Executive summary

The gap in pregnancy-related deaths between developing and industrial countries shows the greatest disparity of any human development indicator. Pregnant women in developing countries face a risk of death that is up to 200 times greater than for women in industrial countries. Unless vigorous, scientifically informed action is taken, more women may die from causes related to pregnancy, childbirth, and unsafe abortion in the 1990s than in any previous decade.

The issue involves more than women's lives. Also at stake are the lives of an estimated 7 million or more newborns who die annually as a result of maternal health problems and the health and socioeconomic prospects for surviving children, families, and communities. Yet most women in the developing world lack regular access to modern methods of contraception and do not receive adequate prenatal or delivery care.

The Safe Motherhood Initiative

In an effort to reduce the high toll of maternal morbidity and mortality, the World Bank, World Health Organization, United Nations Fund for Population Activities, and agencies from more than forty-five countries launched the Safe Motherhood Initiative at a conference in Nairobi in 1987. The goal is to reduce maternal illness and deaths by half by the year 2000.

The short-term strategy would make family planning services and maternal health care more effective - by improving quality, increasing access, and educating the public about the importance of such services and how they can best be used. A more comprehensive plan calls for improving women's socioeconomic status through health, education, and other factors.

The initiative, in its first six years, has brought greater awareness of the problem of maternal health, and countries are beginning to develop plans and programs. The challenge, however, is to accelerate program implementation at the country level.

At a follow-up conference at the World Bank in 1992 on the Safe Motherhood Initiative, international agency representatives and maternal health experts worked to help transform the effort from advocacy to action. This paper, an outgrowth of that meeting, is intended mainly to guide Bank operations staff in their work on safe motherhood programs. It should also prove useful to program planners in borrower countries and in other agencies.

What Is Needed

The experience of developed countries has shown that maternal mortality is not reduced by socioeconomic development alone, that an active program to improve the health infrastructure and behavior is needed. By the same token, research projects in Bangladesh, Ethiopia, Guatemala, and elsewhere have helped show which approaches do and don't work. For example, community-based approaches such as family planning and training and deployment of midwives have helped reduce maternal deaths in high-mortality settings.

Substantial - and sustained - reduction of the risk of dying once pregnant, however, requires adequate referral and treatment to deal with emergency obstetric complications. Deliveries performed by traditional birth attendants without skilled backup services have not reduced the risk of maternal deaths. And the use of demographic factors, such as age and number of previous deliveries, to predict delivery complications has not proved reliable; most obstetric complications occur among women without these "risk" factors. Experience demonstrates that survival and well-being depend primarily on early detection of actual complications or disease and appropriate care. A radio campaign about the risks of labor lasting more than twentyfour hours significantly reduced the mortality and long-term disability that can result from prolonged labor.

The pathway to safe motherhood consists of interlinked steps: an adolescent's nutritional status; a woman's information about contraception, danger signs during pregnancy, and sexually transmitted diseases (including AIDS); access to appropriately trained health providers in a community; access to health care facilities or emergency transport to facilities elsewhere all affect pregnancy outcomes and can be improved through public health interventions. Family planning reduces women's exposure to pregnancy-related risks; it also benefits the newborns, whose health prospects are improved by appropriately timed and spaced pregnancies.

The more than 500,000 maternal deaths each year result mainly from five causes: hemorrhage, unsafe abortion, infection, hypertensive disorders, and obstructed labor. In addition, tens of millions of maternal morbidities and disabilities in developing countries result from complications related to these problems or from life-threatening diseases - such as malaria, viral hepatitis, and AIDS that are exacerbated by pregnancy. But the most immediate determinant of maternal morbidity and mortality is the management of complications directly associated with pregnancy, labor and delivery, the postpartum period, and abortion.

So, a safe motherhood program requires community-based nutrition, health, and family planning services; a continuum of care from community to hospital; and a public information program. Such a program ought to be an integral part of a country's primary health care and overall public and private health system.

Policy Considerations

Programming for safe motherhood requires local flexibility and initiative in planning, combined with strong national and local political support. From the outset, policymakers and planners will need to build commitment among decisionmakers, opinion leaders, and potential program beneficiaries, both women and men. Policymakers will also have to balance needs - based on an analysis of epidemiologic, demographic, and sociocultural factors and on available financial and other resources.

At the same time, in a broader context, the leaders should work to strengthen intersectoral coordination of activities that can advance the socioeconomic and legal status of women. Such factors as a woman's level of education, economic potential, and family and social status clearly affect fertility levels, pregnancy outcomes, the health of women and children - and their capacity to contribute to economic development.

Tailoring a Program to Its Setting

To consider how different settings might affect strategy, this report gives examples of approaches in three different settings - ranging from setting A, which has very limited health service infrastructure, through setting C, which has extensive services. However, nothing can replace an individualized assessment of a country's unique maternal health needs, including considerable variation within a country, in preparation for embarking on program development.

In the example of setting A, high fertility, high mortality, and limited resources indicate that community-based distribution of contraceptives and appropriate abortion should be established as the first line of offence. In setting B. the priority interventions are likely to be strengthening the referral system, upgrading maternity-care provider skills, and expanding health service coverage. In setting C, improving the quality and efficiency of care - with some decentralization of service and developing a more comprehensive strategy for women's health, are probable areas of emphasis.

In all settings, information, education, and communications are essential - to improve community awareness of the need for better health-related practices and health care services and to tell the community how best to use such services.

Projected Costs

Projected costs for a substantial reduction in maternal morbidity and mortality are approximately $2 per capita per year, with half of that for maternal health and half for family planning. A recent World Bank analysis of health sector priorities identified prenatal care and delivery services as among the most cost-effective interventions with which governments can improve adult and child health.

The Bank's Role

The Bank's role in safe motherhood is to support member governments, in coordination with other assistance agencies and nongovernmental organizations, to formulate and implement policies and programs. Bank lending for safe motherhood has grown from nine projects in fiscal 1986 to seventy in fiscal 1992. To complement safe motherhood projects, the Bank assists projects that expand opportunities for women in a variety of sectors.