Ill-Informed and Ineffective Strategies

Alongside family planning, the first WHO expert committee formally put the focus on antenatal clinics and education of the mothers in the early 1950s (OMS 1952). The package of measures introduced to reduce maternal mortality had long remained substantially the same (in actual fact these measures had mainly been directed towards improving the survival prospects of infants).

Nevertheless, there had been evidence in the industrialised West, for as long as since 1932, that screening for maternal death was not very effective: a letter to the Lancet stated that “80 percent of maternal deaths were due to conditions (sepsis, haemorrhage, shock) not detectable antenatally” (Browne & Aberd 1932, Reynolds 1934). Nonetheless, antenatal risk scoring systems were extrapolated from Europe to developing countries in the 1960s. They soon became common wisdom (Lawson & Stewart 1967, King 1970, Van der Does & Haspels 1972, Cranch 1974) and, during the 1970s and 1980s, mainstream doctrine with WHO’s risk approach (WHO 1978, Backett et al 1984).

In the early-1980s the first evidence questioning the cost-effectiveness of antenatal screening in developing countries appeared (Kasongo Project Team 1984), and common wisdom began to be challenged (Smith & Janowitz 1984): “The ineffectiveness of ANC as an overall screening programme not only renders it less than what it claimed to be; it does not even then say what it is.” (Oakley 1984). Six years later Maine became explicit: “No amount of screening will separate those women who will from those who will not need emergency medical care” (Maine et al. 1991). The Rooney report of 1992 formally changed the balance to scepticism⁷ (Rooney 1992). It is hard nowadays to defend antenatal care merely on basis of its potential for screening out preventable maternal death - but many are the administrators or funding organisations that continue thinking that as long as antenatal consultations are being conducted, one has done one’s duty. In the meantime a WHO seminar in Malaysia in 1970 had launched the training and promotion of traditional birth attendants as another strategic axis (Mangay-Maglacas 1990). This strategy was further promoted in the influential recommendations of a 1972 inter-country-study. A decade later the initial enthusiasm still persisted (Williams et al. 1985, Tafforeau 1989, Sai & Meesham 1992), but it gradually gave way to scepticism (Chen 1981, Mathews 1983, Belsey 1990, Maine 1991, Bryant 1990, Smith et al. 2000). Little effect was seen apart from tetanus prevention. The resistance (or inability) to change of TBAs, their lack of credibility in the eyes of the health professionals, the de facto impossibility to organise effective and affordable supervision, all have discredited training of TBAs. Whatever its other merits, it is now considered an ineffective strategy to reduce maternal mortality.