99780 Preventing the Tragedy of Maternal Deaths A REPORT ON THE International Safe Motherhood Conference NAIROBI KENYA February 1987 Prepared lJy ANN STARRS Co-sponsored lJy em WORLDBANk • ~ WORLD HEALTH ~ ~ ORGANIZATION ~ ~ UNITED NATIONS FUND FOR P OPULATION ACTIVITIES The co-sponsors would like to thank the following organisations for their contributions to the Safe Motherhood Conference arulfollow-up activities: United Nations Children's Furul (UNICEF), United Nations Development Programme (UNDP), Carnegie Corporation of New York, the Ford Fourulation, Pathfiruler Furul, and the Rockefeller Fourulation. Photo Credits: photographs are from UNICEF; conference photographs were taken by Halle Studio, Nairobi, Kenya. Design by Dever Designs __.,.o~-IIT~ .... -.....;. - - - .. o - - -- ·___:--;,.......,_ - ....____ 'I - - -----------~~~..-.....-- -- - _____....__ INTRODUCTION- continued -- -- 5 mortality reflect the underlying disadvantages and discrimination suffered by women. It recommends, therefore, that efforts to improve maternal health focus on the chain of poor nutrition, illiteracy, lack of income and employment opportunities, poor environmental conditions, inadequate health and family planning services, and low social status- all the factors that expose women to increased health risks during pregnancy and childbirth. The co-sponsors of the conference pledged to fulfill the recommen- dations of the Call to Action and stated their willingness to provide technical and financial support to developing country governments that request help in designing and implementing programmes to ensure Safe Motherhood. Barber B. Conable, president of the World Bank, announced p lans to dou- ble the Bank's lending for population, health, and nutrition projects to about $500 million annually by 1990, with projects in some fifty countries. In addition, the World Bank and the U.N. Development Programme de- Maternal health care should be clared that they would each contribute $1 million to the establishment of a provided in the context offamily Safe Motherhood Fund. The fund will support operational research in spe- health care - it should be socially cific countries for the development and improvement of maternal health acceptable, scientifically sound, programmes, and will be administered by the World Health Organization. and as simple as possible. The participants at the conference emphasized that maternal health - DR. ADETOKUNBO LUCAS, care, including family planning, is an essential and integral element of pri- Carnegie Corporation mary health care programmes aimed at the goal of Health for All by the Year 2000. As the discussions made clear, saving women's lives is a practical goal as well as a humanitarian one. Women's contributions and productivity are visible not only in the infants they nurture, but in the food they grow, harvest, and cook; in the variety of goods they produce and market; in the teaching and care of their children; in the many tasks they perform every day to serve their families and communities. The death of an infant's mother results not only in the loss of a woman in the prime of her life, but also in the loss of her economic productivity, usually the death of her infant, and in some cases the disintegration of her family. For these reasons, Mr. Conable said in his opening address to the conference, "We are not here just to pub- licise a problem. We are here to attack it, to save lives, and to build better ones ... We can make this conference the beginning of a new commitment to common decency and common sense:' 6 A CALL TO ACTION - THE SAFE THE PROBLEM MOTHERHOOD This conference was organised to remind us that although women INITIATIVE: have been dying in pregnancy and childbirth since time began, maternal A Call to Action mortality is a critical problem that needs to be recognised by all. Only re- cently has serious attention been paid to the full and tragic scope of this Concluding Statement of problem. the International Safe Motherhood We have said that half a million maternal deaths take place every Conference year; 99 percent of these deaths occur in the developing world. In the devel- oped world, there are only 2 to 9 maternal deaths per 100,000 live births; in developing countries the figures range from 300 to 1,000 or more. Thus women in developing countries run a risk of dying in pregnancy and child- birth that is 50 to 100 times greater than that of women in the developed world. These figures do not convey the full measure of the risk. The lifetime risk of a woman in a developing country dying in pregnancy or pregnancy- related illness is 1 in 25 or 1 in 40; this contrasts sharply with the 1 in several thousand risk for women in the developed world. These measures of mater- nal death have not been used as part of the quality of health and quality of life index, and we feel that they should be. No country can claim to be ad- vancing if its maternal death rates remain poor. - THE C AUSES The causes of these deaths are tragic indeed. Illegal abortion from unwanted pregnancies causes some 25 to 50 percent of these unwanted deaths, simply because women do not have access to the family planning services they want and need, or they have no access to safe procedures or to human and humane treatment for the complications of abortion. For the thousands of women who die in pregnancy and childbirth, millions more are permanently disabled. Many of them are ostracised by their families and communities. For every death, it is estimated that 10 to 15 women are handi- capped in one way or another. The question we must ask is why this happens: is it because the major- ity of these women are poor that they are allowed to suffer this silent carnage? A CALL TO ACTION- continued 7 There must be a commitment to stop these deaths. We need to mobi- lise the political will, to mobilise community involvement among men and women, and to implement specific programmes to stop these tragedies from taking place. We must do this for common humanity, because among human rights, the first is the right to life itsel£ We must do this also because women are a major resource to any nation, to any community, and above all to any family. They make a crucial contribution to the productivity and well-being of their families and communities. When a woman dies in childbirth, the death sentence of the child she carries is almost certainly written. Often the children she leaves behind suffer the same fate, and the family stands a good chance of disintegration. For all of these reasons it behooves us to think- and think seriously- about whether we as individuals and as a group should remain silent after this meeting. The causes of this problem are deeply rooted in the adverse social, cultural, political, and economic environment of societies, and especially the environment that societies create for women. Women are discriminated against in terms of legal status, access to education, access to food and proper nutrition, access to appropriate employment, access to financial re- sources, and access to relevant health care, including family planning serv- ices. This discrimination begins at birth and continues through adolescence and adulthood, where women's contributions and roles are ignored and undervalued. These deep-rooted causes need to be addressed if we are to improve the long-term health and status of women. The problems we are discussing will only grow in magnitude with population growth if we do not address these basic causes. We must reduce the pool of women who are most likely to suffer from the complications that result in so many deaths. Let us re- duce the risk and help women achieve healthier, happier lives. The United Nations, at the 1984 International Conference on Popu- lation in Mexico, stressed the need for action in these areas, and reached a consensus. The End of the Women's Decade Conference here in Nairobi in 1985 stressed this need, and reached a consensus. We must cut the vicious circle that creates the conditions that cause these women to suffer and die so needlessly. , 8 A CALL TO ACTION- continued - - - - - - The critical point, however, is that the overwhelming majority of maternal deaths are caused by obstructed labour, haemorrhage, toxaemia, infection, and complications from both spontaneous and induced abortion. The challenge is that there are low-cost, effective, and available interventions that can have a major impact on reducing these mortalities and morbidities if these interventions are specifically planned and practised as a priority. What is needed right now is dedication and action. THE ACTIONS TO BE UNDERTAKEN • We need to generate the political commitment to reallocate resources to implement the available strategies that can reduce maternal mortality by an estimated 50 p ercent in one decade. • We need to remember that the industrialised countries faced this chal- lenge in the past. For some the change has taken place in our lifetime, through dedication and the reallocation of priorities. • We need an integrated approach to maternal health care that makes it a priority within the context of primary health care services and overall development policy. • We need to reach decisionmakers in family and government to change laws and attitudes, and to improve the legal and health status of women generally, especially in areas such as adolescent marriage and restrictions on health care delivery. • We need to mobilise and involve the community and particularly women themselves in planning and implementing policies, programmes, and proj ects, so that their needs and preferences are explicitly taken into account. • We need to utilise a range of information, education, and communication activities to reach communities, women, men, boys, and policymakers, through the media and all culturally appropriate channels. • We need to carry out additional studies to gain better country- and locale-specific information on maternal mortality- its immediate causes, which we know, and its root causes, some of which either we do not know or we ignore. • We need to have ongoing operational research and evaluation activities to assess the effectiveness of various programmes. . -- - . 3 . ·-- - ~,--•~------~~--t INTRODuCTION 4 TABLE OF CONTENTS THE SAFF MOTHERHOOD INI TIATIVE: A CALL TO ACTION (} The Problem 6 The Causes 6 The Actions to be Undertaken 8 DIMENSIONS OF THE PROBLEM 10 The Disparity between Developed and Developing Countries 10 Maternal Morbidity and Its Consequences 14 Women at High Risk 15 The Dangers of Poorly Performed Abortion 16 CAUSES OF THE PROBLEM JH The Road to Maternal Death 18 The M~or Obstetric Complications 21 THE CALL "I 0 ACTION: WAYS TO IMPROVE MATERNAL HEALTH ~~ Improving the Status of Women 22 Changing Attitudes, Practices, and Laws 25 Health Sector Strategies 27 The Three-Pronged Approach 27 Mobilising Community-Based Care First-Referral-Level Facilities "Alarm " and Transport System The Importance of Family Planning------ - - - - - - 35 The Affordability of Safe Motherhood 38 Appropriate Technology and Proper Management _______ 39 The Special Contribution of Nongovernmental Organisations _ _ 40 CONCLUSION · 1~ AGENDA FOR SAFE MOTHERHOOD CONFERENCE t :~ PARTICIPANTS LIST 46 BACKGROUND PAPERS FOR SAFE MOTHERHOOD CONFERENCE :l:) - 4 - --- INTRODUCTION - - - - - . - - - ~- The tragedy of maternal mortality and ill health has been largely ne- INTRODUCTION glected in the development programmes of Third World countries and the priorities of donor agencies. Experts have only recently gathered sufficient data to present a clear portrait of the thousands of women who suffer pain- ful maternal deaths throughout the developing world. These women die during pregnancy or childbirth at home and in hospitals, in urban slums and rural villages, because of their poor health, ignorance, poverty, low so- cial status, and their limited access to essential health care. The United Nations Decade for Women (1976-1985) helped focus international attention on women's critical contribution to the life and de- velopment of their families, communities, and nations. Maximizing this con- tribution requires a committed international effort to improve women's health and reduce high rates of maternal mortality in Africa, Asia, the Mid- dle East, and Latin America. This conference is the beginning The Safe Motherhood Conference that took place in Nairobi, Kenya of what may be the rrwst important in February 1987 had as its goal "not only to draw attention to maternal human rights initiative ever mortality, but more importantly, to mobilise immediate and concerted ac- launched in terms of the number tion at the national and international levels to prevent the continued trag- ofpeople we are addressing. edy;' said Dr. Nafis Sadik, now executive director of the United Nations Fund for Population Activities (UNFPA). The conference was co-sponsored -RAMI CHABBRA, Ministry of Health arui Family by the World Bank, World Health Organization (WHO), and UNFPA. Its Welfare, /ruiia 125 participants included representatives from these and other agencies, to- gether with health experts, development professionals, and policymakers from over forty-five developed and developing countries. Dr. Halfdan Mahler, director general of WHO, explained the motiva- tion for the conference in his opening address: "[Maternal mortality] is a neglected tragedy, and it has been neglected because those who suffer it are neglected people, with the least power and influence over how national re- sources shall be spent; they are the poor, the rural peasants, and above all, women:' William Draper III, administrator of the United Nations Develop- ment Programme, referred to a "lethal chain" of causes for the vulnerability of women during pregnancy and childbirth, and urged the development community to adopt a multidisciplinary approach to the problem. The Call to Action adopted by consensus at the conference (see pages 6-9) highlights the extent and nature of maternal mortality and the need for programmes to reduce it. It recommends specific, affordable health initia- tives to address the health risks and medical emergencies that lead to mater- nal death. The Call to Action also acknowledges that high rates of maternal • We need to expand family planning and family life education pro - grammes, particularly for young people, and make services for planning families socially, culturally, financially, and geographically accessible. • We need to use appropriate technologies at all levels so that women have better care at lower costs. • We need to str engthen community-based maternal health care delivery systems, upgrad e existing facilities, and create relevant new ones if necessary: - We need to ensure that pregnant women are screened by supervised and trained non-physician health workers where appropriate, with rele- vant technology (including partographs as needed), to identify those at risk and to provide pre-natal care and care during delivery as expedi- tiou sly as possible. -We need to strengthen referral facilities- hospitals as well as health centers- and locate them appropriately. They need to be equipped to handle emergency situations effectively and efficiently. - We need to implement an alarm and transport system that ensures that women in need of emergency care reach the referral facilities in time to be helped. These activities need to be seen within a comprehensive, multisec- toral approach , although they do not have to wait for all sectors to achieve improvement simultaneou sly. These activities need to involve governments as well as take advantage of the flexibility, responsiveness, and creativity of nongovernmental organisations. They need to stimulate and support input from the communities themselves. Perhaps the most important contribution of this Safe Motherhood Initiative will be to call attention to the problems related to it, and to create an awareness that something can, should -indeed must- be done, starting with the commitment of heads of states and governments. A philosopher from my country- Ghana - once looked at a map of Africa and said, "It is asking the question 'why?' " Today the women of de- veloping countries, like mother Africa, are asking why. "Why are you letting us die?" The answer is in your hands. This statement was presented by DR. FRED T. SAI, moderator of the Safe Motherhood Conf erence, at the closing session on February 13, 1987. It was adopted by the conference participants by consensus as the con- ference "Call to Action." - 10 DIMENSIONS OF THE PROBLEM - - . DIMENSIONS THE DISPARITY BETWEEN DEVELOPED , AND DEVELOPING COUNTRIES OF THE PROBLEM The World Health Organization estimates that half a million women die in pregnancy and childbirth every year; the vast majority of these deaths -about 99 percent- take place in developing countries. Maternal mor- tality rates vary widely from country to country and from region to region. For every 100,000 live births, in northern Europe there are typically two to nine maternal deaths, while in some parts of Africa there are over 1000. Most developing countries have rates that range from 300 to 800. Few countries, however, have complete and accurate data on the scope of mater- nal mortality. Research supported by the World Health Organization and other agencies has provided a glimpse of the magnitude of the problem. Table 1 ESTIMATES OF MATERNAL MORTALITY, BY REGION Number of Maternal mortality maternal deaths rate (per 100,000 &gion (thousands) live births) AFRICA 150 640 North 24 500 West 54 700 East 46 660 Central 18 690 Southern 8 570 AsiA 308 420 West 14 340 South 230 650 Southeast 52 420 East 12 55 LATIN AMERICA 34 270 Central 9 240 Caribbean 2 220 Tropical South 22 310 Te mperate South 1 110 OcEANIA 2 100 DEVELOPING COUNTRIES 494 450 DEVELOPED CouNTRIEs 6 30 WORLD 500 390 SoURCE: Maternal Mortality Rates: A Tabulation of Available Information (Geneva: World Health Organization, 1985) 12 DIMENSIONS OF THE PROBLEM- continued Mortality rates for infants are, on average, ten times higher in devel- oping than in developed countries. For women in developing countries, by comparison, the risk of dying in pregnancy and childbirth is 50 to 100 times higher, on average, than that of women in northern Europe or North Amer- ica. The typical woman in a developing country confronts that risk not just once in her life, but an average of six to eight times- in Africa, sometimes closer to ten. Her chance of dying in childbirth is between 1 in 15 and 1 in 70; women in the developed world face a much lower risk of between 1 in 3,000 and 1 in 10,000. FiiJUre 1 PERCENTAGE oF LtvE BnrrHs AND MATERNAL DEATHS WORLDWIDE, BY REGION LIVE BIRTHS 14% - - - - - - - - . . . 17% - -----... • South Asia Africa 10% • • Latin America East Asia Developed countries 18% 41 % - - -- - MATERNAL DEATHS 1% - - -- - 3% - - - - - - - . . . 7% - - - - - - . . . 30% SouRCE: 1-\'cn-ld Health Organization, 1986 - - ' ___ .L _ __-·- ~~ _ _DIM:~s~NS o:_.THE PRo_BLF:~ ::- c":'tin~ed B Complications of pregnancy and ch ildbirth are often the leading cause of death among women of childbearing age in developing countries, accounting for 20 to 45 percent of the deaths of these women. In the United States that figure is less than 1 percent- This huge disparity between the developed and developing world is the largest of any of the health in- dicators used by WHO The figures serve as a stark reminder of the poor health and neglect many women suffer in the developing world. They also show what can be achieved when, beginning in childhood, women are well nourished and healthy, have access to prenatal and general health care as well as life-saving obstetric measures, and can practice safe and effective family planning, as is generally the case in developed countries. Table 2 ESTIMATED LIFETIME CHANCE OF DYING FROM PREGNANCY-RELATED CAUSES, BY REGION, 1975-84 Lifetime chance of maternal death AFRICA I in 2I ASIA 1 in 54 SouTH AMERICA 1 in 73 CARIBBEAN 1 in I40 NoRTH AMERICA I in 6,366 NoRTHERN EuROPE 1 in 9,850 SouRCE: Calculated by Dr. Roger Rochat, Emory University School of Medicine, Master in Public Health Program, using data on maternal mortality rates from tht World Hmlth Organization and total fertility rates from the Population Ref.retu:t Rurtau; in Barbara Herz and Anthony R. Measham, The Safe Motherhood Initiative: Proposals for Action (Washington, D.C., The World Hank, 1987) 14 DIMENSIONS OF THE PROBLEM- continued MATERNAL MORBIDITY AND ITS CONSEQUENCES For every woman who dies in childbirth, many more survive but suffer long-term damage to their health. Incontinence, uterine prolapse, infertility, and other illnesses caused by complications in pregnancy and childbirth contribute to the persistent suffering and poor quality of life experienced by millions of women. Dr. Kelsey Harrison, professor of obstetrics and gynaecology in Port Harcourt, Nigeria, stated at the con- ference, "for every maternal death in developing countries, at least fifteen other [women] are incapacitated or disabled ... [In Africa], the number of disabled or incapacitated becomes two to three million, compared to no more than a few thousand in the whole of the developed countries:' For many women, complications during pregnancy, or infection from unclean hands or unsterile instruments, lead to pelvic inflammatory disease which, apart from the pain and suffering it causes, can lead to infertility. Infertility is a major problem in Mrica, where it affects 15 to 20 percent of all women and is often caused by sexually transmitted diseases or the complications of pregnancy. One devastating form of maternal morbidity is the development of fistulae, openings between the vagina and the rectum or urethra that allow urine or faeces to leak through the vagina. Fistulae are generally the result of infection or the trauma of prolonged obstructed labour. Women with fistulae suffer from incontinence and a persistent odour caused by stale ex- creta. Adolescent mothers, because they are not fully developed physically, are particularly susceptible to developing fistulae. Dr. Harrison explained that more than half the women in Africa who suffer from this serious dis- ability are teenagers, who are often ostracised or hidden for the rest of their lives if they are unable to undergo expensive reparative surgery. In his open- ing address, Dr. Mahler said that fistulae and other forms of maternal mor- bidity are in some cases "so devastating to the personal, marital, and social life of the woman that many a time she must bitterly wish she had died:' Maternal morbidity can thus be almost as damaging to women and their families as maternal mortality. I . .! ·~........ - .. _ -~ ~ -~~ . .__ - -- DIMENS!OI>;S OF THE PROBI.fM- continu'd --~---- - - - --"'" -- ...:::.~ -- .. - 15 WOMEN AT HIGH RISK Some groups of women are especially susceptible to death or disa- bility from p regnancy and pregnancy-related illness. Adolescents under the age of 15 are five to seven times more likely to die in pregnancy and child- birth than women in the lowest-risk age group of 20-24. As noted, girls under age 15 who have not attained their full growth often have pelvises too narrow to permit easy passage of an infant. They may suffer from obstructed labour and develop fistulae or die after 24, 48, or even 72 hours of agony. Women who have had five or more pregnancies and women over the age of 35 also face a substantially higher risk than those aged 20-24. Women who become pregnant less than two years after a previous birth often suffer adverse consequences as well, and their children are more likely to be ill and die than infants who are born more than two years apart. Hence a common admonition of health professionals is to avoid pregnancies "too early, too late, too many, too close together:' 'I Many other factors can make women especially susceptible to the complications of pregnancy. Women of small stature are more likely to suf- fer obstructed labour and require a caesarean section in order to avoid uter- ILLEGAL ABORTION, COLOMBIA ine rupture and probable death. Millions of women are malnourished and Esperanza, 30 years old, had al- ready borne five children, including suffer from chronic anaemia, malaria, and intestinal diseases that weaken one who had died at the age of 10 their ability to bear healthy children and survive the delivery themselves. months. Neither she nor her hus- band was happy when she became Furthermore, pregnancy can exacerbate many pre-existing chronic condi- pregnant again. The health centres accessible to her provided maternal tions such as heart disease, hypertension, diabetes, and hepatitis, all of and child health care but no family planning services. Esperanza did which can cause "indirect" maternal deaths. not know about the family planning association clinic in the capital city of the province. Esperanza had re- cently found work as a housemaid in the city, and her wages were much THE DANGERS OF POORLY PERFORMED ABORTION needed by the family. She made the decision alone to visit an abortionist in town. She was frightened and un- Finally, poorly performed abortions contribute significantly to the sure about what was actually done to her. maternal mortality problem. Women who confront an unwanted pregnancy Mter three days of bleeding Es- often choose to risk an abortion, frequently performed with crude and un- peranza developed severe abdomi- nal pain and began to vomit. Her hygienic methods. More than two-thirds of women in the developing world, husband took her to a hospital where she was diagnosed as suffer- excluding China, have no ready access to legal abortion. Nevertheless, huge ing from incomplete septic abor- tion. She was treated and sent home numbers of abortions still take place; an estimated 20-30 percent of the after forty-eight hours. The pain re- turned, but Esperanza did nothing pregnancies that occur worldwide each year end in induced abortion. The about it at first, fearing she would World Health Organization reports that unsafe induced abortion is respon- lose her job if she took any more time off. When she developed a high sible for as many as 50 p ercent of maternal deaths in some regions, espe- fever and started vomiting, she was admitted to the intensive care unit cially Latin America, making abortion "a major killer of women:' Even of the hospital. Abdominal surgery was performed for peritonitis, but where abortion is legal, as in India, poor women can experience much diffi- her condition deteriorated, her heartbeat became irregular, and she culty in obtaining a safe, aseptic procedure. Effective family planning can died five days later. play a significant role in preventing unsafe abortions. As Dr. Mahler stated Source: World Health Organization in his address to the conference , "Since the great majority of abortions arise Case Histories from lack of knowledge of contraception, or the failure to use it, or the inability to obtain it, family planning is the obvious way to save these thou- sands of pitifully wasted lives:' .. ~------- - DIMENSIONS OF THE PROBLEM- continued 17 Figure2 AVERAGE NUMBER OF DEATHS ANNUALLY CAUSED BY ILLEGAL ABORTION, SELECTED CoUNTRIES, 1970s 90 ..!< " " " " ·- " "" " "' "' "0 " "0 " [?., 1: u (:;: ;;l '" E "' -, .~ 5 " ·:;: "' ::E &, " .... ·a. g " .-"! ·;; ..c: "0"' ·- .0 -~ t3 8 ::E " 0.. f- F06 f SoURCE: Debarah Maine, Family Planning: Its Impact on the Health of Women and Children (New !Vrk: Center for Populatirm anti Family Health, Columbia University. 1981) 18 CAUSES OF THE PROBLEM Participants at the conference discussed the causes of maternal mor- CAUSES OF THE tality from two general perspectives. On the one hand, women's low status PROBLEM and poverty are often at the root of their poor health, high fertility, and lack of access to essential health care. In more immediate terms, studies indicate that three-quarters of the maternal deaths in developing countries are caused by one of five obstetric complications: haemorrhage, obstructed labour, infection, eclampsia, and abortion. THE ROA D T O MATERNAL D EATH Dr. Mahmoud Fathalla of WHO presented the case history of "Mrs. x:· typical of thousands of women who die, to illustrate the immediate and underlying causes of maternal death. The immediate cause of Mrs. X's death was haemorrhage caused by placenta previa. This condition, however, is not always fatal, and a closer analysis revealed that Mrs. X died because the health facility where she was taken did not have sufficient blood for a trans- fusion. The clinician was not there when she arrived, so Mrs. X had to wait for surgery after she had travelled for four hours to reach the hospital fol- lowing the onset of heavy bleeding. Efficient transportation and a fully equipped, well-staffed facility could have prevented her death. Mrs. X had also suffered from anaemia and minor bleeding episodes earlier in her pregnancy. Basic prenatal care could have resolved her anae- mia, identified the bleeding as a warning sign of a possibly serious complica- tion, and saved her life. In addition, Mrs. X was 39 years old and had not wanted to become pregnant. She had been pregnant seven times before, and had never used a family planning method. She was illiterate, her hus- band was a poor agricultural worker, and her social status in the community depended on the number of children she bore. The case of Mrs. X illustrates that defining the causes of maternal death for a poor, underprivileged woman is a complex task. From a strictly medical perspective, basic care for Mrs. X at a number of points could have prevented her death. Many other problems, however, line the road to mater- nal death. They begin soon after a baby girl's birth and continue through childhood, when malnourishment and poor education make girls more likely than boys to suffer from ill health and lack of opportunity. The road to death continues through adolescence, when girls often marry and be- 20 CAUSES OF THE PROBLEM- continued come pregnant at an early age. In adulthood, many women have little or no access to land, training, wage employment, or other means of financial sup- port. They may be unable to obtain health care or family planning services without the permission of their husbands. Heavy workloads, poor nutrition, and repeated pregnancies often leave them unable to cope with the physical demands of pregnancy, childbirth, and breastfeed ing. They frequently lack access to prenatal care from trained health workers, and at delivery they Tahle 3 PERCENTAGE OF MATERNAL DEATHS DuE TO DIRECT OBSTETRIC CAUSES, FROM SEL ECT ED STU DIES, 1980-85 P E RCENTAGE OF DEATHS CAUSED BY TH ESE C o MPL ICATIONS Maternal Study area mortality Obstructed labour/ rate* Haemorrhage ection Inf Toxaemia Abortio11 uterine rupture B ANGLADESH 600 22 3 19 31 9 I NDONESIA B a li 718 46 10 5 7 INDIA A n a nta pur 874 18 14 16 14 3 ETH IOPIA A ddis Ababa 566 6 2 6 25 4 TANZANIA Four r egio n s 378 18 15 3 17 Z AMBIA Lusak a 118 17 15 20 17 CUBA 31.3 5 19 12 15 jAMAICA 108 23 9 30 10 3 U N ITED STATES 15.3 10 8 17 6 3 *Number of maternal deaths per 100,000 live births SOURCE: Calculated from table in Barbara Hen a11d Anthony R. Measlulm, The Safe Motherhood Initiative: Proposals for Action (Washington, D.C , The World Bank, 1987), using maternal mortality rates prepared by Dr. Roger Rochat, Emory University School of MediciTif!, Masters in Public Health program, using data from original studies. - j __ _ .l:t_ ----~-""-- - ~w....-&<~~~--"'- CAUSES OF TilE PROBLEM- continued --=--~=--=---- . ._.._____. . _ --._ •• --- -.-. • 21 may be attended by relatives, untrained traditional birth attendants, or by no one at all. When complications arise, the inaccessability of health facili- ties and, often, the facilities' inability to provide adequate care, can be the OBSTRUCTED L ABOUR, NIGERIA final steps on the road to maternal death. Bola, 17, and her husband were farmers living in a remote village of Nigeria. They had their own small house with no eleelricity, and an THE MAJOR OBSTETRIC COMPLICATIONS open field that served for disposal of refuse and excreta. The couple had no formal education, and Bola The five complications which cause an estimated 75 percent of ma- was married at 13. Her first child was born dead after four days of la- ternal deaths require different levels of care for prevention or treatment. bour. The prolonged and obstructed They are defined as "direct" maternal deaths, that is, deaths caused by com- labour created a hole between Bola's bladder and her vagina. The conse- plications of pregnancy, delivery, or their management (e.g., induced abor- quences of this fistula are inconti- nence and a persistent smell of stale tion, caesarean section). Indirect deaths are those due to other medical urine, which makes many women suffering from this injury virtual factors that were aggravated by pregnancy. outcasts. Bola underwent recon- structive surgery, however, and be- • Haemorrhage, one of the most common causes of maternal death, is came pregnant again two years later. difficult to predict. It generally requires treatment within two hours Living far from a health centre, she had no prenatal care. at a health facility able to provide blood transfusions and perform In the seventh month of her preg- nancy Bola started to bleed from other clinical measures if the woman's life is to be saved. the vagina while carrying water home from the river. Later that day • Obstructed labour also requires treatment at a hospital or equivalent her membranes ruptured and la- bour started. After three days of la- facility that can perform operative delivery. bour without progress, Bola was • Infection, or sepsis, is a common result of poorly performed abor- taken to the hospital in a state of distress, with a high temperature tions and unsterile procedures during delivery. It can also result and pulse rate. Although the baby was small, rigid scar tissue from the from prolonged labour; when a woman's membranes have ruptured fistula repair was obstructing its de- livery. The baby died before it could and she has not delivered within twenty-four hours, serious infection be delivered, and was removed by surgery in the hospital. On the third usually ensues unless prevented by antibiotics. day after delivery Bola was still very • Toxaemia is a condition of high blood pressure which can lead to con- ill. Infection from a r uptured uterus was diagnosed, and Bola's poor con- vulsions- eclampsia- and death if not treated in its early stages. It dition because of u ndernourish- ment and anaemia militated against can be detected and its complications prevented by competent pre- her recovery and survival. In spite of surgery to remove her. infected natal care. uterus, Bola died in the hospital. • Unsafe abortion, performed with unclean instruments and in unsani- Source: World Health Organization tary conditions, is the frequent result of unwanted pregnancy. Where Case Histories abortion is illegal, women are often reluctant to seek medical care if they begin to haemorrhage or show signs of infection after under- going the procedure, and consequently many die. 22 WAYS TO IMPROVE MATERNAL HEALTH The participants at the Safe Motherhood Conference did more than THE CALL TO discuss the causes and consequences of maternal illness and death. They ACTION: also recommended specific actions based on background papers from the Ways to Improve World Health Organization, the World Bank, and other experts, and on Maternal Health their own experience in the fields of maternal health and women in develop- ment. Their recommendations fall into two basic categories: improvements in women's overall status, and improvements in the health services that are a key component of primary health care and that women- particularly preg- nant women- need. - ---- IMPROVING THE STATUS OF WOMEN In the long run, participants agreed, women's status must improve if Safe Motherhood is to be realized. Women's status can be improved in sev- eral ways, most notably by recognizing and supporting the contributions Table 4 SELECTED INDICATORS RE LATING TO WOMEN, HEALTH, AND DEVELOPMENT, BY REGION (ABOUT 1982) Percentage of adults who Number ofchildrm are literate Percmtage of women age per woman R£gion Male Female 15-19 married (total fertility rate) AFRICA 33 I5 44 6.4 North 44 IS 34 6.2 West 20 6 70 6.8 East 29 I4 32 6.6 Central 35 9 49 6.0 Southern 55 56 2 5.2 ASIA 56 34 42 3.9 Southwest 58 3I 25 5.8 Middle South 44 I7 54 5.5 Southeast 75 53 24 4.7 East 97 92 2 2.3 LATIN AMERICA 76 70 I6 4.5 Centr al 75 67 2I 5.3 Caribbean 67 66 I9 3.8 Tropical South 74 67 I5 4.6 Temperate South 93 9I IO 2.9 O CEANIA 90 88 IO 2.8 NoRTH AMERICA 99 99 II 1.8 EUROPE 96 93 7 2.0 U.S.S.R. IOO IOO IO 2.4 WORLD 67 54 30 3.8 Developed 98 97 8 2.0 Developing 52 32 39 4.4 SouRCE: Compiled !Jy World H ealth Organization --- - - ---- WAYS TO IMPROVE MATERNAL HEALTH- continued -._- ___ ._ - ----- --" -- --- 23 women routinely make to their families and their communities, and by changing the attitudes and practices that undermine women's health and undervalue the role women play as members of society. However, women's role as producers of children influences and is influenced by their role as producers in the economic arena. Women gather firewood for cooking. They fetch water for cooking and cleaning, sometimes walking five to ten kilometres a day or travelling overnight. Especially in Africa, they grow most of the agricultural produce and as much as 80 percent of the food. They often work in fields or factories for eight or more hours a day, in addition to their responsibility for cooking, cleaning, and caring for the children. Increasingly, women are the sole supporters of the family, as men abandon their wives or go to cities to try to find work. In Bangladesh, where perhaps one-quarter of poor households are headed by women, one study found that when a woman died in childbirth, the infant she was carrying also Figure 3 INFANT MORTALITY BY MOTHER"S Eouc ATION (IN YEARs), SELECTED CouNTRIES 150 7+ 4-fi 1-3 0 Egypt Kenya Peru Trinidad &-li>bago Sri Lanka indonesia •Number of infant druths (under one year of age) per 1,000 live births SoURCE: Calculated IJy Dr. Gwendolyn J ohnson-Acsadi from World Fertilit_v Sumey data. /984. 24 WAYS TO IMPROVE MATERNAL HEALTII- continued -- - - - - - died in 95 percent of the cases. The survival and health of young children usually depend heavily on the continued good health of their mothers. Women in rural areas work particularly hard, and yet rural develop- ment efforts that fail to take women's roles into account sometimes worsen rather than improve their situation. One study in an Indian village found that the purchase of a tractor expanded the area of land in use and facili- tated the men's job of ploughing; but for the women who fertilised, weeded, Out of Safe Motherhood all kinds and processed the crops, the tractor created twice as much work and placed of other safeties flow: safety for even greater demands on their time and bodies. Other development efforts, infants and their older siblings, such as well-designed agricultural extension programmes and efforts to im- safety for the family unit and prove local water supplies, can ease the burden on women and increase structure. Not least in importance their economic productivity. As Dr. Mary Racelis of UN ICEF pointed out, is the safety of women themselves. studies show that women's general health is worsened, and their suscepti- bility to complications in pregnancy and childbirth is increased, by the time -DR. NAFIS SADIK, United Nations Furui for Population and effort they must spend working. Because women work so hard and con- Activities tribute so much to sustaining their families, it is even more important that they have access to the services and support that will ensure their good health and survival. Many of the conference participants emphasised the important con- tribution of education to the health of women and their families. Education, they explained, provides women with the skills, knowledge, and confidence to plan healthy diets and protect family hygiene; to read instructions for giving medicine to their children or for using a family planning method; to improve their farming techniques and count the money they receive from Mothers are not dropped from selling produce; to apply for a loan to purchase fertiliser for their farms; heaven. They are born as under- and to obtain jobs as bank clerks, doctors, or prime ministers. valued, neglected girls and grow Education is only part of the answer. Women also need proper nutri- as exploited, uneducated children. * must look at the suffering and tion from early infancy on; this is especially important if their bodies are to be prepared for the demands of pregnancy and childrearing. They need disadvantages the mother-to-be money to purchase necessities for themselves and their families, and for that has experienced. She must become they generally need employment that does not exploit them or demand long self-confident and self-reliant, hours away from their homes. Perhaps most fundamentally, their contribu- and for that she needs to be edu- tions need to be valued by society, so that they will be encouraged and sup- cated and employed. ported as they strive to control their lives and broaden their choices. -DR. HARCHARAN SINGH, J ennifer Mukolwe, head of the largest grass-roots women's organisation in Health arui Family Welfare Plan- ning Commission, Iruiia Kenya, emphasised that development programmes can be more productive if the people who develop policies and implement programmes listen to women's preferences and involve women in the process. Dr. Nafis Sadik agreed, noting that it is important for women to help design and manage projects as well as be their target. Outside the time of medical crisis during pregnancy and childbirth, which should be prevented as CHANGING ATTITUDES, PRACTICES, AND LAWS often as possible, women should In some countries traditions that contribute to women's poor health not be seen as passive beneficiaries and limit their opportunites are deeply rooted and strongly held. Dr. of health and social services, but Wiltshire johnson, minister of health from Sierra Leone, cautioned that as active and responsible individ- efforts to change such customs as early marriage, female circumcision, and uals, who have the right to giving birth alone need to be undertaken carefully to avoid being rejected. participate in decisions on what Traditional birth attendants (fBAs) and other accepted figures in the com- is good and not good for them- munity have authority and the opportunity for daily interaction with local selves and their families. In order people. Women's groups often address a variety of practical economic or to do that, women need informa- health issues that are important in people's lives. Properly trained and moti- tion and they need the minimum vated, TBAs and representatives of women's groups can provide an effective of material resources. avenue for changing attitudes and teaching better health practices to com- -DR. LisE OsTERGAARD, munity members. University of Copenhagen, Denmark Another avenue for reaching communities is through education pro- grams. Experience has shown that the results of literacy campaigns and other educational efforts are more likely to be retained if they use informa- tion that is directly relevant and useful to the community. Incorporating information on maternal health into general health education efforts is one way to strengthen both educational campaigns and programs to reduce ma- ternal mortality. Radio is frequently used in health education programmes, and is an important channel for communication throughout the developing world. The mass media have already proven useful in promoting family planning and good nutrition, especially in much of Latin America and Asia. Information campaigns not only make people aware of what services exist, but also help convince people to use them. The media are crucial for alerting policy makers as well as the com- munity that a problem exists, and that something can be done to solve it. Hilary Ng'weno, editor of the Kenya Weekly Review, emphasised that report- ers need to have access to information and understand it in order to trans- late it for consumption by the public. The media can help generate and sustain public support for Safe Motherhood programmes, as well as pro- mote social and economic changes necessary to improve women's status. 26 WAYS TO IMPROVE MATERNAL HEALTH- continued One of the urgent needs in much of the developing world, empha- sised Rami Chabbra of India's Ministry of Health and Family Welfare, is to change laws that act as obstacles to women. Laws or customs sometimes severely restrict the provision of family planning services. In some places a Attitudinal change also implies woman must have her husband's permission to legally obtain a con- that programmes to improve ma- traceptive. Other laws prohibit non-physician health workers from providing ternal health should look beyond the most basic health services. In one African country, for example, nurses the reproductive years, to girls at are not allowed to use stethoscopes. Dr. Barbara Kwast of the World Health school and to mature women who Organization reported that in some countries a woman cannot leave her have completed their families and village without the permission of her husband or a male relative- even if who will have a strong influence she is haemorrhaging in childbirth and desperately needs medical care on coming generations. It also within an hour or two. implies a strong commitment to In other countries girls still marry at age fourteen or younger, and attitudinal change among men, society places considerable pressure on them to begin childbearing early to not merely as decision-makers at prove their fertility. In Africa, 55 percent of the teenagers are married; in the higher levels of society, but as the Indian subcontinent that figure is 58 percent. Adolescent pregnancy, fathers, husbands, and sons. which poses a substantial threat to the physical and mental health of young mothers and their infants, is a problem of growing concern to policymakers -DR. NAFIS SADIK, United Nations Fund for Population in almost every society. In many regions, high rates of adolescent fertility Activities also reflect an increasing number of out-of-wedlock pregnancies. For these young people, stated Bradman Weerakoon, secretary general of the Interna- tional Planned Parenthood Federation, counselling and family planning services must be offered in an understanding environment. Several speakers emphasized that before such laws and customs can be changed, decisionmakers at all levels need to understand why change is necessary. A complete understanding enables them to be involved, edu- cated, and committed to maternal health programmes specifically, as well as to the broader social, economic, and political issues relating to women's sta- tus and needs. Conference moderator Dr. Fred T. Sai of the World Bank explained, "Men in the developing world still dominate as decisionmakers in the family, community, and government. They need to understand the im- portance of supporting women's activities and programmes to improve women's health for the sake of the entire community. Our role;' he added, "is both as actors and advocates. We must do what we can to implement these recommendations ourselves, and we must generate the commitment and the political will to convince others to take action:' 27 1 ; WAYS TO IMPROVE MKfERNAL HEALTI--l- continued _: __.._ ~ .1· - -- - - - - - - - -- - HEALTH SECTOR STRATEGIES The participants acknowledged that in the long term, economic de- velopment and the expansion of women's opportunities are critical to im- proving women's health and increasing the availability of health services. But today and tomorrow, in every rural village or urban slum in the developing world, programmes can be implemented in the health field itself that will have an immediate impact on the problem of maternal mortality and mor- Four essential elements for a bidity. These programmes are not expensive; they do not require a huge maternal health programme are: investment in infrastructure and manpower development to save thousands FIRST, adequate primary oflives. What they do require, observed Dr. Carl Wahren of the Swedish health care at all levels and International Development Authority, is the commitment and political will an adequate share of the to implement a few basic strategies, and the creativity to work within limita- availahle food for girls from tions to devise new ways to improve services. Several participants cautioned infancy to adolescence, and that if these programmes are to be effective they must be tailored to the family planning universally needs, conditions, and preferences of the communities they are designed to availahle to avoid unwanted benefit. They should also provide the necessary care at the lowest cost and or high risk pregnancies; most peripheral level possible in order to reach the maximum number of SECOND, after pregnancy be- people. A concerted effort to involve women actively as service providers gins, good prenatal care, in- and educators can help guarantee that such programmes will be culturally cluding nutrition, with acceptable, have wider outreach, and be more successful. efficient and early detection and referral of high-risk patients; THE THREE-PRONGED APPROACH THIRD, the assistance of a The World Bank background paper by Dr. Barbara Herz and Dr. An- trained person for all women thony Measham outlined a three-pronged approach to reducing maternal in childbirth, at home or in a mortality and morbidity. To improve prenatal care, provide help during de- hospital; and, livery, and expand family planning services, this approach focusses on the FouRTH, women at higher following three components: risk and, ahove all, women in 1. Stronger community-based health care that relies on non-physician those dire emergencies of health workers to screen pregnant women, identify those at high risk, pregnancy and childbirth, and refer high-risk cases for timely help. Community-based health must all have effective access workers can provide prenatal care and ensure safe delivery for to the essential elements of women who are not at high risk. They can also provide family plan- obstetric care. ning services and family life education and generally promote better - D R. HALFDAN MAHLER, World family health and nutrition. Health Organization 28 WAYS TO IMPROVE MATERNAL HEAL1H- continued 2. Stronger referral facilities- hospitals and health centres with beds- to serve as a back-up to community-based care. These facilities can treat complicated deliveries and obstetric emergencies and provide clinical and surgical methods of family planning. THE ROLE O F NON-PHYSICIANS IN M ATERNAL HEALT H AND FAMILY PLANNI NG IN KARAWA, ZAIRE The CEUM Hospital ofKarawa serves approximately 250,000 inhabitants in a 19,000 square kilometre area near the equator in northwestern Zaire. Health facilities in the region are very isolated because of poor or nonexis- tent roads and the lack of modern means of communication. The physical facili- ties are inadequate, funds and equipment scarce, and trained medical staff in short supply. There are three to four full-time physicians at the Karawa Hospital, or approximately one physician for 60,000 to 80,000 inhabitants. Because of the extremely low physician-patient ratio, the paramedical staff (consisting of approxi- mately 100 nurses, midwives, auxilliaries, and ancillary health specialists) p lay an innovative role in the provision of health services, especially maternal and ch ild health care. As part of an expanding primary health care programme, the hospital has instituted an extensive outreach programme to increase the access of rural women to maternity care and to expand prenatal care. Traditional Birth Attend- ants (TBAs), nurses, and midwives play a critical part in the programme and in the back-up referral system that has been established. A typical TBA in Karawa is a middle-aged woman, a mother or grandmother, who has been asked on multiple occasions to assist at the deliveries of neighbours or relatives. Almost all are illiterate, and their knowledge is gained by experience or handed down from their mothers. They are recognized and trusted by the peo- ple in their community. A training programme instituted in 1982 teaches them improved delivery practices, how to identify and refer high-risk women, and when to refer problem deliveries !o the hospital. TBAs are also taught and encouraged to provide family planning education and to refer couples who intend to choose a method of contraception to the hospital or nearest health centre. Community participation in the TBA programme is essential. The community contributes money to pay for TBA kits and families are asked to pay a small fee for each delivery. Some villages have built small maternity units where women can go to deliver their babies rather than delivering them at home. A 38-bed maternity centre is staffed by one doctor, five nurses, seven mid- wives, and a variable number of students. Maternity centre staff are responsible for the prenatal clinic, deliveries, family planning clinic, TBA referrals, newborn nursery, and gynaecological surgery. Considerable time is devoted to improving the quality and quantity of prenatal care. The hospital has instituted an extensive outreach programme to encourage women to make at least one visit to the clinic during their pregnancy. They are given tetanus vaccinations, iron and vitamin supplements, and other treatments as necessary. The high-risk women (those with pre-eclampsia, infectious diseases, previous caesareans, etc.) are brought to the attention of the doctor. Low-risk patients are informed that their deliveries may be performed by the village TBA or local health centre nurse. A hospital-based maternal mortality study in 1983 showed that only 9 percent of the women had made no prenatal visit during their pregnancy. These women had a 15-fold in- crease in their mortality rate. Most deliveries at t he centre are attended by midwives or nurses. In order to reduce the demand on physicians and improve patient care, surgical procedures such as caesareans, laparotomies for u terine rupture, and minilap surgical ster- ilizations are performed by specially trained nurses. These nurses have had exten- sive on-the-job training under the supervision of physicians. WAYs,Jro.IMPR6VE ~ATERNAL HEALTH- con~i7J:ued 29 ' I _.l.'-' l · .: _-:s_......._....... -......__ .~.--' ~~-.::...-~ -- . l 3. An "alarm" and transport system to transfer women with high-risk pregnancies and emergencies from the community to the referral facility in time for effective treatment. Experience shows that if the nurses are guided and supervised properly, their performance of obstetric and surgical procedures compares favorably in safety and efficiency with that of the physicians. In addition, nurses are more available and-when they are women-culturally more acceptable to the patients than physicians. The experience of the referral hospital in Karawa indicates that Safe Moth- erhood is possible in rural areas with the use of available resources. Acceptable maternal health care can be provided even in those areas where physicians are in short supply. Non-physicians can provide most maternity care services and can be trained to recognize and refer women at high risk to the health centre physicians. Although the collection and statistical analysis of the data is not complete, some conclusions about the programme are possible: 1. The use of non-physicians, especially TBAs, is the only means by which any health care can be provided to the women and children in the villages of Karawa either now or in the near future. 2. Supervision ofTBAs and the support of the community are the keys to the success of such a programme. 3. A well-equipped centre should be available for emergencies and for referral of high-risk mothers. The establishment of such a centre is essential before a programme for non-physicians can be initiated. 4. Data collection is a difficult problem in rural areas, but it is necessary for measuring the impact of the programme and determining the need for changes. Therefore a simple, low-cost data collection system should be built into the programme. If these recommendations are applied, then the goal of health for all by the year 2000 can be realised and mothers in rural areas can expect to have safe deliveries and healthy babies. Source: Presentation by Dr. Sambe Duale, Medical Director, Rural Health Zone of Karawa Types ofDeliveries and Some Surgical Procedure.f Performed by Nurses or Doctors in Karawa, Zaire, 1986 NURSE DOCTOR Normal deliveries 1943 28 Dystocias 479 69 Caesareans 179 41 Minilaparotomies 93 11 Laparotomy for uterine rupture 13 11 Other laparotomies 11 17 30 WAYS TO IMPROVE MATERNAL HEALTII- continued Mobilising Community-Based Care- Community health workers and tradi- tional birth attendants (fBAs) are often the only viable source of basic pre- natal care and family planning services in isolated communities, and are generally the main source of help in pregnancy and childbirth. Even so, less than half the births in developing countries are attended by a trained health worker. Some training programmes for TBAs have resulted in safer deliv- eries. Other programmes have been less successful. Improving the skills of community health workers and TBAs, providing them with equipment, and enlisting their assistance and support in disseminating information to the community are critical steps to improving health care for pregnant women at the community level. Figure 4 PERCENTAGE OF BIRTHS ATTENDED BY TRAINED PERSONNEL, BY REGION (ABOUT 1982) 100 RO l ] 60 ~ - ---- - ~ l "' ~ 40 :s "" Africa Asia Caribbean South North Northern America America Europe SoURCE: Estimates Jram the World Health Organizaliorl. • I • - - ' ' Jll.fiB'_._ '·- -- - i ......._._:--~-- · · · · ·.....:__..-. WAYS TO ,IMPROVE MATERNAL ..HEALTH -:-,continued 31 -- -- -- TBAs and community health workers can often be trained to detect anaemia and malaria and provide treatment; to recognise signs of potential complications such as toxaemia; and to obtain information on age, men- strual and obstetric history, marital status, general health condition, and TRADITIONAL BIRTH ATTENDANTS IN estimated date of delivery. Some projects that have been particularly suc- SOUTHERN ETHIOPIA cessful in working with TBAs suggest that they may be able to identify a In Southern Ethiopia the govern- ment is working with a nongovern- significant proportion of the pregnant women who develop the majority of mental religious organization in one district to provide a service which the life-threatening complications. A project in rural northeast Brazil, for involves Traditional Birth Attend- ants (TBAs) in a team effort. They example, trained 620 TBAs, who now refer high-risk women to a hospital have succeeded in significantly re- for delivery and conduct safe deliveries in forty communities. ducing the incidence of ruptured uterus caused by obstructed labour. The success of such community-based services often depends on the Trained by the primary health care team- the first rung of the national principle of outreach: the community must be actively involved and mobi- health service, which can deal with emergencies such as haemorrhage lised to contribute to health programmes. Community workers, village but cannot perform surgery - the TBAs are visited regularly once a women's groups, and other nongovernmental organisations that work in iso- month. The job of each TBA is to lated communities are important and often neglected resources for reach- identify all the pregnan t women in her village and to conduct the p l·e- ing women with services and information through house-to-house visits or natal clinic together with the visiting midwife. She and the midwife deter- group discussions. mine who risks having a complicated delivery and at what stage a woman Penina Ochola, a nurse trainer working for the African Medical and should b e taken to a hospital for observation. Research Foundation in Kenya, emphasised the importance of community- Because not all problems can be based efforts for providing information and training so that women can anticipated, the T BA uses a mes- senger who will run and walk- for control their lives and solve their problems themselves. "There is a critical as long as three hours- to alert the nuns at the primary health care post need;' she said, "for community-based health programmes that motivate in cases of an emergency. The nuns then move out with a Landrover to and involve the people in that community, and generate their participation:' pick up the patient and tran sport her to the first-referral facility of These participatory projects, Ms. Ochola explained, help members of the the health care system. community agree on what should be done, and help generate support for The system functions well because there is support and coopera tion all the necessary changes. down the line. Furthermore, the TBA, who already has the trust of Dr. Ransome-Kuti, minister of health from Nigeria, cautioned that the community, can introduce the women to new ideas about preg- because isolated communities have few alternative mechanisms for obtain- nancy and childbir th. ing health care, the activities of community health workers must be ade- Source: World Health Organization quately monitored, supervised, and supported. Health workers need Case Histories ongoing training, he emphasised, and close, frequent supervision to ensure that they have adequate supplies and that the information they are obtaining and providing is accurate and meets the needs of the community. 32 WAYS TO IMPROVE MATERNAL HEALTH- continued Table 5 SELECTED INTERVENTIONS AT PRIMARY AND FIRST-REFERRAL LEVELS Cause of matemal mr>rtalityj morbidity lnterve111ioru Health system level ALL Family Planning P rimary & I st referral Prenatal care Primary Supervised delivery Primary HAEMORRHAGE Risk screening; referral Primar y Other prenatal care, including treatment of anaemia Primary Oxytocics when placenta d elivered" Primary Intravenous fluids Primary Transport to lst referral level Primary Ma nual removal of placenta• Primary Blood typing of donors l st referral Blood transfusion l st referral INFECTlON Risk screening, referral Primary Tetanus immunization Primary Clean delivery Primar y Antibiotics when membranes ruptured if not delivered within 12 hours" Primary Transport to lst referral level Primary H ysterectomy l st referral TOXAEMIA Monitor symptoms, blood pressure, and urine (for protein) Primary Bed rest, sedatives Primary Transport to lst referral level Primary Induction or caesarean section I st referral COMPLICATlONS OF Antibiotics• Primary ABORTION Transport Pr imar y Oxytocics Primary Evacuation 1st referral Hysterectomy I st referral OBSTRUCTED Risk screening, referral Primary LABOUR Partogr aph Primary AND RUPTURED Transport to l st referral level Primary UTERUS Symphysiotomy l st referral Caesarean section l st referral NoTE: Primary level includes outreach programmes and health dispensaries, posts, or centres. First-referral level would usually be a "district" or cottage hospital with twenty or more beds and the capability of giving blood transfusion and performing caesarean sections. a Recommended experimental approaches at the community level. SouRCE: &rbara Hen mul Anthony R. Measham, The Safe Motherhood Initiative: Proposals for Action (Washington, D. C, The World Bank, 1987) _ ' 1 _jJ~---~---'"•- ~---.t-...- WAYS TO IJy~PROVE MATERNAL HEALTH- continued : -. - - ___;c,..'..._,_ 33 First-Referral-Level Facilities- Conference participants agreed that com- munity-based maternal health care needs to be supported by adequately staffed and equipped health facilities at the first -referral-level- usually a district hospital or large health centre with beds. Although community workers and TBAs can provide information, risk screening, prenatal care, simple medications, and treatment, more advanced facilities for delivery and treatment are required for high-risk pregnancies and obstetric emergencies. These include obstructed labour, massive haemorrhage, eclampsia, and se- rious infection, as well as incomplete or infected abortion. Dr. Kwast of WHO explained that approximately 80 percent of maternal deaths are due to these direct obstetric causes and are basically preventable. In deprived areas the complication rate for deliveries can be as high as 30 percent, and even in an ideal situation at least 5 to 10 percent of pregnancies require operative delivery, blood transfusion, or treatment of convulsions. The seven functions defined as essential for first-referral-level facilities lJy the World Health Organization are: 1. SuRGICAL FUNCTIONS which include caesarean section, surgical treatment of sepsis, repair of high vaginal and cervical tear, laparotomy for repair of ruptured uterus, removal of ectopic pregnancy and evacuation of uterus in uncomplicated abortion; 2. ANAESTHETIC FUNCTIONS; 3. MEDICAL TREATMENT FUNCTIONS which include treatment of shock, medical treatment of sepsis, control of hypertensive disorders ofpregnancy and eclamptic fits; 4. BLOOD REPLACEMENT which includes administration of blood transfusion and plasma expanders; 5. MANUAL AND/ OR ASSESSMENT FUNCTIONS, which include manual removal ofplacenta, vacuum extraction and the use of the composite partograph; 6. FAMILY PLANNING FUNCTIONS, which include surgical fam- ily planning (tubal ligation and vasectomy), IUDs, Norplant, and other contraceptives; 7. MANAGEMENT OF WOMEN AT HIGH RISK, which necessitates maternity waiting homes for timely referral. - 34 __._-_ WAYS TO IMPROVE MAfERNAL HEALTH- continued r • - -- - Dr. Kwast drew on her years of field experience in Africa to illustrate CHINA: S YSTEMATIC MATERNAL HEALTH CARE IN SHANGHAI the functions that are essential at the first-referral-level. Facilities at this Established at the time of the rev- level frequently lack blood for transfusions, electricity to run equipment, olution in 1949, the maternal health care system in Shanghai, China, clean water, sterile instruments or gowns, anaesthesia, antibiotics or other covers both the urban district and the rural county of Shanghai. Under drugs, beds, or enough clinicians to staff the facility at all times. These facili- the mun icipal hospital are twelve district and ten county hospitals ties can be upgraded to meet the need for first-referral-level obstetric care with maternal and child health in the surrounding community without a huge investment in equipment or (MCH) care centres and o bstetric- gynaecology and pediatrics depart- personnel. ments. At the next lower level are 104 subd istrict and 200 commune Some remote areas have tested a system of maternity "waiting hospitals with MCH units. They are staffed by both medical personnel homes" located next to referral facilities. Pregnant women can go to these and auxiliary workers such as mid- wives. The final level is the health homes a week or so before they are due to give birth, and can be trans- station where the so-called barefoot ferred promptly to the facility if complications develop. In some cases mem- doctors are based. The municipal hospital focuses on bers of their families stay with the women, providing their own food and referred complications while most normal deliveries occur at district, bedding. The homes are usually maintained by the communities whose county, or commune h ospitals. The district or county hospital screens members use the facilities. for high risk, holds prenatal and postnatal clinics, and sponsors Trained nurses and other non-physician personnel can be taught to maternal and child health care re- perform procedures such as manual removal of the placenta, caesarean sec- search. The subdistrict hospital reg- isters the pregnant woman and gives tion, treatment of septic abortions, and mini-laparotomy for sterilisation. preliminary prenatal care. Further, subdistrict and commune hospitals This was done very successfully in a referral hospital in northwestern Zaire supervise primary health care work- ers, screen and treat gynaecological (see page 28). Some physicians have questioned the use of non-physicians to disease, provide child health care, and collect data. The barefoot doc- perform such functions, but as Dr. Beverly Winikoff of the Population tors make pren atal and p ostpartum Council pointed out, "Given the lack of resources and personnel, it isn't a home visits and offer family plan- ning consultation and distribution, question of a nurse Gsection versus a doctor Gsection. It's a question of a vaccination, education on hygiene, and care durin g menstruation, nurse Gsection or no C-section at all, and probably death:' Dr. Judith pregnancy, puerperium, and lactation. Fortney of Family Health International, discussing the success of the pro- Maternal mortality per 100,000 live births has dropped from 320 in gramme in Zaire, emphasised that the centre there "was no richer, the 1949 to 30. In 1980, a lmost every equipment no better, the patients no healthier than in any other community. pregnant woman in Shan ghai parti- pated in prenatal care with an aver- What made the difference in Karawa was the commitment and creativity of age of 10.5 visits. Even postpartum care had reached 73.1 percent of the people involved" in developing and implementing innovative pro- the women, with an average of 2.6 visits. grammes that make the best use of scarce resources to meet the needs of Referral was facilitated by mater- nity cards given to the mother at the community. registration. The cards were re- turned to the subdistrict or com- mune hospital after birth so that '?i.larm" and Transport System- Ensuring that first-referral-level facilities postpartum visiting could take are staffed and equipped to deal with obstetric emergencies is not enough if place. women cannot reach the facilities in time, or cannot reach them at all. The Source: The World Bank World Bank and WHO, therefore, recommended the implementation of an "alarm" and transport system, especially for rural areas. The system would use local communication channels, including radio, to call on whatever ._ WAYS TO IMPROVE MATERNAL HEALTH- continued 1i.... __ ---...~-~--~- _ ~----. 35 means are available in the community to transport women with high risk and complicated pregnancies to the nearest first-referral-level facility. This mechanism was cited as an excellent example of how the com- munity can make an important contribution to Safe Motherhood. As Dr. Sadik said, "All communities place a high priority on health, which even in low-income societies- as we have found by experience- produces a willingness to mobilise resources for that purpose. If the means and the direction are made clear, the community can often provide staff, premises, and even transport:' In pointing out the importance of adequate transpor- tation mechanisms to the success of Safe Motherhood programmes, Dr. Adetokunbo Lucas of Carnegie Corporation said, "the coverage and effec- tiveness of the health care system need to be measured not by the number of clinics in existence, but by the number of women being served and the num- ber of lives saved:' THE IMPO RTANCE OFFAMILY PLANNING Several conference sessions illustrated how family planning services improve women's health. High rates of maternal mortality in the developing world reflect not only the poor health status of these women but also the large number of pregnancies. Thus, the number of women dying can be lowered both by reducing the risk associated with pregnancy and by reduc- ing the number of unwanted pregnancies through the wider use of family planning. Increased use of effective contr aceptive methods lowers the num- ber of births; the impact on the number of deaths, however, will be more than proportional, explained Dr. Robert Cook of WHO, because women at high risk are more likely to use family planning to avoid pregnancy. Deborah Maine of Columbia University's Center for Population and Family Welfare analysed data from the World Fertility Survey to estimate that maternal deaths in many developing countries would be reduced by 25 to 40 percent if all women who explicitly say that they want no more chil- dren were using a contraceptive method effectively. World Fertility Survey estimates show that some 300 million couples around the world would like to postpone pregnancy or avoid it altogether, but have no access to family planning services. " 36 WAYS TO IMPROVE MATERNAL HEALTH- continued . Table 6 COMPARATIVE ADVANTAGES AND DISADVANTAGES OF CONTRACEPTIVE TEC H NOLOGY Method Major advantages Major disadvantages Commml PILL Effective Some side effects Progestin-only pill more Unrelated to coitus Small mortality risk suited to breast- Helps protect against Must take daily feeding mothers anaemia, PID Not indicated for Protective effect against Can be provided adolescents anaemia, PID nonclin icall y IUD Long term Does not protect against Newer forms much Effective ectopic pregnancy improved Unrelated to coitus Associated with some Can be inserted increase in bleeding, postpartum PID Requires more clinical backup CONDOMS Nonsystemic Not always effective in Easily stored use No side effects May reduce pleasure l NJECTABLES Long acting Minimal side effects Not officially approved as Unrelated to coitus Removal of implants contraceptive Can be provided requires clinical everywhere nonclinically backup fEMALE Effective Virtually permanent Minilaparatomy very safe STERILISATION Unrelated to coitus on outpatient basis MALE Effective Virtually permanent Cultural resistance in STERILISATION Unrelated to coitus some areas R HYTHM AND No side effects Relatively ineffective in Dete rmining time of OTHER Approved by Catholic use because of ovulation can be Church difficulty in difficult if NATURAL calculating safe thermometer not FAMILY period or reluctance available PLANNING to abstain before and Checking mucus in during that time a bsence of clean water not hygienic BREASTFEE DING Relatively unreliable for Inhibits ovulation but the individual not with enough predictability to recommend for individual women NOTE : PID = pelvic inflammatory disease SouRCE: Population Growth and Policies in Sub-Saharan Africa (Washi11gton, D. C, The World Bank, 1986) based on information from the United States Centers for Disease Control ·1. __.---""'"-=-- WAYS TO IMPROVE M.tiTERNAL HEALTH- continued ~~~ •• 4[_--..... - - 37 Several speakers emphasised that family planning programmes need to offer a variety of contraceptive methods, and that services and informa- tion must be of high quality and culturally acceptable. Because women are often more comfortable going to other women for services and advice, hav- ing well-trained women participate as providers helps ensure greater accept- ability by the community. Each individual must be fully informed about the risks and benefits of the methods available as well. Women who lack access to such information often have an exaggerated perception of the health risks of various contraceptive methods, especially in comparison with the potential complications of pregnancy. Dr. Allan Rosenfield, dean of the Figure 5 PERCENTAGE OF MATERNAL DEATHS PoTENTIALLY PREVENTABLE THROUGH FAMILY PLANNING, SELECTED CouNTRIES 100 Mall!mlll t!Ralh< averted if all women with "unmet need"* had no more pref!;TU!ncies 80 Maternal deaths avmed if. in ~ • additiun, womRn aged 35+ had no more pregnaru:zes 60 -- ..- ... I r- ~ ~ r- I"'" 40 M ~ ~ r-- ...- .--- ,........., r-- 20 l l l,i I""" •. ,........ .--- r I· ~~: t ' } ~ }II l,t/ ') II 0 r I i • I J i 0 ~ "0 ~ "' " ·~ ·c: ~ c " "' " I) " "' :0 u ·;; '-'.1 "' J: '-' tZ ~ "0 ::l "' "0 "' "&l c '" ~ "- " ·a. :.§- F "' :; " 0 0 OJ ::E :2 u " ~ "- *Married fecund women who want no more children but are nnlusing an effective contraceptive TTU'lhod. SoURCE: Barbara Her:. and Antlwny R. Measham, The Safe Motherhood Initiative: Proposals for Action (Washington, D.C., The World &nk, 1987), based un data provit!Rd by Deborah Maine, Columbia University. I 8 3• .... ~ - . ,.. WAYSTO ~- - IMPROYE "''"ill - MATERNAL - - - - ..... - HEALlH- continued ----:!!! - ~ " A._ ... I Columbia University School of Public Health, explained that an unwanted, unplanned pregnancy for a woman in a developing country carries a risk twenty times higher than that associated with any commonly available mod- ern contraceptive method. THE AFFORDABILITY OF SAFE MOTHERHOOD Low-income countries currently spend an average of US$9 per cap- ita annually on health care. The three-pronged strategy of providing pre- natal care and basic health and family planning services ~t the community and first-referrallevels can be implemented in developing countries at a cost ofless than US$2 per capita a year, according to Dr. Herz and Dr. Mea- Table 7 EsTIMATED CosT AND IMPACT OF Two SAFE MoTHERHOOD PROGRAMMES Moderate effort More limited effort Before After Before After Population 200,000 200,000 200,000 200,000 Births 9,000 6,000 10,000 8,400 Contraceptive prevalence rate* 9 40 0 16 Birth rate** 45 30 50 42 Maternal deaths 72 24 100 80 Maternal mortality rate*** 800 400 1,000 950 Percent maternal deaths averted 67 20 Number mate rnal deaths averted 48 20 Number births averted 3,000 1,600 US. dollars us_ dollars Total programme cost $300,000 $96,000 Cost per capita $1.50 $0_48 Cost per birth $50 $11 Cost per maternal death averted $6,250 $4,800 Cost per death averted $3, 125 $2,400 Cost per birth averted $100 $60 *Percent of women in union aged I 5 -49 currently using a contraceptive metlwd **Number of live birth.! per 1,000 population ***Number of maternal death.! per 100,000 live births SouRcE: Barbara Herz and Anthony R. Measham, The Safe Motherhood Initiative: Proposals for ACLion (Washing- ton, D.C., The World Bank, /98 7) • - - - ~~ - -·--~~~ ~---~~- WAYS TO IMPROVE MATERNAL HEALTI-I- continued -- - -- -· 39 sham. This investment in "upgrading and expanding referral services and stronger community efforts in maternal health and family planning should reduce maternal deaths by at least half in about a decade:' For countries that cannot afford that investment, increasing annual expenditures by US$1 Improving maternal health per capita could still have a significant impact on maternal mortality. As Mr. services requires: Conable said, '/\. low-cost system that provides basic health care in commu- 1. Upgrading training and nities and timely transportation to more advanced medical help at regional knowledge to improve safety health centers can save thousands of mothers and children. We know that of services for many; such measures can succeed, particularly in conjunction with other develop- 2. Expanding training to new ment programmes to improve women's incomes, food supplies, and levels of personnel to improve education:' access and diminish the dis- tance between women and the location where they may obtain APPROPRIATE TECHNOLOGY AND P ROPER MANAGEMENT adequate assistance; 3. Developing new technologies At both the community level and in referral facilities, health experts that result in simple but safer at the conference emphasised, appropriate technologies need to be adapted techniques which can be made and incorporated into health programmes. Most of these technologies available on a wider scale and already exist; one that has considerable potential for saving lives is the at a lower level of service partograph, a basic tool for assessing the progress of labour that offers an delivery. early warning for complications such as obstructed labour. Vacuum aspira- -DR. BEVERLY WINIKOFF, tion of the uterus can be performed with hand-operated pumps to treat Population Council retained placenta and incomplete abortion. Various drugs, including anti- biotics, can be provided at the community level if health workers are trained in how to use them: oxytocic drugs contract the uterus and its blood vessels in cases of postpartum haemorrhage, and sedatives can be used to treat pre- eclampsia. Research can develop instruments that are easy to use and repair and that do not require reliable electricity. Plasma can be used instead of whole blood. These are only a few examples of practical technologies cited by participants at the conference. Dr. Winikoff of the Population Council emphasised in her presentation that appropriate technology does not only mean new and more complex types of technology; it can also mean advances in knowledge and new approaches to problems. 40 WAYS TO IMPROVE MATERNAL HEAL1H- continued Dr. Ransome-Kuti, minister of health from Nigeria, and others high- MAENDELEO YA WANAWAKE lighted the importance of careful design and good management of health Kenya's largest women's organiza- care systems. Health workers at the community level and at referral facilities tion, Maendeleo ya Wanawake, be- gan providing family planning need to be adequately trained and supervised, and there must be enough of information in 1979. Maendeleo has some 7,500 local groups, with about them; adequate supplies of appropriate drugs, blood, and equipment are 300,000 members, throughout Kenya. Its purpose is to develop needed; and communication channels between the different levels and to projects to raise the living standards the community being served must be clear and reliable. As Dr. Herz and Dr. of its members. According to a recent survey of Measham emphasised, "The system will be no stronger than its weakest ele- women who attended meetings, some 90 percent of Maendeleo's ment .. . No maternal health programme can work effectively through ac- members are farmers and house- wives. About 25 percent have four tion at one level only:· Each country must decide on the most appropriate or fewer children, 30 percent have five or six, and almost 50 percent combination of investing in community-level care, first-referral-level facili- have seven or more. ties, and transportation based on its own needs and available resources. To emphasize the benefits of fam- ily planning, Maendeleo enlisted vil- Different strategies have been devised and implemented to address lage volunteers to provide health and family planning education in a the problem of high rates of maternal mortality, and new methods will con- programme that now reaches most members. The volunteers were tinue to be developed. Conference participants considered operational trained for about two weeks and now hold discussions on family plan- research critical to evaluating the effectiveness and costs of various ning, often for at least half an hour, approaches, and said it should be carried out systematically to ensure that at regular meetings. The volunteers refer interested women to govern- scarce resources are used efficiently and effectively. Operational research ment or private clinics and some- times go with them to reassure can also help ensure that the quality of care is acceptable, and can monitor them. About three-fourths of Maen- deleo members surveyed in five dis- the development and testing of new technologies. parate areas where the programme was operating had heard of family As the Call to Action states, there is a need for more and better infor- planning from these educators or mation on maternal mortality that is country- and locale-specific. Such infor- from Maendeleo leaders. About 40 percent reported using contracep- mation is necessary to tailor programmes to meet the specific needs in the tion, compared with about 8 per- cent of women in the country as a community as fully as possible. whole. Because Maendeleo members had difficulty in actually obtaining fam- ily planning services from clinics- clinics were far away, family plan· THE SPECIAL CONTRIBUTION OF ning workers were unexpectedly ab- sent, and there was a lack of privacy, NONGOVERNMENTAL ORGANISATIONS or the treatment was thoughtless- Maendeleo decided to test outreach programmes that use women from The established position of nongovernmental organisations (NGOs) local communities to help deliver in the communities where they work, their flexibility in responding to the services. Maendeleo now provides services through hundreds of dis- needs and preferences of the people they serve, and their ability to develop tributors in five districts. The orga- nization's efforts have attracted innovative, low-cost programmes often enable them to lead the way in im- considerable attention among pol- icymakers in Kenya, where Maen- plementing effective maternal health initiatives. Dr. Manuel Ruiz de Chavez, deleo members include members of parliament and other political lead- under-secretary of health from Mexico, cited several examples of the inge- ers. Maendeleo also has a seat on nuity with which some organisations have taken advantage of commercial Kenya's National Council for Popu- lation and Development. distribution networks to transport medical supplies or contraceptives. Source: World Bank Other groups have adapted local customs to convey appropriate health -'--·-·--· --~-~-- WAYS TO IMPROVE MATERNAL HEAL1H- continued . ------· ------""'-~· - 41 information on pregnancy, childbirth, nutrition, family planning, and im- munisation. Many representatives of national and international NGOs work- ing in health and education were present at the conference, and spoke of their interest in helping to implement Safe Motherhood programmes. Dr. Sai paid tribute to the importance ofNGOs, saying "they are frequently at the frontier of identifying and solving problems, especially in terms of ad- dressing sensitive problems sensitively:' Local NGOs are sometimes limited, however, by lack of resources, and their strong links to the community can make it difficult for them to expand their programmes to the regional or national level. They need to operate within the framework of national development plans, with the awareness and support of their governments. Participants suggested that governments, in turn, have a responsibility to help and support the activities of NGOs, adopting and duplicating NGO model projects when possible and appropriate. 42 CONCLUSION - I .I Analyses of government health budgets reveal that most developing CONCLUSION countries allocate less than 20 percent to maternal and child health pro- grammes, and the majority of that 20 percent is invested in child health programmes. Yet, the World Bank estimates that the investment of less than $2 per capita per year in programmes to strengthen basic health services for women could cut maternal mortality rates in half in one decade. The com- mitment to make this investment, and to support the improvement of women's general status in society, can ensure that women will be equal part- ners in the development effort. As Mr. Conable said in his opening address, Women'S health is basic to women'S advancement in all fields of endeavour. And as a mother's health is the bulwark of her family, it is the foundation of community and social progress. Working for Safe Motherhood, we will be It is intolerable that so many working for steady development on all fronts. thousands of women are dying It is a goal that is within our reach, and one we must strive to achieve. painful, lonely deaths in the proc- ess of giving life, and we are do- Figure 6 ing so little to stop it. There is no How MANY MATERNAL DEATHS IN THE greater indictment of development YEAR 2000? efforts than the high rates of 2000 Four scenarios maternal death that prevail in much of the world. Noadion 600,000 -DR. ATTIYA lNAYATULLAH, Minister of State for Population, Pakistan 1985 500,000 450,000 MMRhaiVrojr:ctUrn and MMR hal-oed 225,000 SouRCE: Compiled by World Health Organization . •-- ~ ~- ---- - - .. ~ AGENDA 43 DAY 1: Tuesda)'. f(:brum)' 10 AGENDA FOR Presiding Chairman: The Hon. Dr. C.J.O. Nyakiamo, EBS, P.M., SAFE Minister of Health, Kenya MOTHERHOOD Moderator: Dr. Fred T. Sai, The World Bank CONFERENCE N AIROBI, K ENYA OPENING CEREMONY February 10-13, 1987 Speakers: Barber B. Conable, President, The World Bank Dr. Halfdan Mahler, Director General, World Health Organization Dr. Nafis Sadik, Executive Director, United Nations Fund for Population Activities William H. Draper III, Administrator, United Nations Development Programme H.E. The President Daniel T arap Moi, CGH, M.P., President of the Republic of Kenya SESSION 1 Maternal Mortality and Morbidity: Extent and Nature of the Problem Session Chairman: Dr. Shan S. Ratnam, National University of Singapore Speakers: Dr. Robert Cook, World Health Organization Dr. Mahmoud Fathalla, World Health Organization Dr. Kelsey Harrison, University of Port Harcourt, Nigeria S ESSION 2 Role of Women in Maternal Health Problems: Perspectives, Priorities, and Participation Session Chairman: Dr. N afis Sadik, United Nations Fund for Population Activities Speakers: Margaret Kenyatta, Kenya Dr. Lise Ostergaard, University of Copenhagen, Denmark DAY 2: \1/ednt>sda_)', February 11 Presiding Chairman: The Hon. Dr. 0 . Ransome-Kuti, Minister of Health, Nigeria Moderator: Dr. Fred T. Sai, The World Bank SESSION 3 Action Strategies to Improve Maternal Health Session Chairman: Dr. Anthony R. Measham, The World Bank Speakers: Dr. Fred T. Sai, The World Bank Dr. Adetokunb o 0. Lucas, Carnegie Corporation, United States SESSION 4 Community-Based Services: Perspectives from the Field Session Chairman: Dr. Barbara Herz, World Bank Speakers: J ennifer Mukolwe, Maendeleo ya Wanawake, Kenya Dr. H aryono Suyono, National Family Planning Coordinating Board, Indonesia Dr. Ephraim Minya, Ministry of Health, Zimbabwe Dr. Sheldon Segal, Rockefeller Foundation, United States SESSION 5 District Level Interventions Session Chairman: Dr. Allan Rosenfield , Columbia University, United States Speakers: The Hon. Dr. 0. Ransome-Kuti, Minister of Health, Nigeria Dr. Sambe Duale, NIH jSIDA Project, Zaire Dr. Barbara Kwast, World Health Organization Dr. Beverly Winikoff, Population Council, United States - - - - - . - AGENDA- continued .. - ~ - - 45 --~-- SESSION 6 Rnle of the Third Sector: Nongovernmental Organisations Session Chairman: Dr. Ch ristopher H . Wood , African Medical and Research Foundation, Kenya Speakers: Eu nice M. Kiereini, International health consultant, Kenya Bradman Weerakoon, International Planned Parenthood Federation Penina O chola, African Medical and Research Foundation, Kenya D AY 3: J111mday. Febntat)" 12 Presiding Chairman: Dr. Manuel Ruiz de Chavez, Min istry of Health, Mexico Moderator: Dr. Fred T. Sai, The World Bank SESSION 7 Additional Resources for Improved Maternal Health: Contributions from Other Sectors Session Chairman: Dr. Mary Racelis, UNICEF Speakers: Hilary N g'weno, Kenya ~ekly Review Dr. Jose Aristodemo Pinotti , Center for Integral Assistance to Women's Health, Brazil . Dr. Inonge Lewanika, UNI CEF SESSION 8 Building Consensus Themes: Policy Programme Financing Community Mob ilization D AY 4: Frida\', . IJ . Fehrum1· ' SESSION 9 Launching the Initiative Presiding Chairman: Attiya Inayatullah , Minister of State for P&Jlulation, Pakistan Session Chairman: Dr. Fred T. Sai, The World Bank 46 PARTICIPANTS LIST . PARTICIPANTS LIST William Draper, UNDP; The Hon. Mwai Kibaki, Kenya; H. E. The Hon. Daniel arap Moi, President of Kenya; The Hon. C.E.O. Nyakiamo, Kenya DR. ADEDEJI MME. AzARA BAMBA Senior Registrar Ministere de Sante Publique Federal Ministry of Health Ministry of Health Ikoyi Lagos, Nigeria cj o Mr. Richard Traore TELEX 23608 NIGMEA N The World Bank B.P. 622 DR. A.H.M. NuRUL ALAM Ougadougou, Burkina Faso Director, MCH Services TELEX 5265 INBAFRAD, cj o Richard Directorate of Family Planning Traore, World Bank cjo World Bank PHONE 335063 (World Bank) Messrs Sudhakar or Stanton OR TELEX 5555 SEGEGOUV BF GPO Box 97 (Ministry) Dhaka, Bangladesh TELEX 642302 IDABJ (World Bank) Ms. MARINA BARALDINI PHONE 400003/ 4/ 5 (WB) Health Sectoral Policies Unit Directorate for Development MRS. D. c. ANETO Commission of the European Senior Health Planning Officer Communities Federal Ministry of Health 200 rue de Ia Loi Ikoyi Lagos, Nigeria 1040 Brussels, Belgium TELEX 23608 NIGMEA N TELEX 21877 COMEU B DR. HERMAN ANKER PHONE (2) 235-1111 Medical Advisor, Ministry of Development Ms. SHEILA BARRY Cooperation UNICEF Norway lnLernational Development Eastern Africa Regional Office Agency (NORAD) P.O. Box 44145 cj o Oslo City Health Department Nairobi, Kenya St. O laus plass 5 TELEX 22068 UNITERRA 0165 Oslo 1 Norway PHONE 520671 / 2/ 3 or 520734/ 5 TELEX 76548 NORAD N PHONE 47-2-210-070 DR. jOSE L. BARZELATTO Director, Special Programme of DR. ANDREW ARKUTU R esearch, Development and R esearch Deputy Representative and Training in Human Reproduction Senior Adviser on Population in Zimbabwe World Health Organization (WHO) United Nations Fund for Population 1211 Geneva 27, Switzerland ActiviLies (UNFPA) TELEX 27821 UNISANTE cj o UNDP, P.O. Box 4775 PHONE 91-21-11 Harare, Zimbabwe TELEX 4668 MR. M. BECK PHONE 792681 Counsellor Belgian Embassy Development Cooperation Box 30461 Nairobi, Kenya PARTICIPANTS LIST- continued 47 DR. A.l. BEGUM MME. NDEYE SOUKEYE CISSE Chief of Planning Ministry of Social Development Ministry of Health & Family Planning Dakar, Senegal cjo The World Bank TELEX 482 MINAFET SG Messrs Sudhakar or Stanton PHONE (221) 231-088 GPO Box 97 Dhaka, Bangladesh Ms. AMPARO CLARO Coordinator, Latin American & Caribbean TELEX 642302 IDABJ (World Bank) Women~ Health Network PHONE 400003/ 4/ 5 (WB) ISIS International DR. MARK BELSEY Casilla 2067, Correa Central Chief, Maternal and Child Health Rafael Canas 156 World Health Organization (WHO) Departimento 12 1211 Geneva 27, Switzerland Santiago, Chile TELEX 27821 UNISANTE PHONE 490-279 or 225-3629 PHONE 91-21-11 PHONE (6) 656-5842 (ISIS-in Rome) Ms. MARGARET BRAIN MRS. CHARLOTTE CONABLE Honorary Treasurer The World Bank International Confederation of Midwives 1818 H Street NW 57 Lower Belgrave St. Washington, DC 20433, USA London SW1 W OLR, England TELEX 248423 WORLDBK PHONE (1) 730-6137 PHONE 202 477 1234 DR. JAN BROER MR. BARBER CONABLE Margaret Kenyatta, Kenya; Kapenguria District Hospital President Dr. Nafis Sadik, UNFPA P.O. Box 63 The World Bank W. Pokot, Kenya 1818 H Street NW PHONE 9 (w); 64 (H) Washington, DC 20433, USA TELEX 248423 WORLDBK DR. GEORGE BROWN PHONE 202 477 1234 The Population Council One Dag Hammarskjold Plaza DR. RoBERT CooK New York, NY 100I7, USA Senior Medical Officer TELEX 234712 POCO UR Division of Family Health PHONE (212) 644 1760 World Health Organization (WHO) 1211 Geneva 27, Switzerland Ms. RAMI CHABBRA TELEX 27821 UNISANTE Advisor, Media and Communications PHONE 91-21-11 Ministry of Health & Family Welfare Nirman Bhavar DR. BAKO DAOUDA New Delhi, India Medecin, Chef de la Maternite Poudriere TELEX 3166119 DGHS IN Ministere de Ia Sante Publique et des Affaires Sociales MR. K.C. CHIBALE Niamey, Niger Senior Loan Officer TELEX 5270 OMS NI African Development Bank Regional PHONE 160 227 7225231 Office Shelter Afrique House DR. MARCELLA DAVIES Hilary Ng'weno, Kenya P.O. Box 52617 World Health Organization (WHO) Nairobi, Kenya P.O. Box 45335 TELEX 22898 AFDEVNBI Nairobi, Kenya PHONE 723185/ 6 PHONE 720050 Ms. MARY CHINERY-HEssE THE HoN. DR. PATHE DIALLO Resident R epresentative in Tanzania Minister of Health United Nations Development Program Ministere de Ia Sante et des Affaires (UNDP) Sociales cj o One United Nations Plaza Conakry, Guinea New York, NY 10017, USA PHONE 44-3982 PHONE 27411 (in Dares Salaam) MR. WILLIAM H. DRAPER 111 DR. JOHN CHIPHANGWI Administrator Head of OBjGYN United Nations Development Programme Queen Elizabe th Hospital (UNDP) P.O. Box 95 One United Nations Plaza Blantyre, Malawi New York, NY 10017, USA PHONE: 630-333, 633-808 TELEX 125980 PHONE (212) 754-1234 48 PARTICIPANTS LIST- continued DR. SAM BE DUALE DR. KANT! GIRl Medical Director Regional Adviser (Family Health) Rural Health Zone of Karawa World Health Organization (WHO) Gemana, Zaire Regional Office for South-East Asia CURRENT MAILING ADDRESS: World Health House Medical Epidemiologist Indraprastha Estate SIDA Project Mahatma Ghandi Rd. P.O. Box 3494 110002 New Delhi, India Kinshasa-Gombe, Zaire TELEX 3165031 WHOIN TELEX 21405 USEM ZR, cjo Ann Nelson DR. KLAUS GOERDEL at U.S. Embassy in Zaire Head, Department of Health, Population and DR. MAHMOUD FATHALLA Women in Development Special Programme of Human Reproduction Federal Ministry for Economic World Health Organization (WHO ) Cooperationj BMZ 1211 Geneva 27, Switzerland PF 120322 TELEX 27821 UNISANTE D-5300 Bonn I, Federal Republic of Dr. Anthony R. Measham, PHONE 91-21-11 Germany Dr. Barbara Herz, The World TELEX 886 9452 BMZ Bank DR. jOE FERNANDO PHONE 228 535-818 Director-General Health Services Ministry of Health DR. lAID HAMZEH cjo Mr. E. K. Hawkins Minister of Health The World Bank P.O. Box 86 P.O. Box 1761 Amman, Jordan Colombo, Sri Lanka TELEX 21595 HEALTHJO TELEX 21410 (CjO Mr. Hawkins, World PHONE 665131 Bank) DR. KELSEY A. HARRISON PHONE: 21840 or 548070 Professor of OBj GYN DR. J UDITH FoRTNEY University of Port Harcourt Reproductive Epidemiology Division P.M.B. 5323 Family Health International Port Harcourt Rivers, Nigeria Research Triangle Park, NC 27709, USA TELEX 61183 PH UNI (Nigeria) TELEX 579442 DR. BARBARA HERZ PHONE (919) 549-0517 Adviser on Women in Development DR. EDDAH GACHUKIA The World Bank University of Nairobi 1818 H Street NW P.O. Box 30197 Washington, DC 20433, USA Nairobi, Kenya TELEX 248423 WORLDBK Penina O chola, AMREF PHONE 56613 PHONE 202 477 1234 MRs. GAo SHu FEN MR. MICHAEL HEYN Director of Maternal and Child Health United Nations Development Program Department (UNDP) Ministry of Health P.O. Box 30218 CjO The World Bank Nairobi, Kenya P.O. Box 9509 TELEX 125980 Beijing, Peoples' Republic of China PHONE 28776-9 TELEX 22193 MI NIH CN Ms. CoNSTANCE HoLLERAN M. FRANCIS GENDREAU Executive Director Office of Technical and Scientific Research International Council of Nurses Overseas 3 placejean-Marteau Ministry of Foreign Affairs CH 1201 Geneva, Switzerland 213 Rue Lafayette TELEX 4225002 TXC CH 75010 Paris, France Phone (22) 312960 PHONE (I) 48 03 76 88 DR. HUANG XINGHUA Ms. NANCYGEREIN Head of the Department of Obstetrics Health Specialist Beijing Obstetrics and Gynecology Can adian International Development Hospital Agency cj o The World Bank cj o EAZ.Boga, Zaire P.O. Box 9509 P.O. Box 2 1285 Beijing, Peoples' Re public of China Nairobi , Kenya TELEX 22 193 MINIH CN (Ministry) - - - I I !_ARllCIPAN~S!:~-:-':ntinued 49 L __ ~------ _ - - - • ..... .. ,, ...... . .... . •• •• Dr. Inonge Lewanika, UNICEF: Hilary Ng'weno, Kenya; Dr. Fred T. Sai, The World Bank; Dr. Manuel Ruiz de Chavez, Mexico; Dr. Mary Racelis, UNICEF; Dr. Jose Ari stodemo Pinotti, Brazil Ms. l sHRAT Z. HusAIN Ms. EuNICE M. KIEREINI The World Bank Consultant, World Health Organization 1818 H Street NW (WHO) Wash ington, DC 20433, USA P.O. Box 42841 TELEX 248423 WORL DBK Nairobi, Kenya PHONE 202 477 1234 DR. j OHN G. KIGON DU DR. ATTIYA I NAYATULLAH Director, Division of Family Health Member of Parliament and Ministry of H ealth Minister of State for Population Mbagathi Road (Old) 3-A Temple Rd . P.O. Box 43319 Lahore, Pakistan Nai robi, Kenya TELEX 44877 PEARL PK TELEX 22003 Phone 72510545/6/7 DR. LEENA IsoTALO Advisor (Health) DR. MAR JORIE KOBLI NSKY Ministry for Foreign Affairs The Ford Fo u ndation Finnish International Development 320 East 43rd Street Agency (FI NN IDA) New York, NY 10017, USA Manner heimintie 15C PHONE 212 573 4924 00260 H elsinki, Finland DR. WILFRED KARUGA Ko iNANGE TELEX 124636 UMIN SF Director of Medical Services PHONE 406-077 Ministry of Health DR. V. J AGDISH Afya House, Cathedral Road The World Bank P.O. Box 30016 1818 H Street NW Nairobi, Kenya Washington, DC 20433, USA TELEX 22003 TELEX 248423 WORLD BK Ms. KATHY KRAsovEc PHONE (202) 477-1234 ST H Rm 714 SA18 DR. Wu.TSHIRE j OHNSON United States Agency for International Minister of Health, Social Welfare and Youth Development (USAID) Ministry of Health Washington, DC 20523, USA Yonyi Building PHONE (202)235-9823 Freetown, Sierra Leone Ms. ABYGAIL KRYSTALL Ms. BARBARA KENNEDY Consultant Associate Director The Ford Fou ndation Office of Population P.O. Box 41081 ST POP Rm 809 SA 18 Nairobi, Kenya United States Agency for International TELEX 25135 FORDEAC Development (USAID) DR. BAR BARA KWAST Washingto n , DC 20523, USA World Health Organization (WHO) PHONE (703) 235-8117 Maternal and Child H ealth Ms. M ARGARET KENYATTA 1211 Geneva 27, Switzerland P.O. Box 72783 TELEX 27821 UNISANTE Nairobi, Kenya PHONE 91-33-58 TELEX 22022 (C/0 Mr. Adams, World Bank) 50 PARTICIPANTS LIST- continued . Ndeye Soukeye Cisse, Senegal; Dr. N'gone Toure Sene, Senegal; Dr. Wiltshire Johnson, Sierra Leone; Dr. Joe Fernando, Sri Lanka; Dr. Laban Mtimavalye, Tanzania Barber Conable, The World Bank; Dr. Halfdan Mahler, WHO MR. CARSTEN LAAGE-PETERSEN DR. HALFDAN MAHLER Counsellor Director General Danish International Development World Health Organization (WHO) Agency (DANIDA) 1211 Geneva 27, Switzerland Nairobi, Kenya TELEX 27821 UNISANTE TELEX cj o 31292 ETR DK PHONE 91-21-11 DR. 0. A. LADIPO Ms. DEBORAH MAINE College of Medicine Senior Staff Associate University College Hospital Center for Population and Family Welfare P.M.B. 5116 Columbia University University of Ibadan 60 Haven Avenue I badan, OYO, Nigeria New York, NY 10032, USA TELEX 31520 TEAHOS NG or 20311, PHONE 212 305 6960 ATTN: Box 251 PHONE: 400010 Ext 2687 PROFESSOR]. K. G. MAT! Kenyatta National Hospital DR. INONGE LEWANI KA P.O. Box 30588 UNICEF Nairobi, Kenya Eastern and Southern Africa Regional PHONE 726300, ext. 2372, or 725206 Office D.R. MBOYA Nairobi, Kenya Permanent Secretary DR. A DETOK UN BO LUCAS Ministry of Health Program Chair Nairobi, Kenya Carnegie Corporation of New York MRs. CAROLYN McMASTER 437 Madison Avenue New York, NY 10022, USA Canadian International Development PHONE 212 371 3200 Agency TELEX 166776 CARN UT Canadian High Commission PO. Box 30481 Nairobi, Kenya PHONE 334032 PARTICIPANTS LIST- continued 51 DR. ANTHONY R. MEASHAM MR. JOHN D. NORTH Health Adviser The World Bank The World Bank 1818 H Street NW 1818 H Street NW Washington, DC 20433, USA Was hington, DC 20433, USA TELEX 248423 WORLDBK TELEX 248423 WORLDBK PHONE 202 477 1234 PHONE 202 477 1234 THE HoN. C.Y.O. NYAKIAMO MR. GARY MERRITT Minister of Health USAID Kenya Mission Mbagathi Road (Old) Union Tower Bldg. P.O. Box 43319 Mamo Mgina Nairobi, Kenya P.O. Box 30261 TELEX 22003 Nairobi, Kenya Phone 72510545/ 6/ 7 PHONE 331160 Ms. PENINA OcHOLA TELEX 22964 African Medical and Research Foundation DR. M. MIATUDILA P.O. Box 30125 Advisor to Minister of "Condition Feminine et Nairobi, Kenya Famille" TELEX 23254 AMREF cj o Mr. Lan Bui MRS. T.M. 0DUORI The World Bank Chief Nursing Officer P.O. Box 14816 Ministry of Health Kinshasa, Zaire TELEX 21104 INTBAFRAD, cj o Mr. Lan Afya House, Cathedral Road P.O. Box 30016 Bui Nairobi, Kenya DR. EPHRAIM MINYA TELEX 22003 Pruvincial Medical Director Ministry of Health Ms. INGRID 0FSTAD Head, Division for Health, Nutrition and P.O. Box 98 Family Planning Bindura, Zimbabwe PHONE 171-6764 Norway International Development Agency (NORAD) MRs. AsREsu MISIKIR P.O. Box 8142 DEP Head, MCHj FP Health Services 0033 Oslo 1, Norway Coordinating Office TELEX 76548 NORAD N Ministry of H ealth Addis Ababa, Ethiopia DR. MoGENS OsLER Chairman of Danish Family Planning TELEX cj o World Bank: 21154 IBRD ET Association DR. LABAN MTIMAVALYE Cj ODANIDA (representing Tanzania) Asiatisk Plads 2 cjo UNDP 1448 Copenhagen K, Denmark P.O. Box 4775 TELEX 3 1292 ETR DK Harare, Zimbabwe PHONE 542-211 TELEX 4814 WHOREP ZW DR. LISE OsTERGAARD Ms. JENNIFER MUKOLWE University of Copenhagen Maendeleo ya Wanawake Njalsgade 90 2300 P.O. Box 44412 1017 Copenhagen, Denmark airobi, Kenya TELEX 2221 UNICOP PHONE 542-211 MR. EMMANUEL NDUNGUTSE The World Bank Ms. FRANCESCA 0TETE 1818 H Street NW Head of Committee Washington, DC 20433, USA Maendeleo ya Wanawake TELEX 248423 WORLDBK P.O. Box 44412 PHONE 202 477 1234 Nairobi, Kenya MR. HILARY NG'WENO PROF. EMILE PAPIERNIK Kenya Weekly Review WHO Consu/tanl P.O. Box 42271 Chef de Service GYN j OBS Nairobi, Ke nya Hopita1 Antoine Beclere PHONE 339009, 330898, 26084 157 rue de Ia Porte de Trivaux 92140 Clamart, France DR. E. K. NJELESANI PHONE 1 46311599 Director of Medical Services Ministry of Health P.O. Box 30205 Lusaka, Zambia TELEX 41290 PHONE 260 1 211 528 ; 52 , " - --- ' PARTICIPANTS LIST- continued -- ..-....---.-- -~-- .---.....:.-·-------=-"'"""-- --·--.-....:.. - = -- ~ DR. ANGELE P ETROS-BARVAZIAN Ms. ERICA RoYSTON Director, Division of Family Health Division of Family Health World Health O rganization (WHO) World Health Organ ization (WHO) 1211 Geneva 27, Switzerland 1211 Geneva 27, Switzerland TELEX 27821 UNISANTE TELEX 27821 UN ISANTE P HONE 91-21-11 PHONE 91-21-11 DR. j OSE ARISTODEM O PINOTTI DR. MANUEL R urz DE CHAVEZ Center for Integral Assistance to Women's Under Secretary for Health Planning Health Secretar ia de Salud Presciliana Soales 87 Lieja # 7 ler piso Campinas Sao Paulo, Brazil Colonia J uarez TELEX 191150 UCPS BR or 1123709 Codego Postal 06696 SCEDBR Mexico D.E, Mexico PHON E (11) 255 9790 or (192) 5lll97 TELEX 1773429 P HONE (525) 553-0758 DR. M ALCOLMPOTTS Family Health In ternational DR. MATANDA SABW A Research Triangle Park, NC 27709, USA Deputy Representative and TELEX 579442 Senior Adviser on Population in Senegal PHONE 919 549-0517 United Nations Fund for Population Activities (UNFPA) DR. M ARYRACE LIS POP 154 R egional Director Dakar, Senegal Dr. Attiya Inayatullah, United Nations Ch ildren's Fund Dr. Mahmuda Said, Pakistan; TELEX 676 (UN ICEF) Rami Chabbra, India P.O. Box 44145 DR. NAFIS SADIK Nairobi, Kenya Executive Director PHONE 520671, 520734 United Nations Fund for Population Activities (UNFPA) DR. 0 . RANSOME-KUTI 220 East 42nd Street Minister of Health New York, NY 10017, USA Federal Ministry of Health PHONE 212 850 5658 Lagos, igeria TELEX 23608 NIGMEA NG D R. F RED T. SAl P HONE 684 405 Senior Population Adviser or TELEX 21174 IBRD NG (World Bank- The World Bank c/o Ms. Moj idi) 1818 H Street NW Washington, DC 20433, USA DR. s. s. RATNAM TELEX 248423 WORLDBK Head of Department of OBj GYN PHONE 202 477 1234 National University of Singapore National University Hospital PRoF. MAHM UDA SAID Lower Kent Ridge Road, Singapore 0511 Jinnah Post-Graduate Medical Centre TELEX RS 33943 UNISPO RS or cjo Said Manzi!, MAJinnah Road Karachi, Pakistan Ms. DoNNA RoB INETT TELEX 23374 SASM PK Program for Appropriate Technology in PHONE 722890 Health 4 Nickerson St. DR. j OAO B.R. SALOMON Seattle, WA 98109 H ead, International Affairs Office PHONE (206) 285-3500 Ministry of Health TELEX 4740049 PATH UI Esplanada dos Ministerios BlocoG' - S/ 608 DR. Ro GER R ocHAT 70058 Brasilia D.F, Brazil Centers for Disease Control (CDC) TELEX 0611752 MNSA BR cjo International Health Track PHONE (61) 224-5797 MPH Program Emory University School of Medicine M R. EMMERICH M. SCHEBECK 735 Gatewood Road, NE The World Bank Atlanta, GA 30322, USA 1818 H Street NW PHONE 404 727 5724 Washington, DC 20433, USA TELEX 248423 WORLDBK D R. ALLAN RosENFIELD PHONE 202 477 1234 Dean, School ofPublic Health Columbia University Ms. PusHPA ScHWARTZ 600 W. !68th St. The World Bank New York, NY 10032, USA 1818 H Street NW PHONE 212 305 3929 Washington, DC 20433, USA TELEX 248423 WORLDBK PHONE 202 477 1234 RARTICIPANI'S l..IS"fi - continued 53 Dr. Pathe Diallo, Guinea; Gao Shufen, Dr. Huang Xinghua, People's Republic of China; Azara Bamba, Burkina Faso Dr. Fred T. Sai, The World Bank; Dr. Manuel Ruiz de Chavez, Mexico DR. DAVID SEBJNA DR. N'GONE TouRE SENE The World Bank UNIFEM 1818 H Street NW Cj OUNDP Washington, DC 20433, USA 2 avenue Roume TELEX 248423 WORLDBK Bicis Bldg. PHONE 202 477 1234 Dakar, Senegal or Ms. jENNEFER SEBSTAD P.O. Box A287 Program Officer Thies, Senegal Office for Eastern & Southern Africa PHONE (in Thies) 51 14 83 The Ford Foundation TELEX 676 UNDEVPRSG (cjo UNDP) P.O. Box 41081 Silopark House MR. STEVE SIN DING Nairobi, Kenya USAID Kenya Mission TELEX 25135 FORDEAC Union Tower Bldg. PHONE 338123, 25438, 21572 Mamo Mgina P.O. Box 30261 DR.SHELDONJ.SEGAL Nairobi, Kenya Director, Population Sciences PHONE 331160 Rockefeller Foundation TELEX 22964 AMEMB 1133 Avenue of the Americas New York, NY 10036, USA DR. HARCHARAN SINGH PHONE 212 869 8500 Adviser, Health and Family Welfare Planning Commission DR. PRAMILLA SENANAYAKE Parliament Street International Planned Parenthood New Delhi, India Federation (IPPF) TELEX 3161463 PLAN IN Inner Circle, Regents Park London NW1 4NS, United Kingdom Ms. KATHERINE SPRINGER TELEX 919573 IPEPEE LDN Technical Adviser in Basic Needs PHONE 1-486-0741 United Nations Development Program (UNDP) One United Nations Plaza, DCI-2050 New York, NY 10017, USA TELEX 125980 PHONE 212 754 1234 --- 54 PARTICIPANTS LIST- continued DR. WILLIAM STEELER MR. CARL WAHREN Director, Primary Health Care Director, Health and Population Aga Khan Health Services Swedish International Development Secretariat of HHS Aga Kahan Auth ority (SIDA) Aiglemont Birger Jarlsgatan 61 60270 Gouvieux, France 10525 Stockholm, Sweden TELEX 150064 ABCG TELEX 11450 Sida S PHONE 4-457 40 00 PHONE 150001 MR. MICHAEL STERNBERG DR. GODFREY WALKER Head of DANIDA Mission Overseas Development Administration P.O. Box 40412 (ODA) Danish International Development Eland House, Stag Place Agency (DAN IDA) London, SW1E 5DH, United Kingdom Nairobi, Kenya TELEX 26307 ODMLDM G TELEX cjo 3 1292 ETR DK PHONE 213-3000 MR. MAGNUS STIERNBORG MR. BRADMAN WEERAKOON Eunice M. Kiereini, Kenya; Swedish International Development Secretary-General Bradman Weerakoon, IPPF Authority (SIDA) International Planned Parenthood Birger Jarlsgatan 61 Federation (IPPF) 10525 Stockholm, Sweden Inner Circle, Regents Park TELEX 11450 SIDA S London NW1 4NS, United Kingdom PHONE 150001 TELEX 919573 IPEPEE LDN PHONE 1-486-0741 Ms. BIRGIT STORGAARD Adviser to DANIDA DR. BEVERLY WINIKOFF Danish International Development The Population Council Agency (DAN IDA) One Dag Hammarskjold Plaza Asiatisk Plads 2 New York, NY 10017, USA 1448 Copenhagen K, Denmark TELEX 234712 POCO UR TELEX 31292 ETR DK PHONE 212 644 1300 PHONE 542-211 DR. CHRISTOPHER H. WooD DR. BABILL STRAY-PEDERSEN Director General Medical Adviser African Medical and Research Foundation Dr. Fred T. Sai, The World Bank; Dr. 0. Ransome·Kuti, Nigeria; Ministry of Development Cooperation P.O. Box 30125 Dr. Adetokunbo Lucas, Carnegie Norway International Development Wilson Airport, Langata Rd. Corp. of New York Agency (NORAD) Nairobi, Kenya Head, Dept. of GynjOb TELEX 23254 AMREF cjo Aker Hospital, University of Oslo PHONE 501301 / 2/3, or 500508 0514 Oslo 5, Norway TELEX 76548 NORAD N Conference Secretariat PHONE (02) 22505 Ms. JILL SHEFFIELD DR. HARYONO SUYONO President Chairman of National Family Planning Family Care International Coordination Board (BKKBN) 902 Broadway, lOth floor P.O. Box 186 New York, NY 10010, USA Jakarta, Indonesia PHONE 212 995 8870 TELEX 48181 BKKBN IA TELEX 620661 PHONE 819-4650 or 819-3083 Ms. ANN STARRS MR. ARIKA TAKAHASHI Family Care International Resident Representative of Kenya Office 902 Bmadway, lOth floor J apan International Cooperation Agency New York, NY 10010, USA P.O. Box 50572 6th Floor, Matungulu House Ms. NICOLA BLUNDELL BROWN Mamlaka Road African Medical and Research Foundation Narobi, Kenya (AM REF) TELEX 987 22145JICA NOB Nairobi, Kenya PHONE 72 41 21 4 Ms. MARIETTA DE SouzA MR. FRANK VOGL World Bank The World Bank Nairobi, Kenya 1818 H Street NW Washington, DC 20433, USA TELEX 248423 WORLDBK PHONE 202 477 1234 BACKGROUND RAP.ERS 55 The Safe Motherhood Initiative: Proposals for Action Barbara Herz and Anthony R. Measham BACKGROUND The World Bank DP009 (Available only from the World Bank; see order form belaw.) PAPERS 1. Prevention of Maternal Mortality Report of a WHO Interregional Meeting, Novemb er 1985 FOR SAFE World Health Organization FHEj 86.1 MOTHERHOOD 2. Maternal Mortality Rates: A Tabulation of Available Information Second Edition CONFERENCE World Health Organization FHE/ 86.3 3. Essential Obstetric Functions at First Referral Level Report of a Technical Wor king Group, June 1986 World Health Organization FHE/ 86.4 4 . Measuring Maternal Mortality World Health Organization FH Ej SMCj 87.1 5. Maternal Mortality: The Dimensions of the Problem World Health Organization FHEj SMCj 87.2 6. The Status of Women, Maternal Health and Maternal Mortality World Health Organization FHEj SMCj 87.3 7. Causes of Maternal Death World Health Organization FHEj SMCj 87.4 8. Selections from WHO Press Kit prepared for the Safe Motherhood Conference: a. "Fact sheet" b. "Some Unusual Approaches" c. "Childbirth: A Matter of Life and Death" d. "Solving the Problem" e. "Family Planning" f. "Message" from the co-sponsors 9. Road to Maternal Death: Case Histories Barbara E. Kwast World Health Organization 10. Prevention of Mater nal Deaths in Developing Countries: Program Options and Practical Considerations Deborah Maine, Allan Rosenfield, Ann Marie Kimball (Columbia University); Barbara Kwast (World Health Organization); Sharon White (CEUM Hospital, Karawa, Zaire) 11. Medical Services to Save Mother's Lives: Feasible Approaches to Reducing Maternal Mor tality Beverly Winikoff with Charles Carignan, Elizabeth Bernard ik, Patricia Semerar o The Population Couruil 12. Addresses by: a. Barber B. Conable, President The World Bank b. Halfdan Mahler, Director General World Health Organization c. Nafis Sadik, Executive Director United Nations Fund for Population Activities d. William H. Draper III, Administrator United Nations Development Programme e. The Honorable Daniel arap Moi, President of the Republic of Kenya Limited copies of presentations made by panel members at the conference are available on request. The views expressed in all papers are tlwse of the autlwrs or the organisation as specified in the paper, and slwuld not be attributed to the agencies or organisations sponsoring the Safe Motherhood Confertmce. 56 BACKGROUND PAPERS- continued pAPERS REQUESTED In addition, videotapes of several presentations and sessions of the (list by number and letter, where relevant): conference are available at a cost of US$25 each. They are: 1. Mahmoud Fathalla, M.D., " The Road to Maternal Death" (edited) 2. Barbara Kwast, M.D. " Essential Obstetric Functions at the First Referral Level" (edited) 3. Opening Ceremony (two tapes) VIDEOTAPES R EQUESTED 4. Press Conference (2 112 tapes) (list by number and include specifications): 5. Closing Session (three tapes) 6. Panel on " Community-Based Services," chaired by Barbara Herz Please specify whether you need PAL (English-speaking European system), NTSC (U.S. system), or SECAM (French system); whether you need % inch or 112 Please write your full mailing address below: inch tapes; and whether you need VHS or BETA. (If possible please enclose a cheque payable to Family Care International in U.S. dollars.) NAME For copies of the papers andj or videotapes listed, please indicate your ORGANIZATION request and send to: FAMILY CARE INTERNATIONAL STREET OR P.O. ADDRESS SAFE MOTHERHOOD INITIATIVE 902 Broadway, lOth floor CITY, STATE, COUNTRY New l&rk, NY 10010 You may also request papers by calling (212) 995-8870 or sending a telex TELEPHONE AND TELEX to 620661. ••••••••••••••••••••••••••••••••••••••••••••••••••• •• Please write your full mailing address Additional copies of Preventing the Tragedy ofMaternal Deaths are below: available from the World Bank, as are copies of The Safe Motherhood Initia- tive: Proposals for Action. To order, use the following form: NAME ORGANIZATION Send me copies of The Safe Motherhood Initiative: Proposals for STREET OR P.O. ADDRESS Action (#DP0009) US$6.50 each Send me copies of CITY, STATE, COUNTRY Preventing the Tragedy of Maternal Deaths(#IB0988) _ _ _ _ _ _ _ _ US$6.50 each TELEPHONE AND TELEX Air mail outside the U.S.A. _ _ _ _ (US$4.50 ; copy) Please check method of payment: Ocheque TOTAL 0 International Money Order Mail coupon to: or: 0 UNESCO Coupons WoRLD BANK PuBLICATiONs WORLD BANK PUBLICATIONS 0 International Postal Coupons Department 0552 66, avenue d'Iena Make riU'que.< pa_wJJ/r to 1-\inM Bank Publication<. Washington, D.C 20073-0552 75116 Paris, France 0 VISA 0 MasterCard 0 Choice 0 American Express Coupon orders accepted only from the U.S. and France. To order from other countries, request a list of local World Bank publications distributors. CREDIT CARD NUMBER PRICES VARY BY COUNTRY. Allow 6-8 weeks for surface mail delivery outside EXPIRATION DATE the U.S. 0 Send invoice (institutional customers only) SIGNATURE (Credit card orders accepted only for orders addressed to Washington, D. 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