (May 2003).
Women with early or closely spaced pregnancies are at increased risk of entering a reproductive cycle with reduced reserves, according to this review. Studies demonstrate that if the maternal nutrient supply is inadequate, the balance between maternal and fetal needs is disturbed, creating biological competition. In severe nutritional deficiencies, maternal nutrition is given preference; in a marginal state of deficiency, fetal nutrition is favored. In addition to protein and energy nutrition, micronutrient partitioning may also be affected by maternal nutritional depletion. Supplementation with food and micronutrients during the interpregnancy interval may improve pregnancy outcomes and maternal health among with early or closely spaced pregnancies.

Koblinsky, M.A. et al. Organizing delivery care: what works for safe motherhood? Bulletin of the World Health Organization 77(5):399-406 (1999). Available at:
This paper reviews country programs and projects that deliver essential obstetric services. The review yields four basic models of care. In Model 1, deliveries are conducted at home by a community member who has received brief training. In Model 2, delivery takes place at home but is performed by a professional. In Model 3, delivery is performed by a professional in a basic essential obstetric care facility, and in Model 4 all women give birth in a comprehensive essential obstetric care facility with the help of professionals. The review found that Model 1 (home delivery by non-professional) has achieved some success. However, there is no evidence that it can produce a maternal mortality ratio under 100 per 100,000 live births. On introducing a professional attendant (Models 2 through 4) and establishing strong referral mechanisms, the ratio can be reduced to 50 or lower. The authors conclude that successful movement toward Models 2 through 4 requires strong links with the community through traditional providers or popular demand

Kwast, B.E. Building a community-based maternity program. International Journal of Gynecology & Obstetrics 48 (Suppl.):S67-S82 (1995).
This article advocates an integrated approach to maternity care that strengthens services at each of three levels: TBAs practicing in the community, midwifes practicing at health centers, and physicians practicing in hospitals. One key problem is the lack of midwifery or obstetric services at the health center level, so that essential obstetric care is pushed to referral hospitals. The article describes a series of MotherCare projects in Bolivia, Guatemala, Indonesia, Nigeria, and Uganda that were designed to improve service delivery and referral pathways at different levels, depending on local needs.

Lissner, C. and Weissman, E. How much does safe motherhood cost? World Health 51(1):10-11 (January 1998).
The World Health Organization and the World Bank have developed a spreadsheet that allows program managers and planners to estimate the costs of safe motherhood interventions. The Mother-Baby Package Costing Spreadsheet is based on the Mother-Baby Package of interventions designed to reduce maternal and neonatal mortality in developing countries. The spreadsheet can be used to estimate the cost of all or part of a program, and includes estimates of total cost, cost per capita, and cost per birth for a district. It is made up of a series of linked worksheets covering direct costs, staff salaries, overhead costs, annual capital costs, referrals, and demography. Using the model to estimate costs in a low-income country show the Mother-Baby Package would cost $2.60 per capita. This shows that these interventions are affordable and can be easily estimated.

Maine, D. et al. Why did maternal mortality decline in Matlab? Studies in Family Planning 27(4):179-187 (July-August 1996).
This article analyzes which components of the maternity care program in Matlab, Bangladesh were responsible for a substantial drop in maternal mortality due to direct obstetric causes (from 4.4 to 1.4 deaths per 1,000 live births over a three-year period). Multiple data sets, including a Demographic Surveillance System, midwives' cards, and clinic and hospital records, provided information about treatments for specific complications, referral patterns, and fatality rates. The authors conclude that the decline in deaths was probably due both to the efforts of community midwives and to the availability of a new maternity clinic for referrals. They emphasize the importance of a functioning chain of referral with proper transport.

McCarthy, J. The conceptual framework of the PMM Network. International Journal of Gynecology & Obstetrics 59 (Suppl. 2):S15-S21 (November 1997).
This article describes a conceptual framework developed by the Prevention of Maternal Mortality (PMM) Network to analyze the determinants of maternal mortality. Four groups of variables are considered: women's health and reproductive behavior, women's health status, women's access to health services, and unknown factors. The conceptual framework is important because it can help set program priorities, design strategies to reduce maternal deaths, and develop indicators for the utilization and quality of care. The author concludes that family planning services, safe abortion services, and emergency obstetric care have the greatest potential to reduce maternal mortality.

McCormick, M.L. et al. Preventing postpartum hemorrhage in low-resource settings. International Journal of Gynecology & Obstetrics 77:267-275 (2002).
This review of the literature finds that active management of the third stage of labor reduces the risk of postpartum hemorrhage due to uterine atony. Oxytocin is the preferred uterotonic drug, but misoprostol can be used in situations where parenteral drugs are not available. The authors conclude that the data support the expansion of active management of the third stage of labor, especially in developing countries.

Miller S, Lester F, Hensleigh P. Prevention and treatment of postpartum hemorrhage: new advances for low-resource settings. Journal of Midwifery & Women’s Health. 2004;49(4):283-292.
This article reviews evidence for strategies to prevent and treat postpartum hemorrhage in developing countries. Active management of the third stage of labor is effective, but more research is needed to determine which aspects are most important and which might increase risk if not used correctly or in isolation. Oxytocin, delivered intramuscularly is effective. When safe injection is not feasible, oxytocin via the Uniject single-use device, or oral or rectal misoprostol are promising, but await community trials currently underway. The anti-shock garment and balloon condom catheter also appear promising, but need more study.

Miller, S. et al. Where is the “E” in MCH? The need for an evidence-based approach in safe motherhood. Journal of Midwifery and Women’s Health 48(1):10-18 (2003).
Measuring maternal morbidity and mortality are difficult, and assessing the impact of a specific intervention is even more challenging, especially in developing countries. Perhaps because of this, the authors point out that most program planning to date has been done based on theory and “good ideas” rather than on the basis of good evidence of effectiveness. Two “good ideas” that consumed many resources to little measurable effect are training traditional birth attendants and promoting antenatal risk screening. Current efforts to reduce maternal mortality focus on emergency obstetric care and skilled attendance at delivery, although these are also based on theory and noncausal data. There is need for rigorous evaluation of key interventions as detailed in the article. Ultimately, evidence-based approaches to maternal mortality may be the most cost- and time-efficient ways to save women’s lives.

PATH. Preventing postpartum hemorrhage: managing the third stage of labor. Outlook 19(3):1-8 (September 2001). Available at:
This issue of Outlook reviews hemorrhage as a major cause of maternal mortality and the potential effectiveness of active management of the third stage of labor to prevent and manage postpartum hemorrhage. Where appropriately trained providers, necessary equipment, and drug availability and safety can be ensured, active management of labor after the delivery of the baby, but before delivery of the placenta, can improve maternal survival.

Rahman, M. et al. Do better family planning services reduce abortion in Bangladesh? Lancet 358(9287):1051-1056 (September 29, 2001).
This study compared trends in overall abortion rates and rates for intended and unintended pregnancies in two areas of rural Bangladesh. In one area, the Maternal and Child Health and Family Planning (MCH-FP) project has provided more accessible and higher-quality family planning services than those offered in the comparison area by the government. Data from the Matlab Demographic Surveillance System and survey data on fertility preferences showed that abortion rates were significantly lower in the area with better family planning services. Abortion of unintended pregnancies was similar in both areas, but the higher levels of family planning use in the MCH-FP area led to lower levels of unintended pregnancy and abortion. The authors conclude that during the fertility transition in less developed countries, as the desire to limit family size increases, there may be an increase in abortion unless there is widespread availability of quality family planning services.

Rosser, J. HIV and Safe Motherhood. London: Healthlink Worldwide (2000). Available at:
This booklet offers information to health care workers in sub-Saharan Africa about the care of mothers before, during, and after pregnancy. It focuses on how health care workers can reduce the transmission of HIV during pregnancy, labor, and delivery. It includes information about antiretroviral therapy to reduce mother-to-child transmission, as well as information about infant feeding and HIV.

Setty-Venugopal, V. and Upadhyay, U. Birth spacing: three to five saves lives. Population Reports L(13) (Summer 2002).  Available at:
A study using data from 18 countries to assess the outcomes of more than 430,000 births in four regions finds that spacing births 3 to 5 years apart increases the childrens chances of surviving. Data from Demographic and Health Surveys (DHS) show that children born 3 to 5 years after a previous birth are about 1.5 times more likely to survive to age five than children born at 2 to 3 year intervals, and about 2.5 times more likely to survive than children born after intervals shorter than 2 years. While it has long been known that spacing births two years apart is beneficial, these new data show the advantages of 3 to 5 year intervals. Birth spacing also improves maternal survival. A 2000 study in Latin America using data from 450,000 pregnancies in 18 countries shows that women who have their babies 27 to 32 months after a previous birth are more likely to survive pregnancy and childbirth than women who give birth after very short (9 to 14 month) or very long (69 months or longer) intervals. It is suggested that short birth intervals may negatively affect mothers energy, weight, and body mass index. It is not clear why long birth intervals are less healthy, but after five years women may lose the protective effect of previous childbearing on pre-eclampsia and eclampsia. About 26 percent of women worldwide give birth after intervals of less than two years, but surveys indicate many women prefer to wait longer. Providing women with information about birth spacing during the antenatal and postpartum periods can help improve maternal and child survival.

Shiffman, J. Can poor countries surmount high maternal mortality? Studies in Family Planning 31(4):274-289 (Dec. 2000).
There are three prevailing perspectives on the distant determinants of changes in maternal mortality: (1) the health perspective, based on the availability and use of maternal care services; (2) the wealth perspective, based on economic development and the accumulation of material resources; and (3) the empowerment perspective, which emphasizes the position of women in society. This article uses a cross-national regression of data from 64 countries to examine these theories. The analysis finds that wealth indicators explain a portion of the variation in national level of maternal mortality. However, high standards of living are not a necessary condition for lowering maternal mortality. Women's educational levels and the proportion of deliveries attended by trained health personnel are more clearly associated with national levels of maternal mortality. These findings give support to the proponents of safe motherhood programs and their efforts to reduce maternal mortality.

Sloan, N.L. et al. An ecological analysis of maternal mortality ratios [commentary]. Studies in Family Planning 32(4):352-355 (December 2001).
The authors updated a previous analysis of data for 84 countries to assess the correlates of maternal mortality. The results indicate that a greater proportion of deliveries with a skilled attendant and higher contraceptive prevalence rates are both associated with lower national maternal mortality ratios. However, these analyses of aggregate data may be subject to ecologic fallacy, and the observed associations may not be causally related at the individual level. Prior to increasing the proportion of women delivering in the attendance of skilled personnel, it is important to test in different settings where institutional delivery is rare.

Tomkins, A. Nutrition and maternal morbidity and mortality. British Journal of Nutrition 85 (Suppl. 2):S93-S99 (2001).
Studies have shown the impact of micronutrient deficiency (especially vitamin A and zinc) on immune function, morbidity, and mortality in children. New studies indicate that similar deficiencies may contribute to maternal morbidity and mortality as well. A study in Nepal found that supplementing women with vitamin A or beta-carotene before and during pregnancy reduced maternal mortality (by 44%) and morbidity. Micronutrient supplementation of pregnant women in Tanzania showed improved pregnancy outcomes. It is not yet known what the optimal micronutrient supplementation might be, and what the effects would be in countries with well-developed antenatal, midwifery, and obstetric care services. Nonetheless, there is growing support for micronutrient supplementation to aid in the reduction of maternal mortality and morbidity.

Tsu VD. New and underutilized technologies to reduce maternal mortality. Lancet. 2004;363(9402):75-76.
This report of a meeting of maternal health specialists in July 2003 in Bellagio, Italy, highlights several underused and promising technologies (equipment, consumable supplies, and techniques) to reduce maternal deaths. Many of these are simple interventions that can be used by health personnel in remote areas. For example, the Uniject™ prefilled, single-use injection device can be used to deliver a sterile dose of oxytocin to prevent postpartum hemorrhage, and magnesium sulfate can be used to prevent eclampsia. A table lists the priority technologies along with the critical next steps needed to put them into use.

Tsu V, ed. New and underutilized technologies to reduce maternal mortality: papers from a 2003 Bellagio Workshop, July 8-11, 2003. International Journal of Gynecology and Obstetrics. 2004;85(Suppl.1):S1-S93.
Appropriate technologies—equipment, supplies, procedures, and techniques—have been underutilized to reduce maternal deaths. This 2003 workshop brought together experts from 15 countries to discuss the current status of new and existing technologies that could be used in low-resource settings to address maternal mortality. This special supplement of the International Journal of Gynecology and Obstetrics includes the background papers prepared for the workshop and a summary of the priorities for action agreed upon by the participants. The papers cover appropriate use of technology, transport and communication, vitamin A, and key technologies to prevent deaths from pre-eclampsia and eclampsia, postpartum hemorrhage, puerperal sepsis, obstructed labor, and abortion.

Tsu VD et al. Oxytocin in prefilled Uniject™ injection devices for managing third-stage labor in Indonesia. International Journal of Gynecology and Obstetrics. 2003;83:103-111.
This article assesses the use and acceptability of the Uniject™ injection device prefilled with oxytocin by Indonesian midwives attending home births during a four-month intervention. Village midwives (140) and mothers whose deliveries they had attended (2,220) were interviewed in three rural districts and one municipality in Lombok. The midwives reported the Uniject device was easier to use than reusable (99%) or disposable (96%) syringes, and most (96%) preferred it to standard needles and syringes. Rates of postpartum hemorrhage did not change substantially with use of the device. The Uniject offers a safer, more convenient way for trained midwives to deliver oxytocin during home births and potentially reduce the incidence of postpartum hemorrhage.

Tsu, V. and Free, M. Using technology to reduce maternal mortality in low-resource settings: challenges and opportunities. Journal of the American Medical Womens Association 57(3):149-153 (2002).
The use of technology—including equipment, supplies, procedures, and techniques—can help reduce maternal mortality in low-resource settings. Technologies need to be effective, affordable, and acceptable. This article reviews some of the health technologies that could be used in developing countries to save womens lives. Postpartum hemorrhage could be prevented by using a uterotonic drug, such as oxytocin, after delivery. Injection safety can be improved by the use of a pre-filled, single-use injection device. In the absence of a birth attendant, self-administration of oral misoprostol may be an acceptable alternative to prevent hemorrhage. Red blood cell substitutes may eventually be the best way to treat hemorrhage, but the technology is not yet ready for application in developing countries. Manual vacuum aspiration is a proven technology for use in abortion and postabortion care, but it can be made more appropriate for situations where equipment is reused repeatedly. Better measurement of blood pressure and more widespread use of effective drugs can reduce deaths due to pre-eclampsia and eclampsia. Finally, vacuum extraction, partograms, and symphysiotomy can be applied in the diagnosis and treatment of obstructed labor. Technology-based solutions to health problems must take into account the disease burden, the feasibility of the solution, the readiness of industry to commercialize the technology, and the anticipated cost-benefit ratio.

UNICEF. Programming for Safe Motherhood: Guidelines for Maternal and Neonatal Survival. New York: UNICEF (March 1999).
This guide provides evidence-based interventions to address direct and indirect causes of maternal death. It is intended to help UNICEF's country-level staff develop safe motherhood programs. There is a wealth of information in the guide, including specific interventions (such as improving nutrition, care during pregnancy and childbirth, maternal and neonatal health in emergencies, building linkages) to make motherhood safer. For each topic (e.g. delivery care), the guide tells the components of the intervention, and indicates how to do a needs assessment, strengthen policies and capacity building, improve communications and community participation, and undertake monitoring and evaluation. The examples of interventions from different countries provide specific cases where interventions have been successful.

USAID. Family Planning Prevents Abortion. Washington, DC: USAID Center for Population, Health and Nutrition; November 2001. Available at:
This briefing paper reviews data from several countries on the role of family planning in preventing abortion. It presents research findings on the impact of contraceptive use on abortion in a range of countries worldwide including Kazakhstan, Romania, Bangladesh, and Turkey. Linking emergency postabortion care with family planning services plays a crucial role in reducing abortions by providing the means for avoiding future unintended pregnancies.

Villar, J. et al. Nutritional interventions during pregnancy for the prevention or treatment of maternal morbidity and preterm delivery: an overview of randomized controlled trials. Journal of Nutrition 133(5):1606S-1625S (May 2003).
This overview summarizes the effectiveness of nutritional interventions to prevent or treat maternal morbidity, mortality, and preterm delivery. Randomized controlled studies up to July 2002 were reviewed. Iron and folate supplements are shown to reduce anemia, and should be included in antenatal care programs. Calcium supplementation given to women at high risk of hypertension during pregnancy or with low calcium intake reduced the incidence of preeclampsia and hypertension. Fish oil and vitamins E and C show some promise for preventing preeclampsia and preterm delivery, but need more study. Vitamin A and b-carotene reduced maternal mortality in a large trial, and ongoing trials will provide further information. Nutritional advice, magnesium, fish oil, and zinc supplementation appear promising, but need to be tested alone or together in randomized, controlled trials. It is unlikely that any specific nutrient on its own will prevent or treat the major causes of maternal mortality and morbidity and preterm deliveries. Until more information is developed, women and their families should receive support to improve their diets.

West, K. et al. Double blind, cluster randomized trial of low dose supplementation with vitamin A or beta-carotene on mortality related to pregnancy in Nepal. British Medical Journal 318:570-575 (February 27, 1999).
Supplementing reproductive-age women with the recommended dietary allowance of vitamin A each week reduced maternal mortality among rural, undernourished populations in Nepal. In this double-blind, cluster randomized, placebo-controlled field trial, more than 36,000 women were recruited and provided with weekly doses of preformed vitamin A or beta-carotene by female field workers over a period of three and a half years. Overall, 20,119 women (45%) were pregnant 22,189 times during the study. The maternal mortality ratio was 645, 407, and 361 deaths per 100,000 live births in the placebo, vitamin A, and beta-carotene groups. respectively. The risk of maternal death was reduced by approximately 40 percent in this rural, poor Asian setting through dietary supplementation of vitamin A or beta-carotene. The protective effect was established after one and a half years of supplementation. More than three-quarters of the women who became pregnant during the study received at least half of their recommended supplementation, although only half took 80 percent or more of their recommended supplements. This suggests that even modest supplementation with vitamin A or beta-carotene could substantially lower the risk of maternal death among populations deficient in vitamin A.

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